Download CM 35- Blunt Chest Trauma Blunt Chest Trauma Force applied over

CM 35- Blunt Chest Trauma
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Blunt Chest Trauma
Force applied over relatively large area of chest wall
Minor chest wall contusions → fatal intrathoracic injuries
Mortality rate is 10%
Most common mechanisms of BCT
 MVC, Motorcycles—Acceleration and Deceleration injury
 Falls
 Assault
Chest Wall Injuries
 Rib, clavicle, sternal fractures
 Chest wall contusions
Cardiac Injuries
 Cardiac Tamponade*
 Myocardial Contusions*
Pulmonary Injuries
*= not discussed in this lecture
 Pulmonary contusion
 Pneumothorax*/Hemothorax*
 Flail Chest
Vascular Injuries-- Aortic Rupture*
Esophageal Rupture*
Tracheal/Bronchial Injuries*
Diaphragmatic Rupture*
Clinical Presentation
 Mild pain to severe dyspnea, hypotension, cardiac arrest
 Majority of injuries: chest wall contusions & rib fractures
 Exam includes
 Inspection
 Palpation
 Auscultation
 Imaging
 Inspection
 Chest wall
 Contusions, abrasions, swelling
 Seat belt mark
 Paradoxical motion
 Neck
 Distended neck veins – cardiac tamponade
 Tracheal deviation?
 Swelling, abrasions
 Abdomen
 Scaphoid vs. distended-Scaphoid abdomen may indicate diaphragmatic injury with herniation of
abdominal contents into chest
 Bruising & abrasions
 Palpation
 Pain - ribs, sternum, clavicle, abdomen
 Crepitus – ribs, sternum, clavicle
 Subcutaneous emphysema--Upper abdominal tenderness suggests hepatic or splenic injury
 Subcutaneous emphysema suggests pneumothorax until proven otherwise. Air from lung parenchyma
or tracheobronchial tree. Extensive subq air suggests larynx or esophageal injury
CM 35- Blunt Chest Trauma
 Auscultation
 Decreased bowel sounds?
 Bowel sounds in chest?
 Crackles
 Bedside imaging
 Chest X-ray
 Ultrasound (FAST)—Utrasound that you use in trauma for Fluid in abdomen, pneumothorax
 Additional imaging
 CT scanning
Rib Fracture
 True Ribs: 1-7 (connect to sternum by costal cartilages)
 False Ribs: 8-12 (connect by costal cartilage to cartilage of superior rib)
 Ribs 11+12 - Floating ribs: (unattached)
 Costal Cartilages
 Extend from anterior ends of ribs
 Contribute to elasticity & mobility
 1-7 attach directly to sternum
 #7-10 join to form costal margins; together form costal arch
 Fractures of costal cartilages, separation of the costochondral junction & dislocation of costal cartilage from
sternum have same clinical significance as rib fractures!
 First Rib
 Difficult to fracture, takes large amount of force
 Subclavian vessels, brachial plexus crosses 1st rib
 Always look for more injuries!!!
 Lower Ribs
 What other injuries to consider?
Diagnosis and Evaluation
 Xray Limitations
 50% of rib fx missed on initial X-rays
 Costochondral fx / separation not seen - has same significance as rib fx
 Implications
 Diagnosis should be clinical
 Localized & consistent TTP over ribs = fracture even if negative x-rays
 CXR vs “Rib Series”
 CT scans - more sensitive for rib fx
 Consider in significant trauma, multiple rib fx, intraabdominal or intrathoracic injury
 Treatment & Disposition
 Rib fx & no pulmonary injury – D/C home
 Goals of treatment: minimize pain, maximize breathing
 Combination of NSAID & opiate
 Cough, deep breathing exercises hourly – incentive spirometry
 Taping, rib belts?
 Who needs to be admitted?
 Multiple rib fractures
 Additional injuries (pulmonary, intraabdominal, etc)
 Elderly
 Chronic lung disease
 Severe co-morbidity
 Intractable pain
CM 35- Blunt Chest Trauma
Pulmonary Contusion
 Mechanism
 Damage to alveolar-capillary membrane, ↑ membrane permeability
 Collection of blood & edema in alveoli
 V/Q mismatch
 Hypoxia, hypercarbia, acidosis
 Incidence ↑ with ↑ forces imparted
 Multiple rib fx, flail chest
 Common with BCT in children. Why? Because cartilage of ribs is bendable—chest wall is flexible, bends,
and hurts the underlying organs (adults ribs are more stiff and more protection)
 Clinical Features
 Dyspnea, tachypnea, pain common
 Tenderness, ecchymosis, deformity, crepitus of chest wall
 Crackles on auscultation
 Large contusions → tachycardia, cyanosis, hemoptysis
 Evaluation/Diagnosis
 Chest X-ray
 Opacification / consolidation under area of BCT
 CXR findings often lag behind clinical findings, may progress over 6-12 hours (after IVF, blood)—
may lag after the clinical findings (see it later)
 CT of Chest
 Can detect contusions before visible on CXR
 Indicated if significant mechanism of injury, multiple rib fx or high risk patient (elderly,
underlying CV disease etc)
 Treatment
 Maintenance of adequate oxygenation & ventilation
 intubation may be necessary
 Pain control, encourage deep breaths, incentive spirometry
 Generally require admission – contusions tend to worsen over 24 hrs
 Avoid excessive IV fluid - may worsen contusions
 May lead to ARDS, pneumonia, respiratory failure
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Flail Chest
Three or more adjacent ribs, each fractured in 2 or more places
 Chest wall unstable & segment lacks continuity with rest of thoracic cage
Paradoxical motion of chest wall
 Segment moves IN during Inspiration & OUT during Exhalation
 May not be obvious initially (splinting, muscle spasm)
Respiratory compromise
 Related to degree of underlying lung injury - severe pulmonary contusion common
 Pain & mechanics → hypoventilation, atelectasis & hypoxia
Clinical Findings
 Severe pain, tenderness, crepitus, bruising
 Paradoxical motion (sometimes)
 Absence does NOT exclude the diagnosis
Evaluation
 CXR initial test
 Multiple rib fractures
 Pneumothorax, hemothorax, pulmonary contusion, mediastinal injury
 Contrast-enhanced CT of chest
 Significant forces to chest--Evaluate for airway, great vessel injuries
CM 35- Blunt Chest Trauma
 Management
 Oxygenation, ventilation, pain control
 Manual stabilization initially
 Detection & treatment of underlying injuries
 CT scan indicated
 Chest tube if PTX of hemothorax
 Positive pressure ventilation - endotracheal intubation often required
 Provides splinting
 Pain Control - IV narcotics, regional nerve blocks, epidural anesthesia
 If no hypotension, hypovolemia, blood loss limit IV fluids
Sternal Fractures
 Anatomy of Sternum
 Manubrium
 Body & Xiphoid
 Impacts to sternum may cause
 Sternal fracture
 Costochondral separation
 Disarticulation of sternum from ribs (anterior flail chest)
 Major concern - injury to intrathoracic/ mediastinal structures
 Evaluation
 Pain, dyspnea, bruising & tenderness over sternum
 +/- crepitus
 Imaging
 X-ray
 Most are non-displaced & transverse – missed on AP Xray
 Lateral x-rays have higher sensitivity
 CT Scan
 More sensitive / accurate
 Helpful in diagnosing underlying injuries (pulmonary contusion, vascular injury)
 Retrosternal hemomediastinum specific but insensitive
 Management
 Treat underlying injuries!
 Fx itself usually requires only symptomatic treatment
 Pain control, ice
 Displaced fractures may require reduction
 Pts with isolated non-displaced fx may be discharged after other injuries excluded
 Some recommend 6-12 hour observation, esp for elderly
Clavicle Fractures
 Most common newborn/childhood fracture
 Mechanisms
 Force directly to clavicle or to outer end
 Most pts have history of direct fall onto shoulder
 Football, bike accidents, wrestling, hockey, MVC
 Classification of fractures
 Based on dividing clavicle into thirds
 Proximal (5%), Middle (80%), Distal (15%)
 Presentations
 swelling, loss of normal contour, skin tenting, head turned towards affected side, open fx possible
CM 35- Blunt Chest Trauma
 Complications
 Brachial plexus injury, pneumothorax, non-union (0.1-15%)
 Vascular Injury: subclavian artery/vein, internal jugular, axillary artery
Medial (proximal) Third Fractures
 5% of all clavicle fractures
 Mechanism – usually direct blow to anterior chest
 Considerable forces required
 Associated with multi-system trauma - must seek associated underlying injuries
 PTX/hemothorax, pulmonary contusion
 Head and neck injuries
 Diagnosis
 Often difficult to visualize on plain x-rays
 Best seen with CT scan
 Management
 Sling, ice, pain control, early ROM exercise
 Displaced fx require orthopedic referral for reduction
Middle Third Fractures
 80% of all clavicle fractures. Why? Clavicle thin at that area and not tethered to anything
 Mechanism –force applied to lateral aspect of shoulder (fall, MVC)
 Greenstick fractures
 Bone bends, partially breaks - does not extend through opposite cortex
 Non-displaced & heal uneventfully
 Overriding of bone fragments & shortening of clavicle common
 Management
 Standard - sling, ice, pain control
 Surgical – significant displacement, shortening, tenting, open fx
Lateral (Distal) Third Fractures
 15% of clavicle fractures
 Mechanism – direct blow to top of shoulder
 Fracture lateral to the coracoclavicular ligament
CM 35- Blunt Chest Trauma
 Treatment
 Most heal uneventfully & can be followed by PCP
 Ice, pain control
 Sling for immobilization & support
 Figure-of-eight splints vs sling?
 No true benefit in pain control or fracture reduction
 Activity
 Passive ROM exercises encouraged; non-contact sports, full ADL in 6 wks
 Contact & collision sports should be avoided until healing solid (2-4 mos)
 Indications for immediate orthopedic consultation
 Open fractures or severe tenting
 Neurovascular injury
 Surgical treatment if risk for non-union
Sternoclavicular Joint
 Medial clavicle fits poorly with clavicular notch on manubrium
 Joint stability depends on ligaments
 A & P Sternoclavicular (SC) ligaments envelop joint in fibrous capsule
 Costoclavicular ligament - most important stabilizer
 SCJ is least commonly dislocated major joint in body
 Most injuries are simple sprains
 Superior mediastinum: immediately posterior to joint
 Great vessels, trachea, esophagus – potential for injury!
 1st degree SC (Grade I) joint injury
 Sprain of SC joint
 Stretching, incomplete tears of the SC & CC ligaments
 Clinical findings – minimal swelling & tenderness over SC joint
 Nonsurgical treatment
nd
 2 degree SC (Grade II) joint injury
 Subluxation of clavicle from manubrium
 Complete rupture of SC ligament. Incomplete rupture of CC ligament
 Clinical findings - swelling & tenderness over SC joint. Pain with abduction of arm
 Nonsurgical treatment
 3rd degree (Grade III) SC Joint Injury
 Rupture of SC & CC ligaments with complete dislocation of clavicle from manubrium
 Significant forces required
 Most common causes – MVC, contact sports
 Anterior vs Posterior 3rd degree
 Subluxation of clavicle from manubrium
 Anterior more common (9:1)
 Posterior associated with more complications
 PTX
 Laceration of SVC
 Occlusion of subclavian artery/vein
 Compression/Rupture of trachea (rare)
 Most common
 UE may be foreshortened; usually supported across the trunk by opposite arm
 Shoulder appears shortened & rolled forward
 SCJ swollen & tender to palpation
 Anterior Dislocations
 Medial clavicle prominent & palpable anterior to sternum
CM 35- Blunt Chest Trauma
 Posterior Dislocation – pain more severe
 Neck often flexed toward injured side
 Clavicular notch of sternum may be palpable
 Possible associated complaints
 Hoarseness, dysphagia, dyspnea, weakness/ paresthesias of UE
 Intrathoracic or mediastinal injuries in 30%
 Diagnosis often made clinically
 X-rays
 Standard xrays often difficult to interpret 2o overlapping rib, sternum & vertebral shadows
 CT Scan
 Better visualization of dislocations
 Shows associated injuries (posterior)
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Don’t Forget
Know your anatomy! This will make it easy to understand many of the injuries involved in BCT
A key concept with BCT is remembering to look for underlying injuries. Recognize which injuries are red flags for
other, potentially life-threatening ones
Many injuries are not visible on initial imaging studies. Know the best tests to maximize sensitivity. Know which
injuries are clinical diagnoses as well.
Remember to always look for the second, or even third, more subtle injury on any given imaging study. These
are commonly missed.