Chest Trauma

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Chest Trauma

• Kent J. Blanke, D.O., FACOS

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Introduction

• Trauma 3rd leading cause of death in the U.S.
• Trauma is the leading cause of death in those
  under 40 y.o.a.
• There are 100,000 accidental deaths/yr and
  9,000,000 disabling injuries yearly in the U.S.
• 25 of deaths from blunt trauma are due solely to
  chest injuries

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Thoracic Trauma
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Penetrating Chest Injuries

• Majority are stab wounds or gunshot wounds (GSW)
• Lower mortality rates--less likely to include
  multiorgan injury
• 85 of penetrating chest wounds can be treated
  with tube thoracostomy and supportive measures

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Penetrating Chest Injuries

• 25,000 deaths per year in the U.S. due to GSWs to
  the chest

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Penetrating Chest Trauma

• Wounds that enter or exit inferior to the nipple
  or the posterior tip of scapula may perforate the
  dome of the diaphragm.
• Any penetrating wound such as this should be
  considered to have an abdominal component until
  proven otherwise.

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Penetrating Chest Trauma Treatment

• ATLS protocol A,B,C,D,Es
• Emergency management
• Needle thoracentesis
• Tube thoracostomy
• Subxiphoid pericardotomy
• Video assisted thoracic surgery (VATS)

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Work-up of Penetrating Chest Trauma

• Physical examination
• Look, Listen, Feel
• Contusions, diminished or absent breath sounds,
  SQ emphysema can readily be found
• CXR- best, least expensive and fastest initial
  evaluation
• Ultrasound-may soon replace CXR as initial
  radiographic study in chest trauma
• Angiography- to look for great vessel injuries
• CT Scan for better evaluation of chest wall and
  parenchyma
• Transesophogeal Echocardiography

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Penetrating Chest Injuries

• Operative intervention required for
• Massive or persistent bleeding
• Massive air leak
• Tracheobronchial injuries
• Esophageal perforation
• Cardiac or great vessel injuries
• Post-traumatic empyema

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Penetrating Chest Trauma

• Wounds that enter or exit inferior to the nipple
  or the posterior tip of scapula may perforate the
  dome or the diaphragm.
• Any penetrating wound such as this should be
  considered to have an abdominal component until
  proven otherwise.

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Penetrating Chest TraumaIndications for
Mechanical Ventilation
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Intrapulmonary Foreign Bodies

• Bullets, fragments indications for removal
• Greater than 1.5 cm
• centrally located
• irregularly shaped
• sharp edged fragments
• FBs associated with gross contamination should
  be removed

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Intrapulmonary Foreign Bodies

• When left in lung
• 20 developed into chronic bronchitis
• 6 lung abscess
• 10 bronchopleural fistula
• 5 Empyema

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Pulmonary Parenchymal Laceration

• Massive air leaks and hemorrhage require
  immediate operation

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High Velocity Missile Injuries

• Wounds due to high velocity missiles that travel
  gt 25,000 ft/s are being seen with ever-increasing
  frequency
• Military and civilian

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High Velocity Missile Injuries

• Cavitation phenomenon causes damage to
  structures distal to the path of the missile.
• Striking and shattering bone and other tissue may
  add to the damage
• Associated injuries to the large vessels and
  bronchi is common
• Severe pulmonary contusion
• Vietnam experience

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Blunt Chest Trauma

• Higher mortality than penetrating trauma
• More frequent simultaneous injuries of multiple
  organs
• MVA leading cause of chest trauma with 50,000
  deaths and 2 million disabling injuries/year

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Categories of chest wall injuries

• Open pneumothorax
• Contusion and Hematoma
• Sternal fractures
• Scapular fractures
• Flail chest
• Intercostal vessel injury

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Categories of Intra-thoracic Injuries

• Pulmonary
• Pneumothorax, hemothorax
• Pulmonary contusion
• Pulmonary laceration
• Vascular
• Great vessel disruption (Ao dissection, pulmonary
  vasculature)
• Cardiac
• Blunt Cardiac Injury, Penetrating injury

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Work-up of Blunt Chest Trauma

• Physical examination
• Look, Listen, Feel
• Contusions, diminished or absent breath sounds,
  SQ emphysema can readily be found
• CXR- best, least expensive and fastest initial
  evaluation
• Ultrasound-may soon replace CXR as initial
  radiographic study in chest trauma
• Angiography- to look for great vessel injuries
• CT Scan for better evaluation of chest wall and
  parenchyma
• Transesophogeal Echocardiography

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Categories of chest wall injuries

• Contusion and hematoma
• Rich vascular network established by intercostal
  arteries w/ each rib
• Internal mammary arteries on each side of sternum
• Rib fx bleed from raw surface exposure of the
  bone and muscle tears

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Categories of chest wall injuries

• Open pneumothorax
• When the defect in the chest wall is larger than
  the trachea, pt is unable to ventilate.
• Apply occlusive dressing on 3 sides
• Air cannot enter, but can exit through the flap
• Prevents pneumothorax
• Definitive management

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Categories of chest wall injuries

• Pneumothorax
• Needle thoracentesis
• Chest tube

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Operative Intervention for Hemothorax

• As noted previously
• Hemothorax massive initial drainage more than
  1,000 cc or
• Continuous bleeding of 200 cc/hr for 2 hrs

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Fractured Ribs Chest Wall Trauma

• 70 of chest wall trauma is caused by MVAs
• 15 secondary to falls
• Blunt chest trauma accounts from 81 of thoracic
  injuries in children, 78 in the elderly
• Children are more likely to be injured as
  pedestrians (35 vs 11 in the elderly)

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Fractured Ribs Chest Wall Trauma

• The presence of 3 or more fx ribs on x-ray is an
  indication for the need of tertiary care
• Pts with rib fx are more likely to require
  thoracotomy and laparotomy
• The likelihood of splenic and hepatic injury is
  increased by 1.7 and 1.4 times, respectively

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Fractured Ribs Chest Wall Trauma

• Rib fxs are found in 52 of patients with
  documented cardiac contusion
• Mortality doubles with there are 3 or more ribs

• Blunt trauma with chest injury increases
  mortality rate by 27 than without chest
  injuries. Associated risk for death increases
• Pneumo by 38
• Hemothorax by 42
• Pulmonary contusion by 56
• Flail chest by 69

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Blunt Cardiac Injury
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Blunt Cardiac Injury

• EKG (for any blunt chest injury, persistent
  tachycardia, ST-T changes or ectopy)
• Cardiac enzymes (CPK, CK-MB and Troponin I) see
  EAST guideline
• Echocardiography (TEE)

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Categories of chest wall injuries

• Sternal fractures
• 80 associated with steering wheel impact
• 62 have blunt cardiac injury (BCI)

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Categories of chest wall injuries

• Scapular fractures
• 3 of blunt trauma cases
• 54 have pulmonary contusions
• 11 have associated ipsilateral subclavian,
  axillary or brachial artery injury
• Over 1/3 are missed on initial evaluation

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Categories of chest wall injuries

• Flail chest
• Fx of at least 4 consecutive ribs in 2 or more
  places
• Incompetent segment of chest wall large enough to
  impair respirations
• Paradoxic motion hinders creation of the expected
  ipsilateral negative inspiratory force

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Categories of chest wall injuries

• Flail chest
• Combination of pulmonary contusion and flail
  chest has a mortality of 42
• Pulmonary contusion with flail chest 75 require
  ventilation
• Flail chest ALONE 48 require ventilation tx
• Aggressive respiratory txs and IS with pain
  control

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Categories of chest wall injuries

• Flail chest
• Internal splinting of mechanical ventilation
  until fibrous stabilization of the chest wall is
  apparent
• Usually heavy sedation
• SIMV with PS
• PEEP or CPAP
• Sandbagging

• DO NOT use rib belts
• Surgery Staples, Kirschner wires and plates
• Analgesia

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Pulmonary Contusion

• Pulmonary contusions are not innocuous injuries
• 11 of pts with isolated pulmonary contusion die
• ARDS develops in nearly 20 ARDS carries a 50
  mortality

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Intra-thoracic TraumaPulmonary Contusion

• Occurs in nearly 50 of all chest trauma
• Injury occurs to
• Alveolar-capillary walls
• Intra-alveolar hemorrhage
• Interstitial edema
• Increased tissue wt, airway and arterial
  resistance, decreased compliance, decreased
  surfactant content, decreased blood flow

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Pulmonary Contusion

• Increase in pulmonary vascular resistance and
  A-aO2 difference
• Diagnosis
• Dyspnea
• Tachypnea
• Hemoptysis
• Cyanosis
• Hypotension

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Pulmonary Contusion

• Physical signs
• Inspiratory rales, decreased Vt
• Patchy alveolar infiltrates due to intra-alveolar
  hemorrhage
• Intrapulmonary bleeding reaches maximal extent
  within 6 hrs
• Progression of a pulmonary contusion on X-ray
  after 48 hrs should raise suspicion that
  aspiration, bacterial pneumonitis or ARDS has
  developed

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Pulmonary Contusion

• Treatment
• Oxygen to maintain PaO2 above 60 mmHg
• Vigorous chest physiotherapy
• Use colloids instead of crystalloids when rapid
  volume replacement is needed
• Place PA catheter when large or rapid volume
  replacement is needed
• Use of steroids and antibiotics are controversial

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Intra-thoracic Trauma Great Vessel and
Mediastinal Trauma

• Aorta
• Pulmonary vessels
• Tracheobronchial lacerations
• Esophageal lacerations

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Intra-thoracic Trauma Great Vessel and
Mediastinal TraumaWork-up

• Plain CXR to identify thoracic aorta injuries
• Look for air in the mediastinum
• Persistent airleak should cue into
• Bronchopulmonary or tracheobronchial injury
• Mediastinitis, tube feedings in chest tube or
  saliva in chest tube should cue into
• Esophageal injury

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Intra-thoracic Trauma Great Vessel and
Mediastinal TraumaWork-up

• Bronchoscopy
• Esophagoscopy
• CT
• Serial CXR

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Initial CXR of Concern
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Indications for Angiography

• Lateral deviation of the NGT in esophagus
• Widened mediastinum (gt8cm)
• Loss of visualization of the aortic knob
• Hematoma of the Left cervical pleura (pleural
  cap)
• Depressed left main stem bronchus
• Rt lateral deviation of the trachea

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Indications for Angiography

• Widened mediastinum (gt8cm)

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Indications for Angiography

• Forward displacement of the trachea on the
  lateral CXR
• Fx of the 1st or 2nd rib
• Massive chest trauma w/ multiple rib fx
• Fx or dislocation of the thoracic spine
• Major deceleration injury

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Complete Aortogram
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