Chest Trauma

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Chest Trauma

• Dr. Ronald McLean, B.D.S., M.D.
• - St. Barnabas Regional Trauma Center
• - Bronx, New York

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Chest Trauma - BLUNT
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Chest Trauma - PENETRATING
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Chest Trauma - INCIDENCE

• Sudden and dramatic
• Directly gt 20 25 (1 in every 4)
• trauma deaths
• Contribute to 25-50 of the remaining
• deaths
• gt 16,000 deaths per year in USA

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Chest Trauma - CARE

• Improved pre-hospital peri-operative care
• gt More pts getting to ER alive
• Many die after coming to hospital
• Deaths possibly preventable
• gt by prompt Dx and Tx

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Chest Trauma - HISTORY

• 3000 BC treating gladiators chest injuries
• 1635 - De Vacca gt removal of arrowhead from
  chest wall
• 1814 -Larrey reported injuries to subclavian
  vessels
• 1902 - Hill performed first cardiorrhaphy in
  US
• 1934 - Blalock first American to successfully
  repair an aortic injury

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BOUNDARIES of Chest

• Superiorly
• gt clavicles
• Inferiorly
• gt diaphragm
• Laterally
• gt rib cage

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BOUNDARIES of Chest

• Anteriorly
• gt sternum
• Posteriorly
• gt vertebral bodies ribs

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STRUCTURES Injured

• Any organ in chest potentially susceptible
• especially to penetrating trauma

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CONTENTS - Thoracic cavity

• - Chest wall and ribs
• - Lungs and pleura
• - Great and thoracic vessels
• - Heart and mediastinal structures
• - Diaphragm

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CONTENTS - Thoracic cavity

• Esophagus
• Thoracic duct
• Tracheobronchial system

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OTHER ORGANS at risk

• Thoraco-abdominal injury
• any wound below nipples in front and
• inferior scapula angles dorsally
• may result in intra abdominal injury

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OTHER ORGANS at risk

• Peritoneal viscera
• Liver
• Spleen
• Stomach
• Colon small intest.
• Biliary system
• Retro-peritoneum
• kidneys

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RESULTING INJURIES

• Rib fractures
• Sternal fractures
• Open or Closed Pneumothorax
• - unilateral / bilateral
• Hemothorax
• Hemopneumothorax

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RESULTING INJURIES

• Pneumo-mediastinum
• Pulmonary contusion
• Myocardial contusion
• Diaphragmatic rupture

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RESULTING INJURIES

• Subcutaneous emphysema

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CLINICAL CONSEQUENCIES

• RELATED TO
• Mechanism of injury
• Location of injury
• Associated injuries
• Co-morbidities

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Mechanism of Injury

• BLUNT
• Mostly managed non-operatively
• Simple intubation ventilation or
• chest tube placement

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Mechanism of Injury

• PENETRATING
• Low energy
• Medium energy
• High energy

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Penetrating (Low energy)

• Impalements
• Knife wounds
• gt disrupts only structures penetrated

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Penetrating (Medium energy)

• Bullet wounds from most handguns
• gt primary tissue damage
• lt than higher velocity forces

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Penetrating (High energy)

• From rifles and military weapons
• Shotguns (low velocity)
• Transfers kinetic energy to tissues
• gt cavitation
• gt high velocity.
• Amount of tissue damage proportional to amount of
  energy exchanged between the penetrating object
  and the body part.

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Pathophysiology

• Quite serious

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1. HYPOXIA / HYPO-VENTILATION

• Primary acute killer of trauma patients
• inadequate delivery of O2
• to tissues

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Signs of HYPOXIA

• Increased RR
• Change in breathing pattern (shallow)
• Anxious behavior
• Poor air movement
• Diaphoresis
• Dilated pupils
• Cyanosis (late sign)

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2. Hypovolemia

• Inadequate intravascular volume
• gt BLOOD LOSS

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3. Ventilation / Perfusion Mismatch

• Contusion
• Hematoma
• Alveolar collapse

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4. CHANGES IN INTRATHORACIC PRESSURE
RELATIONSHIPS

• - Tension pneumothorax
• - Open pneumothorax

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5. METABOLIC ACIDOSIS

• Hypo perfusion of tissues (shock)

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MANAGEMENT - Chest Trauma

• ABCs
• PRIMARY SURVEY
• Most important feature of chest injury evaluation
  
• gt Aim to identify treat immediately life
  threatening conditions

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MANAGEMENT - Chest Trauma

• EARLY INTERVENTIONS geared towards
• identifying / correcting / preventing problems
• Tension pneumothorax
• Massive hemothorax
• Open pneumothorax
• Cardiac tamponade
• Flail chest

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MANAGEMENT - Chest Trauma

• Resuscitation of vital functions
• REMEMBER
• - Most life threatening injuries txd by
• - Airway control
• - Chest tube

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MANAGEMENT - Chest Trauma - Detailed Secondary
Survey

• Influenced by
• Mechanism of injury
• High level of suspicion

• May show
• Simple pneumothorax
• Hemothorax
• Pulmonary contusion
• Myocardial contusion
• Blunt aortic injury
• Rib fractures
• Diaphragmatic rupture

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MANAGEMENT - Chest Trauma

• Definitive care
• Usually operative

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MANAGEMENT - Chest Trauma

• Adjuncts
• CXR
• gt basis for initiating other investigations
• ALL wounds to thoracic cavity bounded back
  front by
• Neck umbilicus for stabs
• Neck pelvis for GSW
• MUST HAVE CXR
• gt UPRIGHT if possible

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Adjuncts - FAST

• Focused Abdominal
• Sonography for
• Trauma (FAST)
• - All hemodynamically unstable blunt trauma pts

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Adjuncts - Cat Scan - (CT angio)

• Becoming a primary diagnostic tool
• fast (spiral)
• allow for reconstruction etc

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SPECIFIC CHEST INJURIES

• Chest Wall
• Rib fractures
• Most common sign of blunt chest injury
• Fx scapula, first rib, sternum suggest massive
  force of injury
• 1st 2nd rib fx associated with serious other
  injuries
• Upper ones gt suspect vascular injury

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Rib Fractures
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Rib fractures

• Signs and Symptoms
• - Deformity
• - Localized pain
• - Tenderness
• - Crepitus

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Rib Fractures

• Treatment
• Analgesia (PCA)
• Pulmonary toilet
• Observe for possible pneumothorax

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Flail Chest

• Segment of chest wall
• that does not have
• continuity with rest of thoracic
• cage
• Usually 2 fractures per rib in at least 2 ribs
• Segment does not contribute to lung expansion
• Disrupts normal pulmonary mechanics
• Accompanied by pulmonary contusion in 50 of
  patients with flail chest

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Flail Chest - Pathophysiology

• A major problem is the injury to
• the underlying lung
• gt Pulmonary Contusion

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Flail Chest Signs Symptoms

• Dyspnea
• Chest pain
• Paradoxical chest wall movement
• Poor air movement
• Crepitus
• Hypoxia
• Cyanosis

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Flail Chest - Treatment

• Pain control
• Humidified O2
• Close observation for respiratory
• decompensation
• Aggressive pulmonary physical
• therapy

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Flail Chest - Treatment

• Selective intubation and ventilation
• significant other injuries
• respiratory rate gt 35
• paO2 lt 80
• paCO2 gt 66
• Other treatments
• tight fluid resuscitation

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Flail Chest - Treatment

• Operative fixation not usually required
  (historical)

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Lung Injuries

• Pneumothorax or Hemothorax
• most treated with simple tube thoracostomy

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PneumothoraxLess than 1-2 cm may be observed in
otherwise healthy pts if stable on f/u CXR 6-8
hrs after
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Open Pneumothorax

• Open sucking chest
• wound
• if opening 2/3 of diameter of trachea air will
  come through wound (preferentially)
• allows free passage of air into and out pleural
  cavity
• gt effective ventilation impaired
• gt hypoxia hypercarbia

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Open Pneumothorax

• Signs Symptoms
• Penetrating chest wound
• Decreased breath sounds
• Sucking sounds on inspiration

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Open Pneumothorax

• Treatment
• 3 sided occlusive dressing
• Observe for tension pneumothorax
• Operative

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Tension Pneumothorax

• One way valve allows air leak from lung or chest
  wall
• gt air forced into chest cavity
• without escape

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Tension Pneumothorax

• Collapses ipsilateral lung

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Tension Pneumothorax

• Displaces mediastinum to opposite side

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Tension Pneumothorax

• Compresses opposite lung

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Tension Pneumothorax

• Decreases venous return

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Tension Pneumothorax

• Signs Symptoms
• air hunger
• chest pain
• respiratory distress
• tachycardia
• hypotension
• tracheal deviation
• absent breath sounds
• hyper-resonant percussion
• JVD

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Tension Pneumothorax - Treatment

• Immediate decompression
• large bore needle
• 2nd intercostal space
• midclavicular line
• chest tube as definitive tx
• NOTE may mimic a collapsed lung on the other
  side
• - i.e. trachea deviates towards the collapsed
  lung
• - however, one resonant (empty), other tympanic
  (full)

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Pulmonary Contusion

• Largest of pts are those with
• blunt trauma
• Most common chest injury in children
• Usually develops over 24 hours
• Can occur with or without laceration of
  parenchyma

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Pulmonary Contusion

• Results from
• Leakage of blood and fluid into interstitial
  spaces of lung
• - Significant inflammatory reaction to blood
  components in the lung

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Pulmonary Contusion - Pathophysiology

• Loss of normal lung structure function leads to
• - poor gas exchange
• - increased pulmonary vascular resistance
• - decreased lung compliance

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Pulmonary Contusion - Complications

• Atelectasis
• Pneumonia
• ARDS
• Respiratory failure

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Pulmonary Contusion - Diagnosis

• Parenchymal infiltrate seen in CXR adjacent to
  injured chest wall

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Pulmonary Contusion - Diagnosis

• No real clinical findings especially
  initially
• dyspnea
• chest wall contusions / abrasions
• increased RR
• may have crackles

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Pulmonary Contusion - Diagnosis

• Lung gets stiffer causing dyspnea and increased
  RR
• Blood gases worsen 2-3 days as edema increases
• CXR changes may lag 12 - 48hrs behind
• May underestimate the true extent
• CT - very sensitive can allow quantifying

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Pulmonary Contusion - Treatment

• MOSTLY supportive - usually resolve in
  5-8 days
• - O2 observation in milder cases
• - Pain control to allow
• - adequate ventilation and better
  management of secretions
• - Fluid restriction
• - Intubation mechanical ventilation
• if respiratory distress present

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Pulmonary Contusion

• Indications for intubation
• Respiratory distress
• Co-morbidities esp. lung disease
• Other injuries
• intra-abdominal

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Myocardial contusion

• Physical bruising of the cardiac muscle
• Usually associated with fractures of the
  sternum
• Any severe anterior chest injury

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Myocardial contusion

• Difficult to dx
• gt HIGH LEVEL OF SUSPICION
• ALL pts with pattern of injury must have an EKG

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Myocardial contusion - Diagnosis

• Ectopy
• ST elevation
• Tachycardia
• Friction rub
• Enzymes may be normal

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Myocardial contusion - Treatment

• Monitor in ICU treat dysrhythmias
• Serial enzymes
• Analgesia

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Massive Hemothorax

• Pleural cavity hold 3 liters blood
• 200cc 1L in chest cavity seen on CXR
• 90 from internal mammary or intercostals
• 10 from pulmonary vessels

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Massive Hemothorax - Treatment

• Decompression
• Chest tube (most need just that)
• Bleeding may stop when lung re-expands

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Aortic Rupture / Great Vessel Injuries

• Abrupt deceleration or compression injury
• Sudden motion of heart / great vessels within
  thorax
• Great vessel injury may occur in 0.3 gt 10
  penetrating trauma

• Often rapidly fatal
• Only 10 survive to hospital
• Only 20 survive gt 1 hour
• 90 who reach hospital will die
• EARLY DX and aggressive tx best chance

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Aortic Rupture - Signs and Symptoms

• Hypovolemic shock
• Chest wall ecchymosis
• Marked difference in BP b/l arms
• Fx 1st, 2nd, 3rd ribs especially on left

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Aortic Rupture - Diagnosis

• Consider mechanism of injury
• widened mediastinum on CXR
• 40 normalizes with sitting up

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Aortic Rupture - Diagnosis

• Mediastinum gt 8cm wide
• Blurring of aortic knob

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Aortic Rupture - Diagnosis

• Deviation of NGT to right

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Aortic Rupture - Diagnosis

• CT with contrast then angiogram if abnormal

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Aortic Rupture - Treatment

• Contained injury
• gt BP control
• Operative repair

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Cardiac Injury

• Highly lethal fatality rates
• - 70 gt 80
• Mostly ventricular
• right gt left

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Cardiac Tamponade

• gt Blood in pericardial sac
• Occurs most frequently with penetrating injuries

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Cardiac Tamponade - Signs and Symptoms

• Shock
• JVD
• Dyspnea
• PEA
• Becks triad minority of pts
• - Distended neck veins
• - Muffled heart sounds
• - Hypotension

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Cardiac Tamponade - Treatment

• Volume resuscitation
• Pericardiocentesis
• Surgery
• - Pericardial window
• - sternotomy
• - thoracotomy

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Diaphragmatic Rupture

• Traumatic herniation of abdominal contents into
  the chest

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Diaphragmatic Rupture

• Mostly on left side

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Diaphragmatic Rupture

• Liver protective on right side

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Diaphragmatic Rupture

• Frequent in thoracoabdominal trauma
• 15 stab wounds
• 46 GSW
• 15 greater than 2cm long
• May be no immediate herniation of abdominal
  contents

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Diaphragmatic Rupture - Signs and symptoms

• No distinctive signs / symptoms seen
• High index of suspicion needed especially with
  mechanism of injury
• dyspnea
• cyanosis
• shoulder pain
• bowel sounds in lower chest

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Diaphragmatic Rupture - Treatment

• Up to 13 acute injuries missed initially
• 85 presenting in 3 years as
• - obstruction or with
• - decreased cardio / pulmonary reserve
• Goal of treatment
• - Maintain adequate oxygenation
  gt intubate
• - NG decompression of stomach

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Diaphragmatic Rupture - Surgery

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Esophageal Injuries

• Most due to penetrating trauma

• Diagnosis
• - Difficult
• - If delayed gt rapid sepsis high mortality
• - Requires aggressive investigation
• - Radiography
• - Endoscopy
• - Thoracoscopy
• Treatment
• - Thoracotomy, etc.

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Thoracic Duct Injuries

• Accompany thoracic vessel injuries
• Noted much later i.e. not in acute phase
• Huge morbidity due to severe nutritional
  depletion
• Mn
• gt initially aggressive and nonoperative
• hyperalimentation gt TPN
• and if not sealed in 5-7 days
• surgical intervention

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Emergency Thoracotomies

• ACUTE THORACOTOMY
• Cardiac tamponade (relieved)
• Vascular injury to thoracic outlet
• Massive air leak
• Endoscopic/radiographic evidence of tracheal or
  bronchial injury
• Esophageal injury
• Chest tube output
• immediate evacuation of 1500ml blood
• or gt 250cc/ hour
• TREND MORE IMPORTANT than initial output

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ER THORACOTOMY survival rates lt 8
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ER THORACOTOMY - To do or NOT to do

• Type of CARDIAC
• ACTIVITY
• asystole
• bradycardia
• tachycardia

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ER THORACOTOMY - To do or NOT to do

• Type of VITAL SIGNS
• electrical cardiac activity (PEA)
• palpable pulse
• recordable blood pressure

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ER THORACOTOMY - To do or NOT to do

• LOCATION of LOSS
• of vital signs
• street
• in transit ambulance/helicopter
• unloading area
• hallway
• resuscitation area

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ER THORACOTOMY - Unlikely to benefit if ...

• BLUNT injury with arrest
• Arriving without pulse/BP
• Penetrating injury with arrest
• Better chance
• High likelihood of
• isolated / correctable intra-thoracic injury
  (?GSW?)
• still EXTREMELY RARE

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ER THORACOTOMY - Bottom line

• ER THORACOTOMY if presence of MEASUREABLE
• pulse
• blood pressure
• organized cardiac activity
• (or just lost IN trauma bay)

• MUST consider also
• age
• co-morbidities (ie infectious diseases)
• AVOID if arrest
• occurs OUTSIDE OF RESUSCITATION AREA or
• due to BLUNT trauma.

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ER THORACOTOMY - Consider . . .

• Be mindful that circulatory arrest
• gt cerebral hypoxia
• gt permanent neurologic deficits
• gt non-functional survivor
• occurs in 10 gt 15 of survivors

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Chest tube insertion

• Most common intervention
• Relatively simple procedure
• Definitively manage gt 85 of chest trauma
  penetrating or blunt

• Has significant complication rate 2-19
• May be minor but
• May require operative intervention and
• Can result in death

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Chest tube insertion - Indications

• Drain contents of
• pleural space
• air
• blood
• chyle
• gastric contents

• Prevent development of pleural collection i.e.
  after thoracotomy
• Prevent tension pneumothorax in ventilated pt
  with rib fractures

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Chest tube insertion - Indications

• Absolute indications
• pneumothorax
• hemothorax
• traumatic arrest - (b/l)

• Relative indications
• rib fractures and positive pressure ventilation
• profound hypoxia/hypotension with penetrating
  chest injury

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Placement may be diagnostic or therapeutic

• Bright red blood
• suggest arterial injury possible thoracotomy
• Intestinal contents
• esophageal, stomach, diaphragm
• intestinal injury
• Large air leak
• - bronchial disruption
• Technique important to avoid complications

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Chest tube insertion - Insertion Site

• mid or anterior axillary line behind pectoralis
  major
• above 5th rib since on expiration diaphragm rises
  that high
• count down from sternomanubrial joint (2nd rib)

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Chest tube insertion - Analgesia

• Painful especially in muscular pts
• Morpine IV or Ketamine 20mg in adult
• 10-20 ml local analgesia
• along line of incision
• perpendicularly thru all layers of chest wall to
  rib below space
• up into pleural cavity after aspirating air

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Chest tube insertion - Procedure

• Prep and drape
• Incise along upper border of the rib below the
  intercostal space to be used
• Track is to be directed over top of lower rib so
  as to avoid intercostal vessels lying below each
  rib
• should be big enough to fit finger
• Use curved clamp to develop tract by blunt
  dissection only use to spread the muscle
  fibers, develop tract with fingers
• On reaching rib, clamp angled upward just above
  the rib and dissection continued till pleural
  space entered

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Chest tube insertion - Procedure

• Finger inserted into pleural space and area
  palpated
• 32-36 F tube attached to clamp and inserted along
  track into the pleural cavity

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Chest tube insertion - Procedure

• Connect tube to
• underwater seal
• and suture in place
• Examine chest to
• check effect
• CXR to check
• placement and
• position

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POSITION - Dependent on direction of tract

• Blunt chest trauma pts lying flat
• place drain anteriorly
• prevents blockage of tube and development of
  tension pneumothorax

• Penetrating
• Posteriorly basally directed drain
• Last hole should be INSIDE the CHEST CAVITY
• If too far in could cause severe intractable pain
  when up against mediastinum

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Chest tube insertion - Underwater Seal

• Allows air to ESCAPE but NOT RE-ENTER
  chest cavity
• Negative pressure dependent upon level of water
• Pleurovac must always be below level of patient
• Persistent bubbling air leak from lung

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Chest tube insertion - Underwater Seal

• May be connected to suction (water level 20cm
  H2O)
• Aid lung re-expansion especially if
  there is an air leak

• CHEST TUBES SHOULD NEVER BE CLAMPED
• TENSION PNEUMOTHORAX

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Chest Tube Removal

• When?
• When no air leak
• No more fluid draining

• How?
• Occlude hole while pulling tube
• Remove at end of expiration or at peak of
  inspiration
• Avoids air being drawn into cavity
• Remove rapidly and close wound quickly

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Chest tube insertion - Complications

• there is no organ in the thoracic or abdominal
  cavity that has not been pierced by a chest
  drain
• mainly historical since drains used to be
  inserted with
• - a steel trocar
• - excessive force

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Chest tube insertion - Acute complications

• Hemothorax usually laceration of intercostals
  vessel, may require thoracotomy
• Lung laceration especially when adhesions present
• Diaphragm / abdominal cavity penetration - placed
  too low
• Stomach colon injury - diaphragmatic hernia not
  recognized

• Tube placed
• subcutaneously not in
• pleural cavity
• Tube placed too far pain
• Tube falls out not secured properly

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Chest tube insertion - Late complications

• blocked tube
• clot, lung
• retained hemothorax
• empyema
• pneumothorax after removal
• poor technique

119
Chest Trauma - Conclusion

• Chest trauma is
• COMMON
• SERIOUS
• AIM in TREATMENT
• to provide oxygen to vital organs
• Be alert to changes in clinical condition

• Managed MOST of the time with a CHEST TUBE

120
CHEST TRAUMA

• END