Thoracic injuries

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Thoracic injuries

• Incidence
• 10mortality (25 of traumatic deaths)
• lt10 of blunt and 15-30 of penetrating require
  thoracotomy
• mediastinal penetrating trauma
• mortality 20,
• 50 are hemodynamically unstable ? 40mortality
• additional 30 positive diagnostic evaluation
• Patophysiology
• hypoxia, hypercarbia, acidosis (hypovolemia,
  ventilation/perfusion mismatch, changes in
  intrathoracic pressures)

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Thoracic injuries

• Chest wall
• lacerations, l.communicating with pleural
  space?open pneumothorax,
• rib frs with possible pain, splinting,
  atelectasis, hypoxemia?analgesia, pulmonary
  toilet, flail chest, indicative of possible
  internal inj.
• Sternal fractures (consider myocardial contusion)
• Tracheobronchial (respiratory distress, large air
  leak with subcutaneous emphysema)
• Esophageal (penetrating trauma, delayed
  recognotion ??mortality 3fold if over 24h,
  esophagoscopy with contrast studies
  Gastrografin, butressed repair)
• Pulmonary contusion, hemothorax, pneumothorax
• Great vessel
• Cardiac

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Rib fractures 25 of chest inj.

• May be undetectable on CXR (excludes other
  intrathoracic injuries, present in 40 of
  symptomatic patients), US (unreliable)
• Majority IV-IX
• Anteroposterior compression ? midshaft fr.
  (outward bowing), direct blow ? fracture ends
  face inwards ? potential vessel or lung
  parenchymal injury
• X-XII ? suspect hepatosplenic injury
• I-III ? suspect great vessel injury
• Taping, rib belts contraindicated
• Relief of pain (intercostal block, intrapleural
  analgesia, systemic analgetics), pulmonary toilet
• Flail chest bony discontinuity of a chest
  fragment (gt3) serious underlying lung inj.,
  paradoxical chest wall motion, pain, splinting
  (muscle spasm) ? hypoxia
• fluid restriction (if no hypovolemia), adequate
  ventilation with chest wall splinting ?
  mechanical ventilation

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US in rib frs. Time 13min.
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Flail chest complication
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Stove-in chest
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Pulmonary contusion

• Blunt (blast shock wawes, falls from heights) or
  penetrating trauma (high velocity GSW)
• Spalling effect shearing or bursting effect
  occurring at the gas/liquid interface (large
  differences in density)
• Inertial effect low-density alveolar tissue
  is stripped from heavier hilar structures as they
  accelerate at different rates.
• Implosion effect - rebound or overexpansion of
  gas bubbles after a pressure wave passes
• Interstitial and/or alveolar inj. without
  laceration edema, alveolar haemorrhage,
  parenchymal destruction
• Adequate perfusion, inadequate ventilation
  (mismatch ? hypoxemia) - ?airway resistance,
  ?compliance
• Initial CXR diagnostic (irregular patchy
  infiltrates) progress in density over 48h (CXR
  4-6 hours /CT earlier/, resolves in 5-7 days)
• ABGs, pulse oximetry,
• Dyspnea, hemoptysis, chest pain, cough,
  tachypnea, rales, decreased breath sounds,
  tachycardia
• Respiratory support with intubation and
  mechanical ventilation (often unusual ventilation
  modes), aggressive pulmonary toilet, positioning
  on uninvolved side, fluid restriction, no
  steroids or prophylactic antibiotics.

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Pulmonary contusion X-ray
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Pulmonary contusion X-ray5h later
subcutaneous emphysema, pneumomediastinum
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Pulmonary contusion CT GSW
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Pneumothorax

• Blunt or penetrating inj.
• Decreased breath sounds (gt25 of the lung
  collapsed)
• Sucking chest wound communicating ptrx (over
  2/3 of tracheal diameter) ? preferential air flow
  (lung collapses on inspiration and slighly
  expands on expiration) ? occlusive dressing
  chest tube
• CXR diagnostic
• Tension ptrx is a clinical diagnosis
• In significant chest inj. p.p. mechanical
  ventilation ? prophylactic tube thoracostomy
  (prevention of tension P.)
• Chest tube into II or IIIrd intercostal space in
  midclavicular line
• Chest tube ineffictive ? tracheobronchial
  disruption ? diagnosis thoracotomy

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Pneumothorax
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Tension pneumothorax
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3 autopsies in trauma victimsMVAlate diagnosis
in 25-70tachypnoea, sc. emphysema,
pthxpossible no air leak (incompleate inj.,
possible granulation with airway obstruction
2-6w)brochoscopyposterolateral thoracotomy V
ics.
L main stem bronchus disruption
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Subcutaneous emphysema
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Tracheobronchial disruption
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Tension pneumothorax
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Tension gastrothorax
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Hemothorax

• Opacification on CXR (intercostal a., internal
  mammary, Th spine fr., lung laceration,
  mediastinal vessels)
• Chest tube usually sufficient (IV or Vtdh
  intercostal space in anterior or midaxillary
  line) ? bleeding self-limiting
• Thoracotomy guidelines individualized severe
  haemodynamic instability (ERT), initial drainage
  exceding 1,5L, ongoing drainage of 100ml/h over
  6h
• Coagulation, ligation, pulmonary tractotomy,
  pulmonary resection (hilar injury) significant
  mortality
• Air embolism in significant parenchymal injury
  (esp. on positive pressure ventillation) sudden
  cardiovascular collapse steep Trendelenburg
  position, aspirate air from R ventricle,
  cardiovascular support
• Great vessel injury (profound shock, sometimes
  pericardiac tamponade, retrosternal chest pain,
  dyspnea, new systolic murmur, pseudocoarctation
  s., on CXR blunt inj. widend mediastinum,
  obscured aortic knob, deviation of L stem
  brochus, opacification of aortopulmonary window,
  R deviation of nasogastric tube, I or IInd rib
  frs.)
• no diagnostic investigations in unstable patient
• aortography, contrast enhanced CT,
  echocardiography
• fluid restriction (blunt), thoracotomy

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Hemothorax
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Hemothorax
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Hemothorax
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Hemothorax
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Hemopneumothorax
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Chest tube drainage - thoracostomy
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Widend mediastinum
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Mediastinal pseudoaneurysm
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Flail chest - traction
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Flail chest
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Empyema

• Stages (not separated continuum)
• exsudative
• fibropurulent
• organizing
• CXR, US, CT
• Control of infection with appropriate
  antibiotics, drainage (ev.streptokinaze),
  obliteration of pleural space, thoracotomy with
  decortication and pleurodesis

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Cardiac injury

• usually penetrating inj. between midclavicular
  lines
• pericardiac tamponade shock, JVD (JVD ? with
  inspiration - Kussmauls sign), diminished
  (muffled) heart sounds (Becks triad), electrical
  alterans (varying amplitude of the R wave) ?
  warrants operation (often ERT)
• blunt c.inj. history, inappropriate
  cardiovascular response to injury (EKG normal
  excludes, abnormal ? cardiac monitoring,
  echocardiography)
• advanced cardiac life support protocols
• operation for myocardial or valvular rupture,
  ventricular aneurysm

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Commotio cordis

• fatality (SCD) due to blunt thoracic injury
  (usually caused by a hard projectile, such as a
  hockey puck or baseball) without gross structural
  damage to the heart or other intrathoracic
  organs, results in ventricular fibrillation
  aggravated by traumatic apnea.
• trauma occurs during the vulnerable period of
  cardiac repolarization triggering the arrhythmia
  (VF). Most vulnerable phase of the cardiac cycle
  T wave ? heart partially depolarized and then
  repolarized (electrically unstable)
• more common in young athletes and children
  because they have more compliant chest walls,
  thus transmitting the energy from the projectile
  to the heart.

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Thoracotomy
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Pitfalls

• Simple hemothorax ? retained, clotted hemothorax
  with lung entrapement or empyema (if infected)
• Diaphragmatic inj. are often overlooked ?
  respiratory compromise, early or late entrapement
  and strangulation of abd. Contents
• Evaluation of widend mediastinum requires
  cardiothoracic surgical capabilities
• Underestimation of severe pathophysiology of rib
  frs. esp. in the elderly (aggressive pain control
  with no resp. depression)
• underestimation of blunt pulmonary injury
  severety (pulmonary contusion is not always
  correlated with X-ray findings)

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