Cardiac and Thoracic Trauma

1
Cardiac and Thoracic Trauma
2
Introduction

• Chest trauma is often sudden and dramatic
• Accounts for 25 of all trauma deaths
• 2/3 of deaths occur after reaching hospital
• Serious pathological consequnces -hypoxia,
  hypovolaemia, myocardial failure
  

3
Mechanism of Injury

• Penetrating injuries
• E.g. stab wounds etc.
• Primarily peripheral lung
• Haemothorax
• Pneumothorax
• Cardiac, great vessel or oesophageal injury

4

Blunt injuries

• Either - direct blow (e.g. rib
  fracture) - deceleration injury or -
  compression injury
• Rib fracture is the most common sign of blunt
  thoracic trauma
• Fracture of scapula, sternum, or first rib
  suggests massive force of injury

5
Chest wall injuries

• Rib fractures
• Flail chest
• Open pneumothorax

6
Rib fractures

• Most common thoracic injury
• Localised pain, tenderness, crepitus
• CXR to exclude other injuries
• Analgesia..avoid taping
• Underestimation of effect
• Upper ribs, clavicle or scapula fracture suspect
  vascular injury

7
Flail chest

• Multiple rib fractures produce a mobile fragment
  which moves paradoxically with respiration
• Significant force required
• Usually diagnosed clinically
• Rx ABC Analgesia

8
Flail chest
9
Sternum and vertebral Fractures
10
Open pneumothorax

• Defect in chest wall provides a direct
  communication between the pleural space and the
  environment
• Lung collapse and paroxysmal shifting of
  mediastinum with each respiratory effort
  tension pneumothorax
• Sucking chest wound
• Rx ABCsclosure of woundchest drain

11
Sucking Chest Wound
12
Lung injury

• Pulmonary contusion
• Pneumothorax
• Haemothorax
• Parenchymal injury
• Trachea and bronchial injuries
• Pneumomediastinum

13
Pneumothorax

• Air in the pleural cavity
• Blunt or penetrating injury that disrupts the
  parietal or visceral pleura
• Unilateral signs ?movement and breath sounds,
  resonant to percussion
• Confirmed by CXR
• Rx chest drain

14
Pneumothorax
15
Tension pneumothorax

• Air enters pleural space and cannot escape
• P/C chest pain, dyspnoea
• Dx - respiratory distress - tracheal
  deviation (away) - absence of breath sounds
  - distended neck veins - hypotension

16
Needle Decompression
17
Tracheo Bronchial Rupture
18
Haemothorax

• Blunt or penetrating trauma
• Requires rapid decompression and fluid
  resuscitation
• May require surgical intervention
• Clinically hypovolaemia absence of
  breath sounds dullness to percussion
• CXR may be confused with collapse

19
Hemothorax
Where does the blood come from.
Lots of blood vessels
20
Heart, Aorta Diaphragm

• Blunt cardiac injury - contusion -
  ventricular, septal or valvular rupture
  
• Cardiac tamponade
• Ruptured thoracic aorta
• Diaphragmatic rupture

21
Cardiac Tamponade

• Blood in the pericardial sac
• Most frequently penetrating injuries
• Shock, ?JVP, PEA, pulsus paradoxus
• Classically, Becks triad - distended neck
  veins - muffled heart sounds - hypotension
• Rx Volume resuscitation Pericardiocentesis
  OPERATION

22
Cardiac tamponade
23
Aortic rupture

• Usually blunt trauma involving deceleration
  forces especially RTAs
• 90 die within minutes
• Most common site near ligamentum arteriosum
• Dx clinical suspicion, CXR, aortography,
  contrast CT or TOE
• Rx surgical in past
• Rx Stenting
• Prognosis depends on other injuries

24
Traumatic Aortic Rupture
25
Aortic rupture
26
Aortic rupture
27
Aortography
28
Stenting
29
Traumatic Asphyxia

• Results from sudden compression injury to chest
  cavity
• Can cause massive rupture of Vessels and organs
  of chest cavity
• Ultimately Death

30
Symptoms and Signs of Traumatic Asphyxia

• Severe Dyspnea
• Distended Neck Veins
• Bulging, Blood shot eyes
• Swollen Tounge with cyanotic lips
• Reddish-purple discoloration of face and neck
• Petechiae

31
Treatment for Traumatic Asphyxia

• ABCs with c-spine control as indicated
• High Flow oxygen including use of BVM
• Treat for shock
• Care for associated injuries

32
Diaphragmatic Rupture

• A tear in the Diaphragm that allows the abdominal
  organs enter the chest cavity
• More common on Left side due to liver helps
  protect the right side of diaphragm
• Associated with multipile injury patients
• Always look for after pelvic crush injuries

33
Diaphragm Rupture
34
Symptoms and Signs of Diaphragmatic Rupture

• Abdominal Pain
• Shortness of Air
• Decreased Breath Sounds on side of rupture
• Bowel Sounds heard in chest cavity

35
Treatment of Diaphragmatic Rupture

• ABCs with c-spine control as indicated
• High Flow oxygen which may include BVM
• Treat Associated Injuries
• Operative repair

36
Iatrogenic trauma

• NG tubes -coiling -endobronchial
  placement -pneumothorax
• Chest tubes - subcutaneous -
  intraparenchymal - intrafissural
• Central lines - neck -
  coronary sinus - pneumothorax

37
Line in jugular vein
38
Misplaced nasogastric tube
39
Cases in Penetrating Trauma
40
Zones of the Neck
41
Zone I Neck Injury

• Important Vascular Structures
• Carotid (proximal portion)
• Vertebral artery
• Subclavian artery
• Major vessels of the upper mediastinum

• Other structures
• Lung Apices
• Thoracic Duct
• Brachial plexus
• Thyroid
• Esophagus
• Trachea
• Spinal Cord

42
Zone 2

• Important structures
• Carotid artery
• Vertebral artery
• Jugular veins
• Trachea
• Esophagus
• Larynx
• Pharynx
• Vagus nerve
• Recurrent Laryngeal nerve
• Spinal Cord

43
Vascular Injury

• Soft Signs
• Hemoptysis or hematemesis
• Oropharyngeal blood
• Dyspnea
• Dysphonia/dysphagia
• sc or mediastinal air
• Chest tube air leak
• Non-expanding hematoma
• Focal neurologic deficits

• Hard Signs
• Expanding hematoma
• Severe active bleeding
• Shock not responsive to fluids
• Decreased or absent distal pulse
• Vascular bruit/thrill
• Cerebral ischemia
• Airway obstruction

44
Investigations

• Adjuncts to 1o survey
• CXR
• C-spine xray
• Definitive Investigations
• Angiogram
• Gastro-graffin Swallow
• Endoscopy (Gscope, Bronch)
• CT

45
(No Transcript)
46
Angiogram
47
Case 1
48
Case 1
Pneumothorax
49
Case 2
50
Case 2
51
Left Lateral Decubitus
52
Cardiac Tamponade

• CXR
• Pneumopericardium
• Air to the level of the aortic arch (vs. medial
  pneumo)
• Straight left heart border
• Globular heart
• ECG
• ST elevation
• J waves
• ECHO

53
Tamponade
54
GSW vs. Stab

• GSW
• Drag external contaminants into wound
• Tumbles and increases size of tract
• Able to cause injury to distant structures

• Stab
• Cleaner
• Size of tract is that of the sharp object
• Does not injure structures distant from site of
  injury

55
ECG
56
(No Transcript)
57
(No Transcript)
58
Chest trauma summary

• Common
• Serious
• Primary goal is to provide oxygen to vital organs
• Remember Airway Breathing Circulati
  on
• Be alert to change in clinical condition