Chest trauma

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Chest trauma

• cs

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Primary survey chest injuries

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Pericardial tamponade

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Secondary survey chest injuries

• Pulmonary contusion
• Myocardial contusion
• Aortic disruption
• Traumatic diaphragmatic hernia
• Tracheobronchial disruption
• Oesophageal disruption

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Management of the unstable patient

• Indications for emergency room thoracotomy
• Acute pericardial tamponade unresponsive to
  cardiac massage
• Exsanguinating intra-thoracic haemorrhage
• Intra-abdominal haemorrhage requiring aortic
  cross clamping
• Need for internal cardiac massage

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Indications for urgent thoracotomy

• Chest drainage gt1500 ml or gt200 ml per hour
• Large unevacuated clotted haemothorax
• Developing cardiac tamponade
• Chest wall defect
• Massive air leak despite adequate drainage
• Proven great vessel injury on angiography
• Proven oesophageal injury
• Proven diaphragmatic laceration
• Traumatic sepal or valvular injury of the heart

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Haemothorax

• Common after both penetrating and blunt trauma
• Pleural cavity can hold up to 3 litres of blood
• One litre may accumulate before apparent on chest
  x-ray
• 90 due to injury to internal mammary or
  intercostal vessels
• 10 from pulmonary vasculature
• Bleeding usually stops when lung re-expanded
• Most require no more than simple chest drainage

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Pericardial tamponade

• Major complication of penetrating chest trauma
• Haemopericardium prevents diastolic filling of
  the heart
• Classic signs are Beck's triad
• Hypotension
• Venous distension
• Muffled heart sounds
• May be associated with pulsus paradoxus
• Chest x-ray shows a globular heart
• Unstable patient requires urgent thoracotomy
• In stable patient diagnosis can be confirmed by
• Echocardiography
• Pericardiocentesis
• Subxiphoid pericardiotomy is both a diagnostic
  and therapeutic procedure

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Cardiac stab wounds

• Right side of the heart is more commonly injured
• Patients with right ventricular wound is more
  like to survive than with left sided injury
• Atria, inflow and outflow tracts may also be
  damaged
• Patients usually presents with pericardial
  tamponade
• Treatment consists of resuscitation and
  pericardiocentesis
• Stab wounds can be accessed via a median
  sternotomy
• Can be directly repaired without cardiopulmonary
  bypass
• Teflon-pledgeted prolene sutures are generally
  used

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Injuries to the great vessels

• Suspect possibility of injury from the mechanism
  or site of penetrating injury
• Usually present with shock or pericardial
  tamponade
• Chest x-ray may show
• Widening of the mediastinum to greater than 8 cm
• Depression of the left main bronchus to greater
  than 140 degrees
• Haematoma in the left apical area
• Massive left haemothorax
• Deviation of oesophagus ton the right
• Loss of aortic knob contour
• Loss of paraspinal pleural stripe
• Requires emergency thoracotomy or sternotomy
• Injuries to descending thoracic aorta require
  left anterior thoracotomy
• Injuries to proximal aorta and proximal carotid
  arteries require median sternotomy

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Flail chest

• Flail chest is associated with multiple rib
  fractures on the same side
• Flail segment does not have continuity with
  remainder of thoracic cage
• Results in paradoxical chest wall movement with
  respiration
• Often associated with underlying pulmonary
  contusion
• Paradoxical movement results in impaired
  ventilation
• The work of breathing is increased
• Ventilation perfusion mismatch and arterio-venous
  shunting occurs

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Chest x-ray will show

• Multiple rib fractures
• Underlying lung contusion
• Haemopneumothorax
• Other associated injuries

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Treatment requires

• Adequate ventilation
• Humidified oxygen
• Adequate analgesia

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Consider intubation and ventilation if

• Significant other injuries (ISS gt50)
• Respiratory rate more than 35 per min
• Partial pressure oxygen less than 8.0 kPa
• Partial pressure carbon dioxide greater than 6.6
  kPa
• Vital capacity less than 12 ml / kg
• Right to left shunt of more than 15
• Operative fixation is not normally required

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