Blunt chest trauma with surgical emphysema - A case report

BLUNT CHEST TRAUMA

Blunt Chest Trauma followed by Subcutaneous Emphysema- A

Case Report

Presenter: Dr. Hriday Ranjan Roy, Asst. Prof. (Surgery)

Moderator: Assoc. Prof. Dr. B. D. Bidhu

Asst. Prof. Dr. Hamidul Islam

Organized by- Dept of ICU and

Dept of Surgery

Rangpur Medical College, Rangpur

Rasel, a young man aged 30 years hailing from Hazipara, Thakugaon admitted into RpMCH on 27/11/2013 at 11.45 PM in Neurosurgery Dept with the history of RTA (Motorcycle accident) 11 hours back. On admission, he was severely dyspneic, disoriented and huge swelling of his upper chest, neck and face. No sign of any head injury noted.

So on next morning (28/11/2013 at 10.15 AM) he was referred to MSU-IV. On next day (29/11/2013) at 5.30 PM he was transferred to ICU for life support management as his conditions were deteriorating severely.

The patient had history of drug addiction.

Physical examination in ICU revealed-

Severe Respiratory distress (SOB),Peripheral cyanosis,Pulse- >140/min,B.P- 150/100 mm of Hg, Huge surgical emphysema of upper part of

chest, neck and face,Crepitus (#rib) on right lateral chest wall on

palpation,

Physical examination in ICU revealed (cont.)

Pulse oxymeter- saturation <80%,GCS was 14. P/A- normal, Limbs- Normal,Whole body sorting- A 2 inch cut injury on scalp,

otherwise no injury found.

100% oxygen support given. But saturation was not maintaining. Patient gradually became more dyspneic and disoriented.

Photograph of patient (27/11/2013)

Photograph of patient (02/12/2013)

CXR on 29/11/2013

Findings of CXR….

Huge surgical emphysema,

Equivocal finding of rib fracture,

Tension pneumothorax- suspected huge but equivocal radiologically,

No hemothorax noted.

Management given

Urgent chest drainage (Rt) (water seal)

O2 inhalation- 100%

Antibiotics

Analgesics

I/V fluids,

PPIs

Proper technique of IT drainage

Site- 6th or 7th ICS just behind anterior axillary line. In female, just below infra-mammary line.

Anchoring suture- Encircling suture- (matress) to include

muscle, fascia of thoracic wall to avoid IT complications.

How much marking of chest drain tube?Know the proper way to avoid

complications

Landmarks for male

Landmark for female

What happened?

Patient was feeling a sort of pain and saturation fall below 85% immediately after tube thoracostomy. An extra dose of analgesic given (Inj- Anadol).

Within 1 hour, patient began to improve.

Signs of improvement (within 1 hour)

Work of breathing (dyspnea)- reduced gradually,

O2 saturation- raised over 90% and become stable,

O2 flow and percent reduced and it maintained the saturation.

Patient began to fell better.

On next day (30/11/2013)

Patient’s condition was fluctuating,

All of his parameters were improving.

But his O2 saturation was fluctuating between 85-90% on 1st 2/3 days. Close monitoring done with all sorts of equipments.

Post-operative events (cont..)

Except O2 saturation, all other parameters were stable and improving. So Endotracheal Intubation was avoided.

Patient became stable gradually on 3rd POD onwards.

Another CXR was done on 04/12/2013

Findings of CXR

No pneumothorax,

No hemothotax

Surgical emphysema- minimal.

So, chest drain was removed on 04/12/201.

Comparison of pre and post IT CXR

Photograph of patient taken on 04/12/2013

Comparison of Photograph(Pre and Post Treatment)

Smiling family photo….

They are smiling….

Their smile is valued Trillion Dollars to us.

ICU personnel involved in management

Our (ICU) expressions…

We (ICU Staffs) are very much happy,

There were 3 or more similar cases (Trauma) which were managed similarly and results were excellent.

We would like to improve and spread our experiences and thus to serve for humanity.

DISCUSSION (Cont..)

Standard protocol of trauma management- ATLS protocol (Ref- Baily and Love)

• Protocol of surgical emphysema after chest trauma – “Tube Thoracostomy”

(Ref- Porhomayon and Doerr International Journal of Emergency Medicine 2011, 4:10

http://www.intjem.com/content/4/1/10)

Management of Blunt trauma90% of chest trauma managed by- IT drainage,

O2 inhalation, Physiotherapy, Analgesics, Antibiotics and Desiccation therapy.

10% may need Thoracotomy. Indications are-

>1500ml blood at initial IT;

Continuous brisk bleeding >100ml/h for >1h;

Continued bleeding >200ml/h for >3h;

Rupture of bronchus, esophagus, aorta or diaphragm;

Cardiac temponade.

DISCUSSION (Cont…)

Mechanism of Surgical emphysema after chest trauma-

Pneumothoarax

DISCUSSION (Cont…)

How surgical emphysema corrected by chest drain?

Air of emphysema has direct communication with air of pneumothorax.

DISCUSSION (Cont…)

Multiple stab or wide bore needle aspiration- have any value for emphysema?

It may delay improvement due to entrance of atmospheric air into pleural space.

What other protocols?

DISCUSSION (Cont…)

Chest strapping after rib fracture? NO

Disadvantages- Restrict movement of that part of chest. Result- reduced ventilation, increase prone to infection and thus detrimental.

Modern concepts- If no pain, cont. lung injury- nothing to do except drain.

Discussion (Cont..)Indications of Tube

Thoracostomy in General

About 90% of thoracic surgical cases could be managed by Tube Thoracostomy. Indications are: (described earlier)

CONCLUSION

The value of Human life is above all. All doctors are ethically bound for that. Ego should not be practiced here or old concepts (which may be detrimental for patient) should not be applied.

IT drainage has no loss, but valued many. Please don’t hesitate to insert a chest drainage in such patients.

THANK YOU