Thoracic injury

Thoracic injury

Dr Gokul Nachiketh G DNB gen sug

• Thoracic injury accounts for 25% of all injuries.

• In a further 25%, It may be a significant contributor to the subsequent death of the patient.

• In most of these patients, the cause of death is haemorrhage.

Clinical indicators of bleeding

Physiological• Increasing respiratory rate• Increasing pulse rate• Falling blood pressure• Rising serum lactate Anatomical Visible bleeding Injury in close proximity to major vessels Penetrating injury with a retained weapon

• About 80% of patients with chest injury can be managed non-operatively,

• and the key is early physiological resuscitation followed by diagnosis.

investigation

• Routine investigation in the emergency department of injury to the chest is based on clinical examination, supplemented by chest radiography

• In the unstable patient, chest radiography is the investigation of first choice, provided that it does not interfere with resuscitation

• Ultrasound can be used to differentiate between contusion and the actual presence of blood.

• A chest tube can be a diagnostic procedure as well as a therapeutic one

pitfalls of investigation are:• failure to auscultate both front and back

(an inflated lung will‘float’ on a haemothorax, so auscultation from the front may sound normal

• failure to check whether the trachea is central

• failure to pass a nasogastric tube if rupture of the diaphragm is suspected

• pursuing radiological investigation (radiography or CT scan)before, or instead of, resuscitation if the patient is haemodynamicallyunstable.

Computerised tomography scan

• has become the principal and most reliable examination for major injury in thoracic trauma.

• In blunt chest trauma the CT scan will allow the definition of rib and vertebral fractures, as haematomas,

• pneumothoraces and pulmonary contusion

Management

• Penetrating injury managed with appropriate resuscitation and drainage of haematoma.

• sucking chest wound is present, this should not be fully closed but should be covered with a piece of plastic, closed on three sides, to form a one-way valve, and then an underwater drain should .be placed

• In blunt injury most bleeding occurs from the intercostal or internal mammary vessels and it is relatively rare for these to require surgery

• Life-threatening injuries can be remembered as the dozen. Six are immediately life-threatening and should be soughtduring the primary survey and six are potentially life threatening and should be detected during the secondary survey

Immediately life threatening

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

Potentially life threatening

• Aortic injuries• Tracheo bronchial injuries• Myocardial contusion• Rupture of diaphram• Oesophageal injuries• Pulmonary contusion

Airway obstruction

• Early preventable trauma deaths are often due to lack of or delay in airway control.

• Dentures, teeth, secretions and blood causes airway obstructions

• Bilateral mandibular fracture, • expanding neck haematomas producing deviation of

the pharynx and • mechanical compression of the trachea, • laryngealtrauma such as thyroid or cricoid fractures

and• tracheal injury are other causes of airway obstruction.

• Early intubation is very important,• particularly in cases of neck haematoma or

possible airway oedema.

Tension pneumothorax

• develops when a ‘one-way valve’ airleak occurs either from the lung or through the chest wall.

• collapsing the affected lung.• The mediastinum is displaced to the opposite

side,• decreasing venous return and • compressing the opposite lung.

most common causes are

• penetrating chest trauma,• blunt chest trauma with parenchymal lung

injury and• air leak that did not spontaneously close,• iatrogenic lung punctures (e.g. due to

subclavian central venepuncture) and• mechanical positivepressure ventilation

clinical presentation is dramatic

• The patient is panicky• with tachypnoea, dyspnoea and distended

neck veins (similar to pericardial tamponade).• Clinical examination can reveal tracheal

deviation (a late finding – not necessary to clinically confirm diagnosis),

• hyperresonance and absent breath sounds over the affected hemithorax.

• Tension pneumothorax is a clinical diagnosis• and treatment should not be delayed by

waiting for radiological confirmation.

treatment

rapid insertion of a large-bore needle into the second intercostal space in the mid-clavicular line of the affected hemithorax.

This is immediately followed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line.

Pericardial tamponade

• must be differentiated from tension pneumo thorax in the shocked patient with distended neck veins.

• most commonly the result of penetrating trauma.

• Accumulation of a relatively small amount of blood into the non-distensible pericardial sac can produce physiological obstruction of the heart.

• All patients with penetrating injury anywhere near the heart plus shock must be considered to have cardiac injury until proven otherwise

Pericardial tamponade

Clinical presentation

• venous pressure elevation, • decline in arterial pressure with tachycardia,

and• Muffled heart sounds• In cases in which major bleeding from other

sites has taken place, the neck veins may be flat.

treatment

• The correct immediate treatment of tamponade is operative (sternotomy or left thoracotomy), with repair of the heart in the operating theatre if time allows or otherwise in the emergency room.

• Pericardiocentesis has a high potential foriatrogenic injury to the heart and it should at the most beregarded as a desperate temporising measure in a transport situation

• [under electrocardiogram (ECG) control].

Pitfalls of pericardial tamponade

• neck veins may be flat if the patient has bled substantially from elsewhere and is therefore in volume collapse;

• the central venous pressure may not be elevated if the circulating volume is depleted, e.g. because of other injuries;

• pericardiocentesis is a temporising measure only with a high complication rate and is not a substitute for immediate operative intervention – it proves only that there is a ‘clot’on bothends of the needle!

Open pneumothorax (‘sucking chest wound’)

• large open defect in the chest (> 3 cm)• leading to equilibration between intrathoracic

and atmospheric pressure.• Air accumulates in the hemithorax (rather

than in the lung) with each inspiration, leading to profound hypoventilation on the affected side and hypoxia.

• promptly closing the defect with a sterile occlusive plastic dressing (e.g. Opsite), taped onthree sides to act as a flutter-type valve.

• A chest tube is inserted as soon as possible in a site remote from the injury site.

• Definitive treatment may warrant formal debridement and closure, preferably in the operating room

• if the lung does not reinflate, the drain should be placed on low-pressure (5 cm water) suction;

• physiotherapy and active mobilisation should begin as soon as possible.

Opsite

Massive haemothorax

• The most common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally the internal mammary artery

• Accumulation of blood in a hemithorax can significantly compromise respiratory efforts by compressing the lung and preventing adequate ventilation

• presents as haemorrhagic shock with flat neck veins, unilateral absence of breath sounds and dullness to percussion.

• The treatment consists of correcting the hypovolaemic shock,insertion of an intercostal drain and, in some cases, intubation.

Indication for thoracotomy

• Initial drainage of more than 1500 ml of blood or

• on-going haemorrhage of more than 200 ml per hr over 3–4 hours is generally considered an indication for urgent thoracotomy.

Flail chest

• usually results from blunt trauma associated with multiple rib fractures,

• three or more ribs fractured in two or more places

• The diagnosis is made clinically, not by radiography.

• On inspiration the loose segment of the chest wall is displaced inwards

• Traditionally, treatment consisted of mechanical ventilation to ‘internally splint’ the chest until fibrous union of the broken ribs occurred.

• The price for this was considerable in terms of intensive care unit resources and ventilation-dependent morbidity

• Currently, treatment consists of oxygen administration, adequate analgesia (including opiates) and physiotherapy.

• If a chest tube is in situ, intrapleural local analgesia can be used as well.

• Ventelation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen

• Surgery to stabilise the flail chest is currently in use again;

• it may be useful in a selected group with• isolated or severe chest injury and pulmonary

contusion who have been shown to benefit from internal operative fixation of the flail segment.

Potentially life-threatening injuries

• Thoracic aortic disruption• Traumatic aortic rupture is a common cause

of sudden death after an automobile collision or fall from a great height.

The vessel is relatively fixed distal to the ligamentum arteriosum, just distal to the origin of the left subclavian artery. The shear forces from a sudden impact disrupt the intima and media.

• It should be clinically suspected in patients with asymmetry of upper or upper and lower extremity blood pressure, widened pulse pressure and chest wall contusion.

• the most common radiological finding being a widened mediastinum

• The diagnosis is confirmed by aortography or a contrast spiral CT scan of the mediastinumand to a lesser extent by transoesophagealechocardiography.

management

• Initially, management consists of control of the systolic arterial blood pressure (to less than 100 mmHg).

• Thereafter, an endovascular intra-aortic stent can be placed or the tear can be operatively repaired by direct repair or excision and grafting using a

• Dacrongraft.

Diaphragmatic injuries

• Any penetrating injury to or below the fifth intercostal space should raise the suspicion of diaphragmatic penetration.

• The diaphragmatic rupture is usually large, with herniation of the abdominal contents into the chest.

• Diagnosis of blunt diaphragmatic rupture is Missed even more often than penetrating injuries in the acutephase.

• There is no single standard investigation. Chest radiography after placement of a nasogastric tube may be helpful

• The most accurate evaluation is by video-assisted thoracoscopy (VATS) or laparoscopy

• Operative repair is recommended in all cases. All penetrating diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out penetrating hollow viscus injury.

Oesophageal injury

• result from penetrating trauma.• The patient can present with odynophagia

(pain on swallowing foods or fluids), subcutaneous or mediastinal emphysema, pleural effusion, air in the retro-oesophageal space and unexplained fever within 24hours of injury

• The mortality rate rises exponentially if treatment is delayed for more than 12–24 hours

• The treatment is operative repair and drainage.

Tracheobronchial injuries

• Severe subcutaneous emphysema with respiratory compromise can suggest tracheobronchial disruption

• A chest drain placed on the affected side will reveal a large air leak and the collapsed lung may fail to re-expand

• Bronchoscopy is diagnostic.• Treatment involves intubation of the

unaffected bronchus followed by operative repair

Blunt myocardial injury

• Blunt myocardial injury should be suspected in any patient sustaining blunt trauma who develops ECG abnormalities in the resuscitation room.

• most reliable sign of significant injury to the myocardium is an abnormal 12-lead ECG.

• Two-dimensional echocardiography may show wall motion abnormalities. A transoesophageal echocardiogram may also be helpful.

• little evidence that enzyme estimations have any place in diagnosis; a rise in troponin I may be a useful adjunct but is not of primary value in making the diagnosis.

• at risk of developing sudden dysrhythmias and should be monitored for the first 24 hours.

Pulmonary contusion

• caused by haemorrhage into the lung parenchyma, usually underneath a flail segment or fractured ribs.

• This is a very common, potentially lethal chest injury and the major cause of hypoxaemia after blunt trauma.

• It is an independent risk factor for pneumonia and adult respiratory distress syndrome(ARDS).

• The natural progression of pulmonary contusion is worsening hypoxemia for the first 24–48 hours.

• The chest radiography findings are typically delayed and non-segmental.

• Contrast CT scanning can be confirmatory.• If abnormalities are seen on the admission chest

radiograph, the pulmonary contusion is severe.• Haemoptysis or blood in the endotracheal tube is

a sign of pulmonarycontusion

treatment

• In mild contusion the treatment is oxygen administration, aggressive pulmonary toilet and adequate analgesia.

• In more severe cases mechanical ventilation is necessary.

• be careful not to overload these patients with fluid to avoid pulmonary oedema,

• establishment of normovolaemia is critical for adequate tissue perfusion and fluid restriction is not advised.

EMERGENCY THORACOTOMY

• essential part of the armamentarium of any surgeon dealing with major trauma.

• Indications for thoracotomy include:

• internal cardiac massage;• control of haemorrhage from injury to the heart;• control of haemorrhage from injury to the lung;• control of intrathoracic haemorrhage from other

causes;• control of massive air leak.

• Thoracotomy can be broadly divided into the following:

• emergency (resuscitative) thoracotomy for control of life threatening bleeding;

• planned thoracotomy for repair of specific injury.

Emergency thoracotomy survival %

• Blood pressure despite resuscitation Survival (%)

• > 60 mmHg 60%• > 40 mmHg 30%• < 40 mmHg 3%

Left anterolateral thoracotomy

• Left lung and• lung hilum• Thoracic aorta• Origin of left subclavian artery• Left side of heart• Lower oesophagus

Right anterolateral thoracotomy

• Right lung and lung hilum• Azygos veins• Superior vena cava• Infracardiac inferior vena cava• Upper oesophagus• Thoracic trachea

Median sternotomy

• Anterior aspect of heart• Anterior mediastinum• Ascending aorta and arch of aorta• Pulmonary arteries• Carina of the trachea

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