By : Dr Gholamreza Masoumi Assistant Professor of Emergency medicine Iran University Of Medical Sciences

ThoracicTrauma

EPIDEMIOLOGY Thoracic injury directly causes 20% to 25% of deaths resulting from trauma. Accounting for more than 16,000 deaths annually in the United States.

Immediate deaths are often due to a rupture of the myocardial wall or the thoracic aorta.

Early deaths(within the first 30 minutes to 3 hours) resulting from thoracic trauma are often preventable. Causes of these early deaths include tension pneumothorax, cardiac tamponade, airway obstruction, and continued uncontrolled hemorrhage.

Because these problems are often reversible, it is vital that emergency physicians be thoroughly familiar with the pathophysiology, symptoms, and treatment.

Chest Anatomy

Primary Survey Airway obstruction Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade

Secondary Survey Myocardial contusion Traumatic aortic rupture Tracheal or bronchial tree injury Diaphragmatic tears Esophageal injury Pulmonary contusion

Airway obstruction Always assume cervical spine injury Secondary hypoxia Common cause of preventable death Foreign body, tongue, aspiration Always assume cervical spine injury

Signs Of Obstruction Snoring or gurgling Stridor Agitation (hypoxia) Use of accessory muscles Cyanosis

Airway Management Clear mouth Chin lift/jaw thrust Airway Intubation Cervical spine care

Open pneumothorax “Sucking chest wound” Air enters pleural space Ventilation impaired Hypoxia results

PNEUMOTHORAX Erect AP/PA view best Visceral pleural line No vessels or markings Variable degree of lung collapse No shift

Open pneumothorax Close chest wall defect

Flail chest Flail chest results when three or more adjacent ribs are fractured at two points, allowing a freely moving segment of the chest wall to move in paradoxical motion.

Flail chest paradoxical motion of the chest wall outward with expiration inward with inspiration

Management Oxygen should be administered in the field, cardiac and oximetry monitors should be applied if available, and the patient should be observed for signs of an associated injury, such as tension pneumothorax.

Management The cornerstones of therapy include aggressive pulmonary physiotherapy, effective analgesia, selective use of endotracheal intubation and mechanical ventilation, and close observation for respiratory compromise.

Stabilization of the flail segment, by positioning the patient with the injured side down or placing a sandbag on the affected segments, has been abandoned. These interventions actually inhibit expansion of the chest and increase atelectasis of the injured lung.

Tension Pneumothorax Treat before X-ray Should be a clinical diagnosis

Tension Pneumothorax Signs Respiratory distress Tachycardia Hypotension Distended neck veins Resonant percussion note Tracheal deviation ↓ Air entry

Tension Pneumothorax Management Immediate decompression Large bore needle Second intercostal space Mid clavicular line Formal chest drain must follow

The second intercostal space, midclavicular line is preferred for needle aspiration or catheter insertion. B, The fourth or fifth intercostal space,midaxillary line, lateral to the pectoralis muscle and breast tissue, is the preferred site for a chesttube, regardless of pathology.

Massive hemothorax Anxiety and confusion Neck veins Flat: hypovolemia Distended: mediastinal compression Breath sounds decreased Hypotympany if percussed Shock

Cardiac tamponade Beck’s triad Paradoxical pulse Breath sounds equal Hypotension Neck veins distended Heart sounds muffled Paradoxical pulse Breath sounds equal

Neck veins distended

To measure pulsus paradoxus, the patient breathes normally while lying at a 45° angle. The blood pressure cuff is inflated well above systolic pressure and slowly deflated. When the pulse is first heard only during expiration, this is the upper value. The cuff is deflated until the pulse is heard during both inspiration and expiration, and this is the lower value. The difference in the two values is the amount of pulsus paradoxus. A difference of more than 12 mm Hg is abnormal.

Ultrasound: Apical view of a large pericardial effusion in early ventricular diastole; marked right atrial collapse is seen

Myocardial contusion Most common cardiac injury Blunt anterior chest injury Same as myocardial infarction Chest pain Dysrhythmias Cardiogenic shock (rare) Treat as cardiac tamponade

Traumatic aortic rupture Most common cause of immediate death Motor-vehicle collisions or falls from heights 90% die immediately Scene Size-up and history extremely important No obvious sign of chest trauma Hypertension in upper extremities and hypotension in lower extremities (rare)

Tracheal or bronchial tree injury Subcutaneous emphysema Chest, face, neck Ensure adequate airway Cuffed ET tube past site of injury Monitor for: Pneumothorax Hemothorax

Diaphragmatic tear Severe blow to abdomen Herniation of abdominal organs More common on left Breath sounds diminished Bowel sounds auscultated in chest (rare) Abdomen appears scaphoid

Esophageal injury Penetrating trauma Difficult to assess in field If unrecognized, may be lethal

The most reliable symptom of an esophageal injury is pleuritic pain localized along the course of the esophagus that is exacerbated by swallowing or neck flexion. Pain may be located in the epigastrium, substernal area, .or back

1. Mediastinal air with or without subcutaneous emphysema 2 1. Mediastinal air with or without subcutaneous emphysema 2. Left-sided pleural effusion 3. Pneumothorax 4. Widened mediastinum

Pulmonary contusion Common from blunt trauma Hours to develop Marked hypoxemia

Traumatic Asphyxia Severe compression Ruptures capillaries Cyanosis above crush Swelling of head, neck Swollen tongue, lips Conjunctival hemorrhage

Diagnostic Strategies Chest wall and pulmonary injuries are most common. These patients should undergo CT of the chest to identify any potentially serious intrathoracic injuries.

Although the appearance of these patients can be quite dramatic, the condition itself is usually benign and self-limiting.

CHEST WALL INJURY

Rib Fracture Epidemiology Simple rib fractures are the most common form of significant chest injury, The importance of this injury is not the fracture itself, but the associated potential complications, particularly pneumothorax or hemothorax , pulmonary .contusion

The(4-9) fourth through ninth ribs are most commonly involved The(4-9) fourth through ninth ribs are most commonly involved. Ribs 1 to 3 are relatively protected, and ribs 9 to 12 are more mobile at the anterior end; this confers the “high” and “low” ribs' relative resistance to fracture.

Fractures of ribs one to three may indicate severe intrathoracic injury. Fractures of the 9th, 10th, or 11th ribs suggest an associated intra-abdominal injury.

displaced rib fractures Elderly patients with displaced rib fractures may be at higher risk for delayed and profound intercostal artery bleeding, and serial hemoglobin measurements should be done during observation of these patients.

displaced rib fractures In penetrating chest trauma, patients with displaced rib fractures should be observed for the occurrence of delayed pneumothorax with a repeat chest x-ray at 3 hours.

Sternal Fracture Restrained passengers are more likely than unrestrained passengers to sustain a sternal fracture.

isolated sternal fractures are relatively benign patients with sternal fracture should be screened for myocardial contusion with .(ECG) and serum troponin level

Summary Chest injuries common Often life-threatening Require prompt recognition Require prompt intervention Airway and oxygenation always priority