1 CHEST TRAUMA

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4 Blunt Trauma to the Chest Common result of industrial, military and road trauma Chest x-ray important in evaluating lung, mediastinal and vascular conditions Injury to great vessels, life threatening - 90% die immediately Two thirds of victims of major blunt trauma suffer from a thoracic injury

5 Blunt Trauma to the Chest 50% of remainder die within 24 hours if undiagnosed 2-5% of those who survive present later with an aortic aneurysm Diagnosis often hindered by other injuries Chest injuries account for % of the deaths, mainly as a result of injuries from road accidents 70% of multisystem injuries include significant thoracic injuries

6 Blunt Trauma to the Chest Chest x-ray is non specific, though it may demonstrate first clues –there is some relationship between fractures of the 1st and 2nd ribs with aortic tears –caudal displacement of posterior upper ribs with thoracic aortic injury

7 Blunt Trauma to the Chest Aortic contour and mediastinal widening may be suggestive of haemothorax Aortography will confirm the presence of aortic injury, with high sensitivity and specificity

8 Blunt Trauma to the Chest Conventional CT unable to confirm aortic tear, though will show mediastinal widening and haematoma Spiral CTA will be able to show aortic tear and extent of damage or whether the tear originates from the venous system

9 Blunt Trauma to the Chest Spiral CTA will also demonstrate whether mediastinal widening or haematoma is due to small vessel damage Aortography may well be the only option which has the capacity to identify the: –involvement –size and location –direction of an aortic tear

10 Pneumothorax There are two main forms: –Closed –Valvular

11 Pneumothorax Closed –There is no air movement between the lung and the pleural space, Valvular –Air enters on inspiration and remains on expiration, –This will lead to an increase in pressure within the thoracic cavity, –Substantial ‘side effects’ occur as the pressure increases.

12 Pneumothorax Air enters the pleural cavity through penetrating, open chest wound on inspiration. Negative pressure has been lost, thus collapsing the lung towards the mediastinum, reducing venous return to the heart. The shift of the mediastinum towards the opposite side compresses the ‘unaffected lung’.

13 Pneumothorax During the expiration phase, the chest wall contracts, air will be expelled from the pleural cavity through the wound. The mediastinum shifts towards the affected side, beyond its normal central position, thus causing distortion of the vena cava.

14 Tension Pneumothorax Air enters pleural cavity through lung wound. Negative intrapleural pressure is lost and the affected lung collapses, the mediastinum shifts towards opposite side, causing impaired ventilation.

15 Tension Pneumothorax Upon expiration, intrapleural pressure rises, thus closing off the wound. Successive respiration phases increase this pressure thus causing further shift of structures to the opposite side. The diaphragm is depressed and venous return is impaired.

16 Pneumothorax Well seen on conventional chest radiographs Follow up chest radiographs necessary after thoracosotomy tube has been inserted 60% of patients with a lacerated bronchial tree will have a pneumothorax –25% of these will have a tension pneumothorax –1 in 20 will have bilateral pneumothoracicies Fractures of the first 5 ribs a common finding with a pneumothorax

17 Pneumothorax Clues that might indicate the presence of a pneumothorax if the classic findings of pneumothorax are not present on a supine chest radiograph are: –The deep sulcus sign ; abnormal deepening of the costophrenic angle on the affected side –The double diaphragm sign ; the impression of two diaphragms on the affected side –Visualisation of pericardial fat

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21 Flail Chest A loss of stability of the chest wall due to multiple rib fractures, with a rib being fractured in two places Insufficient expansion of the thorax and a corresponding increase energy expenditure for breathing to be effective 20 –30% increase in the likelihood of adult respiratory distress syndrome [ARDS], with a flail chest

22 Flail Chest

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24 On inspiration, the chest expands, and the diaphragm descends. The flail section sinks inwards, impairing the ability to produce negative intrapleural pressure. The trachea and mediastinum shift to the uninjured side, thus reducing the expansion of that lung. Flail Chest

25 When the chest contracts and the diaphragm rise on expiration, the flail section bulges outwards, thus impairing the expiratory effect. The trachea and mediastinum shift now towards the injured side Flail Chest

26 Rib fractures causing flail chest

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28 Haemothorax May occur through either penetrating or non penetrating injuries. The larger the haemorrhage the greater the danger vital functions and shock.

29 Haemothorax Haemothorax implies that the negative pressure in the intrapleural space still exists, therefore the nature of the haemorrhage is typical of a pleural effusion, in terms of its radiographic effect.

30 Haemothorax 3 examples of a haemothorax –A = small haemorrhage of about mls –B = Moderate haemorrhage up to 1500 mls –C = massive haemorrhage over 1500 mls.

31 PLEURAL EFFUSION

32 Sternal Fractures The fracture itself is not important The association with potential serious injuries to the: Aorta Great vessels Pulmonary contusion Cardiac trauma Differential Diagnosis is far more important Sternal fracture require a lateral chest radiograph

33 Aortic and Great Vessel Injuries Acceleration and traction forces are the major mechanism for thoracic and great vessel injuries –Horizontal deceleration create shear forces at the aortic isthmus –Vertical deceleration displace the heart caudally, displacing itinto the left pleural cavity and acutely straining the ascending aorta- innominate artery junction –35 –90% of patients with thoracic aortic rupture die at the scene Chest radiographs is viewed for mediastinal widening, which is 90% sensitive and 10% specificity for traumatic aortic rupture

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36 CARDIAC TAMPONADE

37 Diaphragm Injuries Rupture of the diaphragm occurs in 1 –3% of patients with blunt chest trauma, usually from MVA’s Injury most common the left side due to the protective effect of the liver on the right Nearly all patients have associated injuries with a mortality rate of about 15% Chest radiographs are a useful starting point, though less than half the documented cases of rupture had chest findings

38 Misplaced CVP line in jugular vein

39 Nasogastric tube in bronchus

40 Misplaced chest tube

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