Chest injuries Supervised by: Dr. Waseem Hajjar

INTRODUCTION The chest contains vital organs. Damage to vital organs threatens life. Most common consequence is hypoxia. Chest injuries result in a significant number of deaths each year. One in every 4 cases of trauma death caused by chest injury.

*Chest injuries can be divided into: -Immediate life threatening injuries -Potentially life threatening injuries

Immediate life threatening injuries Injuries that can cause death in a matter of minutes and, therefore, must be identified and treated during the initial evaluation and resuscitation.

Airway obstruction Tension pneumothorax Open pneumothorax Massive heamothorax Cardiac tamponad Flial chest

Potentially life threatening injuries Injuries that, left untreated, would likely result in death but that usually allow several hours to establish a definitive diagnosis and institute appropriate treatment

Traumatic aortic rupture. Myocardial contusion. Tracheal bronchial injury. Rupture diaphragm. Esophageal trauma. Pulmonary contusion.

Mechanism of injury : 1) Blunt chest trauma 2) Penetrating trauma Most common cause of serious chest injuries. Post RTA, falls, direct blows, and crushing injuries. Many injuries are not immediately apparent in physical exam. 2) Penetrating trauma Immediate result can be severe bleeding or impaired breathing. Any chest wound can involve underlying organ injury. No matter how superficial it looks. Injuries to the heart, lungs, and great vessels can quickly lead to shock and cardiac arrest. 3) Iatrogenic

Signs and symptoms: Assessment: Most common symptoms: pain and difficulty breathing. Signs are obvious injury to the chest wall ( looking at both the front and back of the chest). Note any subcutaneous emphysema, or air present under the skin Assessment: Follow all steps in the assessment of the trauma patient: Primary survey( A. Airway B. Breathing C. Circulation). Resuscitation. Detailed secondary survey (CXR , ABG ,ECG , CT Chest , Aortogram).

Management Ensure patient has adequate oxygenation and perfusion Provide high-flow oxygen, ventilating when necessary Halt any obvious bleeding Support circulation when needed Rapidly transport patient to definitive care

Rib fracture Simple rib fractures are the most common injury sustained following blunt chest trauma More common in adults than children. The most common mechanism of injury for rib fractures in elderly persons is a fall from height or from standing. In adults, motor vehicle accident (MVA) is the most common mechanism.

Ribs four through nine (4-9) are the most commonly injured. Ribs commonly fracture at the point of impact or at the posterior angle (structurally their weakest area(. Ribs four through nine (4-9) are the most commonly injured. Dr slides its written that ribs 5-9 are the most commonly injured

Signs and Symptoms: Pain when breathing or with movement Patient often presents with guarding and shallow breathing Chest wall instability Deformity, discoloration Local swelling and tenderness may be the only sing of broken rib

Complication s of rib fracture: Chronic chest pain Lung contusion Pneumo or hemothorax Injury to aorta or bronci Flail chest Fracture of the 8th to 12th ribs can damage underlying abdominal solid organs: liver, spleen or kidneyes

Management: Move the patient carefully to prevent the bone ends from puncturing the lung. Administer O2. Allow patient to self-splint by assuming the most comfortable position possible. Encourage patient to limit movement. Analgesia like Morphine, PCA, Epidural. Evaluation: hx, px and tests (CBC, CXR and MRI)

FLAIL CHEST Blunt chest trauma, causing extensive anterior and posterior rib fractures or sternocostal disconnection, results in paradoxical chest wall movement

Management: Adequate pain control Quickly stabilize flial segment by placing gloved hand over injured area After manual stabilization, place folded universal dressing over segment and tape securely. Fixation (external, internal) Chest tube as required Mechanical ventilation may be required in severe cases.

Paradoxical chest movement

Post Traumatic Pneumothorax Types: Opened pneumothorax. Close pneumothorax.

Open Pneumothorax An injury in which an open wound in the chest wall has exposed the pleura space to the atmosphere. The open wound allows air movement through the defect during spontaneous respiration, causing ineffective alveolar ventilation.

Signs: difficulty breathing Cyanosis Diminished breath sounds on the affected side

Management: Cover open chest wounds with occlusive dressing and inserting a thoracostomy tube Gloved hand is an effective temporary occlusive dressing High flow oxygen Transport with unaffected side slightly elevated Later closure of the wound may be necessary

Tension Pneumothorax Potentially life-threatening condition that must be treated immediately. Can occur in blunt or penetrating chest trauma.

Right sided pneumothorax Right sided pneumothorax. An arrow indicatingthe edge of the collapsing lung

What Happen in Tension Pneumothorax One-way valve forms in lung or chest wall Air enters pleural space; cannot leave Air is trapped in pleural space Pressure rises Pressure collapses lung Shifting of the mediastinum to the contralateral side, which compreses the vena cava and obstructs venous return to the heart.

Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation Decreased breath sounds Hyperresonance to percussion Cyanosis Subcutaneous emphysema Rapid, weak pulse Decreased BP Tracheal shift away from injured side Jugular vein distension Early dyspnea/hypoxia - Late shock

Management: The thorax must be decompressed with a needle, which is replaced by an intercostal tube with underwater seal and suction.

Hemothorax Sign & symptoms : Blood in the pleural space . Most common result of major chest wall trauma Present in 70 to 80 % of penetrating and major non penetrating trauma . Sign & symptoms : Signs of Shock , Frothy Bloody sputum , collapsed neck veins ,cool, clammy skin, chills and restlessness Source of bleeding : intercostal vessels, internal mammary vessels , lung parenchyma, bronchial arteries, major pulmonary vessels ,heart and great vessels

Management ABC’s : secure airway , assist the breathing with high o2 . Rapid transport . A hemothorax is managed by removing the source of bleeding and by draining the blood. *Indications for urgent thoracotomy Chest drainage >1250 ml or >1000 ml with hypotension or >200 ml per hour for 3 hours

Chest tube indicated to drain the contents of the pleural space , usually air or blood ,but may include other contents .

Relative indication Absolute indications Contra-indication: Refractory  coagulopathy . lack of cooperation by the patient diaphragmatic hernia Relative indication Rib fracture & positive. pressure ventilation. Profound hypoxia/ hypotension and penetrating injury. Profound hypoxia / hypotension and unilateral hemothorax. Absolute indications Pneumothorax (tension , open or closed ) Hemothorax . Bilateral traumatic arrest

Pulmonary contusion Bleeding into the lung itself is a pulmonary contusion The excess fluid interferes with gas exchange , potentially leading to inadequate oxygen levels (hypoxia) . occurs in 25–35% of all blunt chest trauma . About 70% of cases result from motor vehicle collision .

Sign & symptoms: Diagnosis : Soft crackles may be heard over injury site Chest pain, point tenderness, and localized swelling over area of impact Diagnosis : X-ray CT is a more sensitive test for pulmonary contusion

A CT scan showing a pulmonary contusion (red arrow) accompanied by a rib fracture (blue arrow)

Management : Supply high-flow supplemental oxygen . analgesics. Support ventilation as needed with Mechanical ventilation (in the patient with worsening pulmonary insufficiency).

Cadiac inuries 1 )Pericardial tamponade :  Emergency condition in which fluid accumulates in the pericardium (the sac in which the heart is enclosed). Usually result from a penetrating chest trauma with laceration to the heart itself . Blood filling the pericardial sac compresses the heart, witch prevents the heart's ventricles from filling properly. This in turn leads to a low stroke volume The end result is ineffective pumping of blood , shock , and often death.

Sign & symptoms: Management : The classical cardiac tamponade presents three signs known as Beck's triad. (Hypotension , jugular-venous distension , and muffled heart sounds )  . other signs , like pulses paradoxux and ECG changes as well as general signs & symptoms of shock . Management : ABC’s With High Flow oxygen . Treat S/S of shock . Notify Hospital and ALS Unit as soon as possible Pericardiocentesis :Using aseptic technique, Insert at least 3” needle at the angle of the Xiphoid Cartilage at the 7th rib.

2 ) Myocardial contusion : Common site: Rt ventricle Considered in trauma patients with blunt chest injury and unexplained hypotension or ECG abnormalities Diagnosis : clinical eg: fractured sternum ECG: (arrhythmia, ST elevation). CPK-MB Echocardiography

Management : ABC + high flow o2, ventilation support as needed Cardiac monitor Antiarrhythmic drugs. Inotropic support. request ALS backup .

Blood vessel injuries Aortic injury (Traumatic aortic rupture) : The aorta is torn or ruptured as the result of trauma. It s frequently fatal due to the profuse bleeding  Occurs when the body suddenly decelerates but the organs continue to move. Common sites: The most common site of injury is the aortic isthmus , Symptoms-signs: sever chest or back pain, weak or absent femoral pulses, unequal arm BPs .

Diagnosis After a clinical evaluation, most patients are best evaluated wit CXR followed by Chest CT or Angiography. however CXR demonistrat a classical finding

widened mediastinum. blurred aortic knob. Aortopulmonary window opacification. First or second rib #. NG tube deviation. Depressed Lt mainstem bronchus. Pleural apical capping. Widened paratracheal stripe.

Management ABC’s Surgical repair, usually with cardiopulmonary bypass technique

Diaphragmatic Rupture Common site: Lt hemidiaphragm Symptoms-signs: dyspnea, orthopnea, chest pain, bowel sounds in the chest

Diagnosis CXR: NG tube or bowel in the chest, gastric distention with ipsilateral lung collapse. Management surgical repair

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