1. Chest and CVS Trauma Dr Abdulaziz Alrabiah, MD
Emergency Medicine, Trauma and EMS specialist

2. objectives
different life threatening injuries
assessment
management

3. Tension Pneumothorax air between visceral and partial pleura
one way valve —> allow air to go inside the pleural space but not out
it is a clinical diagnosis , do not wait for chest Xray
presentation
distended neck vein
tracheal deviation to the opposite
hypotension / evidence of hypo perfusion i.e. decrease LOC, tachycardia
absent breath sound in the ipsilateral site
Treatment :
high flow O2 15 L
needle (14G) decompression : 2nd intercostal space , mid clavicular line i.e. 3 cm away from sternal border, why ? avoid internal mammary artery
then intercostal chest drain: 5th intercostal space , between mid and anterior axillae lines

5. chest X-ray

6. Pneumothorax air in the pleural space signs decrease breath sounds
hyper resonant on percussion
no signs of tension
size of pneumothorax
horizontal line from 3rd rib
( apical line+ middle line + lower line ) / 3
each 1 cm roughly correspond to 10%
treatment :
<20 % —> high flow O2 , repeat X-ray after 4 hours
if improve no need for chest tube
if worse needs chest drain
> 20 % —> put chest drain

8. Massive Hemothorax Def :
> 1500 ml of blood immediately after chest drain placement
200 ml / hr of blood drained for 4 hours
on chest X-ray : > 2/3 of the available space in the hemithorax
causes :
lung parenchymal injury
intercostal artery injury
internal mammary artery
clinical signs
decrease breath sounds on the affected side
dull on percussion on the affected side
chest X-ray

9. Treatment
high flow O2 15L
chest drain
if drained > 1500 ml of blood immediately or > 200 ml of blood / hr for 4hours —> operative thoracotomy

10. Open Pneumothorax

11. open pneumothorax penetrating chest trauma
communication between pleural space and outside environment
i.e. sucking chest wound
may be associated with hemothorax
clinical signs
wound
plus tension pneumothorax features
treatment
high flow O2 15 L
3 way dressing —> air escape but doesn't enter the pleura
chest drain away from the wound

13. Flail chest fractures of 2 or more ribs in 2 or more locations
segment of the chest wall that is no longer in continuity with the rest of the thoracic cage
Paradoxical movement results,
the segment moves inwards on inspiration as the rest of the chest moves outwards on expiration
treatment
high flow O L
analgesia i.e. NSAID , Opioids, intercostal block
chest physiotherapy
respiratory monitor due to risk of respiratory failure

15. Pulmonary contusion1 Suspect in any significant thoracic trauma.
May occur in small children in the absence of fractures due to the high compliance of the chest wall.
Respiratory distress, hemoptysis, cyanosis
Decreased breath sounds and crackles in the affected lung area
Hypoxia and/ or hypercapnia on ABG
Pulmonary contusions are detectable on bedside ultrasound
Alveolar opacities on CXR

16. Pulmonary contusion2 High flow O2 15 L/min
‘Fluid restriction’ may reduce size of contusion but may not affect outcomes
Analgesia for pain
Respiratory support — severe cases require intubation and mechanical ventilation

18. Pneumomediastinum it is a sign of other serious injuries
larynx , trachea , major bronchi , pharynx, oesophagus
FB aspiration and perforation of oesophagus / Trachea
sings
sub cut emphysema
crunching sound ( Hamman sign) over the heart
treatment : treat the cause

20. Cardiac Tamponade
more common in penetrating thoracic trauma than blunt trauma
50-75 ml of blood in pericardial sac may result in tamponade
Anxiety and agitation
Obstructive shock — tachycardia, hypotension, cool peripheries
Beck’s triad: muffled heart sounds, hypotension and distended neck veins
Pulsus paradoxus (drop in systolic blood pressure >10 mmHg on inspiration)
Mostly diagnosed following identification of a pericardial effusion on FAST exam

21. Cardiac Tamponade2 High flow oxygen 15L/min via non-rebreather
May transiently respond to fluid challenge
Needle pericardiocentesis, preferably ultrasound guided, may be lifesaving may be life
Pericardotomy is definitive treatment

22. Aortic Dissection1
blood entering the medial layer of the wall with the creation of a false lumen
classification —————>

23. Aortic dissection2 clinical features chest pain ( tearing )
pain radiate to back between shoulder blades
HTN
aortic regurgitation
ischaemic heart disease
syncope
seizure
flank pain
RISK FACTORS
Marfan’s syndrome, Ehlers-Dalos syndrome, Turner syndrome
syphilis
arteritis
cocaine abuse
iatrogenic

24. Aortic Dissection3 clinical exam aortic regurgitation is common
hypertension -check BP in the arm with best radial pulse
shock – ominious signs: tamponade, hypovolaemia, vagal tone
heart failure
neurological deficits: limb weakness, paraesthesiae, Horners syndrome
SVC syndrome – compression of SVC by aorta
asymetrical pulses (carotid, brachial, femoral)
haemothorax

25. Aortic Dissection4 complications aortic rupture AR AMI tamponade
end-organ ischaemia – brain, limbs, spine, renal, gut, liver
death

26. Aortic Dissection5 investigations chest X-ray
widened mediastinum (56-63%)
abnormal aortic contour (48%)
aortic knuckle double calcium sign >5mm (14%)
pleural effusion (L>R)
tracheal shift
left apical cap
deviated NGT
Normal’ in 11-16%

27. Aortic Dissection5

28. Aortic Dissection6 Treatment :
control BP (Labetalol, GTN) (aim SBP mmHg and pulse / min)
fluid and blood resuscitation
call cardiothoracic surgeon , indication for surgery
Persistent pain
Type A
Branch Occlusion
Leak
Continued extension despite optimal medical management

29. Thank you !