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CHEST INJURY- BLUNT- Trauma Surgery Slide 2 CHEST INJURY- BLUNT- Trauma Surgery Slide 3 CHEST INJURY- BLUNT- Trauma Surgery Slide 4 CHEST INJURY- BLUNT- Trauma Surgery Slide 5 CHEST INJURY- BLUNT- Trauma Surgery Slide 6 CHEST INJURY- BLUNT- Trauma Surgery Slide 7 CHEST INJURY- BLUNT- Trauma Surgery Slide 8 CHEST INJURY- BLUNT- Trauma Surgery Slide 9 CHEST INJURY- BLUNT- Trauma Surgery Slide 10 CHEST INJURY- BLUNT- Trauma Surgery Slide 11 CHEST INJURY- BLUNT- Trauma Surgery Slide 12 CHEST INJURY- BLUNT- Trauma Surgery Slide 13 CHEST INJURY- BLUNT- Trauma Surgery Slide 14 CHEST INJURY- BLUNT- Trauma Surgery Slide 15 CHEST INJURY- BLUNT- Trauma Surgery Slide 16 CHEST INJURY- BLUNT- Trauma Surgery Slide 17 CHEST INJURY- BLUNT- Trauma Surgery Slide 18 CHEST INJURY- BLUNT- Trauma Surgery Slide 19 CHEST INJURY- BLUNT- Trauma Surgery Slide 20 CHEST INJURY- BLUNT- Trauma Surgery Slide 21 CHEST INJURY- BLUNT- Trauma Surgery Slide 22 CHEST INJURY- BLUNT- Trauma Surgery Slide 23 CHEST INJURY- BLUNT- Trauma Surgery Slide 24 CHEST INJURY- BLUNT- Trauma Surgery Slide 25 CHEST INJURY- BLUNT- Trauma Surgery Slide 26 CHEST INJURY- BLUNT- Trauma Surgery Slide 27 CHEST INJURY- BLUNT- Trauma Surgery Slide 28 CHEST INJURY- BLUNT- Trauma Surgery Slide 29 CHEST INJURY- BLUNT- Trauma Surgery Slide 30 CHEST INJURY- BLUNT- Trauma Surgery Slide 31 CHEST INJURY- BLUNT- Trauma Surgery Slide 32 CHEST INJURY- BLUNT- Trauma Surgery Slide 33 CHEST INJURY- BLUNT- Trauma Surgery Slide 34 CHEST INJURY- BLUNT- Trauma Surgery Slide 35 CHEST INJURY- BLUNT- Trauma Surgery Slide 36 CHEST INJURY- BLUNT- Trauma Surgery Slide 37 CHEST INJURY- BLUNT- Trauma Surgery Slide 38 CHEST INJURY- BLUNT- Trauma Surgery Slide 39
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CHEST INJURY- BLUNT/ Trauma Surgery


Dear viewers,
Greetings from “Surgical Educator”
Today I have uploaded a video on CHEST INJURY- BLUNT- an important topic in trauma. Even the blunt chest trauma can turn into penetrating one because of jagged edges of the broken ribs. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about pathophysiology, clinical approach, symptoms, signs, investigations, different individual types of Chest injuries and management of all the varieties of Chest injuries. My aim is, after watching this video all of you should be able to arrive at a correct working diagnosis of the type of chest injury and should also be able to institute immediate lifesaving treatment to the patients if there is a need. You can watch the video in the following links:
surgicaleducator.blogspot.com
youtube.com/c/surgicaleducator
Thank you for watching the video.

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CHEST INJURY- BLUNT- Trauma Surgery

  1. 1. CHEST TRAUMA- BLUNT Dr.B.Selvaraj MS;Mch;FICS; Professor of surgery Melaka Manipal Medical College Melaka 75150 Malaysia AN OVERVIEW Dr.B.Selvaraj MS;Mch;FICS; Professor of Surgery Melaka Manipal Medical College Melaka 75150 Malaysia
  2. 2. CHEST TRAUMA-Blunt
  3. 3. CHEST TRAUMA-Blunt INTRODUCTION: 1.Second leading cause of trauma deaths 2. 65-70% of Chest injuries are due to RTA 3. 25% of trauma deaths are due to chest injury 4. 50% of patients who die from multiple trauma have significant chest injury 5. Jagged edges of the broken ribs due to blunt trauma can cause penetrating injuries to underlying structures
  4. 4. CHEST TRAUMA-Blunt Mechanism of chest injury: 1.Body acceleration and deceleration (organ inertia lags behind skeletal acceleration or deceleration) Eg: RTA 2.Body compression (force > the strength of skeleton) Eg: Crush injury and falls 3.Penetrating wounds (open pneumothorax and organ injury) Eg: Assaults- Stab and Missile injuries
  5. 5. CHEST TRAUMA-Blunt Types of Chest Injury: 1.Blunt Chest Injury (Closed Chest Injury) -Eg. RTA, Fall, Crush injury - Associated with multiple injuries such as head, limb, abdomen 2. Penetrating chest injury (Open chest injury) - mostly by assault - Associated with chest wall damage, open pneumothorax and organ injury
  6. 6. CHEST TRAUMA-Blunt Mode of death: 1.Death - can be immediate within seconds to minutes - Can be early within few minutes to hours - can be late within few days to weeks 2. Immediate deaths - disruption of heart or great vessels injury 3.Early deaths - airway obstruction, tension pneumothorax, pulmonary contusion, or cardiac tamponade 4.Late deaths - pulmonary complications, sepsis, and missed injuries
  7. 7. CHEST TRAUMA-Blunt Classification: -Immediate Life Threatening Injuries( Lethal Six) -Potential life Threatening injuries ( Hidden Six)
  8. 8. CHEST TRAUMA-Blunt Immediate life threatening injuries(Lethal Six) Fatal if they are not recognized and treated immediately -Airway obstruction - Tension Pneumothorax - Open Pneumothorax- “ Sucking chest wound” - Massive hemothorax - Flail chest - Cardiac tamponade
  9. 9. CHEST TRAUMA-Blunt Potential Life Threatening injuries(Hidden Six) Primary or Secondary survey may reveal one of eight potentially life-threatening chest injuries 1.Cardiac contusion 2.Aortic disruption 3.Diaphragmatic rupture 4.Esophageal injury 5.Pulmonary contusion 6.Tracheo-bronchial injuries
  10. 10. CHEST TRAUMA-Blunt Clinical Approach The most common injuries to the chest wall—fractures of the ribs, sternum, and clavicle—are rarely life threatening They may portend more significant underlying visceral or neurovascular injury. The primary survey (ABCs) of the ATLS algorithm will direct you to evaluate for the six conditions that results from immediate life threatening injuries- Lethal Six. Only after assessment of hemodynamic stability and stabilization of airway, breathing, and circulation, you have to proceed to the secondary survey
  11. 11. CHEST TRAUMA-Blunt Clinical Approach Chest radiography assists in the dx of pneumothorax, hemothorax, chest wall injuries, or pulmonary contusions. Focused assessment sonography in trauma (FAST) examination will rule out cardiac tamponade and will assist in the dx of associated abdominal injury. Once primary and secondary surveys are completed, obtain chest, abdominal, and pelvic CT scans in stable patients. Unstable patients may need urgent operative intervention, but ED thoracotomy in blunt trauma is virtually never successful.
  12. 12. CHEST TRAUMA-Blunt History/Symptoms What was the mechanism of injury? If a motor vehicle collision, what details can be obtained from paramedics? VS in the field and en route? Patient’s complaints; localization of pain? AMPLE (Allergies; Medications; Past medical hx; Last meal; Events leading to presentation)
  13. 13. CHEST TRAUMA-Blunt Physical Exam/Signs Head-to-toe physical examination (secondary survey) Evaluate and re-evaluate the VS and pulse oximetry. Look for JVD and observe chest wall motion, flail segments, or sucking wounds. Check for pulsus paradoxus. Interrupt the physical examination if a life-saving procedure such as airway or chest tube placement is needed. Evaluate and re-evaluate areas of ongoing blood loss, including open wounds and fractures. Are there associated abdominal, pelvic, or extremity injuries that could account for blood loss?
  14. 14. CHEST TRAUMA-Blunt Investigations CXR: Evaluate for pneumothorax, tension pneumothorax, hemothorax, chest wall fractures, and pulmonary contusions. FAST examination: Evaluate for cardiac tamponade. CT of chest, abdomen, and pelvis (for stable patients only): Perform with IV contrast. Rapid, reliable imaging of lacerations and contusions. CT angiography: Can be performed at the same time as routine CT on many high-speed spiral scanners. Catheter angiography: Remains the gold standard for evaluation of aortic injury.
  15. 15. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -With excessive energy transfer during blunt trauma, any of the thoracic bones may potentially fracture —ribs, sternum, clavicle, or scapula. -Simple rib fractures are the most common injuries and, although rarely life threatening, may be indicators of more significant underlying injury. - Pain and tenderness over the fractured area and discomfort with deep breathing - Local tenderness, swelling or ecchymosis around the fracture. -A palpable defect or fracture-related crepitus may be present. -Respiratory insuffi ciency seen in more severe cases and can be identified by observing for tachypnea, use of accessory muscles, and cyanosis. -AP chest films are used routinely in the initial assessment -CT of the chest may provide more specific information regarding location and extent of specific injury. -Pain control and observation for patients with simple chest wall fractures -Analgesic agents, intercostal nerve blocks, and epidural analgesia all have been used -Aggressive pulmonary toilet to prevent atelectasis and pneumonia. -Operation is rarely needed for simple fractures but required for significant comminution, hemorrhage from fractures that lacerate vessels, or chronic non-union. CHEST WALL FRACTURES
  16. 16. CHEST TRAUMA-Blunt Chest Wall Fractures Chest x-ray with fractures of the upper ribs. These cases should always be evaluated for thoracic inlet vascular injuries, especially the subclavian vessels. Plain radiographs of multiple mid rib fractures, with underlying lung contusion . Adequate analgesia with intercostal block, epidural or patient-controlled analgesia should be considered early, especially in elderly patients.
  17. 17. CHEST TRAUMA-Blunt Chest Wall Fractures (A) Radiograph showing fractures of the right lower ribs (arrows) (left). Injuries to intra- abdominal solid organs are common and CT scan evaluation should be considered. (B) Intraoperative photograph of the associated liver injury in the same patient.
  18. 18. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment - Flail chest is an injury that involves 3 or more consecutive rib fractures in two or more locations, producing a comminuted fracture with a free-floating, unstable bony segment that is detached from the remainder of the chest wall. -Associated injuries are common and should be aggressively sought. -Pulmonary contusion is the most common local disturbance in association with flail segment. Mortality is significant. -Respiratory distress is the most common initial presentation. Dyspnea, tachycardia, tachypnea, pain, and tenderness usually are present. -The flail segment often moves in a paradoxical motion, opposite to that of the remainder of the hemithorax. -Respirations may be labored. As the acute condition progresses, pulmonary function worsens. -Auscultation virtually always demonstrates decreased breath sounds over the affected area. -Dx is made by physical examination and CXR. -CT may help in identification of early pulmonary contusion. -Hypoxemia may be present and should be assessed with pulse oximetry and blood gas analyses. -The tx modalities described for patients with chest wall fractures are appropriate for flail chest. -Pain control, pulmonary toilet, and supplemental oxygen are the primary therapies for pulmonary contusions. -The severity of flail injuries and associated contusions frequently require endotracheal intubation and positive pressure mechanical ventilation- IPPV. -Optimal ventilatory management is crucial -Judicial IV fluids to avoid fluid overload. FLAIL CHEST
  19. 19. CHEST TRAUMA-Blunt Flail Chest Flail Chest: Paradoxical movement
  20. 20. CHEST TRAUMA-Blunt Flail Chest Flail chest. (A) Double fractures of at least three adjacent ribs are required in order to produce a flail chest. (B) Chest x-ray showing a left flail chest with underlying lung contusion.
  21. 21. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment - Simple pneumothorax is accumulation of air within the pleural space producing a collapsed lung. -Air leak is secondary to a fractured rib penetrating the lung or stab wound through the parietal and visceral pleura. -Hyper resonance on the affected side on percussion -Decreased breath sounds on the affected side on auscultation -Dx is made by CXR, provided hemodynamics are stable. -Chest tube placement is appropriate Simple Pneumothorax
  22. 22. CHEST TRAUMA-Blunt Simple Pneumothorax
  23. 23. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -Though more common in penetrating wounds, open pneumothoraces may occur with blunt thoracic trauma also -Pathophysiology is similar to that of a tension pneumothorax however, the chest wall is compromised, and the pleural cavity is in communication with the atmosphere. -Since the negative intrathoracic pressure is lost, all dynamic lung mechanics are affected. -Intrathoracic pressures rise and can shift mediastinal components to the opposite side and ultimate cardiovascular decompensation. -Patients typically present with respiratory distress due to collapse of the lung on the affected side. Physical examination should reveal an obvious chest wall defect. -Auscultation reveals complete or near- complete loss of breath sounds. -Dx is made by physical examination and CXR -Sucking chest wound is treated by placing a three-way occlusive dressing over the wound to allow outfl ow of air with exhalation while preventing continued inflow of air with inhalation. -Intent is to prevent the rise of intrathoracic pressures in the affected hemithorax. -A chest tube is then placed. After initial stabilization, most patients undergo operation for defi nitive chest wall closure. Open Pneumothorax
  24. 24. CHEST TRAUMA-Blunt Open Pneumothorax
  25. 25. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -A tension pneumothorax is created when ongoing air leak allows continual ingress of air into the pleural space but not the egress. This accumulation of air compresses the lung and mediastinal structures. -Early findings include anxiety, dyspnea, tachypnea, tachycardia. -Diminished breath sounds and hyperresonance of the chest wall on the affected side may be present. -The typical patient will have hypoxia related to collapse of the ipsilateral lung and hypotension related to shifting of the mediastinum -The trachea may be deviated away from the side of the pneumothorax. JVD may be present. -Dx should be made by physical examination. Chest radiography should not be needed to identify a tension pneumothorax, and therapeutic intervention should not be delayed. -Immediate needle decompression of the chest with a 16- gauge angiocath in the second intercostal space, midclavicular line should be performed when a tension pneumothorax is suspected -Once accomplished, a chest tube is placed in a standard location Tension Pneumothorax
  26. 26. CHEST TRAUMA-Blunt Tension Pneumothorax
  27. 27. CHEST TRAUMA-Blunt Tension Pneumothorax Chest x-ray showing a large tension pneumothorax on the left side, mediastinal shift to the opposite side, and downward displacement of the left hemidiaphragm. Arrows point to tension pneumothorax. Tension pneumothorax on the CT scan (arrow). Note the deviation of the heart to the right.
  28. 28. CHEST TRAUMA-Blunt Tension Pneumothorax
  29. 29. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -Hemothorax following a blunt or penetrating wound to the chest can be caused by bleeding from any structure in the thorax: the intercostal arteries, the lung, the great vessels, or the heart. -Initial findings include anxiety, dyspnea, tachypnea, and tachycardia. -Diminished breath sounds and dullness to percussion are found over the affected hemithorax. -Massive hemothorax can produce signifi cant hemodynamic instability secondary to hemorrhagic shock. -By physical examination and CXR -When confronted with decreased breath sounds, place a chest tube. -Findings of 1,500 mL of blood initially, or more than 200 mL/hour for 2 to 4 hours, generally mandate a thoracotomy to control bleeding. -Witnessed loss of vital signs in the ED is an indication for ED thoracotomy -The possibility of subdiaphragmatic injury must also be considered HEMOTHORAX
  30. 30. CHEST TRAUMA-Blunt Hemothorax
  31. 31. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -Pericardium is a two- layered membrane surrounding the heart that normally contains 20 to 50 mL of fluid. Rapid accumulation of as little as 150 mL of fluid after trauma can produce cardiac tamponade and hypotension. -Traumatic sources of intrapericardial blood include chamber rupture, usually right- sided, because of the anterior orientation, or coronary artery laceration. -increasing pericardial pressures cause reduction in systemic venous return, diastolic filling, and cardiac output -If untreated, cardiac tamponade can produce cardiovascular collapse and death. Beck’s triad (arterial hypotension, venous hypertension, and muffled heart tones) is the classic presentation of tamponade. -Narrowing of pulse pressures and pulsus paradoxus, a change of greater than 10 mmHg in the systolic pressure between inspiration and expiration, may also be seen -Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea. -Dx is made by vital signs and by physical examination. -FAST scan may reveal pericardial fluid. -Echocardiography may used in stable patients. A surgical pericardial window may be required for diagnosis. -Cardiac tamponade is treated by pericardiocentesis if it is due to blunt trauma - If it is due to penetrating trauma operative exploration and repair of the source of bleeding should be done immediately -. Fluid resuscitation is needed to maintain preload and sustain cardiac output during transport to the OR. Cardiac Tamponade
  32. 32. CHEST TRAUMA-Blunt Cardiac Tamponade
  33. 33. CHEST TRAUMA-Blunt Cardiac Tamponade
  34. 34. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -Rapid deceleration or severe compression applied directly to the tracheobronchial tree are the usual causes of tracheobronchial Disruption -The viscera are crushed between the anterior chest wall and the posterior vertebrae -Most patients with severe tracheobronchial injuries die from airway obstruction or associated injuries before reaching the hospital. -Respiratory distress is the most notable finding in these patients, who are stridorous and unable to phonate -If a chest tube has been placed, there is usually a massive air leak. Pneumothorax and subcutaneous emphysema are almost universally present. -If the patient survives the initial assessment, CXR and/or CT will usually identify this major injury. -Bronchoscopy may be required in the subacute setting to evaluate less pronounced injury. -Laboratory studies are rarely useful. - Surgical tx is required since blunt tracheal injuries are immediately life threatening and will not heal without repair. -If the airway is compromised, endotracheal intubation should be performed. Flexible bronchoscopy may permit the tube to be guided distal to the site of injury. -An emergent surgical airway may be needed if conventional endotracheal tube placement fails. Tracheo-Bronchial Tree Disruption
  35. 35. CHEST TRAUMA-Blunt Tracheo Bronchial Tree Disruption Tracheobronchial tree showing complete transection of the right intermediate bronchus (two-way arrow). (Courtesy of Dr Montserrat Bret, University Hospital La Paz, Madrid)
  36. 36. CHEST TRAUMA-Blunt Rib Fractures Etiopathogenesis Clinical Features Diagnosis Treatment -Traumatic rupture of the aorta should be suspected in any patient sustaining blunt chest trauma in association with deceleration injury. -Although the proximal descending aorta is most commonly involved at the ligamentum arteriosum where it is fixed, other areas may be involved as well by mechanisms such as compression between bony fragments or temporary brief intraluminal hypertension. -Physical findings may include infrascapular murmur, upper extremity hypertension, and unequal blood pressure or pulses in the extremities. -Findings on CXR include mediastinal widening greater than 8 cm, obliteration of the aortic knob, depression of the left main-stem bronchus, apical pleural cap, or simply “a funny Looking mediastinum -a normal CXR does not r/o the injury. -CT, CT angiography, MRI, are all variants of screening modalities and will show a mediastinal hematoma. These tests have not been validated for areas of the thoracic aorta other than the proximal descending portion -Aortography remains the gold standard for dx. In a patient with an obvious mediastinal hematoma on CXR,aortography should be performed. - Hemodynamically unstable patients with a dx established by aortography require prompt surgical attention if attempts at resuscitation have not stabilized VS. -In stable patients, permissive hypovolemia and aggressive minimization of the dP/dT are important principle of care -In selected patients, stent grafting of aortic tears may be preferred over open surgical repair Traumatic Rupture Of Aorta
  37. 37. CHEST TRAUMA-Blunt Traumatic Rupture Of Aorta
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CHEST INJURY- BLUNT/ Trauma Surgery Dear viewers, Greetings from “Surgical Educator” Today I have uploaded a video on CHEST INJURY- BLUNT- an important topic in trauma. Even the blunt chest trauma can turn into penetrating one because of jagged edges of the broken ribs. I haven’t talked elaborately but have included the essential minimum an undergraduate medical student should know. I have talked about pathophysiology, clinical approach, symptoms, signs, investigations, different individual types of Chest injuries and management of all the varieties of Chest injuries. My aim is, after watching this video all of you should be able to arrive at a correct working diagnosis of the type of chest injury and should also be able to institute immediate lifesaving treatment to the patients if there is a need. You can watch the video in the following links: surgicaleducator.blogspot.com youtube.com/c/surgicaleducator Thank you for watching the video.

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