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Thoracic trauma presentation
- 2. INTRODUCTION Thoracic trauma 25% all injury related deaths Contributory factor in further 50% (hypoxia, hypovolaemia) To lung and pleura low (<1%) Cardiac involvement increases by 20%! Approx. 85% can be treated successfully without need for surgical intervention However; important to realise that patients often have OTHER injuries (particularly to the head), which contributes to the high overall mortality
- 3. THORACIC TRAUMA • Blunt / Penetrating / Both • Majority may require simple procedures (eg. Thoracostomy tube) • Minority require urgent surgical exploration due to bleeding • Most life-threatening injuries can be identified in the primary survey • Repeated / serial examination and use of adjuncts important, as initial normal examination does not exclude
- 4. PRIMARY SURVEY ATOM FC 1. Airway obstruction / disruption 2. Tension pneumothorax 3. Open chest wound / open pneumothorax 4. Massive haemothorax 5. Flail chest 6. Cardiac tamponade Physical examination • Look (RR & depth) • Wall asymmetry, paradoxical movement • Bruising, seat belt / steering wheel, penetrating wounds • Feel tracheal deviation, adequate & equal chest wall movement • Chest wall tenderness, rib ‘crunching’ indicating # • Surgical emphysema • Listen breath sounds • Both sides! • Percuss for dullness / resonance
- 5. TREAT LIFE THREATENING INJURIES AS THEY ARE IDENTIFIED
- 7. SECONDARY SURVEY 1. Rib # and flail chest 2. Pulmonary contusion 3. Simple pneumothorax 4. Simple haemothorax 5. Blunt aortic injury 6. Blunt myocardial injury
- 8. ADJUNCTS Monitoring • BP / Pulse • Oxygen saturation • End-tidal CO2 (if intubated)
- 9. ADJUNCTS Diagnostic • CXR • FAST USS • ABG Interventions • Chest drain • ED Thoracotomy • Transfer to critical care area for ventilation / observation Further investigation may include • CT scan • Angiography • Bronchoscopy • Oesophagoscopy / oesophagram
- 11. R
- 12. AIRWAY OBSTRUCTION / DISRUPTION Loss of upper airway muscle tone, usually due to a reduced conscious level The presence of blood, vomit or foreign bodies Trauma to the face or neck Chest trauma compromises respiratory function Need for ventilation (traumatic brain injury) Airway at risk of swelling (burns, c-spine fractures, subcutaneous emphysema Laryngeal spasm Bronchospasm
- 13. SOUNDS Breath sounds Snoring Inspiratory stridor / crowing Expiratory wheeze Gurgling
- 16. BASIC TECHNIQUES • Chin lift • Jaw thrust
- 17. ADJUNCTS • Oropharyngeal airway (Guedel) • Nasopharyngeal airway • Supraglottic airway devices • Laryngeal mask airway (LMA) • I-gel • Laryngeal tube (LT) • Orotracheal intubation • Surgical airway • Needle or surgical cricothyroidotomy • Mechanical ventilation
- 19. TENSION PNEUMOTHORAX • ‘One way’ valve • Gas on inspiration • Pressure increases rapidly • Atelectasis • Diaphragm flattened • Hemi-thorax distended • Mediastinal shift Hypoxaemia reduced cardiac output hypotension Increased sympathetics adrenaline discharge tachycardia and vasoconstriction
- 22. MANAGEMENT Immediate chest decompression Lateral thoracostomy Insertion of chest drain Bilateral may be necessary if you get bilateral tension?! (or if in doubt, a situation which can arise in the suddenly decompensating, intubated and ventilated patient) Needle decompression (thoracocentesis) should be considered a last resort (14g cannula, 2nd intercostal space, midclavicular line) Open procedure; blunt dissection 5th intercostal space 1cm anterior to mid-axillary line Complications: Haematoma, intercostal neurovascular injury, thoracic and abdominal visceral injury, infection Tube malposition (ie. Not in pleural cavity) or slippage
- 23. MANAGEMENT
- 25. OPEN CHEST WOUND / OPEN PNEUMOTHORAX ‘Sucking chest wound’ – may develop tension Overlying dressing? (1 way adhesive seal to permit gas / blood to escape, and preventing air to re-enter) – this is to buy time, not definitive! Rarely occurs in ventilated patients, as pressure within lungs is positive, which keeps them inflated 100% oxygen; occlusive dressing; place intercostal drain
- 26. MASSIVE HAEMOTHORAX (…HOW MASSIVE?) Small – will not be detectable by physical examination More likely - CXR / CT / FAST How much blood does it take to occlude the costo-phrenic angle on a CXR? (ie. A fluid level)
- 27. …400-500 MLS Hypovolaemic shock Hypoxia Dull percussion Decreased breath sounds ‘Unilateral whiteout’ (supine) IV warmed fluid resuscitation, major haemorrhage protocol, autotransfusion
- 29. THORACIC CAGE INJURIES Trauma; rib #’s (ribs 1, 2, 11, 12 protected, often escape #) Crush injuries, penetrating chest wounds (gunshot / stab) Clavicular, scapular # indicates high energy transfer Pain caused by rib #’s can be intense (expansion and contraction of rib cage during respiration), sometimes requiring palliation by anaesthetising the intercostal nerve (nerve block) Paradoxical movement (Flail chest)
- 30. FLAIL CHEST 2 or < adjacent ribs # @ 2 or < places Tender, crepitus, shallow rapid breathing High-flow, warmed & humidified Oxygen Cautious fluid resuscitation (overload / pulmonary oedema) Analgaesia (IV opioids) allowing maximal movement
- 32. INDICATIONS For tracheal intubation and ventilation in cases of flail chest: Oxygen • Falling PaO2 or PaO2 <7 kPa (55 mmHg) breathing air • PaO2 <10 kPa (75 mmHg) on high flow oxygen Carbon dioxide • Increasing PaCO2 or >6 kPa (45 mmHg) Respiratory rate • Exhaustion (RR <8 r/min) • Tachypnoea (RR >30 r/min) • Associated injuries compromising ventilation
- 35. DANGER BOX
- 36. MECHANISM Penetrating injury bleeding in pericardium laceration seals with clot Only small mls restricts ventricular filling reduces preload / stroke volume HR increases initially to compensate as does perfusion pressure (increases peripheral vascular resistance) Leads to profound hypotension reduced coronary perfusion myocardial injury death
- 37. BECK’S TRIAD 1. Hypotension 2. Raised JVP (distended veins) 3. Decreased heart sounds • Pulsus paradoxus (>10 mmHg fall in pressure during inspiration) • Kussmaul’s sign (raised JVP on inspiration) Only seen in 1/3rd of patients Sonography / echo best diagnostic
- 39. INITIAL MANAGEMENT Augment venous return Raise patient’s leg (if possible) Rapid IV fluid infusion Surgical evacuation of clot / repair of cardiac laceration (via median sternotomy) If urgent, thoracotomy in ED can be effective Pericardiocentesis should be considered only if expertise not available and patient is dying
- 48. PITFALLS • Simple pneumothorax tension pneumothorax • Retained haemothorax • Diaphragmatic injury • Severity of rib fractures / pulmonary contusion • Elderly people • Think: airway, gas exchange, perfusion, circulation…
- 49. You are the radiologist on call and are asked to interpret this chest x-ray of a 56 year old male who presented to the trauma bay after being struck by a motor vehicle while riding his bike home from work.
- 50. D) LEFT PNEUMONECTOMY ‘looks like he’s missing a lung’ Explanation • Total opacification should prompt DDx • Atelectasis • Pleural effusion • Pneumonia • Haemothorax • Pneumonectomy (removal of lung tissue)
- 51. WHAT ELSE Pulmonary contusion / laceration Blunt cardiac injury Pneumomediastinum Ruptured diaphragm Traumatic disruption of aorta Ruptured oesophagus
- 52. TOPICS 1. Cardiothoracic trauma 2. Chest wall trauma 3. Lung injuries 4. Tracheobronchial injuries 5. Diaphragmatic injuries 6. Blunt injuries to the heart 7. Trauma to great vessels 8. Oesophageal and thoracic duct injuries
- 53. QUESTIONS
Notas del editor
- Mechanism of injury is important in so far as blunt and penetrating injuries have different pathophysiologies and clinical courses. Most blunt injuries are managed non-operatively or with simple interventions such as intubation and ventilation and chest tube insertion. Diagnosis of blunt injuries may be more difficult and require additional investigations such as CT scanning (when the patient is STABLE). In contrast, penetrating injuries are more likely to require operation, and complex investigations are required infrequently. Patients with penetrating trauma may deteriorate rapidly, and recover much faster than patients with blunt injury.
- The assessment should ideally be a TEAM approach, with a designated leader, and members assigned to each of the above, with A personnel being capable skill’s wise with intubation and ventilation, and C person being able to perform fast scan, that kind of thing. Disability should be assessed with A who should ideally be communicating with a conscious patient.
- Chest fully examined, front and BACK. Special attention is paid to identifying any missed injuries or progression of previously identified injuries. The examination is also directed by findings on CXR or by info from monitoring adjuncts.
- Ox Sats – Non invasive, continuous, assessment of arterial Hb O2 sat. Should be used for all resuscitation / trauma patients End-tidal CO2 – should be used in all INTUBATED trauma patients. It is only definitive method of confirming placement of tracheal tube. Other methods, such as watching for chest wall movement and listening to breath sounds or for air in stomach are inaccurate, especially in hectic resus rooms. Also allows for estimation of arterial PaCO2 level, and for continuous monitoring. Important for all mechanically ventilated patients, and vital for patients with traumatic brain injury. (Oxygen dissociation curve; http://www.frca.co.uk/article.aspx?articleid=100345) (Capnogram; http://www.paramedicine.com/pmc/End_Tidal_CO2.html)
- CXR – plain AP remains standard initial investigation Blunt – portable CXR in trauma room; rapid screening tool. Taken in supine position, as unstable spinal fractures not ruled out at this stage; need slight over-penetration to allow better visualisation of thoracic spine, paraspinal lines and aortic outline Penetrating – stab wound which may have violated thoracic cavity or mediastinum should have CXR, this means anybody stabbed between neck and umbilicus (front, back or sides) Bullets – especially if bullet track is unclear, missing bullet or odd number of exit / entry wounds. Taken with patient upright (if possible) as increases sensitivity for detecting pneumo/haemothorax or diaphragm injury FAST – Focused Abdominal Sonography for Trauma looks for BLOD (peritoneum, peicardium or hemithoraces; indicated in all haemodynamically unstable blunt trauma patients (and some with penetrating) ABG – especially if intubated and ventilated patients, and any with significant chest injury or evidence of haemodyanamic instability
- Size of injury, position of patient will affect clinical findings Eg. Small haemothorax – no findings at all Moderate haemothorax – dull to percussion with absent breath sounds at bases in erect pt Note how collapsed lung can mimic tension pneumothorax on THE OTHER SIDE (common error!) – usually occurring when tracheal tube has been incorrectly placed in the right main bronchus, obstructing the right upper lobe bronchus, leading to collapse of the right upper lobe and shift of trachea to the right. The left chest appears to be hyper-resonant compared to the left, and breath sounds difficult to determine (thus like image, patient may end up with unnecessary chest drain).
- Note how collapsed lung can mimic tension pneumothorax on THE OTHER SIDE (common error!) – usually occurring when tracheal tube has been incorrectly placed in the right main bronchus, obstructing the right upper lobe bronchus, leading to collapse of the right upper lobe and shift of trachea to the right. The right chest appears to be hyper-resonant compared to the left, and breath sounds difficult to determine (thus like image, patient may end up with unnecessary chest drain). http://www.trauma.org/archive/imagebank/chest/images/chest0036.html
- Breath sounds – on auscultation, air entry will be diminished Snoring – arises when the pharynx is partially occluded by the tongue or palate Inspiratory stridor / crowing – caused by obstruction at the laryngeal level or above (ie. Laryngeal spasm) Expiratory wheeze – suggests obstruction of the lower airways, which tend to collapse and obstruct during expiration Gurgling – suggests the presence of liquid or semisolid foreign material in the upper airways
- CXR signs of ruptured airway Pneumomediastinum – visualised as linear air density shadows tracking along tissue planes of the mediastinum Surgical emphysema Collapse of lung or lobe Pneumothorax
- Chin lift – grasps patients chin & lifts mandible Complications – failure, loss of airway on release Pitfalls – insufficient force used to lift mandible Jaw thrust – upwards and forwards pressure at angles of mandible Complications – movement of C-spine, loss of airway on release, may worsen obstruction if mandible is #’d Pitfalls – failure to clear airway, failure to recognise inadequate oxygenation / ventilation
- Complications / pitfalls Backward displacement of tongue exacerbating obstruction, assuming a patent airway means oxygenation, patients level of consciousness prevents insertion Bleeding, vomiting due to gag reflex if too long, do not use of base of skull # Failure to insert as pushed ‘up’ patients nose, rather than long floor of nose Leak around mask, gastric insufflation, inadequate or excessive ventilation, exacerbation of injury due to use of excessive force Presence of C-spine collar means technically difficult to perform without anaesthetic help
- Any signs of cardiovascular compromise requires rapid decompression of the chest. This can occur suddenly and without warning and for this reason a team member should stay with the patient whilst the x-ray is being taken.
- Ipsilateral hyper-expansion Lung collapse Hemi-diaphragmatic depression Increased separation of ribs Increased thoracic volume Loss of lung markings (Possibly reduced heart sounds?)
- Surgical emphysema, sounds? / feels like crackling under the skins surface
- Common pit falls; misinterpreting the absence of air leak as a sign that the pneumothorax has been treated; cannula may block or kink, and could have failure to reach pleural cavity with needle (esp. in muscular men or fat people)
- Lateral thoracostomy can be done with a repeated finger sweep to exclude re-accumulation of the tension should patient deteriorate again (Don’t assume this is what is happening, something else might be going on, especially in a trauma patient!)
- Open chest wound / open pneumothorax
- 1.5 litres blood in the thoracic cavity Dual pathology – hypoxia and hypovolaemia 400-500 mls
- Be warned; chest drain insertion may dislodge clots and cause further bleeding, important to ensure adequate venous access for volume resuscitation achieved simultaneously. Chest drainage will improve respiratory function Most patients need surgery to control bleeding (definitive management) NEVER clamp chest tube as blood that is evacuated is already lost from circulation and preventing drainage will not contribute to the reduced blood loss by a tamponade effect
- Injuries to the chest wall can result in fractured ribs (injuries to 1, 2, 11, 12 suggest high mechanism of injury; suspect abdominal pain in ribs 10-12). These are extremely painful during normal respiratory movements, and especially when coughing or sneezing. More serious injuries to the chest wall that involve fractures to several ribs can result in a large portion of the chest wall moving freely. In this situation the ‘free’ section moves inwards on inspiration and outwards on expiration – there is said to be paradoxical movement of this portion of the rib cage (flail chest). This impairs ventilation seriously and affects oxygenation of the patient, thus free-moving sections must be fixed so they cannot compromise respiration in this way
- May not be initially obvious in young adult where muscles splint the fractured ribs; in these situations paradoxical movement will be apparent only if the victim becomes exhausted, the flail is large (>6 ribs) or is central (involving sternum). Intercostal blocks, epidural analgaesia and opioid / ketamine infusions or patient-controlled analgaesia should be considered later during the secondary survey, depending on the expertise available. Some patients require tracheal intubation and controlled ventilation.
- Massive pericardial effusion causes triad: Tachycardia Low voltage (caused by ‘damping’ effect of increased layers of fluid, fat or air between heart and electrode, or loss of viable myocardium) Electrical alternans (when consecutive, normally-conducted QRS complexes alternate in height, and is produced by the heart swinging backwards and forwards within a large fluid-filled pericardium) Eventually PEA
- Suspect in any victim with penetrating wound, neck or upper abdomen. Particularly dangerous site is the central chest area from clavicles xiphisternum / between right nipple and left lateral chest wall (described as the ‘danger box’) Can be seen in blunt trauma in patients on anticoagulants or antithrombotic drugs
- Subxiphisternal needle aspiration High degree of suspicion that tamponade is present (sonography) Patient in extremis (about to die) Blood clots in sac, thus chance of negative tap when tamponade still exists False positive when aspiration penetrates coronary arteries / ventricle Axial CT (http://radiopaedia.org/cases/pericardiocentesis-1)
- Cardiogenic shock
- Pulmonary contusion / laceration
- Blunt cardiac injury
- Continuous diaphragm sign – the entire diaphragm is visualised from one side to the other because air in the mediastinum outlines central portion which is NORMALLY obscured by heart and soft tissue structures / red arrow points to air
- Diaphragmatic rupture Most diagnosed on the left Blunt / Large tears
- Disruption of aorta / ruptured oesophagus Needs aortography or helical CT Rapid acceleration / deceleration mechanism Blunt oesophageal injury – pain / shock is out of proportion to injury (received severe blow to epigastrium, forceful expulsion of gastric contents into oesophagus) Contrast swallow / particulate matter in chest tube would reveal problem, or oesophagoscopy (wide drainage of pleural space needed with operative repair of injury)
- Petechiae / Swelling / Plethora (above nipples) / Cerebral oedema (Temporary compression of superior vena cava), venous return impaired from upper torso / head Most mild with recovery after weight removed and head elevated
- Application of dressing over wound associated with a simple may produce tension Attention to chest tube placement and thorough evacuation of pleural space important to reduce risk of retained haemothorax / infection Pain relief to avoid complications from rib fractures Elderly with comorbidities are at high risk of complications if adequate ventilation / expansion not maintained
- Left haemothorax incorrect, as trachea and heart would be expected to be shifted to the right in absence of other pathology Right pneumothorax incorrect because there are visible lung markings at periphery Ruptured left diaphragm is incorrect because whilst obscured, left hemidiaphragm one would expect stomach and or bowel to herniate into chest