Chest trauma

Chest trauma

30 yo male

M: Driver in 80 kph head on collisionRestrained

I: Chest wall & sternal pain, leg injuries S: 140/80 110bpm sats 90% T: 15 mg IV morphine, Oxygen

Arrives in ED moaning, disorientated, splint on leg, hard collar on neck

High flow oxygen

Chest trauma The key to effective trauma management is to minimize the time to

definitive management so the initial management should be focused and abbreviated

List significant differential diagnosis in chest trauma Inspection;

Retractions Symmetrical chest wall expansion Wounds, flail segments

Palpation; Chest wall tenderness crepitus Subcutaneous emphysema Position trachea

Auscultation Very difficult in ED room; low sensitivity but good specificity Determine absence / asymmetry of breath sounds

JVP (difficult to ascertain in neck collars and low in low volume states Absence of pain, tenderness and auscultatory abnormalities in the

patient with normal mental status has a NPV near 100%

Chest trauma

Soon after arrival

100/70, PR 130, sats 92% on oxygen mask, skin dusky

What would you do and what are you looking for?

Chest trauma

Pneumothorax

how reliable is the clinical examination?

how reliable is the trauma CXR?

how is a tension pneumothorax treated?

what do we do with occult PTx on CT?

how do we treat stab wound to the chest?

Chest traumaPneumothorax - simple

- open- tension

Cause - Sudden increase in intra thoracic pressure - Rib fractures lacerate the lung - Deceleration injury tears the lung - Blunt force disrupts the alveoli

Examinationuniversal finding - chest pain. Respiratory distresscommon (50-7% - tachycardia, ipsilateral decreased air entryinconsistent(<25%)- low sats, tracheal dev, hypotensionrare (10%) - cyanosis, hyperresonance, drowsy

- ipsilateral; hyper-expansion, hypo-motility

Tracheal deviation is inconsistent and poorly predictive

In the ventilated patient; rapid onset drop in saturations and blood press

Chest trauma

CXR supine misses 30 - 50% the supine AP CXR is much less sensitive (75%)than the erect CXR Air accumulates in the anteromedial recess abnormal hyperlucency in lower chest/upper abdomen as air collects

in the anterior costo-phrenic abscess Sub-pulmonary air collection or hyperlucency Deep sulcus sign; abnormally deep and lucent costophrenic angle.

Ant PTx Unusually well defined mediastinal structures because of postero-

medial air Depression of hemi-diaphragm

U/S (more sensitive than CXR >90%)

ultrasound

Chest trauma Tension pneumothorax

Any patient you clinically suspect of having tension PTx and in distress, is hypoxic or hypotensive decompress urgently without radiologic confirmation

(sats < 92% on O2, syst < 90, RR < 10, drowsy, cardiac arrest)mortality is 4 fold in intubated patients if thoracotomy is delayed waiting for CXR

Needle thoracotomy14# cannula in 2/3 ICS MCL. however, up to ⅓ patients have a thicker chest wall than cannula lengthcan use 4/5 ICS MAL if chest wall too thickfollow by insertion of a chest tube

Wait for CXR confirmation in stable patients (with PTx) Confirms diagnosis and may prevent unnecessary thoracostomy May reveal diaphragmatic rupture which would make thoracostomy

dangerous

what would happen if we inserted a L sided chest tube?

tension pneumothorax

Chest trauma

Occult pneumothorax; diagnosed by CT in 2 – 8 % 20% will require tube thoracostomy

When do we treat occult pneumothorax?guidelines for thoracostomy 1. > 5×80mm

2. associated rib fractures 3. requiring future positive pressure ventilation 4. multiple injuries, haemorrhagic shock, brain injury

What do you do if you elect to do nothing? repeat CXR in 6 and 24 hours

stabbing Most are clinically stable on arrival 15% require operative management ‘normal CXR’ require repeat in 6 hrs Injury to ‘cardiac box’ = clavicle-costal margin

between midclavicular lines Less than 25% make it to hospital; of which 41% present haemodynamically stable CXR; 59% widened mediastinum

27% haemothorax CT; replacing angiogram, shows trajectory

10-30% involve the abdomen; when wound is below 4th nipple

Chest trauma

58 yo male motorbike rider hit by truck from behind

Complaining of chest pain, no LOC 120 bpm, 140/90, RR 28, sats 94% on 8L O2

Chest trauma Haemothorax

clinical Decreased chest expansion, decreased breath sounds (dull to percussion)CXR (sens 50%, spec 90%)

moderate size: >400-500 mls blood to detect on supine CXRdiffuse non-segmental opacification through which lung markings can be

seen, large size >1500mlsground glass appearance on CXRhaemodynamic compromise from blood loss and mediastinal shift

U/S ( sens 90%, spec 95%)

tube thoracostomylung re-expansion will tamponade bleedplace ICC posteriorly unless there is a pneumothorax as well10-15% require thoracotomythoracotomy if stable and bleeds>200mls/hr or >1500ml in total

if unstable and bleeds>100mls/hr or > 100ml in total no improvement in haemothorax will require a second ICC

antibiotics prob not required if adequate drainage of haemothorax and sterile technique used

Chest trauma – rib# Compression or shearing of the lung parenchyma leads to localized disruption

of the alveolar capillary membrane and lung interstitium. Blood leaking out into the interstitium

50% rib fractures undetectable radiologically Rib fractures cause severe pain, delayed morbidity and mortality that leads to

pneumonia Chest wall injury; ⅓ have pulmonary complications

30% pneumonia ↑rib#s → ↑mortality esp>3-4 ribs (13% mortality)

age; > 65yo mortality (8 vs 61%)(Bulger) each additional rib# increases mortalityby 19% elderly patients with rib fractures should be admitted

concurrent ≥ 2 extra-thoracic injuries ↑↑ mortality Blunt chest injury treatment;

pain control (epidural analgesia better outcome, esp if > 4 rib# and > 65yo) chest physio mobilisation Unnecessary IV fluid administration should be meticulously avoided

Rib #

1st and 2nd rib# may indicate severe neurovasc injuries

most common in ejected MVA victims Lower rib#s may indicate -abdo injuries

diaphragmatic injuries Admit ≥ 3 rib#s, underlying resp disease, complications (pneumo,

heamo, pul contusion), pain not controlled (must be able to deep breathe and cough), unable to cope at home, elderly

Sternal fractures; ECG

troponin; not routinely required unless haemo unstable

1. Deep sulcus

2. Widened mediastinum, obscured aortic knuckle, opacified aorto-pul window

3. R side Contusion

4. L Haemothorax

5. 7 – 10 R rib#

Chest trauma

52 yo male Hit by car travelling at 70 kph Brief LOC, chest pain 120 bpm, 100/70, sats 90%

You are the doctor completing the primary survey

Chest trauma Flail chest

most severe form of blunt chest trauma; mortality 10-20% Poor outcome is due to the underlying pulmonary contusion Causes long term chest wall pain and exertional dyspnoea Advances in knowledge and ICU techniques over the last 3 decades

have not impacted on mortality Management

Unnecessary IVF infusion should be avoided Obligatory mechanical ventilation should be avoided (Trinkle)

(intubate to improve gas exchange and not for mechanical correction) Optimal analgesia (epidural) Chest physio CPAP works (Tanaka, Gunduz) Surgical fixation worked in old studies not comparing new techniques

Cardiac echo

Blunt Cardiac Injury Sustained from rapid deceleration with direct blow to the

chest Suspect with mechanism or poor cardiovascular response to

their injury Difficult diagnosis

Chest pain or SOB Chest wall tenderness, flail, crepitus Sinus tachy, arrhythmia, pump failure

No single or combination of test reliably diagnoses it Normal ECG in stable patient with blunt chest trauma

essentially rules out significant risk of blunt myocardial injury Cardiac echo for unexplained hypotension, ECG changes or

pump failure Troponin has no important clinical value in diagnosis of BCI

Blunt aortic injury Mainly MVA, pedestrian, falls, impact from any direction Second most common cause of death in blunt injuries; 85% die pre-hospital CXR can be used as a initial screening tool (98% NPV if normal)

Widened mediastinum most common trigger for additional workup to exclude BAI

supine 10cm, PA 8cm and mediastinal/chest ratio 0.38 (at level or aortic arch) Other signs; obscured or indistinct aortic knob

depression L main bronchusdeviation NGTopacification aorto-pul windowdisplaced L parasternal stripefracture 1st rib, apical cap

CXR may be normal in 25% Screen with CTA; 100% NPV Angiography; gold standard and may be used when CT equivocal Requires immediate repair unless there are more urgent issues requiring

laparotomy or craniectomy Endoluminal stent or surgical repair (complication; spinal cord ischaemia or renal

failure) Treat hypertension to reduce shearing forces with b -blockers