Management of Thoracic Trauma

By

Dr.Imran Sadiq

Introduction

• Motor Vehicle Accidents/Road Traffic Accidents are one of the leading cause of death among young age (16---44yrs) in KSA.

• 17 persons are died daily due to MVA in KSA.• Thoracic Trauma accounts for 25% of deaths related to

Trauma.• 2/3rd of these deaths occur after reaching the hospital.• Abdominal injuries are commonly associated with

Thoracic Trauma.• About 70% of patients of Poly Trauma have Major

Thoracic Trauma.

Objective of Presentation

• To provide sufficient knowledge & information that one can recognize and manage Thoracic Trauma effectively and efficiently to minimize that 2/3rds of deaths that occur after reaching the Hospital.

Anatomy and Physiology of the Thorax

• Thoracic Skeleton– 12 Pair of C-shaped ribs

• Ribs 1-7: Join at sternum with cartilage end-points• Ribs 8-10: Join sternum with combined cartilage at 7th rib• Ribs 11-12: No anterior attachment

– Sternum• Manubrium

– Joins to clavicle and 1st rib– Jugular Notch

• Body– Sternal angle (Angle of Louis)

» Junction of the manubrium with the sternal body» Attachment of 2nd rib

• Xiphoid process– Distal portion of sternum

• Diaphragm

– Muscular, dome-like structure

– Separates abdomen from the thoracic cavity

– Affixed to the lower border of the rib cage

– Central and superior margin extends to the level of the 4th

rib anteriorly and 6th rib posteriorly

– Major muscle of respiration• Draws downward during inspiration

• Moves upward during exhalation

• Associated Musculature

– Shoulder girdle

– Muscles of respiration• Diaphragm

• Intercostal muscles– Contract to elevate the ribs and increase thoracic diameter

– Increase depth of respiration

• Sternocleidomastoid– Raise upper rib and sternum

• Physiology of Respiration– Changing pressure assists:

• Venous return to heart• Pumping blood to systemic circulation

– Inhalation• Diaphragm contracts and flattens• Intercostals contract expanding ribcage• Thorax volume increases

– Less internal pressure than atmospheric– Air enters lungs

– Exhalation• Musculature relaxes• Diaphragm & intercostals return to normal

– Greater internal pressure than atmospheric– Air exits lungs

• Trachea, Bronchi & Lungs

– Pleura• Visceral Pleura

– Cover lungs

• Parietal Pleura

– Lines inside of thoracic cavity

• Pleural Space

– POTENTIAL SPACE

» Air in Space = PNEUMOTHORAX

» Blood in Space = HEMOTHORAX

– Serous (pleural) fluid within

» Lubricates & permits ease of expansion

• Mediastinum– Central space within thoracic cavity– Boundaries

• Lateral: Lungs• Inferior: Diaphragm• Superior: Thoracic outlet

– Structures• Heart• Great Vessels• Esophagus• Trachea• Nerves

– Vagus– Phrenic

• Thoracic Duct

• Great Vessels

– Aorta• Fixed at three sites

– Annulus

» Attaches to heart

– Ligamentum Arteriosum

» Near bifurcation of pulmonary artery

– Aortic hiatus

» Passes through diaphragm

– Superior Vena Cava

– Inferior Vena Cava

– Pulmonary Arteries

– Pulmonary Veins

• Esophagus

– Enters at thoracic inlet

– Posterior to trachea

– Exits at esophageal hiatus

Pathophysiology of Thoracic Trauma

• Blunt Trauma– Results from kinetic energy forces– Subdivision Mechanisms

• Blast– Pressure wave causes tissue disruption– Tear blood vessels & disrupt alveolar tissue– Disruption of tracheobronchial tree– Traumatic diaphragm rupture

• Crush (Compression)– Body is compressed between an object and a hard surface– Direct injury of chest wall and internal structures

• Deceleration– Body in motion strikes a fixed object– Blunt trauma to chest wall– Internal structures continue in motion

» Ligamentum Arteriosum shears aorta

– Age Factors• Pediatric Thorax: More cartilage = Absorbs forces• Geriatric Thorax: Calcification & osteoporosis = More fractures

• Penetrating Trauma– Low Energy

• Arrows, knives, handguns

• Injury caused by direct contact and cavitation

– High Energy• Military, hunting rifles &

high powered hand guns

• Extensive injury due to high pressure cavitation

• Penetrating Injuries (cont.)

– Shotgun• Injury severity based upon the distance between the victim and

shotgun & caliber of shot

• Type I: >7 meters from the weapon

– Soft tissue injury

• Type II: 3-7 meters from weapon

– Penetration into deep fascia and some internal organs

• Type III: <3 meters from weapon

– Massive tissue destruction

• Open Pneumothorax– Free passage of air between atmosphere and pleural space– Air replaces lung tissue– Mediastinum shifts to uninjured side– Air will be drawn through wound if wound is 2/3 diameter

of the trachea or larger– Signs & Symptoms

• Penetrating chest trauma• Sucking chest wound• Frothy blood at wound site• Severe Dyspnea• Hypovolemia

• Hemothorax

– Accumulation of blood in the pleural space

– Serious hemorrhage may accumulate 1,500 mL of blood• Mortality rate of 75%

• Each side of thorax may hold up to 3,000 mL

– Blood loss in thorax causes a decrease in tidal volume• Ventilation/Perfusion Mismatch & Shock

– Typically accompanies pneumothorax• Hemopneumothorax

• Pulmonary Contusion– Soft tissue contusion of the lung

– 30-75% of patients with significant blunt chest trauma

– Frequently associated with rib fracture

– Typical MOI• Deceleration

– Chest impact on steering wheel

• Bullet Cavitation– High velocity ammunition

– Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar tissue• Progressive deterioration of ventilatory status

– Hemoptysis typically present

• Myocardial Contusion

– Occurs in 76% of patients with severe blunt chest trauma

– Right Atrium and Ventricle is commonly injured

– Injury may reduce strength of cardiac contractions

• Reduced cardiac output

– Electrical Disturbances due to irritability of damaged myocardial cells

– Progressive Problems

• Hematoma

• Hemoperitoneum

• Myocardial necrosis

• Dysrhythmias

• CHF & or Cardiogenic shock

Myocardial Contusion Signs & Symptoms

• Bruising of chest wall

• Tachycardia and/or irregular rhythm

• Retrosternal pain similar to MI

• Associated injuries– Rib/Sternal fractures

• Chest pain unrelieved by oxygen– May be relieved with rest

– THIS IS TRAUMA-RELATED PAIN• Similar signs and symptoms of medical chest pain

• Pericardial Tamponade

– Restriction to cardiac filling caused by blood or other fluid within the pericardium

– Occurs in <2% of all serious chest trauma• However, very high mortality

– Results from tear in the coronary artery or penetration of myocardium• Blood seeps into pericardium and is unable to escape

• 200-300 ml of blood can restrict effectiveness of cardiac contractions

– Removing as little as 20 ml can provide relief

Pericardial Tamponade Signs & Symptoms

• Dyspnea

• Possible cyanosis

• Beck’s Triad

– JVD

– Distant heart tones

– Hypotension or narrowing pulse pressure

• Weak, thready pulse

• Shock

• Kussmaul’s sign

– Decrease or absence of JVD during inspiration

• Pulsus Paradoxus

– Drop in SBP >10 during inspiration

– Due to increase in CO2 during inspiration

• Electrical Alterans

– P, QRS, & T amplitude changes in every other cardiac cycle

• PEA

• Traumatic Aneurysm or Aortic Rupture

– Aorta most commonly injured in severe blunt or penetrating trauma

• 85-95% mortality

– Typically patients will survive the initial injury insult

• 30% mortality in 6 hrs

• 50% mortality in 24 hrs

• 70% mortality in 1 week

– Injury may be confined to areas of aorta attachment

– Signs & Symptoms

• Rapid and deterioration of vitals

• Pulse deficit between right and left upper or lower extremities

• Other Vascular Injuries– Rupture or laceration

• Superior Vena Cava

• Inferior Vena Cava

• General Thoracic Vasculature

– Blood Localizing in Mediastinum

– Compression of:• Great vessels

• Myocardium

• Esophagus

– General Signs & Symptoms• Penetrating Trauma

• Hypovolemia & Shock

• Hemothorax or hemomediastinum

• Traumatic Esophageal Rupture

– Rare complication of blunt thoracic trauma

– 30% mortality

– Contents in esophagus/stomach may move into mediastinum• Serious Infection occurs

• Chemical irritation

• Damage to mediastinal structures

• Air enters mediastinum

– Subcutaneous emphysema and penetrating trauma present

• Tracheobronchial Injury– MOI

• Blunt trauma

• Penetrating trauma

– 50% of patients with injury die within 1 hr of injury

– Disruption can occur anywhere in tracheobronchial tree

– Signs & Symptoms• Dyspnea

• Cyanosis

• Hemoptysis

• Massive subcutaneous emphysema

• Suspect/Evaluate for other closed chest trauma

Traumatic Asphyxia

• Reddish-purple discoloration of the face and neck (the skin below the face and neck remains pink).

• Jugular vein distention.

• Swelling of the lips and tongue.

• Swelling of the head and neck.

• Swelling or hemorrhage of the conjunctiva (subconjunctival petechiae may appear).

• Hypotension results once the pressure is released.

• Scene Size-up• Initial Assessment• Rapid Trauma Assessment

– Observe• JVD, SQ Emphysema, Expansion of chest

– Question– Palpate– Auscultate– Percuss– Blunt Trauma Assessment– Penetrating Trauma Assessment

• Ongoing Assessment

• Ensure ABC’s– High flow O2 via NRB– Intubate if indicated– Consider RSI– Consider overdrive ventilation

• If tidal volume less than 6,000 mL• BVM at a rate of 12-16

– May be beneficial for chest contusion and rib fractures– Promotes oxygen perfusion of alveoli and prevents atelectasis

• Anticipate Myocardial Compromise• Shock Management

– Consider PASG• Only in blunt chest trauma with SP <60 mm Hg

– Fluid Bolus: 20 mL/kg– AUSCULTATE! AUSCULATE! AUSCULATE!

• Tracheobronchial Injury– Support therapy

• Keep airway clear• Administer high flow O2

– Consider intubation if unable to maintain patient airway• Observe for development of tension pneumothorax and SQ emphysema

• Traumatic Asphyxia– Support airway

• Provide O2

• PPV with BVM to assure adequate ventilation

– 2 large bore IV’s– Evaluate and treat for concomitant injuries– If entrapment > 20 min with chest compression

• Consider 1mEq/kg of Sodium Bicarbonate

• Traumatic Asphyxia– Results from severe compressive forces applied to the

thorax– Causes backwards flow of blood from right side of heart

into superior vena cava and the upper extremities– Signs & Symptoms

• Head & Neck become engorged with blood– Skin becomes deep red, purple, or blue– NOT RESPIRATORY RELATED

• JVD• Hypotension, Hypoxemia, Shock• Face and tongue swollen• Bulging eyes with conjunctival hemorrhage

FLAIL CHEST

Segment of chest wall that does not have

continuity with rest of thoracic cage

• Usually 2 fractures per rib in at least 2 ribs

• Segment does not contribute to lung expansion

• Disrupts normal pulmonary mechanics

• Accompanied by pulmonary contusion in 50% of patients

MYOCARDIAL CONTUSION

• Physical bruising of

the cardiac muscle

• Associated with

fractures of the

sternum

• Any severe anterior

chest injury

MYOCARDIAL CONTUSION

DIAGNOSIS:• Ectopy• ST elevation• Tachycardia• Friction rub• CPK enzymes, Troponin

Monitor in ICU & treat dysrhythmias• Serial enzymes• Analgesia

AORTIC RUPTURE

• CT with contrast

angiogram

• Contained injury

treat with BP control

• Operative repair

CARDIAC INJURY AND TAMPONADE

• Fatality rates > 80%

• Mostly ventricular, right > left

• Blood in pericardial sac causes

tamponade

• Occurs with penetrating injuries

DIAPHRAGM RUPTURE

•Associated with

blunt trauma or

blast injury

•Can be due to

stab wounds

DIAPHRAGM RUPTURE

• Surgical repair to replace herniated contents back into abdomen

• Close muscular diaphragm to restore pulmonary function

• Chest tube to treat pneumothorax

ESOPHAGEAL INJURY

Most due to penetrating trauma

Difficult to diagnosis

If delayed or missed, rapid sepsis & high

mortality

Radiography

Endoscopy

Thoracoscopy

Treatment: surgical repair via thoracotomy