Acute Chest Trauma

Acute Chest TraumaDr Anil KumarAssistant ProfessorDepartment of Surgical DisciplinesAll India Institute of Medical Sciences19/11/2015

Objective:Burden of Chest Trauma.

Types of chest trauma.

Background & Consequences/effect of chest injury

Basic Principle to manage chest Trauma.

Life threatening chest injuries

Role of X-Ray & E-FAST in chest trauma

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Burden of chest trauma:Chest trauma : 10- 15% of all the cases .

Responsible for 25% of death

The rising burden of serious thoracic trauma sustained by motorcyclist in road traffic crashes (Bambach MR,Mitchell RJ 2014 Jan;. Epub 2013 Oct 19)

The high burden of injuries in South Africa (WHO:Rosana Norman, Richard Matzopoulos, Pam Groenewald, Debbie Bradshaw)

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Types of Chest Trauma:Blunt

Penetrating

Explosion related

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Background:Significant cause of mortality.

Immediate cause of death: Myocardial injury, Aortic rupture

Can be preventable : Prompt Diagnosis & Treatment.

Thoracotomy : < 10 % of BTC & only 15-30 % of PTC.

Majority of Chest Trauma patient can be managed: simple intervention.

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Issues in chest Trauma: Hypoxia, Hypercarbia & AcidosisHypoxia: Inadequate delivery of oxygen to the tissue.

(A)Hypovolemia(Blood Loss)

(B)- Pulmonary ventilation/Perfusion mismatch e.g- Contusion, Hematoma & Alveolar collapse

(C)Change in ITP relationship e.g - Tension Pneumothorax - Open Pneumothorax

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Issues in chest Trauma : Hypoxia, Hypercarbia & AcidosisHypercarbia: Inadequate ventilation.

(A) Change in ITP relationship e.g - Tension Pneumothorax - Open Pneumothorax

(B) Dec Level of consciousness

Metabolic Acidosis: Hypo-perfusion of the tissu(Shock).

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Basic principle of Management:Primary survey

Resuscitation of vital functions

Adjunct of primary survey including CXR & E-FAST

Detailed secondary survey

Definitive care.19/11/2015

Primary SurveyAirway with cervical spine protection

Breathing and ventilationCirculation with Hemorrhage control

Disability: GCS

Exposure(Undress)/Events with Hypothermia control19/11/2015

InspectionPalpationPercussion

AuscultationDiagnosisRestricted Chest moveCCT=+/-Hyper-resonantB.S= Dec/ -Tension Pneumothorax.

Open woundCCT=+/-Hyper-resonantB.S=Dec/-Open Pneumothorax

Restricted chest moveCCT=+/-DullnessB.S=Dec/-Massive Haemothorax

Paradoxical movementAsymetryCCT=+Dull/HyperB.S=Dec/-Flail Chest with pulmonary contusion

Life threatening chest injuries:19/11/2015

Tension Pneumothorax One-way valve air leak

Air is forced to enter into the thoracic cavity without any means of escape

Completely collapsing the affected lung

Mediastinal shift & compressing the opposite lung19/11/2015

Tension Pneumothorax: EtiologyMechanical Ventilation with PPV in patients with visceral pleural injury.

CVP Insertion Iatrogenic Esophageal Endoscopy

Thoracic Spine #

Chest Trauma (15-50% of severe chest trauma)

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Tension Pneumothorax:Dx Absolutely clinical-Restricted Chest Movement-Absent Breath Sound-Hyper-resonant note on Percussion

Don't wait for radiological confirmation

Immediate do the needle thoracostomy/ICD ( Definitive t/t)

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T/t of Tension Pneumothorax:

Needle Thoracostomy in 2nd I.C.S in M.C.L.Chest tube insertion in 5th I.C.S in M.A.L.

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CXR - Pneumothorax.

JPNATC, AIIMS19/11/2015

How to read CXR: ABCDEFAirway- Trachea

Broncho alveolar Marking

Cardiac Shadow

Diaphragm

External cage i.e the Bony Area

Foreign Bodies like ET tube, Chest tube, Central line, Nasogastric tube

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Open Pneumothorax (Sucking chest wound)19/11/2015

Open Pneumothorax (Sucking chest wound)

Sucking wound19/11/2015

T/t of open Pneumothorax:Apply Sterile Occlusive dressing over the defect

Taped securely on 3 sides

Provide Flutter -TypeValve effect.

Breath in- Dressing occlu- des the wound & prevent air to enter from out & vice versa

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T/t of open Pneumothorax:Dont put ICD through the defect

Site of ICD Remote from the wound Definitive surgical closure of the defect after ICD insertion, when pneumo subsides

Open wound

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Flail Chest & Pulmonary Contusion:If 2 or more ribs fractured in 2 or more places.Flail segment don't have bony continuity.Paradoxical movement of flail segment with underlying normal chest movement .High association with Pulmonary Contusion

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Flail Chest & Pulmonary ContusionAsymmetrical & uncoordinated chest movement

Pain , Tenderness & Crepitation.

CXR

ABG

CT 19/11/2015

Flail Chest & Pul. Contusion -M/nBetter to admit- ICU ( Intubation & Ventilation)

Administration of Humidified Oxygen.

Fluid Resuscitation judiciously

Analgesia- IV Narcotics/ Intercostals nerve block/ Epidural Anesthesia(Prefered)

ICD (If A/w Pneumo/Haemo)

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Massive Haemothorax:Rapid accumulation of more than 1500 ml of blood in the chest cavity

Mainly caused by Penetrating wound- Disruption of systemic & hilar vessels.

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Massive Haemothorax: DxRestricted Chest Movement(Inspection)

Breath Sound = Absent

Dullness to Percussion

Chest X-RayABGCT.

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Massive Haemothorax: M/n Follow the ABC.

ICD (In Safety Triangle )

IV Fluid Infused 2 lit warmed RL very fast.

5-10 ml blood for grouping & cross matching to start Blood Transfusion at earliest.

Auto transfusion from the ICD Bag.

Plan- Thoracotomy (If indicated)

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Indication of Thoracotomy1500 ml blood collected immediately in ICD bag

Blood loss @200ml/hr for 2-4 hrs.

Persistent need of BT.

Penetrating Injury -medial to the nipple line ( Over anterior chest wall ) & medial to the scapula(Over posterior chest wall) 19/11/2015

Penetrating Chest Trauma:

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Operative finding: Lacerated Lung

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E-FASTLung USG is more sensitive than CXR for Pneumothorax

Perform rapidly at bed side by Surgeon, don't wait for radiologist.

Safe, fast & effective for detecting the pneumo

Very easy to learn

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30

To detect Pneumothorax??A Line

B Line

Seashore sign

Barcode sign

Lung Point.19/11/2015

E-FAST in Chest Trauma

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Bats Sign: Normal Finding: B Mode

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E-FAST in Chest Trauma: B mode

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Seashore sign & Barcode sign

Normal LungPneumothorax- Find the lung pointSeashore signBarcode sign19/11/2015

Lung Point: Pneumothorax

19/11/2015Barcode signLung Point

Chest Trauma- Follow ABC

Nn

Bats Sign, Pleural Line & Lung SlidingLung Sliding= AbsentBar Code SignScan laterally & Find the Lung PointSeashore sign

Put needle or Chest tube

Switch to M Mode

Normal Lung

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Pneumothorax

Bar codeLung Point

Home Message!!!!!!!!!!!Thoracic trauma is a significant cause of mortality.

Hypoxia, Hypercarbia & Acidosis- main concerned.

Basic principle of m/n is the primary survey ( ABCDE)

Life threatening injuries should be managed during Primary survey.

> 90% of BTC & > 70 % of PTC - simple intervention.

E-FAST- Rapid, accurate & easily deployed and can be lifesaving

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19/11/2015ThankYou