14.2 Chest & Vascular Trauma Flashcards
Life threatening conditions chest trauma can lead to
• airway obstruction
• Open pneumothorax
• Tension pneumothorax
• massive haemothroax
• Fail chest
• Cardiac tamponade
• Thorasic aortic injuries
Pneumothorax
Def
Two mechanisms
Types
Further classification
Def:
Collection of air outside the lung, but inside the pleural cavity (air between parietal and visceral pleura). Air accumulation can cause the lung to collapse
Two mechanisms:
- trauma causing communication through the chest wall
- from the lung by rupture of the visceral pleura
Types:
- Traumatic ( Blunt vs Sharp trauma)
- Atraumatic (Primary vs Secondary)
Further Classification
- Simple{does not move internal structures like tension},
- Tension or Open{space through chest that lets air in and our}
Pathogenesis of Pneumothorax
- pressure gradient inside chest changes
- Pressure if pleural space is negative compared to atmospheric pressure
- Lungs collapse due to elastic rebar
- Lungs collapse until equilibrium is achieved or rupture is sealed
Types of pneumothorax
Spontaneous pneumothorax
- due to rupture of bulae or bleps
- sec: presence of underlying lung disease (malignancy, TB, cystic fibrosis, etc)
Traumatic
Iatrogenic
- complication of medical procedures
- Thoraco synthesis
Tension
- life threatening
- Continuous entering and entrapment of air into pleural space
- Compresses lungs, heart and other vessels
- accumulation of air puts + pressure on lungs and prevents it from expanding
- Trachea and other structures pushed away from pneumothorax = ⬆️ difficulty breathing
- ⬆️ pressure, compress the heart = ⬇️ venous return and CO
- Leads to cardiovascular collapse / cardiac arrest
Pneumothorax
Causes or Associations
Primary spontaneous
- Smoking
- Tall thin body habitus in an otherwise healthy person
- Pregnancy
- Marfan syndrome
- Familial pneumothorax
Sec spontan
- COPD
- Tuberculosis
- Sarcoidosis
- Cystic Fibrosis
- Malignancy
Iatrogenic
- COPD
- Tuberculosis
- Sarcoidosis
- Cystic fibrosis
- Malignancy
Traumatic
- Blunt or Penetrating trauma
- Tension = barotrauma, percutaneous tracheostomy, open pneumothorax with occlusive dressing
Flail chest segment
- 2 or more adjacent ribs are broken in at two or more sites
- A portion of the thoracic cage losses contiguity with the rest of the thoracic cage (significant transfer of energy due to high velocity injuries)
- Paradoxical chest movement, and loss of the chest wall’s ability to create negative pressure in the pleural space during inspiration
- damage done to the underlying tissues is more relevant and can be life threatening (lung contusions, haemo-/pneumothoraces)
Underlying injuries: Thoracic aortic injuries
Mechanisms
- penetrating
- Acceleration / deceleration (tear at isthmus; distal to left subclavian artery)
- Osseous pinch (aorta pinched between sternum and vertebra; pt crushed between two objects)
- Shear / torsion stretch
Cardiac tamponade
- accumulation of fluid in pericardium sac
- impaired diastolic filling and reduces CO
- Accumulation due to: haemorrhage, ventricular wall rupture
- RF: infections, autoimmune diseases, neoplasia, uraemia, inflam diseases
- Hypotension, Distended neck veins (JVD), muffled heart sounds
Commotio cordis
- V Fib precipitated by blunt trauma to heart
- Important cause of sudden death in young athletes
- Time and space dependant
- Usually during T-wave
Oesophageal injuries (also related to thoracic trauma)
Iatrogenic
- 60%
- Endoscopic procedures
- Risk increases with intervention
Trauma
- 25%
- Penetrating (common) vs Blunt (rare)
- Foreign body (children)
- Associated injuries (immediate threat) – delay in dx
Ingested foreign bodies
- Accidental
- Anatomical radius – pathological and physiological reasons for obstruction
- Direct pressure necrosis or puncture
Caustic injury/ chemical burns
- Corrosives (alkali vs acid)
- Adults (para-suicide) Children (accidental)
- Partial vs Full-thickness
Thoracic duct injuries
- Starts at the cisterna chyli in the abdomen, ascends on the right side of the chest and empties at the junction between the left internal jugular vein and left subclavian vein
- Lymph contains various essential compounds including Chylomicrons, Triglycerides and cholesterol; Fat soluble vitamins; T cell lymphocytes and antibodies; Water, electrolytes & proteins.
- Classically injured with a zone 1 left neck penetrating injury.
- Normally 4 litres of lymph produced is per day
- Lymph leaks into the pleural space = Chylothorax
Complications of a large chylothorax
- Malnutrition
- Hypovolemia
- Acidosis
- Hyponatremia
- Hypocalcemia
- Immune suppression (loss of lymphocytes in chylothorax)
Neck zones and trauma
Zone 1
- between clavicle and tricloi cartilage
Zone 2
- tricloi cartilage and angle mandible
- Easy examination
Zone 3
- angle of mandible and base of skull
- difficult examination
Slide 22
Mechanism for neck injuries
- blunt (includes C-spine injury)
- Penetrating (violation of platysma)
- Hanging and strangulation
Slide 17 - Zone 2: most common
- Zones 1&3: vascular control more difficult to achieve
Penetrating injuries and vascular trauma
- Mortality for penetrating injuries as high as 10%
- Vascular injuries are the most common cervical injuries (40% of patients with penetrating neck trauma)
- Zone 2 = most common injuries, Zone 1 = high risk injuries, Zone 1 and 3 = occult injury
