28.- 31 chest trauma Flashcards
Rib fracture
cause and clinical features. assoc condition
etiology: mostly blunt trauma, pathologic fractures, nonaccidental trauma (child abuse
- Clinical features
- Pain on inspiration
- Focal chest wall tenderness
- Crepitus
- Chest wall deformity
- assoc w/ flail chest
dg of rib fracture
Chest x-ray = gold standard (AP and lateral view): fracture lines , displaced fractures
Possible CT if complications are suspecte
rib fracture complications
Pneumothorax
Hemothorax
Especially in the elderly: pain → splinting and hypoventilation → atelectasis and/or pneumonia
Pulmonary contusion
Respiratory failure
Fracture of the lower ribs → abdominal organ injury
why is rib fracture rx an eneasthetists job
Usually no surgery necessary
Analgesia
- NSAIDs
- Opiates
- Local Intercostal nerve block, usually performed under the affected rib
Intubation with positive pressure ventilation in severe flail chest (bridge to surgery)
indications for surgery in rib fracture
Significant chest wall deformity
Severe flail chest
Nonunion aka Pseudarthrosis
- Failure of bone healing caused by nonunion of long bone fragments (e.g., due to insufficient immobilization). Results in the creation of a false joint (pseudarthrosis) due to the nonunion.
flail chest definition
severe disruption of normal chest wall movement from trauma associated with multiple rib fractures-3 ribs broken in 2 or more places
occurs when a segment of the chest wall does not have bony continuity with the rest or the thoracic cage.
dg of flail chest
clinical anatomic diagnosis
noted in blunt trauma patients with paradoxical or motion of a chest wall segment while spontaneously breathing.
Arterial blood gas (ABG) measurements
show the severity of the hypoventilation created by both
the pulmonary contusion and the pain of the rib fractures, to assess the need for mechanical ventilation and to follow the patient during management.
posteroanterior (PA) chest radiography to note number of fractured ribs
2 types of rxx for FLAIL CHEST
Internal/ external pneumatic stabilization
Surgical Stabilization
Traumatic hemothorax DEFinition
thoracic sources of blood
A hemothorax is defined as the presence of blood in the pleural space.
Thoracic sources of blood
- lung parenchyma,
- chest wall including the intercostal* or *internal mammary arteries,
- the heart and great vessels.
def and etio of massive heamothotax
The rapid accumulation of more than 1500 ml of blood or one-third or more of the patient’s blood volume in the chest cavity
- etio: mc by a penetrating wound that disrupts the systemic or hilar vessels;
sx dg of massive hemothroax
shock! associated with the
absence of breath sounds or dullnes to percussion on one side of the chest;
similar findings of
MASSIVE hemothorax and TENSION pneumothorax
decreased breath sounds on auscultation;
DX betw /tension pneum and massive hemothroax
on PHYSICAL EXAM (percussion)
hyperresonance confirms a pneumothorax,
whereas dullness confirms a massive hemothorax.
general treatment of hemothroax (ttd)
Tube Thoracostomy drainage
-
hemopneumothorax, placement of two chest tubes preferred,
- with the tube draining the pneumothorax placed in a more superior and anterior position.
- if over 1500ml evac = massive hemothorax
complication so hemothorax
- Empyema usually develops from superimposed infection in a retained collection of blood
- Fibrothorax is a late uncommon complication that can result from retained hemothorax.
Thoracotomy and decortication are required for treatment.
what is the deathly dozen in surgery
definition and etiology of traumatic PNEUMOthorax
collection of air in the pleural space 2ndary to trauma
etio= blunt/ penetrating trauma
what is the classification/ types of PNEUMOthorax
There are three subtypes of pneumothoraces:
- simple/closed pneumothorax,
- open pneumothorax,
- tension pneumothorax.
define simple pneumothroax
collection of air trapped in pleural space.
define open Pneumothorax
list it’s characteristics
- Full thickness defects of the chest wall that remain open;
- enables free comm bet/ chest wall and atmosphere leading to equilibrium:
- intrathoracic pressure = atmospheric pressure
- Effective ventilation is thereby impaired as air enters the pleaura with each breath
- leading to hypoventilation, hypoxia and hypercarbia.
treatment of pneumothorax
promptly closing the defect with a sterile occlusive 3 sided dressing for a flutter-type valve effect
inspiration= the dressing occludes the wound,preventing air from entering.
exhalation= the open end of the dressing allows air to escape from the pleural space
define the cahracteristics of tension Pneumothorax
- A tension pneumothorax develops when a tear in the lung/ chest wall causes a “one-way valve“ air leak
- inhaled Air is forced into the pleural space without any means of escape, making the oringially negative space to become positive
- positive presure causes complete collapse of the affected lung which displaces the mediastinum to the opposite side
- this compresses the opposite lung decreasing it’s venous return
Iatrogenic cause of Tension Pneumothorax
Mechanical Positive Pressure ventilation
(PEEP? Positive End Expiratory Pressure)
how is Tension Pneumothorax diagnosed
clinical diagnosis based on characteristic sx, do not wait for radio confirmation!!
characteristic sx and signs of tension pneumothorax
Cyanosis & Chest pain
respiratory distress
Tachycardia & Tracheal deviation
hypotension (1/3 of becks triad)
unilateral absence of breath sound (1/3 of beck’s triad)
neck vein distention (1/3 of becks triad)
what are the 2 DX of Tensino Pneumothorax
-
cardiac tamponade !!!
- TENSION pneumothorax has a hyperresonant note on percussion (CT is dull on percussion d/2 blood accum) and absent breath sounds over the affected hemithorax!!!
-
hemothorax
- TENSION pneumothorax has a hyperresonant note on percussion (HEMOthorax is dull on percussion d/2 blood accum)
imaging dg to confirm tension pneum
what is the gold standard imaging for tension pneumothorax
- U.S. - BARCODE SIGN: aka ‘stratosphere’ shows lack of lung sliding w/ insp/exp
- C.T. - GOLD STANDARD - Collapsed lung visualised
treatment of tension pneumothorax
Initial rx: immediate decompression
- to create an OPEN pneumothroax
- rapidly inserting a large-caliber needle into the second intercostal space in the midcavicular line of the affected hemithorax for
Definitive rx: Thoracostomy
- insert a chest tube into the fifth intercostal space (usually the nipple level), just anterior to the midaxillary line.
main mechanisms causing pneumothorax
2 alveioli
2 lung
(1) a sudden increase in intrathoracic pressure may rupture alveoli resulting in an air leak,
(2) blunt forces may directly crush and disrupt alveoli.
(3) rib fractures may be displaced inward and lacerate the lung itself,
(4) deceleration injuries may tear the lung, causing an air leak
causes of pericardial tampnade
Acute
- chest trauma- damage coronary vessels
- Post MI free wall rupture (C.I of pericardiocentesis)
- Aortic dissection( rapid accum, C.I. pericardiocentesis)
chronuc/ painless causes
- uremic pericarditis 2ndary to renal failure
- TB pericaditis
- neoplasias of pericardium
other to watch out for
- post cardiac interventions
Definition of Cardiac tamponade
life-threatening clinical syndrome where accumulation of blood and blood clots, in the [non distendable] pericardial space exerts enough pressure (>15mmhg) on the cardiac muscles to in reduced ventricular filling and subsequent hemodynamic compromise
PathoPhys of Cardiac Tamponade
- Fluid accumulates (around 250-300 ml )in the pericardial sac surrounding the heart → reduced heart sounds (1/3 becks)
- onset of sx depends on speed of fluid accumulatiON (X 100)
- S L O W = 2 L
- FAST = 20 ml
- onset of sx depends on speed of fluid accumulatiON (X 100)
- intraventricular septum is pushed to the left side of the heart
- reduced atrial compliance
- venous backflor and JVD (2/3 becks)
- reduces the room available for LV End Diastolic volume
- this therefore reduces the SV by Frank starling law
- ↓ CO and ↓ BP (3/3 becks)
- this therefore reduces the SV by Frank starling law
- reduced atrial compliance
what is pulsus paradoxus
Inspiratory drop of systolic bp over 10mmhg
or
Exaggerated drop in inspiratory systolic bp over the physiological limit of 10mmhg
normal volume of pericardial fluid in the pericardial sac
30-40 ml
Beck’s triad for acute tamponade
- Increased JV pulse/ Jugular venous distension 2ndary to increased central venous pressure
- wide & sharp x descent
- lost Y descent
- Low BP causing Tachycardia to compensate
- muffled heart tones. especially apex beat
- Pulsus paradoxus
dg of cardiac tamponade
clinical dg w/ beck’s triad
Echocardiography to confirm dg
ECG = QRS w/ different heights
management of Cardiac Tamponade
definitive therapy: Removal of pericardial fluid by one of three methods:
- Emergency subxiphoid percutaneous drainage
- Pericardiocentesis (with or without echocardiographic guidance)
- Percutaneous balloon pericardiotomy
when is pericardiocentesis C.I.
Post M.I
Aortic dissection
complications of cardica tamponade
SHOCK- hypovolemic/ cardogenic
pulmonary oedema d/2 venous HTN
most sensitivr of the becks for cardiacc tamponedae
lost y descent d/2 increased JVP
3 exceptions of tamponade wthout cardinal sx of tachycardia
- myxedema( hypothyrodism)
- uremia (heart blocks)
- beta blockers
- terminal stage
sx of tamponad
- hemodynamic instability (becks triad assoc)
- features of underlying caus of disease
- features of acut pericarditis ( chest pain)
other causes of pulsus paradoxus
air way diseases d/2 deep breathing for compensation
constrictive pericarditis but not as oftern (30%), kussmaul sign predominates ( increas in JVD w/ inspiration)
massive Pulmonary embolosism
severe hypovolemeic shock
definition of & causes Pulmonary Contusion
Rx
lung parenchymal hemorrhage with avleolar distruption
MOST LEHTAL chest injury?
- etiology
- mc: high force blunt trauma from cars ( assoc w/ flail chest)
- Proejctiles
- explosions
RX = supportive
specific rx of pumonary contusion
supportive heals on it’s own
- breathing= 02 therapy w/ PEEP
- circulation = fluids to maintain hemodynamics
- analgesics
- chest physiotherapy
dx of pulmonary contusion
- pulm hematoma
- hemothorax
- pneumothroax
- pneumonia
how is pulmonary contusion diagnosed
why is x ray not a great diagnosis
What is goldstandard
ABG
CT- GOLD
X ray
- consolidation of the lung takes 6 hours to occur
- this can be obstructed incase of assoc
- pneumothorax
- hemothorax
- this can be obstructed incase of assoc
PP of pulm contusion
which age group is most susceptible in Pulmonary Contusion
- trauma causes chest wall to bend inwards on lungs
- crushes lung tissure and damages cappilaries
- leads to oedema and hemorrhage
- severe cases= consolidation and atelectasis from collapsed alveoli
children as their more flexible chest wall is more flexible
trachea basic anatomy
- spinal level
- innervation
- arterial supply
- venous drainage
lower border of cricoid cartilage (C6) to the carina (T6)
innervated by the reccurent laryngeal nerve
supplyed by the inferior thyroid artery
drained by jugular arch (anterior) & aortic arch (left)
Oesophagus basic anatomy
- length
- course: C6, T1-4, T10
- 4 constrictions = ABCD
- spinal level
- innervatoin
- vascular supply and drainage
- length= 25 cm long
- from pharynx (C6) to the stomach
- Descends to Mediastinal lvl at (T1-4) betw/ the trachea
- enters the abdomen via abdominal hiatus (T10)
4 constrictions
- Aortich arch 2. Bronchus 3. Cricoid cartilage 4. Diaphragm
vascular supply - Thoracic aorta=> inf thyroid a=> left gastric a
etiology for both TRACHEAL and OESOPHAGEAL injury
blunt and penetrating injuries
blunt and penetrating injuries of the TRACHEA
Trachea
- Blunt:
- hyperextensions in car accidents,
- shattering injuries to Cervical & Mediastinal trachea
- Penetrating
- CERVICAL => usually involves the oesophagus too
- MEDIASTINAL=> lethal injury
SX in Trachea injury vs OE injury
OEE in HER
Tracheal sx (HER)
- Emphysema of the neck (subcutaneous air)
- RDS
- Hemopytsis= rx w/ 2 drains
OE injury (OE)
- Odynophagia = painful swallowing
- Emphysema of the mediastinum
- Emphysema of the neck & mediastinum = aerodigestive airway affected (trachea AND OE injury)
whic is more severe, Tracheal injury or OE injury
OE as death occurs in 12-24 hrs without treatment
dg of Tracheal injury vs Dg of OE injury
Tracheal injury dg by = Bronchoscopy
OE injury dg by = 1) Oesophogram in decubitus position 2)Oesophagoscopy
how is TRACHEAL INJURY treated
- Visualisation by LMA
- Ventilation by endotracheal intubation if possible
- Further rx depending on the state of trachea and type of injury e.g.
- Disrupted bronchi = thoracotomy
- Upper tracheal injury = tracheotomy/cricothyroidotomy
- Severe surgery = CardioPulm Bypass & debridment
rx of bronchial disruption in Tracheal injury
risks of the procedure
Thoracotomy is used to rx Bronchial disruption
risk= iatrogenic Pneumothorax (air in thoracic cavity)
how ti intubate in case of Penetrating TRACHEAL injury
intubate through the penetrating wound (connection already dont make another)
side effect of endotracheal intubation in Tracheal injury
Postintubation tracheal STENOSIS d/2 irratation and healing
caused by either cuff-induced ischemic damage to the trachea, stomal injury from a tracheostomy, or a combination of the two. Patients who present with stridor or unexplained dyspnea after a period of mechanical ventilation should be investigated for postintubation tracheal stenosis.
how is Upper trachea linjury treated in TRACHEAL injury
Thoracotomy/ Cricothyroidectomy
risk: infection and stenosis
how is Debridement performed during TRACHEAL injury
- only 5cm max can be debrided/ resected
- anastomosis and dilation of the trachea post resection
- mobilisation of the trachea
Complications of Tracheal injury
Mediastinitis - if mediastinal area injured- Lethal- DEATH
Stenosis- from primary injury or iatrogenic fom intubation/ tracheostomy
Atalectasis- collapsed lung 2ndary to lack of tracheal airflow
how is OE injury treated
Surgical repair and Drainage
dx betw/ alkali and acid injury to OE
A L K A L I
- more common
- no immediate sx, deveops over 3 phases
- worse
- dissolves tissue by liquefactive necrosis
- rx = V I N E G A R / CITRIC ACID
ACID
- less common
- imediate mouth burning
- coagulative necrosis .
- forms eschar limits tissue penetration (less severe)
- RX = Milk / antacids
what is the 3 phase progression of ALKALI injurt to OE
-
Acute necrosis.
- day 1-4. Coaglation of IC proteins & inflamm
-
Ulcerisation & Granulation.
- day3-5. slouging and granulation weakns OE
-
Cicatrisation.
- 3weeks
