9. Thoracic traumas - blunt and penetrating. Pneumothorax. Haemothorax. Flashcards
Thoracic traumas - Main Point
25% of all injuries. Cause of death from these injuries is haemorrhage
Thoracic traumas - Etiology
Gunshot wound sharp objects explosions falls crushes stabs
Thoracic organs
Trachea
Bronchi
Mediastinum
Diaphragm
Thoracic traumas - Classification:
- Closed: soft tissue + muscles effected. Rib fracture. Pneumothorax, hemothorax
- Open: non-penetrating. Penetrating: injury to parietal + visceral layers of pleura
Thoracic traumas - Pathophysiology:
- Blunt trauma: results from kinetic energy forces – no open injuries.
Subdivision:
o Blast = pressure waves cause tissue disruption – tear bv – traumatic rapture of diaphragm
o Crush (compression) = body compressed between object + hard surface. Direct injury to chest wall
o Deceleration = body in motion strikes fixed object – blunt trauma to chest wall – internal structures continues in motion
o Age factor: paediatric thorax – children have more cartilage thus absorbs force. Geriatric thorax – adult thorax calcified – osteoporosis thus more fracture
- Penetrating trauma: low (stabs), medium or high energy – open injury to lung, trachea, heart + other thoracic organs or could be without injury to thoracic wall
Clinical Presentation of thoracic trauma:
Pain (could be diffuse or concentrated)
respiratory asphyxia (pneumothorax)
haemoptysis
flail chest
open wound
shock
cyanosis
enlarged veins of neck in compression injuries
Treatment
Resuscitation + drainage of hemothorax.
Control bleeding (vessels may need tying off) + wounds
“Deadly dozen” for life injuries:
- 6 immediately life threatening: Airway obstruction (early intubation)
tension pneumothorax
pericardial tamponade
open pneumothorax
massive hemothorax
flail chest
Potentially life threatening:
Aortic injuries
tracheobronchial injuries
myocardial contusion
rupture of diaphragm
oesophageal injuries
pulmonary contusion
Pericardial tamponade
Type of pericardial effusion in which fluid, pus, blood, clots, gas accumulation in pericardium
This results in compression of heart - which leads to Beck’s triad = low BP, enlarged JVP, muffled heart sounds
Pericardial tamponade - treatment
Pericardiocentesis = done in subxiphoid space – between the 4/5th rib at angle of 450 degrees –
If needle shows blood – sternotomy needed to fix underlying injury
Dry pericardiocentesis = clot present – pericardiocentesis allows time to take pt to OP room for repair to heart
How is Pericardial Tamponade Differentiated from tension pneumothorax
By distended JVP
Flail chest - Definition
Condition that occurs when segment of rib cage breaks under extreme stress + becomes detached. This part then moves independently i.e. during inspiration inwards instead of outwards
Flail chest - Diagnosis
paradoxical motion of chest wall
Flail chest -Treatment
o2 administration
adequate analgesia (before weight would be put on it and that led to atelectasis + pneumonia – only pain meds used now – preferably epidural + paravertebral block), + physiotherapy
o If this doesn’t work then ORIF (for severe cases)
o In anterior flail chest - Intubation at place of accident from axilla to axilla
o In lat + post flail chest – pt put or rested on injury site – intubation left for 15-20 days until stabilisation
Flail chest -Types
parasternal
lateral
paravertebral
Pneumothorax:
Normal lung physiology:
With normal breathing the diaphragm just relaxes + moves back up – causes the intrapleural pressure to become less negative (i.e. from -3 to -2 to -1)
- This causes the lungs not to stretch as much so they shrink + contract back (which also contracts alveoli inside the lungs – pressure inside alveoli becomes +ve and air goes from alveoli – trachea + out of the mouth)
Pneumothorax:
With pneumothorax for example if there’s a hole poke through intrapleural space this causes intrapleural pressure to drop to 0 b/cos atm pressure outside chest is connected to space inside thorax – lung not getting pulled out anymore and it collapses
Pneumothorax: Clinical Presentation
absence or decreased breath sounds
Pneumothorax: Treatment
drain.
Puncture at 2nd intercostal put drain @5th intercostal mid axillary line
Pneumothorax: Types
Tension pneumothorax
Open Pneumothorax
Closed Pneumothorax
Tension pneumothorax: pressure
pleural cavity pressure is higher than atmospheric pressure
Tension pneumothorax: Etiology
When the chest is pierced a flap develops and that acts as a “one way valve” which sucks air into chest cavity but doesn’t let it out – accumulation of pressure in intrapleural space and this causes the lung to push the heart
This results in decreased preload + BP drops
Tension pneumothorax: Clinical Presentation
panicky pt
tachypnea
dyspnea + distended JVP
cyanosis – pt becomes hypotensive with distended JVP
Tension pneumothorax: Immediate Treatment
rapid decompression by insertion of large bore needle into 2nd intercostal mid clavicular line of affected hemithorax + then followed by insertion of chest tube through 5th intercostal space in ant axillary line
Open pneumothorax: Pressure
pleural cavity pressure same as atm pressure
Open pneumothorax: Etiology
Due to large open defect in chest (>3cm) leading to equilibrium b/w intrathoracic + atm pressure.
Air accumulates in hemithorax (rather than lung) with each inspiration leading to hypoventilation + hypoxia
- If there is a valvular effect will lead to tension pneumothorax
Open pneumothorax: Initial Treatment
closing the defect with sterile occlusive plastic dressing taped on 3 sides to act as a flutter type valve
chest tube inserted asap – if lung does not re-inflate, drain should be placed in low pressure (5cm water) suction
Closed pneumothorax - Pressure
Pleural cavity pressure is less than atm pressure
Closed pneumothorax - Etiology
can be caused by air blebs that rupture due to either increased pressure (high altitude/diving – this is primary)
or
due to underlying lung disease (i.e. cancer or cystic fibrosis - secondary)
Hemothorax - can be
Massive hemothorax
Massive Hemothorax - Definition
Blood comes from contusion of lung, injury to parietal vessels (intercostal or mammary arteries) – most common.
Injury to heart or great vessels
Hemothorax - Types
o Low: <50ml of blood in pleural space @ angle b/w diaphragm + chest (50-300ml)
o Middle: 300-600ml of blood in pleural space up to 5th rib
o Total: blood covers entire cavity
o Subtotal: blood up to sub clavicle – collapsing of lung
Hemothorax - Clinical Presentation
decreased ventilation, haemorrhagic shock, flat neck veins, absence of breath sounds, dull percussion
White out x-ray
Hemothorax - Treatment
Correct hypovolemic shock = blood transfusion, aspiration of blood from pleural cavity – insert drain
Indication of urgent thoracotomy = >200ml/hr over 3-4hrs of blood being drained
Thoracocentesis = 7th/8th ICS by mid-axillary line – any lower could cause puncture to liver or spleen – hemoperitoneum
Thoracotomy - Types
- Sternal (middle): heart surgery, access to arch of aorta + major vessels
- Anterolateral: open chest massage, access to upper half of oesophagus (right side)
- Posterolateral: access to hilum of lung, lower half of oesophagus (left side)
