9. Thoracic traumas - blunt and penetrating. Pneumothorax. Haemothorax.

Question 1

Thoracic traumas - Main Point

Answer 1

25% of all injuries. Cause of death from these injuries is haemorrhage

Question 2

Thoracic traumas - Etiology

Answer 2

Gunshot wound
sharp objects
explosions
falls
crushes
stabs

Question 3

Thoracic organs

Answer 3

Trachea
Bronchi
Mediastinum
Diaphragm

Question 4

Thoracic traumas - Classification:

Answer 4

• Closed: soft tissue + muscles effected. Rib fracture. Pneumothorax, hemothorax
• Open: non-penetrating. Penetrating: injury to parietal + visceral layers of pleura

Question 5

Thoracic traumas - Pathophysiology:

Answer 5

• 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

Question 6

Clinical Presentation of thoracic trauma:

Answer 6

Pain (could be diffuse or concentrated)

respiratory asphyxia (pneumothorax)

haemoptysis

flail chest

open wound

shock

cyanosis

enlarged veins of neck in compression injuries

Question 7

Treatment

Answer 7

Resuscitation + drainage of hemothorax.

Control bleeding (vessels may need tying off) + wounds

Question 8

“Deadly dozen” for life injuries:

Answer 8

- 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

Question 9

Pericardial tamponade

Answer 9

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

Question 10

Pericardial tamponade - treatment

Answer 10

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

Question 11

How is Pericardial Tamponade Differentiated from tension pneumothorax

Answer 11

By distended JVP

Question 12

Flail chest - Definition

Answer 12

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

Question 13

Flail chest - Diagnosis

Answer 13

paradoxical motion of chest wall

Question 14

Flail chest -Treatment

Answer 14

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

Question 15

Flail chest -Types

Answer 15

parasternal

lateral

paravertebral

Question 16

Pneumothorax:

Normal lung physiology:

Answer 16

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)

Question 17

Pneumothorax:

Answer 17

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

Question 18

Pneumothorax: Clinical Presentation

Answer 18

absence or decreased breath sounds

Question 19

Pneumothorax: Treatment

Answer 19

drain.

Puncture at 2nd intercostal put drain @5th intercostal mid axillary line

Question 20

Pneumothorax: Types

Answer 20

Tension pneumothorax

Open Pneumothorax

Closed Pneumothorax

Question 21

Tension pneumothorax: pressure

Answer 21

pleural cavity pressure is higher than atmospheric pressure

Question 22

Tension pneumothorax: Etiology

Answer 22

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

Question 23

Tension pneumothorax: Clinical Presentation

Answer 23

panicky pt

tachypnea

dyspnea + distended JVP

cyanosis – pt becomes hypotensive with distended JVP

Question 24

Tension pneumothorax: Immediate Treatment

Answer 24

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

Question 25

Open pneumothorax: Pressure

Answer 25

pleural cavity pressure same as atm pressure

Question 26

Open pneumothorax: Etiology

Answer 26

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

Question 27

Open pneumothorax: Initial Treatment

Answer 27

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

Question 28

Closed pneumothorax - Pressure

Answer 28

Pleural cavity pressure is less than atm pressure

Question 29

Closed pneumothorax - Etiology

Answer 29

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)

Question 30

Hemothorax - can be

Answer 30

Massive hemothorax

Question 31

Massive Hemothorax - Definition

Answer 31

Blood comes from contusion of lung, injury to parietal vessels (intercostal or mammary arteries) – most common.

Injury to heart or great vessels

Question 32

Hemothorax - Types

Answer 32

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

Question 33

Hemothorax - Clinical Presentation

Answer 33

decreased ventilation, haemorrhagic shock, flat neck veins, absence of breath sounds, dull percussion

White out x-ray

Question 34

Hemothorax - Treatment

Answer 34

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

Question 35

Thoracotomy - Types

Answer 35

• 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)