Chest Injury Flashcards
Mortality of chest injuries?
Cause of ~25% trauma deaths
Causes of immediate death in chest injuries?
due to major disruption of heart and great vessels
Cause of early death in chest injuries?
- airway obstruction
- cardiac tamponade
- aspiration
Common chest injuries?
- Pneumothorax (simple, tension, open)
- Haemothorax
- Pulmonary contusion
- Rib fractures
- Flail chest
- Pericardial tamponade
- Myocardial contusion
Name life threatening chest injuries?
- Tension pneumothorax
- Open pneumothorax
- Haemothorax
- Flail chest
- Cardiac tamponade
What is a tension pneumothorax?
Air enters the pleural space but cannot leave
Describe the physiology behind a tension pneumothorax?
- ↑ Intrathoracic pressure
- Mediastinal shift
- ↓ venous return + ↓ cardiac output
Clinical features of tension pneumothorax?
- respiratory distress
- hypotension
- Tracheal deviation
- Absent or reduced breath sounds
- Subcutaneous emphysema.
- Other signs distended neck veins, tachycardia and loss of consciousness
Management of a tension pneumothorax?
Management is by needle decompression then thoracostomy
- Needle decompression traditionally is 2nd intercoastal space mid-clavicular line but now 4th or 5th intercostal space mid-axillary line
Note: Chest drain should be inserted in the safe triangle
What are the borders of the safe triangle?
superiorly - base of axilla
anteromedially - lateral border of pectoralis major
inferiorly - horizontal at the level of the nipples (5th intercostal space)
posteriorly - anterior border of latissimus dorsi
Note: this area is safe because it avoids damage to the chest wall muscles and breast
How do you insert a chest drain?
- patient is lying at 45 degrees with arm above head
- identify safety triangle
- make a 2cm incision
- use blunt dissection to find the pleura
- use a clamp to insert the chest drain into the pleura above the the rib (neurovascular bundle runs underneath)
- chest tube is connected to a cylinder of water with 300 mls of sterile water creating a water lock - chest drain should be secured in place with a large silk suture
- incision should be closed with a suture
- chest tube dressing should be put to keep the tube at a neutral position
What is an open pneumothorax?
- Sucking chest wound
- air builds up in in pleural cavity through hole in the chest wall
- puts pressure on the lung and can lead to collapse
Note: Air escapes on expiration
Clinical features of open pneumothorax?
- sudden chest pain
- shortness of breath
- rapid and shallow breathing
- fast heart rate
- hypoxia
Management of open pneumothorax?
- urgent insertion of chest drain
- three way dressing
- surgical repair
What is a three way dressing?
taping the dressing on only 3 of the edges
- to prevent the individual from breathing in air through the opening in the chest wall while allowing them to exhale air from their lungs
Note: if dressing is not properly applied and allows air in the chest space without allowing it to escape it can lead to a tension pneumothorax
What is a haemothorax?
collection of blood in the pleural cavity
What is a massive haemothorax?
Blood more than 1500ml (200ml/hr in 4hr)
Commoner in penetrating than in blunt trauma
Note: May lead to hypovolaemic shock
Management of massive haemothorax?
- Consider thoracotomy if bleeding continues > 200-300 ml/hr
- Management involves thoracostomy/thoracotomy
- Large bore chest drain - Lung re-expansion may stop bleeding
What is a flail chest?
Occurs when 2 (sometimes 3) or more contiguous ribs are fractured in at least 2 locations
Presentation of a flail chest?
- Associated with pulmonary contusion
- Unstable segment
- Paradoxical movement with ventilation
- May lead to severe respiratory distress
Note: Adequate analgesia vital
Management of flail chest?
- Give oxygen (if available)
- Consider intubation
- Physiotherapy
- Chest drain if concurrent pneumothorax or haemothorax
What is a cardiac tamponade?
compression of the heart caused by fluid collecting in the sac surrounding the heart
- puts pressure on the heart and keeps it from filling properly
Presentation of cardiac tamponade?
- Muffled heart sounds
- Distended neck veins
- Hypotention
Investigatiions?
- Xray’s:
- Straighted left cardiac border
- USS: Fluid
- ECG: J-wave
Management of a cardiac temponande?
- Treatment is pericardiocentesis
1-2cm inferior left xiphochondral junction aiming laterally and posteriorly at 45 degrees towards scapula tip
Name associated chest injuries?
- Great vessel injury
- Airway rupture
- Oesophageal trauma
- Diaphragmatic injury
