Chest wall trauma Flashcards
What are the most commonly injured structures in penetrating trauma?
- myocardial laceration: right ventricle -> left ventricle -> right atrium -> left atrium
- coronary arteries: LAD -> RCA -> LCX
What is the most cause of aortic injuries?
motor vehicle accidents
fall
pedestrians
How can u diagnose an aortic injury?
- wide mediastinum
- first & 2nd rib fractures
- clavicle fracture
CT CHEST with IV CONTRAST TO CONFIRM
How should aortic injuries be managed?
- stable patients with intramural hematoma -> repeat CT chest before discharge
- Aortic dissection -> OR -> endovascular stent / open thoracotomy & aorta repair
- Hemothorax/hemomediastinum -> OR -> ENDOVASCULAR STENT (TEVAR)
What is the general appearance of patients with life-threatening thoracic trauma?
- shortness of breath
- pain
- desaturation
- hypotension
- tachycardia
- low cardiac output
What are the causes of hypoxia & hypercapnia?
HYPOXIA
- airway obstruction
- pneumo/hemothorax
- fracture & hernia
- ventilation-perfusion mismatches (lung contusion/atelectasis)
HYPERCAPNIA
- altered mental status (hypoventilation)
- airway obstruction
- pneumo/hemothorax
- fracture & hernia
- ventilation-perfusion mismatches (lung contusion/atelectasis)
How does a patient with a sternal fracture present?
- chest pain
- tenderness over sternum
- deformity
- crepitus/hematoma
DIAGNOSE BY LATERAL XRAY/CT CHEST
conservative treatment
How does a patient with a rib fracture present?
- localized chest pain
- localized tenderness to palpation
- crepitus
- palpable or visible deformity
DIAGNOSE WITH XRAY/CT
What injuries could be associated with rib fractures?
- hemo/pneumothorax
- 1st & 2nd rib -> aortic disruption
- left 9-11 -> spleen/diaphragm
- right 9-11 -> liver/diaphragm
CONTROL PAIN
What is flail chest?
presence of 2 or more fractures in 3 or more consecutive ribs
- instability of chest wall -> severe trauma
- paradoxical chest wall movement
- manage with pain meds & surgical fixation if needed
How can pulmonary contusion be diagnosed?
- low PaO2 & well defined infiltrate underlying the contused area -> 24-48 hrs after injury
- treat with pain control & oxygenation
What is the pathophysiology of a pneumothorax?
air enters from injured lung, airway or esophageal injury or from atmosphere & gets trapped in pleural cavity
- causes chest pain & dyspnea
What are the signs of pneumothorax?
- tachypnea
- desaturation
- decreased expansion of effected lung
- decreased breath sounds
- hyper-resonance
- subcutaneous emphysema (crepitus)
How should pneumothorax be managed?
tube thoracostomy (CHEST TUBE)
What is the pathophysiology of a tension pneumothorax?
one way valve allowing air to enter pleural cavity without escape
SVC/IVC are compressed so venous return to the heart is impaired
eventually contralateral lung is compressed -> hypotension, hypoxia, & cardiorespiratory arrest
How can tension pneumothorax be diagnosed & treated clinically?
- hypotension
- hypoxia
- cardiorespiratory arrest
- tachycardia
- high JVP
- Kussmaul’s sign
TREAT WITH LARGE BORE NEEDLE (14-16 gauges) -> in 2nd intercostal space in midclavicular line -> chest tube
What is an open pneumothorax? How is it managed?
- sucking chest wound
- apply occlusive dressing & place chest tube away from wound before closure of chest wall defect
What are the symptoms of a hemothorax?
- chest pain
- dyspnea
- hemorrhagic shock
- tachycardia
- hypotension
- low JVP
- low CO
What will be discovered on examination of hemothorax?
- decreased chest movement
- decrease breath sounds
- DULLNESS ON PERCUSSION
- erect x-ray -> meniscus sign & blunting of Costophrenic angle (50ml or more)
How should a hemothorax be managed?
- chest tube if significant in XR/CT
- emergency thoracotomy IF -> initial chest tube output is 1000mL or more
- > persistent drainage of 200mL/2hr or >100ml/h for 3 hours
Diaphragmatic injury is more common in which side after blunt trauma? How can we diagnose it?
LEFT SIDE (liver protects right side)
- XRAY -> elevated or irregular hemidiaphragm
- > visceral herniation & nasogastric tube in left lower chest - US CHEST -> contents of abdomen in chest
- CT SCAN -> contents of abdomen in chest
what are the types of diaphragmatic injury repairs?
- direct primary repair
- mesh patch repair
What are the signs of esophageal injury?
DYSPHAGIA
- if content leaks into mediastinum -> sepsis
DO CT neck & mediastinum + esophagoscopy
How should an esophageal injury be managed?
1- ACT IMMEDIATELY 2- correct other injuries 3- stop spillage of esophageal contents 4- drain the area 5- supportive measures
What are the signs of tracheobronchial injuries?
- SOB
- Tachypnia
- O2 DESAT
- air leak under skin
- hoarseness
- wheeze
- stridor
ENSURE ADEQUATE AIRWAY (intubate)
What size chest tube should be used?
PNEUMOTHORAX -> 24-28
HEMOTHORAX -> 30-38
suction at -20 -> if more than 1000mL is out CLAMP IT
How should chest tubes be placed?
pneumothorax -> upwards
pleural effusion -> downwards
- use lidocaine 1% (10mg/mL) or 2% (20mg/mL) -> 5-7mg/kg MAX
When should you remove a chest tube?
- if there is NO air leak & lung is fully expanded
- if drainage is less than 200cc per 24hrs & lung is fully expanded
How should a spontaneous pneumothorax be managed?
usually in young tall patients
- conserve if <2cm without indications for surgery
- chest tube if >2cm or tension pneumothorax
What are the indications for surgery in spontaneous pneumothorax?
FIRST EPISODE
- early complication post chest tube insertion
- > prolonged air leak (more than 3 days)
- > non re-expanding lung
- > bilateral pneumothorax
- > pneumo-hemothorax
- complete or tension pneumothorax
- other diseased lung
- patient lives far away
- associated single large bulla
SECOND EPISODE
- ipsilateral recurrence
- contralateral recurrence after first pneumothorax
What surgery should be done for spontaneous pneumothorax?
Video assisted thoracoscope (VAT)
- resection of apical blebs
- pleurodesis (pleurectomy/pleural abrasion)
