Chest trauma

- Penetrating – rubture of Porictal pleura – blunt – with fracture ( single, Multiple) , without fracture

- Rib Fracture – Blunt injury- Clinically - Localized pain

-Tenderness -Cripitus at the site of fracture - Sever pain associated with multiple fracture - May limit inspiration lead to atelectasis and infection - Plain CRX – To detect air , fluid collaction in pleural space

Treatment : pain relief – to allow pt to expand the lungs analgesics – pelthidine or NASIDs):-

1- Flail chest – paradoxical breathing (This occurs when more than 3Hbs are fractured at 2 points - The integrity of the chest wall is lost and the flail segment will move paradoxically to the rest of

chest wall.- During inspiration flail segment will beretracted - During expiration flail segment will expanded

2- Paradoxical breathing limits the pts ability to create negative pressure (intrathorasic ) to ventilate the lung sputum and CO2 retention

Treatment :-

- If small segment – external immobilization of the segment by a cotton PA decrease and adhesive plaster

- In pts with sever paradoxical breathing especially if elderly people the best policy is to introduce endotracheal tube and start intermittent positive pressure breathing which lead to internal stabilization of segment

- If period more than 2 day it preoferd to do tracheostomy endotrochial intubation .- Thoractomy – fractured ribs secured by stainless steel wires . Types of fixation – External ,

Internal - External – intramedullary and extramedulary wiresinsertion - Haemothorax – etiology – traumatic , post operation pathological - Clinically – Chest pain , Dyspnea , Clinical picture of hypovolemia - Dullness to percussion , Absence of breath sound - In Massive haemothorax – Sheft of mediastinum to the opposite side

Treatment : Analgesics :-

- Drainage – chest tube insertion in 5th Intercostal space at midd – axillary , tube is connected to underwater seal

- Helps to draine blood and monitoring - Thoractomy indications- Drainage of more than 12 of blood simultaneous or bleeding continus during 4H- Blood less more than 200 ml/h and bleeding continues during 4h- Clotted haemothorax - Loctated haemothorax - CRX- Negative – Shadow – is fluid

-Increase transparency – is gas - Horizontal line – fluid + Air- Pneumothorax – Penetrating - Etiology – Traumatic (Blunt , Penetrating)- Spontaneous – Rubture of emphysematow bull a- Spontaneous – Rubture o small subpleural TB cavity - Iatrogenic – Barotrauma – positive pressure ventilation that is complicated by rupture of alveol - During insertion of central venus line in the neck (tympanic sound , lung collaps , CXR : Lower

parts of lung field homogeneously black)- Types :Open , Simple , Tension- By side left , or right , in both side - By lung collapse degree :-

-Partial – paraco54ml

-Subtotal (Smaller than 2/3 of lung volume )

-Total more than 2/3

- Open pneumothorax : sucking chest wound occurs sentary to in the chest wall leading to communication between the pleural space and atmosphere

- Its an emergency situation and should be treated by applying adhesive dression on the wound to stop air from intering the pleural tube in sertion or ABCs – closure of wound and chest drainage

- Tension pneumothorax – tachycardia - The air after enter the pleural cavity during inspiration but does not exit during expiration

(Valvemechanism)- The lung gradually collapse and mediastinum shifts to the opposite side - The patient becomes severly dyspnoe compression of the opposite lung . and respiratory arrest

may follow .- It rabidly fatal

- Clinically : - Chest pain

-Decrease Dyspnya

-Hypotension

-Dislended neck veins

-Tracheal deviation mediastinum

- X-ray – increase intercostal space - -Mediastinal shift to the opposite side- - Decrease diaphragam

Treatment – Tension pneumothorax is an Emergency

Awide – bore needle should be immediately inserted in the 2nd intrcosta spase to allow decompression

-Later insert chest tube connected to under water seal CXR to confirm site of insertion

-If air bubbling continuous through the intercostal tube this indicate the possibility of broncho pleural fistula .

-Active thoracostomy – sucting machine

- 3 Ampula system

Cardiac injuries

- Penetrating wunds e.g : stable gun-shot - Cardiac temponade – due to bleeding into the pericardial sac which compresses the heart

prevents diastolic filling and reduce cardiac output as a result :-1- Destention of neck veins |2- Muffled heart sound | Beck’s triad , Normal Pericardial fluid - 70 - 503- Bp Decrease hypotension |

Pules is weak

Treatment : - intial life saving Ipericardiocentesis Immidiat aspiration of the pericardium

- Then – left thoracotomy – evacuation of blood- Bleeding vessels are ligated and tear of the myocardium are repaired - Th pericardium should be left open to allow any effusion to escape into the pleura which

should be drained

II – Volume resuscitation

- To confirm if bleeding is stopped or it continuous - Rtvola – Grigoar test – - Take blood sample from the pleural space - 1 – Wait for 3 – 6 mins if clothing occurs that indicate bleeding is contioues – positive - 2 – If no coagulation occurs after 5 min . that indicate bleeding is stopped – Negative - The dangerous zone of heart injury area :-

-Right parasternal line

-1st rib superiorly

1st arterally – anterior axillary line

-inferiorly – arch of rib

- Diaphramatic – 4th intercostal space around the chest wall