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Chest Trauma
Dr Csaba Dioszeghy MD PhD FRCEM FFICM FERC
East Surrey Hospital Emergency Department
Scope• Thoracic injuries are common and can be life threatening
• In ESH we usually see blunt chest trauma but penetrating injuries also treated here (usually as single injuries, like stab wound)
• Most acutely life threatening injuries are usually identified and dealt with during the primary survey – often needs relatively simple intervention to save the life
• Blunt chest trauma can be deceptive: severe injuries with grave consequences might be missed unless specifically looked for
• Approximately 12 / million population per day (US)
• 20-25% of trauma related death
Fatal outcome often occurs early: 30 min – 3 hrs
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Life threatening injuries• Airway obstruction
Direct laryngo-tracheal or trachea-bronchial injury
External compression due to soft tissue swelling/haematoma
• Tension or open pneumothorax
Respiratory failure (open)
Respiratory and circulatory failure (tension)
• Flail chest
Respiratory failure
• Massive haemothorax
Circulatory and respiratory failure
• Cardiac tamponade
Circulatory failure
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Life threatening injuries• Airway obstruction
Direct laryngo-tracheal or tracheo-bronchial injury
External compression due to soft tissue swelling/haematoma
• Tension or open pneumothorax
Respiratory failure (open)
Respiratory and circulatory failure (tension)
• Flail chest
Respiratory failure
• Massive haemothorax
Circulatory and respiratory failure
• Cardiac tamponade
Circulatory failure
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Airway• Look: bruise, injuries, surgical emphysema
• Listen: stridor, hoarseness
• Feel: Surgical emphysema, tracheal deviation
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Airway• Look: bruise, injuries, surgical emphysema
• Listen: stridor, hoarseness
• Feel: Surgical emphysema, tracheal deviation
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CD1
Slide 6
CD1 Csaba Dioszeghy, 16/11/2016
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Tension pneumothorax• Clinical diagnosis (challenge)
• Respiratory distress
• Asymmetrical chest movement
• Distended neck veins, tracheal deviation
• Absent breath sounds, hyper-resonance
• Clinical signs are different and more rapid in the ventilated patient leading to circulatory collapse
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EMJ 2005; 22:8-16
Clinical diagnosis ? DDX:Haemothorax
Flail chestRib fractures
Sternal fracturePrev.chest / lung disease 8
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RADIOLOGYIs this a clinical failure to have these images taken?
What is the specificity and sensitivity of radiology for TPT?
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Ultrasound
Better clinical sensitivity than supine chest X-Ray
Easy, fast and safe method but needs trained operator
LUNG SLIDING
NO LUNG SLIDING
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TPTX: decompression (1/2)• Needle decompression
Needs long enough needle! 1/3 of trauma patients have chest wall > 5 cm.
38% unsuccessful (Barton, 1995) needs finger thoracostomy
Re-tension
2nd ICS Midclavicular line
Most likely to reach the air
Longer needle might be needed
Mamillar artery, intercostal aretry
4th or 5th ICS Mid-axillary line (ATLS)
Less fat – shorter needle might be enough
Increased risk of lung damage
Intercostal artery
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TPTX: decompression (2/2)• Finger or tube thoracostomy
Needle decompression is often unsuccessful
Safe and effective, even in pre-hospital care
1% complication on insertion
Less likely to develop re-tension
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Open PTX• Usually obvious clinical signs
• Ventilation is ineffective
• Occlusive dressing (first aid)
• Chest tube
Inserted different site
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Passive suction (underwater)
The level of suction2-5 cm
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Passive suction (underwater)
The level of suction2-5 cm
NEVER EVER CLAMP A BUBLING CHEST DRAIN.SERIOUSLY. NEVER EVER.
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Suction and drain for haemo-PTX
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BLOODcollected
WATER(safety)Suction pressure will not
exceed the wcm set here (A)WATER
This is the negative pressure (B) set in wcm for the chest
A
-A
B
-A-B
Atm Suction (any)Suction (-A-B wcm)
-A
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Flail chest• Three or more adjacent ribs fractured in two places creating a floating segment
• Multiple broken ribs lots of pain
• Destroy chest mechanism respiratory failure
Clinical signs:
• Distress +++
• Pain +++
• Paradox chest wall movement
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Flail chest: management• Analgesia (thoracic epidural) and chest physiotherapy
• Evaluate and monitor ventilation regularly (pCO2)
• Might need RSI and ventilation
• Surgical fixation might be considered
Not enough good quality evidence…
Always look for further injuries:
• Lung contusion
• Pneumothorax
• Haemothorax
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Massive haemothorax
• Massive amount of blood loss (>1500ml)
• Circulatory failure
• Ventilation mechanics respiratory distress
• No breathing sound
• Dull percussion
Management:
• Chest drain (large calibre)
• Massive Haemorrhage Protocol as required
• If blood loss is ≥ 20 ml/kg /24 hr or 200 ml/hr for successive hours Thoracotomy or video assisted thoracoscopic surgery (VATS)
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Cardiac tamponade• Haemodynaimc collapse
• Distended neck veins
• ECG signs
• FAST Scan
Management
• Pericardiocentesis is useless
• EMERGENCY SURGERY
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Traumatic aortic rupture• Deceleration injury
• Usually at the site of the lig. arteriosum
• Usually fatal (80% on scene) – 15% of all RTC death
• Survivals might developed a pseudoaneurysm
• Management: urgent surgical
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Further injuries of blunt chest trauma
• Tracheo-bronchial injuries
• PTX, HTX
• Lung contusion
• Blunt cardiac injury (cardiac contusion)
• Rib fractures
• Sternal fracture
• Diaphragmatic injuries
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Tracheo-bronchial injuries• Less than 1% of blunt chest trauma
• Persistent PTX / air leak
• Pneumo-mediastimum
• Surgical emphysema
Diagnosis
• CT, bronchoscopy
Management
• Depends on the site and extent of injury
• Selective lung ventilation
• Thoracic surgery
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Tracheo-bronchial injuries• Less than 1% of blunt chest trauma
• Persistent PTX / air leak
• Pneumo-mediastimum
• Surgical emphysema
Diagnosis
• CT, bronchoscopy
Management
• Depends on the site and extent of injury
• Selective lung ventilation
• Thoracic surgery
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Pulmonary contusion• Common in blunt chest trauma
• Develops over the first 24 hrs
• Resolves in about a week
• Might cause respiratory failure (rarely need intubation)
• Possible complications are pneumonia, ARDS
Diagnosis
• Chest XRay
Management:
• Analgesia, chest physiotherapy
• Normal fluid therapy (no need for fluid restriction)
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Blunt Cardiac Injury• Direct hit over the heart
• Range of pathology: arrhythmia, contusion, wall rupture, septal or valvular rupture, myocardial infarction (coronary dissection)
• Cardiac contusion: probably the most common but not clear definition !
Diagnosis:
• ECG: arrhythmia (most common: ST and AF) nonspecific signs, T / ST segment changes, RBBB
• Echo: RWMA, pericardial effusion
• Biomarkers (troponin): not needed and no added value (does not change management, not reliable for prognostication either)
Management:
• Cases of wall rupture, septal or valvular rupture will need cardiac surgery
• Cardiac contusion: serial ECG and monitoring for 4-6 hrs if haemodynamically stable
• Unstable patients needs HDU for haemodynamic monitoring and support as required
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Rib fractures• 4th-10th rib fractures are the most
common
• 1st-3rd rib fractures are associated with high energy trauma CT scan is mandatory to evaluate
associated injuries
• Lower rib fractures (10-12) might be associated with liver / spleen injuries
• Chest X-Ray (AP) will likely miss 50% of fractures Rib fracture is not X-Ray indication
unless other injuries are suspected
• Clinical diagnosis: point tenderness, deformity
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Fact:Most common site of rib# in blunt chest trauma (RTC): anterior and lateral ribs
Fact:CXR is better to detect
fractures on the posterior ribs and misses the rest!
Rib fracturesRed flags:
• Multiple rib fractures
• Elderly
• Co-morbidity especially lung disease
• Associated injuries
Management:
• Analgesia
• Chest physiotherapy
• Surgery is very rarely indicated
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Sternal fracture• 3-7% occurrence in blunt anterior chest trauma
• Mortality is low (0.7%)
• Localized sternal pain
• Shortness of breath (15-20%)
• Local bruising (55%)
• Lateral (sternal) view X-Ray
• ECG is indicated
• Consider cardiac contusion
But if ECG normal and patient is stable, no further testing is necessary
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Diaphragmatic injury• Less than 1% of blunt chest injuries
• Happens mostly on the left side
• Chest and abdominal pain with SOB Pain may get better when upright
• Bowel sounds and reduced/missing breath sounds on the left side
• Diagnosis: Chest X-ray / CT scan
Management
• NG tube to decompress
• Chest drain might be considered (avoid viscera!)
• Surgical repair early is better
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Summary
• Chest injury is very common
• Life threatening injuries are often identified and treated during the Primary Survey
• Initial stabilization usually requires simple maneuvers: Difficulty is the decision making!
• Stable patients with blunt thoracic trauma might still have serious injuries and therefore careful evaluation and targeted investigations are mandatory
• Remember the limitations of X-Ray and use of U/S and CT
• Remember to look outside the box: associated injuries are common!
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