Chest Trauma

Chest Trauma
by:Kent J. Blanke, D.O., FACOS
Introduction
Thoracic Trauma
Penetrating Chest Injuries
* Majority are stab wounds or gunshot wounds (GSW)
* Lower mortality rates--less likely to include multiorgan injury
* 85% of penetrating chest wounds can be treated with tube thoracostomy and supportive measures
Penetrating Chest Trauma
* Wounds that enter or exit inferior to the nipple or the posterior tip of scapula may perforate the dome of the diaphragm.
* Any penetrating wound such as this should be considered to have an abdominal component until proven otherwise.

Penetrating Chest Trauma: Treatment
* ATLS protocol: A,B,C,D,E’s
* Emergency management
o Needle thoracentesis
o Tube thoracostomy
o Subxiphoid pericardotomy
o Video assisted thoracic surgery (VATS)

Work-up of Penetrating Chest Trauma
* Physical examination
o Look, Listen, Feel
o Contusions, diminished or absent breath sounds, SQ emphysema can readily be found
* CXR- best, least expensive and fastest initial evaluation
* Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
* Angiography- to look for great vessel injuries
* CT Scan: for better evaluation of chest wall and parenchyma
* Transesophogeal Echocardiography

Penetrating Chest Injuries
* Operative intervention required for:
o Massive or persistent bleeding
o Massive air leak
o Tracheobronchial injuries
o Esophageal perforation
o Cardiac or great vessel injuries
o Post-traumatic empyema
* Wounds that enter or exit inferior to the nipple or the posterior tip of scapula may perforate the dome or the diaphragm.
* Any penetrating wound such as this should be considered to have an abdominal component until proven otherwise.

Penetrating Chest Trauma:Indications for Mechanical Ventilation
Intrapulmonary Foreign Bodies
* Bullets, fragments: indications for removal
Intrapulmonary Foreign Bodies
Pulmonary Parenchymal Laceration
High Velocity Missile Injuries
Blunt Chest Trauma
Categories of chest wall injuries
* Open pneumothorax
* Contusion and Hematoma
* Sternal fractures
* Scapular fractures
* Flail chest
* Intercostal vessel injury
Categories of Intra-thoracic Injuries
* Pulmonary
o Pneumothorax, hemothorax
o Pulmonary contusion
o Pulmonary laceration
* Vascular
o Great vessel disruption (Ao dissection, pulmonary vasculature)
* Cardiac
o Blunt Cardiac Injury, Penetrating injury

Work-up of Blunt Chest Trauma
* Physical examination
o Look, Listen, Feel
o Contusions, diminished or absent breath sounds, SQ emphysema can readily be found
* CXR- best, least expensive and fastest initial evaluation
* Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
* Angiography- to look for great vessel injuries
* CT Scan: for better evaluation of chest wall and parenchyma
* Transesophogeal Echocardiography

Categories of chest wall injuries
* Contusion and hematoma

Categories of chest wall injuries
* Open pneumothorax
* Pneumothorax
Operative Intervention for Hemothorax
* As noted previously
* Hemothorax: massive = initial drainage more than 1,000 cc or
* Continuous bleeding of 200 cc/hr for 2 hrs

Fractured Ribs: Chest Wall Trauma
Blunt Cardiac Injury
Categories of chest wall injuries
* Sternal fractures
Categories of chest wall injuries
* Scapular fractures
* Flail chest
Pulmonary Contusion
Intra-thoracic Trauma: Pulmonary Contusion
Intra-thoracic Trauma: Great Vessel and Mediastinal Trauma
* Aorta
* Pulmonary vessels
* Tracheobronchial lacerations
* Esophageal lacerations

Intra-thoracic Trauma: Great Vessel and Mediastinal Trauma—Work-up
* Plain CXR to identify thoracic aorta injuries
* Look for air in the mediastinum
* Persistent airleak should cue into:
o Bronchopulmonary or tracheobronchial injury
* Mediastinitis, tube feedings in chest tube or saliva in chest tube should cue into:
o Esophageal injury
* Bronchoscopy
* Esophagoscopy
* CT
* Serial CXR

Initial CXR of Concern

Indications for Angiography
* Lateral deviation of the NGT in esophagus
* Widened mediastinum (>8cm)
* Loss of visualization of the aortic knob
* Hematoma of the Left cervical pleura (pleural cap)
* Depressed left main stem bronchus
* Rt lateral deviation of the trachea
* Widened mediastinum (>8cm)
* Forward displacement of the trachea on the lateral CXR
* Fx of the 1st or 2nd rib
* Massive chest trauma w/ multiple rib fx
* Fx or dislocation of the thoracic spine
* Major deceleration injury
Complete Aortogram

Chest Trauma.ppt

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Radiographic Findings in Blunt Chest Trauma

Soft Tissue Radiographic Findings in Blunt Chest Trauma
By:Jonathan Yarris MSIV

Trauma
* Trauma is the leading cause of death in patients < 40 years
* 4th leading COD overall
* 80% of trauma is due to blunt mechanisms

Blunt Chest Trauma (BCT)
* Seen in about ½ of blunt trauma cases
* ~20% of trauma deaths attributable to BCT
* Etiology: typically deceleration injury
* Radiographic evaluation should begin immediately after initial trauma team assessment

Approach to Trauma Radiographs
* Initial exclusion of life threatening injuries
* Followed by search for less critical injuries
* Life threatening Injuries:
Pneumothorax
Deep Sulcus Sign
Tension Pneumothorax
Tension PTX
Pulmonary Contusion
Laceration
Laceration with Pneumatocele
Hematoma
Pulmonary hematoma
Pneumatocele
Pulmonary Contusion with pneumatocele
Blunt Cardiac Injury (BCI)
Hemopericardium
Great Vessel Injury
Thoracic Aorta Injury
Intimal Flap with double lumen
Airway Injury
* Tracheobronchial tears are uncommon
* Leads to persistent PTX
* Specific Symptom: persistent PTX after chest tube placement
* Finding: “Fallen Lung Sign”, pneumomediastinum, pneumopericardium, sub cut. Emphysema
* ET Tube balloon inflation >2.8cm implies tracheal rupture
Pneumomediastinum
* Etiology: alveolar, tracheobronchial or esophageal rupture
* Most common cause: alveolar rupture due to sudden increased intra-alveolar pressure (Macklin Effect) with air tracking centrally
* Findings:
o Air outlining mediastinal soft tissues and parietal pleura.
o Continuous diaphragm sign
Pneumomediastinum
Pneumopericardium with tamponade
Esophageal Injury
Other
* Skeletal injuries:
* Diaphragm injuries:

Radiographic Findings in Blunt Chest Trauma.ppt

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Lung Examination: Abnormal

Lung Examination: Abnormal
By:Arcot J. Chandrasekhar, M.D.

Illustrative Pathological problems
* Consolidation
* Atelectasis
* Pleural effusion
* Pneumothorax
* Mass
* Diffuse lung disease

Steps
* General Examination
* Mediastinal position
* Chest expansion
* Lung resonance
* Breath sounds
* Adventitious sounds
* Voice transmission
* Respiratory rate
* Pattern of breathing
* Cyanosis
* Clubbing
* Weight
* Cough
* Hospital setting
* Effort of ventilation
* Shape of thorax

Respiratory Rate
* Bradypnea: rate less than 8 per minute
* Tachypnea: rate greater than 25 per minute

Pattern of Breathing
* Kussmals
* Sleep apnea
* Cheyne strokes
* Pursed lip breathing
* Orthopnoea: Short of breath in supine position, gets some relief by sitting or standing up.

Sleep apnea syndrome
Central Cyanosis
Corpulmonale
Clubbing
Significance: Clubbing Observed In:
* Intrathoracic malignancy: Primary or secondary (lung, pleural, mediastinal)
* Suppurative lung disease: (lung abscess, bronchiectasis, empyema)
* Diffuse interstitial fibrosis: Alveolar capillary block syndrome
* In association with other systemic disorders
Effort of Ventilation
* Person appears uncomfortable. Breathing seems voluntary.
* Accessory muscles are in use, expiratory muscles are active and expiration is not passive any more.
* The degree of negative pleural pressure is high.
* The respiratory rate is increased.

Resting Size and Shape of Thorax
* Barrel chest
* Kyphosis
* Scoliosis
* Pectus excavatum
* Gibbus
Barrel Chest
AP Diameter = Transverse Diameter
Tracheal Position: Mediastinum
Chest Expansion
Percussion: Decreased or Increased Resonance is Abnormal
* Dullness
* Hyper resonance
* Traube's space

Breath Sounds: Diminished or Absent
* Intensity of breath sounds, in general, is a good index of ventilation of the underlying lung.
* Breath sounds are markedly decreased in emphysema.
* Symmetry: If there is asymmetry in intensity, the side where there is decreased intensity is abnormal.
* Any form of pleural or pulmonary disease can give rise to decreased intensity.
* Harsh or increased: If the intensity increases there is more ventilation and vice versa.
* Bronchial breathing anywhere other than over the trachea, right clavicle or right inter-scapular space is abnormal.
* In consolidation, the bronchial breathing is low pitched and sticky and is termed tubular type of bronchial breathing.
* In cavitary disease, it is high pitched and hollow and is called cavernous breathing. You can simulate this sound by blowing over an empty coke bottle.

Bronchial breathing
Rhonchi
Pleural Rub
Crackles
Voice Transmission (tactile fremitus, vocal resonance)
* Asymmetrical voice transmission points to disease on one side.
* Increased:
* Decreased
* Qualitative alteration:
Voice Transmission
Bronchophony
Whispering Pectoroliquy
Normal whisper
Egophony

Lung Examination: Abnormal.ppt

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