Chest Trauma Chest Trauma

Dr Mike NoonanDr Mike Noonan

Overview

Introduction:•Epidemiology

Pathophysiology of Chest Injuries:•Hypoventilation•Impaired Gas Exchange•Shock

Management Principles:•Chest Decompression•Analgesia, Physiotherapy, Mobility and Nutrition•Ventilatory Support•Resuscitative Thoracotomy

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Epidemiology and Classification

Chest Injury:•Common:

– Major chest trauma is 10th most common injury via DRG classification for all trauma admissions.

– 58 patients 2010-2011

•Primary cause of mortality in 20-25% of deaths•Contribute to death in a further 25% of deaths

Classification:•Blunt•Penetrating•Alfred: Major Trauma- 3.6% penetrating

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Trauma Service Audit 2010-11

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Injury Profile by AIS body region – major trauma

0

500

1000

1500

2000

2500

Head Legs Chest Spine Face Arms Abdomen External Neck

injuries

2009/10 2010/11

Pathophysiology

Pathophysiologic consequences of chest trauma:•Hypoventilation

– Mechanical failure of ventilatory mechanism

•Hypoxia– Secondary to hypoventilation– Impaired gas exchange

•Shock– Hypovolemia– Pump (cardiogenic) failure– Neurogenic shock due to spinal cord injury

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Decreased tissue oxygenation

Decreased tissue perfusion

Decreased tissue oxygenation

Decreased tissue perfusion

Spectrum of Injuries• Rib fracture(s)• Simple pneumothorax• Simple haemothorax• Tension pneumothorax• Open pneumothorax• Massive haemothorax• Cardiac tamponade• Flail chest• Pulmonary contusion• Ruptured diaphragm• Aortic Injury• Oesophageal injury

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Scenario 1

51yo male. Fall against table while intoxicated.

PHx: •Alcohol abuse •Poorly controlled Insulin-requiring Type II DM•HPT•Smoker (20/day; 30 pkt year history)

On arrival:•A: Speaking in full sentences. Cx collar applied•B: RR 28. Satn 90% high flow oxygen. Complaining of right chest pain and ‘unable to catch breath’. Decreased breath sounds on right with subcutaneous emphysema.•C: HR 95. BP 178/94. FAST negative.•D: Agitated E4 V4 M6=14

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Scenario 1

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Scenario 1

Initial Management:

•O2 via Hudson mask, high flow.

•Set up for right ICC•Intravenous access: warmed crystalloid. 8/24

Adjuncts to Primary Survey:•CXR PXR•ABGs:

– Type 1 or Type 2 respiratory failure

– CO2 retention

•Venous blood: Hb/U&E/LFTs/Clotting/EtOH/Glucose

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Scenario 1

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Scenario 1

ABG:•pH 7.40

•pCO2 55

•pO2 110

•HCO3- 32

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Management Priorities?

Scenario 1

• Drainage of blood and pneumothorax to maximise ventilation: ICC• Analgesia – CALL APS

– Systemic– Local– Regional

Patient needs to be able to deep breath and cough• Position and mobility:

– Spine clearance so that the patient can be sat up

• Physiotherapy: chest as well as general mobility• Optimisation of comorbidities:

– Diabetes– EtOH withdrawal– Nutrition

• ? ICU admission12

Scenario 2

19yo male. HSP MVA into tree.

At scene:

A: Grunting, obvious facial fractures. Cx collar applied

B: Decreased air entry right chest. Seat belt bruising right upper chest wall. RR 26.

C: HR 135 with thready pulse. SBP 80/.

D: GCS E1 V2 M4=7

Initial Treatment:•Cx collar. RSI.•Right pneumocath.•Iv access with 1.0 l Nsaline commenced. Pelvic binder applied.

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Scenario 2

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Scenario 2

On arrival (45 minutes post-accident):•A: Intubated. Cx collar in situ.

•B: Absent air entry right chest. Satn 87% on 100% FIO2. Trachea midline.

•C: HR 145. SBP 89 after 1.5 litres crystalloid. Cool, clammy, shut down. Plethoric face(?). Deformed right femur.

•D: GCS E1 VT M1

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Scenario 2

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Scenario 2

Progress:•Post ICC insertion:

– Improved air entry right chest

– HR 95 BP 115/62– 200ml blood from right ICC

•FAST negative, PXR normal•Femur reduced and splinted•Further 1000ml Nsaline

Key Points:•Tension Pneumothorax is a cause of shock- easy to treat!•Do not need tracheal deviation

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Scenario 3

35 year old depressed man:•Penetrating chest wound just above and medial to the left nipple•Self presented to triage

On arrival:•A: Speaking in short sentences, very agitated.•B: Tachypnoeic with RR 34, Sat 89%•C: HR 130, thready. SBP 90

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Scenario 3

Treatment:• Supplemental Oxygen• iv access: 500ml Nsaline

Progress:• Became less agitated though drowsy. Airway maintained.• B: RR 26. Sat 87%. Air-entry equal bilaterally.• C: HR 140, thready. SBP80.

• Plethoric face and distended neck veins noted

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Scenario 3

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Scenario 3

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HaemopericardiumHaemopericardium

Right VentricleRight Ventricle

Scenario 3

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What does this patient need?

Where will this be performed?

Scenario 3

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•Identification of immediately life-threatening situation (tamponade) via systematic attention to A, B and C.

•Transfer of the patient to theatre in a timely fashion, or

•Perform emergency room thoracotomy if SBP remains <70 mmHg despite iv resuscitation

NB: ATLS Guidelines 8th edition: Treatment of Cardiac Tamponade

Questions?

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Summary

• Chest trauma is common

• Most injuries are diagnosed with simple clinical and imaging techniques

• Most life-threatening injuries can be managed with simple procedures and attention to analgesia, physiotherapy and nutrition

• Severe chest trauma requires more advanced life support

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