RESUSCITATION & THORACIC

TRAUMA

PRESENTERS: DR UMAR & DR MARYAMSUPERVISOR: DR FAIZUL

OUTLINE

• INTRODUCTION

•LIFE THREATENING THORACIC INJURY

•COMMON CONDITION OF THORACIC INJURY

• TAKE HOME MESSAGES

INTRODUCTION• Trauma causes 100,000 deaths and more than 9 million disability

injury annually in worldwide (6th leading cause of death).

• Chest injuries are responsible for 20-25% of all trauma death.

•The World Health Ranking 2011 has ranked Malaysia at number 20 with the most deaths caused by road accidents.

•An average of 18 people were killed on Malaysian roads daily.

* Malaysian Institute of Road Safety (MIROS)

CLASIFICATION

•Anatomy•Lungs, pleura and ribs•Cardiac injury•Trachea , oesophagus & major vessels•Diaphragm

•Mechanism of injury•Blunt•Penetrating•Shearing / acceleration-decelaration injury

•Cause / Aetiology•MVA / trauma•Fall from height•Gunshot / sharp or blunt object

LIF

E T

HR

EA

TEN

ING

C

ON

DIT

ION

TENSION PNEUMOTHORAX

TENSION PNEUMOTHORAXDevelops when air leak occurs from the lung or through chest wall.

Air is forced into thoracic cavity without means of escape

Creating a “one-way valve”.Affected lung collapsedDisplaced mediastinum to opposite siteDecrease venous returnCompressing the opposite lung

TENSION PNEUMOTHORAXSIGNS AND SYMPTOMS

TENSION PNEUMOTHORAX

RADIOGRAPHIC FINDINGS

Mediastinal shift to the right

TENSIONPNEUMOTHORAX

Tension pneumothorax is a clinical diagnosis.Treatment should not be delayed to wait for radiologic confirmation.

TENSION PNEUMOTHORAX

Management1. Initial Management: needle thoracostomy

- convert the injury to simple pneumothorax.

2. Definitive management: chest tube insertion

3. Supportive management:

- Analgesia

- Ventilatory support

- CXR monitoring

- Chest phyisotherapy

NEEDLE THORACOSTOMY

OPEN PNEUMOTHORAX

OPEN PNEUMOTHORAX:Pathophysiology

•Known as “sucking chest wound.”

•Air allowed to enter pleural space from the outside.

•Ineffective ventilation because air goes in and out from the chest wound, rather than from trachea.

•Leading to hypoxia and hypercarbia.

Open PneumothoraxClinical Findings

•A defect in the chest wall with air coming in & out

•A sucking sound on inhalation

•Tachycardia & tachypnea•Respiratory distress•Subcutaneous emphysema

•Decreased breath sounds on the affected side

OPEN PNEUMOTHORAXMANAGEMENT

1. Initial management:• 3 sided sterile occlusive dressing•Treat concurrent shock

2. Definitive management•Chest tube insertion

3-sided occlusive dressing

FLAIL CHEST & PULMONARY

CONTUSION

FLAIL CHEST

• Described as the paradoxical movement of a segment of chest wall caused by fractures of 3 or more ribs in 2 or more placed.

FLAIL CHEST

Severe hypoxia resulting from: •The underlying lung injury disturbance of ventilation & perfusion •Restricted chest wall movement associated with pain impaired ventilation

FLAIL CHESTClinical findings

INSPECTION-Chest wall contusion-Paradoxical chest wall movement-Respiratory distress

Palpation-Crepitation of rib

FLAIL CHEST

Investigation

•CXR : multiple ribs fracture

•ABG: respiratory failure with hypoxia

FLAIL CHESTManagement

1. Initial management:- adequate ventilationfluid resuscitation

In absence of systemic hypotension, fluid resuscitation should be carefully controlled to prevent overhydration.

FLAIL CHESTManagement

2. Definitive management

Positive-pressure ventilation may be needed.•Reverses the mechanism of paradoxical chest wall movement•Restores the tidal volume

Adequate analgesic•Reduces the pain of chest wall movement

Assess for the development of a pneumothorax•May need chest tube insertion

MASSIVE HEMOTHORAX

MASSIVE HEMOTHORAX

Defined as presence of >1.5 liter of blood drained from the pleural space upon chest tube insertion

or >200cc/hour in first 4 hours.

MASSIVE HEMOTHORAXClinical Findings

MASSIVE HEMOTHORAXManagement

Large caliber IV linesCrystalloid infusionBlood transfusion

Chest tube insertionConsider for thoracotomy

MASSIVE HEMOTHORAX

Chest tube insertion

MASSIVE HEMOTHORAX

10 days after chest tube insertionOn admission

CARDIAC TAMPONADE

CARDIAC TAMPONADE

•Suspect if injury within the “box”.

•May need prompt involvement of cardiothoracic team

CARDIAC TAMPONADE

Pathophysiology •A blunt or penetrating trauma may cause tears in the myocardial walls, allowing blood to leak from the heart.

If 150 to 200 mL of blood enters the pericardial space acutely, pericardial tamponade can develops

CARDIAC TAMPONADE

CARDIAC TAMPONADE

CARDIAC TAMPONADE

Cardiac Tamponade Management•Airway and ventilation •Circulation—IV fluid challenge•Pericardiocentesis•Prompt involvement of cardiothoracic team.•Do not take out the penetrating object

CARDIAC TAMPONADE

Pericardocentesis

OTHER CHEST INJURIES

1. RIB FRACTURE2. SIMPLE PNEUMOTHORAX3. HEMOTHORAX4. PULMONARY CONTUSION5. TRACHEOBRONCHIAL TREE INJURIES6. CARDIAC CONTUSION7. TRAUMATIC MAJOR VESSEL DISRUPTION8. DIAPHRAGMATIC INJURIES

*Hemorrhage should be excluded in all patients who are in shock after major trauma†Neck vein distention may be absent in patients with hypovolemic shock.

GENERAL MANAGEMENT•Primary & secondary survey•Serial clinical assessment & SPO2 monitoring•Adequate analgesia (pain control CPG)•Oxygen therapy tailored to oxygenation status•Chest tube insertion•Intensive & vigorous chest physiotherapy, deep breathing exercise & incentive spirometry

•Mucolytic & nebulizer•Early referral to appropriate team (i.e. anaest, CTC)•± Assisted ventilation or intubation•± Thoracotomy / thorachoscopy and proceed

TAKE HOME MESSAGES1. Life threatening condition in thoracic injury are

• Tension pneumothorax

• Open pneumothorax

• Massive hemothorax

• Flail chest

• Cardiac temponade.

2. Tension pneumothorax required emergent needle thoracotomy without waiting for CXR if highly suspected clinically

3. Do not remove the object causing the penetrating thoracic injury

4. Open pneumothorax is managed with flutter-valve dressing or three sided dressing

TAKE HOME MESSAGES

5. Flail chest is defined as segmental fractures in 2 or more places of 3 or more consecutive ribs.

6. Massive hemothorax happen when

• more than 1.5 liters blood drained upon chest tube insertion

• Or more than 200cc/hour in 4 hours

7. All symptomatic traumatic pneumo/hemothorax require chest tube insertion

8. Cardiac tamponade is recognized by presence of Beck’s Triad which are

• Muffled heart sound

• Hypotension

• Distended neck veins

TAKE HOME MESSAGES

9. Key management in thoracic injury include

• Identifying the life threatening condition

• Resuscitation and oxygen therapy

• Chest tube insertion

• Adequate pain control and aggressive chest physiotherapy

• Ventilation and early associate team referral

REFERENCES

• ATLS for Doctors, 8th Edition• Bailey & Love Short Practice of Surgery, 25th

Editions• Emergency Medicine Clinics of North America

- Volume 30, Issue 2 (May 2012)• SRB’s Manual of Surgery 4th edition