Dr Khalid Javeed Khan FCPS - FRCS Associate Professor Surgery Fatima Jinnah Medical College
Learning Objectives
Identify & initiate the Management of Immediately Life Threatening Injuries
1. Airway Obstruction 2. Tension Pneumothorax 3. Open Pneumothorax 4. Massive Hemothorax 5. Flail Chest 6. Cardiac Tamponade
Learning Objectives
Identify & initiate the Management of
Introduction
Thoracic Injuries cause 1 out of 4 trauma deaths
Pathophysiology
Hypoxia Hypercarbia Acidosis
Thoracic Trauma
Initial Assessment
Hypoxia is the most serious feature of chest injury so early interventions to ensure adequate oxygenation Most life threatening injuries are treated by an appropriately placed chest tube or needle
Thoracic trauma
Primary Survey of LifeLife-Threatening Injuries
Airway
Listen for air movement at nose and mouth Assess for supracostal & intercostal retractions Assess the oropharynx for Foreign Body Obstruction
Breathing
Expose the chest Look feel and listen for respiratory movement Tachypnea change of breathing pattern esp. shallow breathing
Circulation
Pulse volume, rate and regularity (attach monitor) Skin color and temp BP Neck veins engorged?
Tension Pneumothorax
"One way valve" air leak from the lung or chest, Collapse of ipsilateral lung, shift of mediastinum and collapse of opposite lung A Clinical Diagnosis (not by radiology) Respiratory distress, tachycardia, hypotension tracheal deviation and neck vein distension unilateral absence of breath sounds, may be confused with cardiac tamponade, hyper resonance may help differentiate.
Chest intubations
Open Pneumothorax
"Sucking Chest Wound" If the opening in chest wall is equal to 2/3 of tracheal diameter, air passes preferentially through the defect Hypoxia due to lack of effective ventilation Management Promptly close the defect by sterile dressing taping on three sides to prevent tension Chest tube remote from defect Definitive repair of defect is usually required
Massive Hemothorax
Pathophysiology Rapid accumulation of u 1500 ml blood penetrating wounds disrupting systemic or hilar vessels, sometimes blunt trauma Blood loss hypoxia Diagnosis Shock + dullness + absent breath sounds Flat or distended neck veins
Massive Hemothorax
Management Restoration of blood volume (2 I/V lines) Chest decompression (# 38 French tube) If 1500 ml evacuated, or > 200 ml/hour continuous loss, operative intervention is likely required
Flail Chest
Pathophysiology A segment of chest wall looses continuity with rest Major difficulty is Hypoxia from injury to underlying lung Diagnosis Asymmetric & incoordinated movement of chest Palpation of abnormal motion and crepitus aid diagnosis X-ray chest --> # ribs --> ABG --> hypoxia and acidosis -->
Flail Chest
Management Oxygen ReRe-expand lung Judicious fluid administration Intubation as indicated Analgesia
Cardiac Tamponade
Pathophysiology Penetrating trauma Human pericardium is a fixed fibrous structure, small amount of blood required to restrict cardiac activity Diagnosis Beck's Triad ( o venous pressure, BP, muffled sounds) Tension Pneumothorax on left may mimic tamponade
Cardiac Tamponade
Management
High index of suspicion is all that is needed to initiate Pericardiocentesis in patients who don't respond to usual treatment for shock and have the potential for tamponade All +ve Pericardiocentesis require open pericardotomy
Technique of Pericardiocentesis
Resuscitative Thoracotomy
Secondary Survey
In-depth Physical Examination InUpright X-ray Chest XABG ECG Detection of potentially lethal injuries
Simple Pneumothorax Pulmonary Contusion Myocardial Contusion Aortic Rupture Diaphragmatic rupture Tracheobronchial Disruption Esophageal Disruption
Simple Pneumothorax
Hemo-pneumothorax
Pulmonary Contusion
Most common potentially lethal injury Maintain Adequate Ventilation Selective Intubation & Ventilation if significant Hypoxia Equipment needed Pulse Oximetry ABG determination ECG monitoring Ventilator
Myocardial Contusion
Blunt Trauma History Associated with sternal # ECG changes 2D Echo Treat Complications
Risk of sudden arrhythmias (CCU observation)
Esophageal Rupture
Blunt vs. Penetrating Severe epigastric blow Pain / Shock > Injury Pneumothorax Without # Chest tube --> Particulate matter --> Mediastinal Air Confirm by Contrast swallow / Esophagoscopy Treatment by operative repair
Summary
Thoracic injuries are common in polytrauma LifeLife-threatening Injuries need immediate attention Potentially lethal injuries need to be looked for Usually simple measures required Intubation and ventilation Chest tube Needle Pericardiocentesis Develop skills to treat Monitoring using appropriate equipment
The End
Thanks for patience