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Management of chest trauma

Management of chest trauma. By Dr ABHIJITH. Etiology of chest trauma. Blunt force trauma M.V.A Fall Assault Penetrating injury Shooting Stabbing Iatrogenic. Initial management. ATLS. Component of chest trauma. RIB fracture Flail chest Pneumothorax Haemothorax Lung: laceration

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Management of chest trauma

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  1. Management of chest trauma By Dr ABHIJITH

  2. Etiology of chest trauma Blunt force trauma • M.V.A • Fall • Assault Penetrating injury • Shooting • Stabbing • Iatrogenic

  3. Initial management ATLS

  4. Component of chest trauma • RIB fracture • Flail chest • Pneumothorax • Haemothorax • Lung: laceration • Esophageal & Tracheobronchial • Cardiac: contusion, rupture • Aortic :rupture

  5. Chest wall injury [simple] • Rib fracture most common • Serious in elderly& chronic lung D/S • Management • Analgesic • Physiotherapy & early ambulation

  6. Serious chest injury High energy transfer Associated with major vascular ,thoracic & cranial injury Management: Pulmonary toilet Surgical interference …displaced fragment. Ist & IInd RIB FRACTURE

  7. Flail chest • Definition: 3 or more consecutive rib facture in 2 or more place producing free Floating/unstable segment. • Classification: Anterior flail chest Lateral type

  8. Management • General: • Analgesic • Splinting • Intubation's / ventilation • Specific: • Pericostal suturing • External/internalfixation • Thoracotomy

  9. Complications: • 22% disability rate with 63% having long term problems • Persistent chest wall pain • Deformity • Dyspnoea on exertion

  10. M.V.A Upper & middle 3rd Clinical feature :- Local tenderness Echymosis Swelling Crepitus Sternal fracture

  11. X ray & Echo Uncomplicated Analgesic Bed rest Complicated Open reduction & internal fixation Management

  12. Pneumothorax • Definition: Air trapped within pleural cavity following injury to chest , lung or airway.

  13. Clinical presentation • Tachyponea • Hypotension • Respiratory distress • Breath sound decreased

  14. Management • X-ray • Tube Thoracostomy • Chest decompression with wide bore needle inserted in llnd I.C.S.

  15. Indications: • Spontaneous /traumatic pneumothorax • Haemothorax • Recurring pneumothorax after removal of chest tube • Prophylaxis pre-operatively in flail chest

  16. Complications: • Haemorrhage from IC vessel injury • Subcutaneous emphysema • Injury due to malpositioned tube • Local infection • Pain • Re expansion pulmonary oedema after prolonged collapse & rapid reinflation • Inadequate drainage of pleural space due to clots & plugging or kinking of the tube

  17. Open pneumothorax [sucking chest] • Defect in chest wall following trauma. • Air enter from out side. • Intrathoracic pressure raised with mediastinal shift . • Management: Chest tube with occlusive dressing

  18. Tension pneumothorax • Leaking of air from an underlying pulmonary parenchyma. • Management; Needle thoracostomy[14- 16guage inserted through llnd I.C.S] • Tube thoracostomy

  19. Heamothorax • Definition ;collection of blood in pleural cavity .varies from minor to massive based on vessel injured . • Management: • Chest tube thoracostomy{>28F}. • Thoracotomy.

  20. Thoracotomy • Indications: • 1000 ml drained at insertion of chest drain • Bleeding>100 / 15min • >200ml/hr for 3-4 hr • Cardiac tamponade • Major bronchus ,oesophageal ,diaphragm injury

  21. Lung contusion • Laceration following penetrating or blunt trauma.

  22. Uncomplicated Antibiotic Lasix Dexamethasone Bronchodilator Suction drainage Physiotherapy Complicated Thoracotomy Pneumonectomy[high mortality >50%] Management

  23. Rare High mortality Pathophysiology:- Direct compression of airway with closed glottis or injury producing partial or complete avulsion Injury to Major Airway

  24. Management • Adequate air supply • Endotracheal intubation • Tracheostomy • Bronchoscopy for definitive diagnosis • Definitive measure ;restoration of airway with end to end anastomosis. Defect >3cm proximal and distal mobilization required.

  25. Diaphragmatic injury • Rare • Clinically left side commonly identified • Autopsy & CT show equal incidence • Incidental diagnosis • X-ray • Diaphragmatic distruption • Ipsilateral hemidiaphragm elevation • Abdomen visceral herniation

  26. Management • Laparotomy :Using continuous or interrupted braided suture • Thoracotomy :Postrolateral injury

  27. Rare Cause: Clinical feature:- Sudden increase in luminal pressure. Chest pain Pneumothorax Intraabdominal free air Systemic sepsis Esophageal injury

  28. Management • Fluid resuscitation • I.V broad spectrum antibiotic • multiple chest tube drainage • Surgical • Within 24hr debridement and primary closure • After 24hr primary closure with autologus tissue transplantation. • Poor general condition & advanced mediastinitis • Esophageal exclusion & diversion • Cervical esophagotomy

  29. 15-16%chest trauma show cardiac involvement. Associated with sternal injury. Diagnosis 12 lead E.C.G Echocardiogarphy Enzyme elevation Cardiac injury/ myocardial contusion

  30. Management Constant monitoring for 48hr Resuscitation Antiarrhythmic

  31. High mortality RT atrium & ventricle Chest pain to collapse Sign: Muffled heart sound Jugular venous distension Hypotension Cardiac rupture

  32. Management • Cardioraphy with or without cardiopulmonary bypass. • Counter pulsation using balloon pump.

  33. Causes:- Stabbing Shooting Iatrogenic Diagnosis: Feature: Hypotension Tachycardia High C.V.P Pulsus paradoxus E.C.G Echocardiography Penetrating heart injury

  34. Management • Left anterior Thoracotomy • Aspiration & repair with buttressed suture

  35. Mechanism:- Diagnosis shearing force Direct luminal pressure against point of traction. X-ray : widening of mediastinum with shadow CT Aortic Transection

  36. Thoracotomy:- Via left 4th I.C.S Direct suture with or without interposition graft. Management

  37. Summary: Chest Trauma • Common • Serious • Primary goal is to provide oxygen to vital organs • Remember AirwayBreathing Circulation • Be alert to change in clinical condition

  38. Thank u!

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