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Chest Trauma

Chest Trauma. Ian Maxwell. Chest wall Rib # Flail chest Sternal # Lung Contusion Pneumothorax Hemothorax Tracheobronchial injury. Heart Blunt BTAI esophagus. Outline:. Case:. 24 yo male was kung fu fighting. Kicked in left chest by a kung fu kick.

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Chest Trauma

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  1. Chest Trauma Ian Maxwell

  2. Chest wall Rib # Flail chest Sternal # Lung Contusion Pneumothorax Hemothorax Tracheobronchial injury Heart Blunt BTAI esophagus Outline:

  3. Case: • 24 yo male was kung fu fighting. • Kicked in left chest by a kung fu kick. • A/B: In pain no resp distress. Speaks easily. O2 sat 97% RA. • C: no concerns. P 88. BP 134/88

  4. CXR

  5. Rib # • # of ribs 9,10,11: • R side: 3X ↑ risk hepatic injury • L side: 4X ↑ risk splenic injury Shweiki E. J Trauma. 2001 Apr;50(4):684-8

  6. 1st Rib # • Used to be considered harbinger of vascular trauma • Now only if • Wide mediastinum on CXR • Posterior displacement • Sublavian groove # anteriorly • Brachial plexus injury • ↑ing hematoma Gupta A Cardiovasc Surg. 1997 Feb;5(1):48-53

  7. 1st rib # • If associated with • Major head injury • Long bone # • Other rib #’s • Abdominal trauma Then vascular injury 24% of the time

  8. Rib # • Watch out for: • Occult pneumothorax • Atelectasis (encourage breathing) • Pneumonia • Occasionally neuroma or chostochondroma Consider admission in older patients with difficulty breathing and/or 2+ rib #’s

  9. Sternal fracture Brookes, Dunn. J Trauma. 1993 Jul;35(1):46-54 • More common with seatbelts less with airbags • >90% from MVC • Associated injuries most important consideration

  10. Associated injuries:(from Knobloch and Brookes) • Soft tissue injury 56% • Spine injury C>T>L 30% • Brain injury 24% • Pulmonary injury 18% • Limb # 17% • Multiple rib # 13% • Heart injury 4.5%

  11. Association with heart damage(more on this shortly) • In Knobloch’s study 12/267 (4.5%) had myocardial contusion • In Brookes’s study only 4/272 (1.5%) had arrhythmias that required treatment: • ¾ had pre-existing heart disease • ¾ fib/flutter Knobloch. Ann Thorac Surg. 2006 Aug;82(2):444-50

  12. Sternal fracture • No proven association with Aortic injury • None in Brookes or Knobloch papers • These studies don’t include the pre-clinical (deceased) though Sturm JT. Ann Thorac Surg 1989;48:697– 8.

  13. Sternal Fracture • Sternal # per se is usually benign Therefore management: similar to rib # except in extreme cases

  14. Flail chest: • What is it? • What about it is dangerous?

  15. Flail Chest • 3 or more adjacent ribs fractured at two points: • Allows that separated segment to move in opposite direction • Underlying pulmonary contusion the main cause of problems • Mortality of 8% - 35% (usually from associated pathology)

  16. Management of flail chest • Don’t put sandbags on them • Deal with associated injuries promptly i.e. • PTx (especially tension) • HemoTx • Intubate if necessary (try to avoid) • Respiratory failure • Shock • Airway control • Surgery needed soon

  17. Management of flail chest • Pain control: • Intercostal nerve blocks: • 0.25% bupivacaine with epi (longer acting) along inferior edge of rib, posterior to fracture site • High thoracic epidural

  18. Flail chest • Key points • Exposure is crucial to avoid miss • Should prompt further imaging (CT) • Deal with associated injuries promptly • Pain control important • Try to avoid intubation

  19. Case: • 18 yo male kicked out of bar by bouncers • Was held down by 4 people • In ER: • Intoxicated • Normal vital signs • GCS 15

  20. What is the Diagnosis?

  21. Traumatic Asphyxia • Petechiae • Violet colour to skin • Sub-conjunctival hemorrhages • Facial edema

  22. Traumatic asphyxia • From compression of thorax and ↑thoracic pressure • Leads to retrograde flow up SVC • Usually benign – look for other injuries • 1/3 have LOC • May lead to retinal hemorrhage which could cause permanent vision loss • CT head if neuro symptoms/signs

  23. Case: Too much talking not enough listening • 27 yo male kicked repeatedly in L chest by stampede bouncer wearing cowboy boots • Initially: • A/B: speaking a few words, 91% RA w/ EMS, RR 22 • C: 145/88, P 98 • Spit up blood in ambulance, no facial trauma • ↓AE over area of injury

  24. CXR

  25. Pulmonary Contusion • Clinical features: • Dyspnea • Tachypnea / tachycardia • Cyanosis • Hypotension • Chest wall bruising • Hemoptysis in 50% • ↓AE, rales over affected area

  26. Pulmonary Contusion • Radiographic features • Initially may be masked by more apparent injuries • Patchy infiltrates / consolidation • Rapidity of onset of x ray features correlates with severity • CT also useful • Must differentiate from ARDS

  27. Pulmonary Contusion • Low PaO2 on ABG • Wide AA gradient

  28. Case: continued • Now 30 minutes later: called back to bedside for • RR 36 • Using accessory muscles • O2 sat 89% non-rebreathe mask • What now?

  29. Pulmonary contusion • Management • Same as usual intubation indications • Sometimes double lung ventilation used • Injured lung has less compliance • Pulmonary toilet • Pain control • Restrict IV fluids • No need for empiric ABx

  30. Case: iatrogenic trauma • 53 yo Male, just had unsuccessful subclavian line insertion attempt by me • Looks very unwell… what is your first concern?

  31. Case: Iatrogenic trauma • In trauma bay • A/B: Agitated, cyanotic, not speaking, rightward deviated trachea, 83% HF mask, • C: BP 88/39, P 120, distant heart sounds, ↑JVP

  32. CXR – iatrogenic trauma

  33. Pneumothorax • Simple Ptx • No communication with outside • No shift of mediastinum • Communicating Ptx • Hole in chest wall • Tension Ptx • Shift of mediastinum – compression of cavoatrial junction - ↓preload: shock

  34. Ptx: clinical presentation • May be normal, or: • Cyanotic, dyspnea, tachypnea • Decreased breath sounds, hyperresonance over Ptx • Possibly subcutaneous emphysema

  35. Tension Pneumothorax • An emergency! • Signs, symptoms: • Same as non tension Ptx + • Agitated and possibly ↓LOC • Deviated trachea • Beck’s triad: ↑JVP, ↓BP, distant HS • Should not be diagnosed on CXR

  36. Pneumothorax - Imaging • CXR: Upright – need 50cc air to be visible - seen as white pleural line with no lung vessels Supine – need 500cc - may see line or may just see deep sulcus sign, anterolateral mediastinal air, anterior pleural air outline

  37. Ultrasound dx of pneumothorax • Gaining popularity Soldati G.Chest. 2008 Jan;133(1):204-11. Epub 2007 Oct 9 • Looked at 109 chest trauma patients • ED U/S shown to be 92% sensitive

  38. Blaivas M, Acad Emerg Med 2005; 12:844–849 • 176 chest trauma patients, 53 with Ptx • Ultrasound: Sensitivity 98.1% (89.9%, 99.9%) • Supine CXR: Sensitivity 75.5% (61.7%, 86.2%)

  39. Pneumothorax - Size • Can estimate size by Collins method Apical distance (mm) + midthoracic + basal __________________________________ 3 = % pneumothorax Or: lateral width of 1cm = 10% Or just call it big or small: chest wall → pleura > 2cm

  40. Collins method

  41. What do you do for management of tension PTx? When do you put a chest tube in someone?

  42. Ptx - Management • Tension Ptx: • Immediate needle decompression • 16G angiocath to 2nd Interspace, Mid-clavicular line • Followed by chest tube • Communicating Ptx: • Chest tube • Cover defect in the field

  43. Ptx - Management • Chest tube if • Tension • Trauma • Large • Symptoms regardless of size • Increasing size with conservative therapy • Re-accumulation after tube removal • Bilateral Ptx • Need for positive pressure ventilation • Flying • Bilateral • Associated hemothorax

  44. Case: ATV rollover • 23 yo Female • Trying to go uphill slowly on ATV: rolled over backwards and ATV landed on her chest • Stable with EMS • A/B: speaking with some distress, O2 sat 97% 5LNP, • C: BP 144/72, P 92

  45. Supine CXR in trauma bay

  46. CT

  47. Hemothorax • Usually from • lacerated lung • Intercostal vessel • Internal thoracic artery • Heart, hilar and great vessels less common, obviously more deadly

  48. Hemothorax • Clinical • ↓AE on affected side • Shock if lots of bleeding • Radiographic • Upright superior but impractical in trauma • 200-300cc will yield blunting for upright • Look for haziness on supine film • Often discovered on CT

  49. What do we need to do for hemothorax?

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