In ESH we usually see blunt chest trauma but penetrating injuries also treated here (usually as single injuries, like stab wound)

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1 Chest Trauma Dr Csaba Dioszeghy MD PhD FRCEM FFICM FERC East Surrey Hospital Emergency Department Scope Thoracic injuries are common and can be life threatening In ESH we usually see blunt chest trauma but penetrating injuries also treated here (usually as single injuries, like stab wound) Most acutely life threatening injuries are usually identified and dealt with during the primary survey often needs relatively simple intervention to save the life Blunt chest trauma can be deceptive: severe injuries with grave consequences might be missed unless specifically looked for Approximately 12 / million population per day (US) 20-25% of trauma related death Fatal outcome often occurs early: 30 min 3 hrs 2 1

2 Life threatening injuries Airway obstruction Direct laryngo-tracheal or trachea-bronchial injury External compression due to soft tissue swelling/haematoma Tension or open pneumothorax Respiratory failure (open) Respiratory and circulatory failure (tension) Flail chest Respiratory failure Massive haemothorax Circulatory and respiratory failure Cardiac tamponade Circulatory failure 3 Life threatening injuries Airway obstruction Direct laryngo-tracheal or tracheo-bronchial injury External compression due to soft tissue swelling/haematoma Tension or open pneumothorax Respiratory failure (open) Respiratory and circulatory failure (tension) Flail chest Respiratory failure Massive haemothorax Circulatory and respiratory failure Cardiac tamponade Circulatory failure 4 2

3 Airway Look: bruise, injuries, surgical emphysema Listen: stridor, hoarseness Feel: Surgical emphysema, tracheal deviation 5 CD1 Airway Look: bruise, injuries, surgical emphysema Listen: stridor, hoarseness Feel: Surgical emphysema, tracheal deviation 6 3

4 Slide 6 CD1 Csaba Dioszeghy, 16/11/2016

5 Tension pneumothorax Clinical diagnosis (challenge) Respiratory distress Asymmetrical chest movement Distended neck veins, tracheal deviation Absent breath sounds, hyper-resonance Clinical signs are different and more rapid in the ventilated patient leading to circulatory collapse 7 Clinical diagnosis? DDX: Haemothorax Flail chest Rib fractures Sternal fracture Prev.chest / lung disease 8 EMJ 2005; 22:8-16 4

6 RADIOLOGY Is this a clinical failure to have these images taken? What is the specificity and sensitivity of radiology for TPT? 9 Ultrasound Better clinical sensitivity than supine chest X-Ray Easy, fast and safe method but needs trained operator LUNG SLIDING NO LUNG SLIDING 10 5

7 TPTX: decompression (1/2) Needle decompression Needs long enough needle! 1/3 of trauma patients have chest wall > 5 cm. 38% unsuccessful (Barton, 1995) needs finger thoracostomy Re-tension 2 nd ICS Midclavicular line Most likely to reach the air Longer needle might be needed Mamillar artery, intercostal aretry 4 th or 5 th ICS Mid-axillary line (ATLS) Less fat shorter needle might be enough Increased risk of lung damage Intercostal artery 11 TPTX: decompression (2/2) Finger or tube thoracostomy Needle decompression is often unsuccessful Safe and effective, even in pre-hospital care 1% complication on insertion Less likely to develop re-tension 12 6

8 Open PTX Usually obvious clinical signs Ventilation is ineffective Occlusive dressing (first aid) Chest tube Inserted different site 13 Passive suction (underwater) The level of suction 2-5 cm 14 7

9 Passive suction (underwater) NEVER EVER CLAMP A BUBLING CHEST DRAIN. SERIOUSLY. NEVER EVER. The level of suction 2-5 cm 15 Suction and drain for haemo-ptx Suction (-A-B wcm) Atm Suction (any) BLOOD collected -A-B -A B WATER This is the negative pressure (B) set in wcm for the chest A -A WATER (safety) Suction pressure will not exceed the wcm set here (A) 16 8

10 Flail chest Three or more adjacent ribs fractured in two places creating a floating segment Multiple broken ribs lots of pain Destroy chest mechanism respiratory failure Clinical signs: Distress +++ Pain +++ Paradox chest wall movement 17 Flail chest: management Analgesia (thoracic epidural) and chest physiotherapy Evaluate and monitor ventilation regularly (pco2) Might need RSI and ventilation Surgical fixation might be considered Not enough good quality evidence Always look for further injuries: Lung contusion Pneumothorax Haemothorax 18 9

11 Massive haemothorax Massive amount of blood loss (>1500ml) Circulatory failure Ventilation mechanics respiratory distress No breathing sound Dull percussion Management: Chest drain (large calibre) Massive Haemorrhage Protocol as required If blood loss is 20 ml/kg /24 hr or 200 ml/hr for successive hours Thoracotomy or video assisted thoracoscopic surgery (VATS) 19 Cardiac tamponade Haemodynaimc collapse Distended neck veins ECG signs FAST Scan Management Pericardiocentesis is useless EMERGENCY SURGERY 20 10

12 Traumatic aortic rupture Deceleration injury Usually at the site of the lig. arteriosum Usually fatal (80% on scene) 15% of all RTC death Survivals might developed a pseudoaneurysm Management: urgent surgical 21 Further injuries of blunt chest trauma Tracheo-bronchial injuries PTX, HTX Lung contusion Blunt cardiac injury (cardiac contusion) Rib fractures Sternal fracture Diaphragmatic injuries 22 11

13 Tracheo-bronchial injuries Less than 1% of blunt chest trauma Persistent PTX / air leak Pneumo-mediastimum Surgical emphysema Diagnosis CT, bronchoscopy Management Depends on the site and extent of injury Selective lung ventilation Thoracic surgery 23 Tracheo-bronchial injuries Less than 1% of blunt chest trauma Persistent PTX / air leak Pneumo-mediastimum Surgical emphysema Diagnosis CT, bronchoscopy Management Depends on the site and extent of injury Selective lung ventilation Thoracic surgery 24 12

14 Pulmonary contusion Common in blunt chest trauma Develops over the first 24 hrs Resolves in about a week Might cause respiratory failure (rarely need intubation) Possible complications are pneumonia, ARDS Diagnosis Chest XRay Management: Analgesia, chest physiotherapy Normal fluid therapy (no need for fluid restriction) 25 Blunt Cardiac Injury Direct hit over the heart Range of pathology: arrhythmia, contusion, wall rupture, septal or valvular rupture, myocardial infarction (coronary dissection) Cardiac contusion: probably the most common but not clear definition! Diagnosis: ECG: arrhythmia (most common: ST and AF) nonspecific signs, T / ST segment changes, RBBB Echo: RWMA, pericardial effusion Biomarkers (troponin): not needed and no added value (does not change management, not reliable for prognostication either) Management: Cases of wall rupture, septal or valvular rupture will need cardiac surgery Cardiac contusion: serial ECG and monitoring for 4-6 hrs if haemodynamically stable Unstable patients needs HDU for haemodynamic monitoring and support as required 26 13

15 22/11/2016 Rib fractures 4th-10th rib fractures are the most common 1st-3rd rib fractures are associated with high energy trauma CT scan is mandatory to evaluate associated injuries Lower rib fractures (10-12) might be associated with liver / spleen injuries Chest X-Ray (AP) will likely miss 50% of fractures Rib fracture is not X-Ray indication unless other injuries are suspected Clinical diagnosis: point tenderness, deformity Fact: Most common site of rib# in blunt chest trauma (RTC): anterior and lateral ribs Fact: CXR is better to detect fractures on the posterior ribs and misses the rest! 27 Rib fractures Red flags: Multiple rib fractures Elderly Co-morbidity especially lung disease Associated injuries Management: Analgesia Chest physiotherapy Surgery is very rarely indicated 28 14

16 Sternal fracture 3-7% occurrence in blunt anterior chest trauma Mortality is low (0.7%) Localized sternal pain Shortness of breath (15-20%) Local bruising (55%) Lateral (sternal) view X-Ray ECG is indicated Consider cardiac contusion But if ECG normal and patient is stable, no further testing is necessary 29 Diaphragmatic injury Less than 1% of blunt chest injuries Happens mostly on the left side Chest and abdominal pain with SOB Pain may get better when upright Bowel sounds and reduced/missing breath sounds on the left side Diagnosis: Chest X-ray / CT scan Management NG tube to decompress Chest drain might be considered (avoid viscera!) Surgical repair early is better 30 15

17 Summary Chest injury is very common Life threatening injuries are often identified and treated during the Primary Survey Initial stabilization usually requires simple maneuvers: Difficulty is the decision making! Stable patients with blunt thoracic trauma might still have serious injuries and therefore careful evaluation and targeted investigations are mandatory Remember the limitations of X-Ray and use of U/S and CT Remember to look outside the box: associated injuries are common! 31 16