chest trauma &Thoracostomy

prepared by Anbese w. HU,2nd yr IES dept oct 2011 anbese4@gmail.com

thoracic cavity
thorax (chest)-sup part of trunk b/n neck& abd thoracic cavity is surounded by thoracic wall-contains heart,lung,thymus,distal trachea & most of esophagus thoracic wall -consists of skin,fascia,nerves ,vesseles,muscles & bones -protects thoracic & abd internal organs

ribs
12 pairs of ribs & costal cartillages separated by ICS-occupied by muscles,vessels&nerves 12 thoracic vertebrae ribs r curved flat bones-3 types; true(vertebrocostal) -directly to sternum w their own costal cartilage 1-7 false(vertebrochondral)-their cartilages joins to c of ribs above 8-10 floating(free)-not connect to sternum 11,12

...ribs

chest injury..
25% of all trauma deaths are due to chest injuries+resp problems early deaths after thoracic trauma are caused by hypoxemia, hypovolumia, & tamponade immedite death-aortic/great vessel tear avoidable by simple measures first step is Dx&Rx as early as possible follow ATLS protocol classification blunt trauma-85% penetrating trauma-15% of chest injuries stab&gunshot wounds

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generally chest injury can involve chest wall lung mediastnal structures diaphragm liver

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1st& 2nd rib suggest significant force great vessel,tracheobronchial,spinal injuries sternal injury -myocardial contusion lower ribs -abd visceral injury-liver spleen,kidney

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chest wall injuries simple rib - below 3rd rib z first three ribs are protected by soulder girdle pain ,motion during breathing,point tenderness may be serious in elderlies or people w CPD of lower ribs may involve underlying abd viscera- spleen(Lt) &Liver (Rt) intercostal @ bleeding haemothorax confirmed by CXR mgt uncomplicated - pain relief &chest physiotherapy

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major chest wall injuries flail chest -paradoxical mov't of segement of chest wall as aresult of of 2 or more ribs at two or more places or bilateral costochondral junction separation free floating rib segments inward during inspiration & out ward -expiration hypoxia due to limited chest mov't & underlying lung contusion

C/F-PR,RR,BP,dyspnoea,cyanosis
paradoxical chest motion,rib crepitus

x-ray-multiple rib + segmental

....flail chest
MGTusually supportive follow ATLS protocol ABC iv fluid,analgesics,oxygen severe cases -ETI + positive pressure ventilation for up to 3wks

Fracture of 1st,2nd rib &sternum -major injuries -force usually causes associated injury to underlying structures-vessels or nerves 1st rib-serious injury w/c requires force -usually associated w great vessel ,head &neck injuries mortality rate is >30% similar for sternum & scapula sternum risk of underlying myocardial damage pt should be observed in hospital w ECG aortic rupture&spinal injury should be excluded lung contusion -bloody sputum during cough injury to mediastnal structures - trachea,bronchus,major vessel,& heart-rare -usually fatal, pt may not reach H.facility

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diaphramatic injury - should be suspected in penetrating thoracic trauma below 4th interspace-anteriorly below 6th " laterally below 8th " posteriorly diaphramatic rupture -results due to high speed blunt abd trauma w closed glottis -herniation of intra abdominal organs like stomach,colon in to chest -visceral herniation may result in ischemia,obstruction or perforation -lung compression /collapse may be significant /hypoxia/ -Lt side is commonly affected as liver protects Rt

.......diaphragm rupture
-in acute settings, c/f-obscured by other injuries DDX later-pud,GB ds,IHD - PR,RRBP,absent breath sound,bowel sound in z chest x-ray shows loop of bowel or fluid level in thoracic cavity,mediastnal shift contrast study may confirm Dx MGT ABC insert NG tube-decompress GI contents treat sepsis early if perforation is suspected immediate surgical repair

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cardiac tamponade compression of z heart 2 to fluid in pericardial sac(normally <50ml) occur as aresult of penetrating & blunt injuries penetrating wound of z heart is associated w high mortality rate pericardial fluid collectsintrapericardial pressure heart cannot fillpumping stops tamponade caused by stab wound require thoracotomy C.T may also follow Dxtic cardiac procedures pacemaker insertion,c.catheterizn ,&metastasis from malignacies-breast ca,lung ca

...tamponade
C/F SOB,anxiety,faintness hypotension,JVP,muffled heart sound,=beck's triad palsus paradoxus (pulse fade on insp) kussmaul's sign(JVP during inspiration)

investigation
CXR-globular heart, Rt cardiophrenic angle <90 ECG

MGT
pericardiocentesis- brings relief insert needle at 45 to skin below&Lt of xiphisternum aiming at tip of Lt scapula removal of even 20 ml -brings marked improvement-COP fluid replacement, oxygen(high flow)

.....pericardiocentesis
complications aspiration of ventricular blood, laceration to ventricle. or coronary @ puncture of aorta

Thoracostomy ... defn insertion of tube in to pleural cavity

chest tube insertion & under waterseal drainage purpose to maintain negative intrapleural pressure & re-expansion of underlying lung

....thoracostomy
important to know -Indications ,C/I -Tube size -Anatomy-Technique -complications

...thoracostomy
indications; pneumothorax haemothorax haemopneumothorax acute empyema,lung abscess chylothorax recurrent pleural effusion

Contraindication coagulopathy

pleural effusion
pleural effusion-accumulation of fluid w in pleural space specific terminologies; hydrothorax-collection of serous fluid transudate/exudate pyothorax/empyema-pus haemothorax -blood pneumothorax-air chylothorax-chyle

normal pleural physiology potential space b/n parietal&visceral pleura contains only about 5ml fluid at one time amount of pleural fluid is governed by factors w/c produce or absorb it 1. capillary hydrostatic pressure 2. colloid osmotic pressure 3. capillary permeability 4. lymphatic drainage any disturbance in z equilibrium leads to pleural effusion

...pleural effusion
abnormal pleural fluid accumulates as aresult of one of z ffg;1.pulmonary vascular hydrostatic pressure 2.vascular osmotic pressure 3.capillary permeability due to inflammation eg.pneumonia 4. intrapleural pressure(atelectasis) 5.rupture of vascular or lymphatic structure eg .trauma drainage >1Lis not allowed initially , 200ml Q 2hrs for 2448hrs controlled draining avoids re-expansion pulm. edema

...pleural effusion

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pneumothorax the presence of air in thoracic cavity out side lung-b/n visceral &parietal layers of pleura w/c r normally separated by thin film of fluid lung is collapsed when displaced by pneumothorax

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classification of pneumothorax spontaneous -any lung ds that breaches pleura eg. ch.obst.airway ds traumatic -blunt iatrogenic-CVP monitoring open -penetrating injury(sucking chest wound) closed-rib simple/tension pntx when air in z pleura is under pressure +mediastnal shift-Tension pneumothorax

......tension pneumothorax
C/F severe chest pain ,dyspnoea, PR, BP,distended neck veins chest-hyperesonant on affected side w poor resp mov't& absent breath sound trachea & apex beat deviated to other side subcutaneous emphysema

.......pneumothorax
x-raysimple pneumothorax -volume loss on affected side(raised hemidiaphragm) -visible pleural edge -small pneumothorax may not be seen on std inspiratory film(expiratory film may be required) Tension.pntx collapse of z lung on affected side, mediastnal shift(tracheal deviation away from affected side) absence of lung markings flattening of diaghragm widening of ICS

.........pneumothorax
MGT -depends on size & severity of pntx
simple pntx -no need to insert chest drain unless severe dyspnoea or there is enough air in pleura to lower apex of lung 3cm below top of pleural cavity small pntx-conservative mgt w followup CXR or may be aspirated large symptomatic pntx-require chest drain, tension pneumothorax may need immediate needle decompression followed by tube thoracostomy

haemothorax/haemopneumothorax
haemothorax-accumulation of blood in z pleural cavity following blunt or penetrating trauma commonly associated w pneumothorax haemorrhage from lung parenchyma than specific vessel injury intercostal or internal mammary vesseles are more commonly injured than hilar/great vessels massive haemothorax may cause hypovolemic shock

.....haemothorax
C/F - depends on amount of blood lost, hypotension hypovolemic shock or absent breath sound dullness to percussion over affected side x-ray -opacification of hemithorax -blunting of costophrenic angles (>250ml)

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......haemothorax
mgt
fluid resuscitation ,iv access before tube oxygen Hct/hgb ,blood gp,x-match blood transfusion for massive hemothorax chest drain -lung re-expansion&estimate blood loss chest drain >1000ml of blood or >200ml/hr refer urgently to cardiothoracic surgen

Thoracostomy technique; explain z procedure obtain consent, ensure venous access, prepare skin w antiseptic infilterate skin ,muscle & pleura w local anesthesia,at z appropriate ICS-5th or 6th in z midaxillary line aspirate to confirm Dx make small transverse incision just above z lower rib to avoid damage to vessels use large curved artery forceps, penetrate pleura &enlarge z opening,grasp z tube tip &insert into z chest, clamp z tube until connected to z bottle connect z tube to under w seal drainage,mark z initial fluid in z drainage bottle close z incision w silk,anchor z tube w z stich,apply gauz dressing ask him to cough blood or bubble should come out of z

......thoracostomy
after care
place artery forceps at z bed side for clamping z tube when changing z bottle end of tube 5cm below water keep z bottle below heart level record daily drainage change z connecting tube& bottle at least once Q48hrs if no drainage for 12 hrs despite milking z tube,clamp z tube for further 6hrs& send for control CXR if z lung satifactorly expands,remove z tube to remove tube hold wound edges w thumb & fingers over gauz ,cut stich anchoring tube then withdraw z tube & dress wound

.....thoracostomy
complications
injury to diaphragm,IC nerves,liver(low insertion) failure to guide tube in to pleural space, lung fails to re-expand z tube should be removed & placed in pleural space subcutaneous emphysema neurovascular bundle injury infection along tube tract empyema ,abscess phrenic n. injury esophageal perforation these complications can be minimized by following strict sterile technique & Std procedure

....thoracostomy
if air continues to bubble out of under water seal after 5days attach high vol.low pressure suction pump to chest tube,this may expand his lung . if still not expand wks or months later-may be undiagnosed bronchial tearrefer for bronchoscopy

References
SCADH,WHO manual surgery for HOs,lecture note washington manual of surgery,5th edn surgery current Dx&Rx 13th edn emergency radiology essential clinical anatomy,3rd edn

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