Klinika úrazové chirurgie LF MU a TC FN Brno I ntroduction v ital s tructures chest trauma is often sudden and ID: 1045430
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1. Chest traumaPetráš M.,.Klinika úrazové chirurgie LF MU a TC FN Brno
2. Introduction vital structures – chest trauma is often sudden and dramaticheart, great vessels, tracheobronchial tree and lungsabdominal injuries are common with chest traumathe most common type of injuries is bluntserious pathological consequences – hypoxia, hypovolaemia, myocardial failure
3. Physiologyventilation the mechanical process of moving air into and out of the lungsrespiration the exchange of oxygen and carbon dioxide between the outside atmosphere and the cell of the body
4. Anatomy skinbones12 pair of ribsribs 1-7: join at sternum with cartilage end-pointsribs 8-10: join at sternum with combined cartilage at 7th ribribs 11-12: no anterior attachmentsternumthoracic spine
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6. Anatomy topographical thoracic reference linesmidclavicular lineanterior axillary linemid-axillary lineposterior axillary lineintercostal spaceartery, vein and nerve on inferior margin of each rib
7. Anatomymuscles of respirationdiaphragmintercostal musclescontract to elevate the ribs and increase thoracic diameterincrease depth of respirationsternocleidomastoidraise upper rib and sternum
8. Anatomy tracheahollow & cartilage supported structurebronchiright & left extend for 3 centimetersenters lungs at pulmonary hilumalso where pulmonary arteries & veins enterfurther subdivide and terminate as alveolibasic unit of structure & function in the lungssingle cell membranelungsright = 3 lobesleft = 2 lobes
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10. Anatomy pleuravisceral pleuracover lungsparietal pleuralines inside of thoracic cavitypleural spacePOTENTIAL SPACEAir in Space = PNEUMOTHORAXBlood in Space = HEMOTHORAXserous (pleural) fluid within
11. Anatomy mediastinumcentral space within thoracic cavityboundarieslateral: lungsinferior: diaphragmsuperior: thoracic outletstructuresheartgreat vesselsesophagustracheanervesvagusphrenicthoracic duct
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13. Classificationsskeletal injurypulmonary injuryheart and great vessel injurydiaphragmatic injury
14. Classification mechanism of injuryblunt thoracic injuries - most commonforces distributed over a large area deceleration compression age factorspediatric thorax: more cartilage = absorbs forcesgeriatric thorax: calcification & osteoporosis = more fractures penetrating thoracic injuries
15. Pathophysiologyimpairments in cardiac output blood loss increased intrapleural pressures blood in the pericardial sac vascular disruptionimpairments in gas exchange atelectasis contused lung tissue disruption of the respiratory tract
16. Assessment findingspulse deficit tachycardia bradycardiablood pressure narrowed pulse pressure hypertension hypotension
17. Assessment findingsrespiratory rate and effort tachypnea bradypnea laboured other evidence of respiratory distress
18. Assessment findingsSkin diaphoresis pallor cyanosis open wounds other evidence of trauma
19. Assessment - neckposition of tracheasubcutaneous emphysemajugular venous distentionpenetrating wounds
20. Assessment - chestcontusionstendernessasymmetrylung sounds absent or decreased unilateral bilateral location bowel sounds in hemothorax
21. Rib fracturesincidenceis the most common thoracic injurymost often elderly patients older ribs are more brittle and rigidribs 3 to 8 are fractured most often they are thin and poorly protectedlower ribs fracture are associated with spleen and liver injury
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23. Rib fracturessigns and symptomslocalized paincrepitus
24. Rib fracturesmanagementanalgesics – for pain and improve chest excursionoxygenencourage coughing and deep breathingposition of comfort
25. Flail chest3 or more ribs broken in 2 or more placessegment of the chest that becomes free to move with the pressure changes of respiration
26. Flail chestsigns and symptomschest paincrepitusrespiratory distresstachypneaparadoxical chest wall movement
27. Flail chestmanagementanalgesics oxygenposition of comfortstabilize the flail segmentsendotracheal intubation, positive pressure ventilation
28. Sternal fracturehigh association with myocardial or lung injury myocardial contusion myocardial rupture cardiac tamponade pumonary contusion association with thoracic vertebrae fractures
29. Sternal fracturemanagementanalgesics high –concentration oxygenrestrict fluids if pulmonary contusion suspectedtransport to cardiology if myocardial injury suspected
30. Pulmonary injury Closed pneumothoraxoccurs when lung tissue is disrupted and air leaks into the pleural spaceincidence 10% to 30% in blunt chest traumamorbidity/ mortality extent of atelectasis associated injuries
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33. Pulmonary injury Closed pneumothoraxsigns and symptoms - absent or decreased breath sounds on the injured side - hyperresonant percussion - tachypnea - dyspnea - chest pain referred to the shoulder or arm on the injured side - respiratory distress
34. Pulmonary injury Closed pneumothoraxManagementanalgesics position of comforthigh –concentration oxygenpositive-pressure ventilation if necessaryif respiration is rate <12 or >28 per minute, ventilatory assistance with a bag-valve mask may be indicated
35. Pulmonary injury Closed pneumothoraxmanagementtube thoracostomy – pleural decompression4nd intercostal space in mid-axillary lineTOP OF RIB
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37. Pulmonary injury Open pneumothoraxincidence gunshot wounds knife wounds falls motor vehicle collisionsIf the chest wound opening is greater than two-thirds the diameter of the trachea, air follows the path or least resistance through the chest wall with each inspiration
38. Pulmonary injury Open pneumothoraxsigns and symptoms - decreased breath sounds on the injured side - a defect in the chest wall - a sucking sound on inhalation - subcutaneous emphysema - tachypnea - tachykardia - respiratory distress
39. Pulmonary injury Open pneumothoraxmanagementanalgesics high – flow oxygenpositive-pressure ventilation if necessaryventilatory assistance with a bag-valve maskcirculation – treat for shock with crystalloid infusion cover site with sterile occlusive dressing taped on three sidestube thoracostomy, videothoracoscopy, thoracotomy – in- hospital management
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41. Pulmonary injury Tension pneumothoraxoccurs when air enters the pleural space from a lung injury or through the chest wall without a means of exitresults in death if it is not immediately recognized and treatedwhen air is allowed to leak into the pleural space during inspiration and becomes trapped during exhalation, an increase in the pleural pressure results
42. Pulmonary injury Tension pneumothoraxincreased pleural pressure produces mediastinal shiftmediastinal shift results in: - compression of the uninjured lung - compression of the superior and inferior vena cava, decreasing venous return to the heartprogression of simple or open pneumothorax
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44. Pulmonary injury Tension pneumothoraxsigns and symptoms - absent breath sounds on the injured side - hyperresonance to percussion - subcutaneous emphysema - tachypnea and increasing dyspnea - tachykardia - cynosis - hypotension - jugular venous distention - extreme anxiety - respiratory distress
45. Pulmonary injury Tension pneumothoraxmanagementemergency care is directed at reducing the pressure in the pleural spaceocclude open woundneedle thoracostomytube thoracostomy – in-hospital management4nd intercostal space in mid-axillary lineTOP OF RIB
46. Pulmonary injury Tension pneumothoraxmanagement pleural decompression should only be employed if the patient demonstrates significant dyspnea and distinct signs and symptoms of tension pnemothorax
47. Pulmonary injury Hemothoraxaccumulation of blood in the pleural space caused by bleeding from -penetrating or blunt lung injury -chest wall vessels -intercostal vessels -myocardium
48. Pulmonary injury Hemothoraxincidence -associated with pnemothorax – it is called a hemopnemothorax -blunt or penetring trauma -rib fractures are frequent causehypovolemia results as blood accumulates in the pleural space
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50. Pulmonary injury Hemothoraxsigns and symptoms - diminished or decreased breath sounds on the injured side - hypotension - tachypnea - dyspnea - narrowed pulse pressure - pale, cool, moist skin - respiratory distress
51. Pulmonary injury Hemothoraxmanagementanalgesics high – flow oxygenpositive-pressure ventilation if necessaryventilatory assistance with a bag-valve maskcirculation – volume-expanding fluids to correct hypovolemiatube thoracostomy videothoracoscopy or thoracotomy - if it is blood loss by tube thoracostomy more than 2000ml or next 3 hours is blood loss more than 500ml/hours
52. Pulmonary injury Contusion30-75% of patients with significant blunt chest traumafrequently associated with rib fractureyounger patients – also without rib fracture signs and symptoms - cough - tachypnea - tachycardia - dyspnea - cyanosis - respiratory distress
53. Pulmonary injury Contusionmanagementanalgesics high – flow oxygenpositive-pressure ventilation if necessaryventilatory assistance with a bag-valve maskrespiratory rehabilitationantibioticsbronchoscopy
54. Cardiovascular injuries Myocardial contusioninjury may reduce strength of cardiac contractionsreduced cardiac outputprogressive problemsmyocardial necrosisdysrhythmiascardiogenic shock S/S tachycardia and/or irregular rhythmretrosternal pain associated injuriesrib/sternal fractures
55. Cardiovascular injuries Myocardial contusionmanagementmonitor ECGAlert for dysrhythmias
56. Cardiovascular injuries Pericardial tamponaderestriction to cardiac filling caused by blood or other fluid within the pericardiumoccurs in <2% of all serious chest traumahowever, very high mortalityresults from tear in the coronary artery or penetration of myocardiumblood seeps into pericardium and is unable to escape200-300 ml of blood can restrict effectiveness of cardiac contractions
57. Cardiovascular injuries Pericardial tamponadeincreased intrapericardial pressure - does not allow the heart to expand and refill with blood - results in a decrease in stroke volume and cardiac outputmyocardial perfusion decreases due to pressure effects on the walls of the heart and decreased diastolic pressures ischemic dysfunction may result in infarctionremoval of as little as 20ml of blood may drastically improve cardiac output
58. Cardiovascular injuries Pericardial tamponadesigns and symptoms - tachycardia - respiratory distress - Becks triad - narrowing pulse pressure - neck vein distention - muffled heart sounds - ECG changes
59. Cardiovascular injuries Pericardial tamponademanagementhigh flow O2IV therapypericardiocentesis – needle insertion through the skin incision directed toward the left shoulder at a 45 degree angle to the abdominal wall.
60. Cardiovascular injuries Aortic ruptureoccurs almost exclusively with extreme blunt thoracic trauma - rapid deceleration in high-speed motor vehicle crashes - falls from great heights85-95% of these patients die at the scene as result of massive hemorrhagesigns & symptomsrapid and deterioration of vitalsretrosternal pain
61. Cardiovascular injuries Aortic ruptureIV therapy mild hypotension may be protectivekeep patient calmendovascular repairoperativ repair – is associated with high mortality