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CHEST INJURIES A chest injury is any form of physical injury to the chest including the heart and lungs. Typically chest injuries are caused by blunt mechanisms such as motor vehicle collisions or penetrating mechanisms such as stabbings.

Classification

on the basis of mechanism of injury

on the basis of anatomical part involvement Compres sion Injury-

blunt trauma

penetrating trauma

chest wall injuries

pulmonar y injuries

airway injuries

cardiac injuries

blood vessels injuries

ON THE BASIS OF MECHANISM OF INJURY 1. Blunt trauma is the Blunt force to chest when there is no injury to the skin but trauma to chest occurs. blunt steering wheel injury crush injury fall sudden force to the chest due to hit of baseball, cricket ball 2. Penetrating trauma Projectile that enters chest causing small or large hole. Gunshot or stab wound to chest 3. Compression Injury- Chest is caught between two objects and chest is compressed. ON THE BASIS OF ANATOMICAL PART INVOLVEMENT Injuries to the chest wall o Chest wall contusions or hematomas. o Rib fractures o Flail chest o Sternal fractures o Fractures of the shoulder girdle 2. Pulmonary injury (injury to the lung) and injuries involving the pleural space o Pulmonary contusion o Pulmonary laceration o Pneumothorax o Hemothorax
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Prepared by Ms. Kawaljit Kang, M.Sc. Med. Surg

Hemopneumothorax 3. Injury to the airways o Tracheobronchial tear 4. Cardiac injury o Pericardial tamponade o Myocardial contusion o Traumatic arrest 5. Blood vessel injuries o Traumatic aortic rupture, thoracic aorta injury, aortic dissection Causes Motor vehicle accidents Fall Assault with blunt object Crush injury Explosion Penetrating injuries due to knife, gunshot, stick, arrow

Common chest injuries A.) PNEUMOTHORAX is defined as air in the pleural space, so there is partial or complete collapse of the lungs occurs mostly due to the blunt trauma to the chest. Types I. a. b. c. d. Causes Injury to the lungs from mechanical ventilation Injury to the lungs from insertion of subclavian catheter Injury to the lungs from broken ribs Ruptured blebs or bullae in a patients with COPD Perforation of the esophagus Closed pneumothorax Opening in lung tissue that leaks air into chest cavity Blunt trauma is main cause May be spontaneous Usually self correcting

Sign and symptoms Chest Pain Dyspnea

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Tachypnea Decreased Breath Sounds on Affected Side II. Open Pneumothorax Opening in chest cavity that allows air to enter into the pleural cavity Causes the lung to collapse due to increased pressure in pleural cavity Can be life threatening and can deteriorate rapidly Causes Stab or gunshot wounds Surgical thoracotomy Sign and symptoms Dyspnea Sudden sharp pain Subcutaneous Emphysema (Air collects in subcutaneous fat from pressure of air in pleural cavity, Feels like rice crispies or bubble wrap, Can be seen from neck to groin area) Decreased lung sounds on affected side Red Bubbles on Exhalation from wound B. Tension Pneumothorax Air builds in pleural space with nowhere for the air to escape due to the rapid accumulation of the air in the air space. Results in collapse of lung on affected side that results in pressure on mediastium, the other lung, and great vessels S/S of Tension Pneumothorax Anxiety/Restlessness Violent Agitation Air hunger Narrowing Pulse Pressures Hypotension Tracheal Deviation Severe Dyspnea Absent Breath sounds on affected side Tachypnea Tachycardia Cyanosis Accessory Muscle Use JVD (jugular vein distension)

C. Hemothorax Occurs when pleural space fills with blood Usually occurs due to lacerated blood vessel in thorax
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As blood increases, it puts pressure on heart and other vessels in chest cavity Each Lung can hold 1.5 liters of blood Causes Chest trauma Lung malignancy Complications of anticoagulant therapy Pulmonary embolism Tearing of pleural adhesions

S/S of Hemothorax Anxiety/Restlessness Tachypnea Signs of Shock Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side Tachycardia Flat Neck Veins Dullness to percussion

D. Chylothorax It is defined as the lymphatic fluid in the pleural space due to a leak in the thoracic duct. Causes Trauma Surgical procedures Malignancy Sign and symptoms Mild to moderate tachycardia Dyspnea Shallow or rapid respirations E. Flail chest It results from multiple rib fractures causing unstable chest wall. The flail segment usually involves the anterior or lateral rib fractures The affected area move paradoxically S/S of Flail Chest Shortness of Breath

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Paradoxical Movement Bruising/Swelling Crepitus( Grinding of bone ends on palpation) F. Pericardial Tamponade Blood and fluids leak into the pericardial sac which surrounds the heart. As the pericardial sac fills, it causes the sac to expand until it cannot expand anymore Once the pericardial sac cant expand anymore, the fluid starts putting pressure on the heart Now the heart cant fully expand and cant pump effectively. With poor pumping the blood pressure starts to drop. The heart rate starts to increase to compensate but is unable The patients level of conscious drops, and eventually the patient goes in cardiac arrest

Sign and symptoms Classic Becks triad elevated venous pressure - neck veins decreased arterial pressure - BP muffled heart sounds May find pulsus paradoxus - a decrease of 10 mm Hg or greater in systolic BP during inspiration Distended Neck Veins Increased Heart Rate Respiratory Rate increases Poor skin color Narrowing Pulse Pressures Hypotension Death

G. Traumatic Aortic Rupture The chances of survival are very slim and are based on the degree of the tear. If there is just a small tear then the patient may survive. If the aorta is completely transected then the patient will die instantaneously Sign and symptoms Burning or Tearing Sensation in chest or shoulder blades Rapidly dropping Blood Pressure Pulse Rapidly Increasing Decreased or loss of pulse or b/p on left side compared to right side Rapid Loss of Consciousness

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Diaphragmatic Rupture A tear in the Diaphragm that allows the abdominal organs enter the chest cavity More common on Left side due to liver helps protect the right side of diaphragm Associated with multiple injury patients Sign and symptoms Abdominal Pain Shortness of Air Decreased Breath Sounds on side of rupture Bowel Sounds heard in chest cavity

Diagnostic evaluation CT Scan MRI Chest X- ray ABG analysis

Initial management Goal Maintain the patent airway. Maintain the respiratory pattern. Decrease the level of pain so that patient can breathe normally. Promote good chest expansion.

Management A = Airway Assess for airway patency and air exchange - listen at nose & mouth Assess for intercostal and supraclavicular muscle retractions Assess oropharynx for foreign body obstruction

B = Breathing Assess respiratory movements and quality of respirations look, listen, feel Shallow respirations are early indicator of distress cyanosis is late

C = Circulation Assess pulses for quality, rate, regularity Assess blood pressure and pulse pressure
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Skin - look and feel for color, temperature, capillary refill Look at neck veins - flat vs. distended Cardiac monitor

Collaborative care Administer high flow oxygen to the patient. Begin fluid resuscitation as appropriate. Most blunt injuries are managed with relatively simple interventions like tracheal intubation and mechanical ventilation and chest tube insertion. Penetrating injuries often require surgery, and complex investigations are usually not needed to come to a diagnosis. Patients with penetrating trauma may deteriorate rapidly, but may also recover much faster than patients with blunt injury. Stabilize the flail rib segments with hand followed by application of large piece of tape horizontal across the flail segment. Place the patient in a semi fowlers position. Monitor vital signs, level of consciousness, oxygen saturation, urinary output and respiratory status of the patient. Administer opioids to the patient with caution because these cause respiratory depression.

Needle Decompression Locate 2-3 Intercostal space midclavicular line Cleanse area using aseptic technique Insert catheter ( 14g or larger) at least 3 in length over the top of the 3rd rib( nerve, artery, vein lie along bottom of rib) Remove Stylette and listen for rush of air Place Flutter valve over catheter Reassess for Improvement Pericardiocentesis Using aseptic technique, Insert at least 3 needle at the angle of the Xiphoid Cartilage at the 7th rib Advance needle at 45 degree towards the clavicle while aspirating syringe till blood return is seen Continue to Aspirate till syringe is full then discard blood and attempt again till signs of no more blood

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Closely monitor patient due to small about of blood aspirated can cause a rapid change in blood pressure Chest tube drainage Large-bore (32 to 36 F) tube to drain blood If moderate sized (500 to 1500 ml) and stops bleeding, closed drainage usually sufficient If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated

Thoracotomy

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