eMentorSurgery

Dear students, This is only for your revision and NOT A FULL TEXT.

Chest Injuries

•Chest injuries have high mortality

•8% ofpatients succumb-either due to trauma or post injury complications

•Mortality can be prevented by simple methods- airway control and Intercostal tube insertion

Pathophysiology

•Thorax-delivery of oxygen to tissues

•3consequences are possible either independently or in combination

•Hypoxemia

•Hypovolemic shock

•Myocardial failure

•Hypoxemia 

üDueto disturbance to airway and ventilation

üObstruction to airway

üFlail chest

üLung contusion

üPneumothorax

üTracheobronchial injury

•Hypovolemic  shock :

üDue to loss of blood

üUpto 40% of circulating blood can accumulate in the pleural cavity in haemothorax

•Myocardial failure 

•Direct blow to heart-arrhythmias

•Cardiac tamponade,  rupture of ventricular septum

Initial Treatment

•Goal is resuscitation

üAdequate airway

üAdequate ventilation

üRestore circulation

•Airway

üClear throat, mouth

üOropharyngeal airway placement

üSuction of mouth and throat

•Breathing

üCheck breath sounds

üInsertion of Intercostal drainage tube

üTracheostomy

üMechanical ventilation

•Circulation

üIntravenous lines- peripheral and cnetral

üRapid restoration of blood volume

üBlood transfusion

Investigations

•FBC, Electrolytes,Blood Group

•Chest X-Ray,CT Scan

•Arterial Blood Gases

•Pulsoximetry

 Specific Treatment

•85%patients  are treated by general measures

•Few  conditions require intervention- thoracotomy or other measures

Flail Chest

•Definedas Paradoxical movement of a portion of the chest wall due to multiple rib fractures or multiple fractures in the same rib

•Types

üUnilateral– 4 or more ribs anteriorly or posteriorly

üBilateral anterior

üCostochondral fracture 4-5 ribs

•Interruption of the normal negative intrathoracic pressure needed to effect spontaneous ventilation.

•As the patient’s pulmonary condition worsens, the paradoxical rib motion becomes more severe, making respiration inefficient.

•Dyspnea.

•Severe pain.

•Underlying injury.

•Crepitance of broken ribs.

•Inward motion of the ribs will become more pronounced with inspiration.

•Cyanosis.

•CBC.

•ABG.

•Chest  x-ray- the radiological identification of the fracture pattern.

•CT scan.

vIidentifies rib fractures quite well.

vCconcomitant internal thoracic injury.

•A large flail segment may be temporarily stabilized with towel rolls, tape, or sandbags placed against it.

•Analgesia.

•Chest physiotherapy.

•Intubation &Mechanical ventilation

vPersistent respiratory insufficiency

vFailure after adequate pain control

vLarge flail segments (bigger than 4-6inches)

vUnderlying acute or chronic lung disease

•Surgical stabilization of the chest is an option but is rarely necessary

•Operative fixation is most commonly performed in patients requiring a thoracotomy for other reasons or in cases of gross chest wall deformity

Tension Pneumothorax

True

surgical

emergency

•Acute

•Life threatening

•Progressive entry of air into pleural cavity

•No point  for air to escape

•Flap valve leak allows air to enter but not to escape

•Rapid collection of air in the pleural cavity leading to acute respiratory distress and shock

•Lung compression

•Mediastinal shift

•Impaired venous return

•Cardiogenic shock

•Breathless

•Cyanosed

•Tachycardia

•Hypotension

•Trachealshift

•Hyperresonace

•Raised JVP

•Large bore needle insertion 2nd or 3rd Intercostal space- midclavicular line

•Intercostal chest tube- mandatory

•Other measures

 Open Pneumothorax

•Large chest wall defect

•Sucking chest wound

•Disruption of chest wall mechanism to provide adequate negative pressure

•Seal off the chest wall by tape

•Intercostal drainage tube

 Haemothorax

•Collection of blood in the pleural cavity

•Massive –1500ml  of chest  tube output or @ 200ml/hour

•Penetrating trauma

•Blunt trauma

•Rib fracture– lacerating a lung

•Disruption of large blood vessel

•Breathlessness

•Hypovolemic shock

•Treat shock and insert ICT sixth Intercostal space

•Thoracotomy in case of massive haemothorax

 Intercostal Drainage

•Insertion of a tube into Pleural Cavity

•To drain air and/or fluid from the pleural cavity to allow full lungre-expansion

•Two sites: anterior and lateral.

•For Pneumothorax :

•Second (2nd) intercostal space in the mid clavicular line (MCL).

•LATERAL CHEST TUBES:

•For Effusion or Empyema

•5th or 6th Intercostal Space at Midaxillary Line

Indications :

Empyema Thoracis

Pneumothorax

Haemothorax

Following Thoracotomy

•Site : 5th Intercostal Space

•Mid-Axillary Line

•Incision Along Upper Border of Lower Rib

•IC Tube Should be Connected to Underwater Seal

•Check Movement of Water Column

•X-RayChest PA to Verify

Removal of Tube

Pt. Takes a Deep Breath

Tube Pulled Out

Wound Closed immediately with a Purse String Suture without airleak