Injury of the Chest and Abdomen Thoracic Trauma • Introduction • PRIMARY SURVEY: life-threatening injuries • Airway • Breathing • Circulation • SECONDARY SURVAY: potentially life- threatening injuries Introduction • leading cause of death UNDER 40 years • 25% of deaths from blunt trauma are due to chest injuries • chest injuries result from • BLUNT or/and • PENETRATING trauma • chest injuries interfere with • respiration, • circulation • or both Primary Survey • A - airway patency and air exchange should be assessed • B - tension pneumothorax, open pneumothorax flail chest and pulmonary contusion, massive hemothorax • C - massive hemothorax, cardiac tamponade Open Pneumothorax • collection of air in the pleural cavity resulting in collapse of the lung on the affected side • follows a penetrating chest trauma such as a stab wound, gunshot injury of fractured rib • breathing shallow,rapid,laboured. Reduced expansion of the hemithorax • sucking chest wound – visibly bubbling • first aid: cover the wound with non-occlusive dressing • definitive: chest drain insertion Open Pneumothorax Pneumothorax Tension Pneumothorax • develops when a one-way valve air leak occurs from the lung or through the chest wall • air is forced into the thoracic cavity without any means of escape • mediastinum is displaced to the opposite side, decreasing venous return and compromising the opposite lung • chest pain, air hunger, tachycardia, hypotension, tracheal deviation, cyanosis, neck vein distention, unilateral absence of breath sounds • requires immediate decompression and chest drain insertion Tension Pneumothorax Tension Pneumothorax Needle Decompression Chest Drain Insertion Flail Chest and Pulmonary Contusion • chest wall does not have bony continuity with the rest of the thoracic cage • unilateral fractures of four or more ribs or bilateral • chest wall instability leads to paradoxical motion of the chest wall • underlying lung injury - Pulmonary Contusion Massive Hemothorax • accumulation of blood in a hemithorax (>1500ml) • may significantly compromise respiratory efforts by compromising the lung and preventing adequate ventilation • C - more dramatically present as hypotension and shock • decreased breath sounds, signs of shock (pulse rate, respiratory rate, skin circulation) • it is necessary to place the chest tube and check the bood loss Hemothorax Cardiac Tamponade • penetrating injuries • small amount of blood in the pericardial sac will restrict cardiac activity • pericardiocentesis Secondary survey • simple pneumothorax • hemothorax • pulmonary contusion • tracheobronchial tree injury • blunt cardiac injury • traumatic aortic disruption • traumatic diaphragmatic injury • blunt esophageal rupture Trachea and Bronchus Injuries • mediastinal and deep cervical emphysema, hemoptysis,tension pneumothorax • or PNO with a massive air leak • respiratory distress is frequent • bronchoscopy and inserting the endotracheal tube beyond the injury • small lesions may be managed without surgical treatment • for an early stricture either resection or an bronchoplastic procedures /stents/ Heart and Aorta Blunt cardiac injury • spectrum of cardiac changes - from wall bruise to ventricular, septal or valvular rupture • diagnosis is difficult • arrhythmia can occur • many cardiac contusions are unrecognised Traumatic Aortic Disruption • traumatic aortic rupture is a common cause of sudden death after RTA (road trafic accident) • most patients die immediately from exsaquination • treatment: • primary repair, • replacement with a graft or endovascular Other injuries • Ruptures of diafragm - may result of herniation of viscera • herniation of viscera may not occur immediately • Esophagus - blunt injury of oesophagus is rare • both require surgical treatment Abdominal Trauma • blunt trauma- organs most frequently injured 1. Spleen (40-55%), 2. Liver (35-45%), 3. Small bowel (5-10%) • penetrating trauma - stab wounds, low velocity wounds: tissue damage by lacerating and cutting - high velocity wounds: transfer more kinetic energy to abdominal viscera Assessment • history • physical examination - inspection: abrasions, contusions from restraint devices, lacerations, penetrating wounds - auscultation: presence or absence of bowel sounds - percussion and palparion: peritoneal irritation • FAST - Focused Assessment Sonography in Trauma • DPL - Diagnostic Perironeal Lavage • CT - Computed Tomography Ultrasonography FAST = Focused Assessment with Sonography in Trauma TRANSDUCER POSITION VIEW • RUQ:hepato-renal recessus (Morrisons pauch) perihepatic view • LUQ: spleno-renal recessus perisplenic view • PERICARDIAL SAC subxiphoideal and parasternal view • PELVIC CAVITY retrovesical view FAST scan •fast,non=invasive •rules in,not out •can be repeated CT Diagnostic Peritoneal Lavage Spleen • is the most commonly injured intraabdominal organ • the diagnosis and prompt management of potentially lifethreatening hemorrhage is the primary goal • diagnosis is confirmed by CT scan • therapy: surgical– splenectomy • the preservation of functional splenic tissue is secondary (non operative management) Liver and Biliary Tree • The liver is one of the most commonly injured organ. • definitive confirmation: CT • operative intervention to manage the liver injury is needed in about 14 % of patients management needed in 15% of patients Stomach • Most gastric injuries are due to penetrating trauma • Blunt trauma is rare • If vomitus or gastric aspirate is bloody, an injury to the stomach should be suspected. • Therapy: Laparotomy: can be treated simply with debridement and closure in layers. Other injuries of abdomen • Duodenum • Pancreas: pancreatic trauma is relatively uncommmen • Intestines • Colon and rectum • Major abdominal vessels • Urinary tract: hematuria is present Pelvic Trauma • pelvic cavity surrounded by the pelvic bones containes rectum,bladder,iliac vessels,female reproductive organs • pelvic fractures – with opening of the pelvic ring, there may be hemorrhage from the posterior pelvic venous complex and branches of the internal iliac artery Mechanism of injury/Classification Management • splint unstable pelvic fracture -sheet wrapped around the pelvis as a sling -commercially available pelvic splints