Chest and CVS truama

Chest and CVS Trauma

Dr. Abdulaziz Alrabiah

Objectives

• Different life-threatening injuries
• Assessment
• Management

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Tension Pneumothorax

“It will kill the patient”

• Air between visceral and parietal pleura.
• One-way valve → allows air to go inside the pleural space but not out.
• It is a clinical diagnosis, do not wait for chest X-ray.

Presentation

• Distended neck veins
• Tracheal deviation to the opposite side
• Hypotension / evidence of hypoperfusion (e.g., decreased LOC, tachycardia)
• Absent breath sounds on the ipsilateral side

Treatment

1. High flow O2 (15 L)
2. Needle decompression (14G): 5th intercostal space
3. Intercostal chest drain: 5th intercostal space, between mid and anterior axillary lines

Chest X-ray

Warning: Not for diagnostic use in Tension Pneumothorax (Clinical diagnosis).

Clinical Diagnosis Triad:

• Hypotension
• Shortness of Breath
• Tracheal deviation

0845HRS | L | PORTABLE | AP | Air | Lung

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Pneumothorax

“Will not kill the patient” (Normal Blood Pressure)

• Air in the pleural space.

Signs

• ✓ Decreased breath sounds
• ✓ Hyper-resonant on percussion
• ✗ No signs of tension if no tracheal deviation, normal BP

Management

Treatment is decided according to the size of the pneumothorax.

Sizing (Collins Method estimate):

• Horizontal line from 3rd rib.
• Formula: (Apical line + Middle line + Lower line) / 3
• Each 1 cm roughly corresponds to 10%.

Treatment Protocol: If BP and Pulse are good:

• < 20%: High flow O2, repeat X-ray after 4 hours.
  • If improved: No need for chest tube.
  • If worse: Needs chest drain.
• > 20%: Put chest drain.

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Open Pneumothorax

Definition & Signs

• Penetrating chest trauma.
• Communication between pleural space and outside environment (i.e., sucking chest wound).
• May be associated with hemothorax.
• Clinical signs:
  • Visible wound
  • Plus tension pneumothorax features

Treatment

1. High flow O2 (15 L)
2. 3-way dressing: Allows air to escape but prevents air from entering the pleura.
3. Chest drain: Insert away from the wound (usually one space up).

3-Way Dressing & Chest Tube

Chest X-ray consistent with Pleural Effusion (PE) or Hemothorax.

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Massive Hemothorax

Definition

• > 1500 ml of blood immediately after chest drain placement.
• > 200 ml/hr of blood drained for 4 hours.
• Note: Do not rely on color. On Chest X-ray: > 2/3 of the available space in the hemithorax.

Causes

• Lung parenchymal injury
• Intercostal artery injury
• Internal mammary artery injury

Clinical Signs

• Decreased breath sounds on the affected side
• Dullness on percussion on the affected side

chest X-ray

Treatment

• High flow O2 (15 L)
• Chest drain
• Operative Thoracotomy indicated if:
  • Drained > 1500 ml of blood immediately ⇒ operative thoractomy
  • Drained > 200 ml/hr for 4 hours ⇒ operative thoractomy

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Pulmonary Contusion

“Bruising with no bleeding”

Overview

• Suspect in any significant thoracic trauma.
• May occur in small children in the absence of fractures due to high compliance of the chest wall.
• Signs: Respiratory distress, hemoptysis, cyanosis.
• Exam: Decreased breath sounds and crackles in the affected lung area.
• Labs: Hypoxia and/or hypercapnia on ABG.
• Diagnosis:
  • Detectable on bedside ultrasound.
  • Alveolar opacities on CXR.

Management

• High flow O2 (15 L/min).
• Analgesia for pain.
• Respiratory support: Severe cases require intubation and mechanical ventilation.
• Fluid restriction: May reduce size of contusion but might not affect outcomes (controversial).

Chest X-ray: “fluid but not in Pleura, in lung itself”.

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Pneumomediastinum

• It is a sign of other serious injuries: Larynx, trachea, major bronchi, pharynx, esophagus.
• Causes: Foreign Body (FB) aspiration, perforation of esophagus/trachea.

Signs

• Subcutaneous emphysema: Crepitus when touching the skin.
• Hamman’s sign: Crunching sound over the heart.

Treatment

• Treat the underlying cause (trachea, esophagus, etc.).

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Cardiac Tamponade

Fluid in pericardial space

• More common in penetrating thoracic trauma than blunt trauma.
• 50-75 ml of blood in pericardial sac may result in tamponade.

Clinical Features

• Anxiety and agitation.
• Obstructive shock: Tachycardia, hypotension, cool peripheries.
• Beck’s Triad: Z
  1. Muffled heart sounds
  2. Hypotension
  3. Distended neck veins
• Pulsus paradoxus: Drop in systolic blood pressure > 10 mmHg on inspiration. Z

Diagnosis

• Mostly diagnosed following identification of a pericardial effusion on FAST exam.
• Clinical diagnosis.

Management

• High flow oxygen (15 L/min via non-rebreather).
• May transiently respond to fluid challenge.
• Needle pericardiocentesis: Preferably ultrasound-guided (may be lifesaving).
• Thoracotomy: If patient arrests.
• Pericardiotomy: Definitive treatment.

Ultrasound image showing pericardial effusion. only tempound - its clinically

Technique for needle pericardiocentesis (A: Xiphoid process).

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Aortic Dissection

Blood entering the medial layer of the wall with the creation of a false lumen, caused by a tear.

Classification

Percentage	60%	10–15%	25–30%
Type	DeBakey I	DeBakey II	DeBakey III
Stanford	Type A (Proximal)	Type A (Proximal)	Type B (Distal)
Note	Involves Ascending + Descending	Ascending only	Descending only
Management	Surgery	Surgery	Medical (Beta Blockers, Control BP)

Clinical Features

• Chest pain: Tearing sensation.
• Radiation: Radiates to back between shoulder blades.
• History of:
  • HTN
  • Aortic regurgitation
  • Ischaemic heart disease
  • Syncope, Seizure
  • Flank pain

Risk Factors: Y

• Marfan’s syndrome, Ehlers-Danlos syndrome, Turner syndrome
• HTN
• Syphilis
• arteritis??????Arthritis
• Cocaine abuse
• Iatrogenic

Clinical Exam Y

• BP: Check BP in the arm with the best radial pulse (look for asymmetrical pulses: carotid, brachial, femoral).
• Aortic Regurgitation is common.
• Shock: Ominous signs (tamponade, hypovolemia, vagal tone).
• Heart Failure.
• Neurological deficits: Limb weakness, paraesthesiae, Horner’s syndrome.
• SVC syndrome: Compression of SVC by aorta.
• Haemothorax.

Complications Y

• Aortic rupture
• Aortic Regurgitation (AR)
• Acute Myocardial Infarction (AMI)
• Tamponade
• End-organ ischaemia (brain, limbs, spine, renal, gut, liver)
• Death

Investigations

1. Chest X-ray

Note: Normal in 11-16% of cases. Not sensitive.

• Widened mediastinum (> 8 cm) (56-63%)
• Abnormal aortic contour (48%)
• Aortic knuckle double calcium sign (> 5 mm) (14%)
• Pleural effusion (Left > Right, obliterated angle)
• Tracheal shift
• Left apical cap
• Deviated NGT

Chest X-ray showing findings of aortic dissection: shifted trachea, calcium sign, widened mediastinum, hemothorax, effusion, left apical cap.

2. Imaging Comparison

Modality	Advantages	Disadvantages	Notes
CT	• Bedside • Detects intimal flap, true/false lumen, AR, tamponade • Assess LV function • Quick	• Iodinated contrast • Radiation exposure • Can’t assess coronaries well	Semi-invasive.
TOE (Transesophageal Echo)	• High sensitivity/specificity • Safe contrast (Gadolinium) • Detects AR • No radiation	• Not readily available • Inconvenient (>30 min) • Limited access/monitoring
MRI	• Detects intimal flap & AR • Assess LV function, tamponade, blocked coronaries	• Not readily available • Invasive (contrast) • Long duration	Remote location.
Aortography	Gold Standard

Treatment

• Medical Management:
  • Control BP (Labetalol, GTN).
  • Aim for SBP 100-120 mmHg and Pulse 60-80/min.
• Fluid and blood resuscitation.
• Call Cardiothoracic Surgeon.
• Indications for Surgery:
  • Persistent pain
  • Type A Dissection
  • Branch Occlusion
  • Leak
  • Continued extension despite optimal medical management