Transcript of Injury ches tmodified (4)
- 1. Chest Injuries Mechanisms of injury blunt injuries crush
injuries penetrating injuries inhalation burns aspiration of
foreign bodies 1
- 2. 2 major forces within chest which lead to injury: 1.
Compression and distraction. Compression results in destruction of
vascular components, haemorrhage, oedema and impairment of
function. 2.Distraction injuries usually result in shearing forces
which destroy integrity of intrathoracic viscera 2
- 3. Blunt trauma - mode of injury important - where there has
been massive deformity of a car or a history of a fall of 5 metres
or more major intrathoracic injuries should always be suspected.
The physical nature of chest wall allows for considerable elastic
recoil, especially in young patients and therefore degree of injury
within chest may need to be judged initially by deformity to car
rather than appearance of patient 3
- 4. Blunt injuries occur in 3 major directions: 1.AP 2 lateral
and 3.transdiaphragmatic AP deformity results in relative backward
motion of heart. This may result in disruption of aorta at level of
ligamentum arteriosum just below left subclavian. As heart swings
back and up it may cause so-called wishbone # of a proximal
bronchus - Injuries to heart occur in up to 1/2 of patients after
deceleration injuries 4
- 5. deceleration with impact to back causes relatively few
intrathoracic injuries - lateral compression of chest during
deceleration causes fractures typically of lower ribs with risk of
injury to liver, spleen and kidneys - when lateral compression
results in flail segments damage to thoracic cavity is usually
relatively small and most frequently limited to contusion and
laceration of lung parenchyma - lap belt of seat belts leads to
rise in intrabdominal pressure in massive deceleration and this,
combined with shearing and twisting of upper trunk may result in
diaphragmatic rupture 5
- 6. Penetrating injuries result in parenchymal damage related to
track of missile or stabbing implement and velocity more solid
structures (eg heart and major vessels) suffer greater injury where
high- velocity missiles are penetrating weapon most lethal
complication is haemorrhage often associated with abdominal trauma
6
- 7. Crush injury occurs where elastic limits of chest and its
contents have been exceeded patients usually have AP deformity
majority have flail chests with multiple fractures, pneumothorax or
haemothorax most have pulmonary contusion injuries of heart, aorta,
diaphragm, liver , kidney and spleen are common 7
- 8. another group of patients with crush injuries are those with
"traumatic asphyxia" syndrome, where constrictive forces are
applied over a wide area for as little as 2-5 mins. Profound venous
hypertension associated with relative stasis is mechanism of
injury. There is widespread capillary dilatation and rupture,
subconjunctival haemorrhage and retinal haemorrhage. Simultaneous
injuries (eg intracranial haemorrhage) must be suspected severe
crush injuries have a high mortality 8
- 9. Chest trauma haemodynamics hypovolaemia most important
mechanism cardiac tamponade myocardial contusion valve injury
intracardiac shunt 9
- 10. Chest trauma hypoxiaDue to: reduced blood volume
ventilatory failure contusion displacement of mediastinum
pneumothorax 10
- 11. Clinical features: Initial history and examination are
often abbreviated Examination air hunger; use of accessory muscles;
tracheal deviation; cyanosis or distended neck veins; (evidence of
tension pneumothorax, or tamponade); tracheal deviation (evidence
of tension pneumothorax) major defects in the chest (sucking chest
wounds 11
- 12. unilaterally diminished breath sounds or hyperresonance to
percussion (evidence of closed pneumothorax or tension
pneumothorax); decreased heart sounds (pericardial tamponade);
location of foreign bodies; location of entry and exit wounds
12
- 13. Investigations CXR - CXR most useful screening
investigation - Look for subcutaneous air, foreign bodies, bony
fractures, widening of mediastinum, pneumothorax,
pneumomediastinum, pleural fluid, pulmonary parenchymal
abnormalities(infiltrates, atelectasis etc 13
- 14. Look in particular for the - pneumothorax: ( up to 30% of
pneumothoraces missed on supine CXR) air collects in
anterior-inferior pleural space producing deep" costophrenic sulcus
14
- 15. - pneumomediastinum parietal pleura visible along left
mediastinal border. pleura descends below mid- hemidiaphragm
sharply defined edge to descending aorta which can often be
followed into upper abdomen "continuous diaphragm" sign under
cardiac shadow subcutaneous, retroperitoneal or intraperitoneal
emphysema 15
- 16. - pneumopericardium air around heart that does not rise
above level of pericardial reflection at root of great vessels air
shifts with position of patient (unlike pneumomediastinum 16
- 17. - pleural effusion uniform increase in density over
hemithorax pleural cap 17
- 18. - pulmonary contusion homogenous infiltrates that tend to
be peripheral and non-segmental may be associated with adjacent rib
fractures air bronchograms are rare due to blood in small airways
18
- 19. - ruptured hemidiaphragm:- more commonly left sided
non-specific signs include: apparent elevation of hemidiaphragm,
obliteration or distortion of contour of hemidiaphragm,
contralateral displacement of mediastinum, pleural effusion
presence of gas containing viscera in thorax, particularly with a
focal constriction across gas- containing bowel is pathognomonic
haemopneumothorax may be misdiagnosed when dilated stomach gives
horizontal air-fluid interface on erect CXR 19
- 20. in absence of right rib #s a small right haemothorax with a
"high R diaphragm" suggestive of ruptured diaphragm findings may be
absent in 25-50% initially- chest wall injuries- may give clues to
associated injuries fractures of first 3 ribs in particular
indicates significant trauma thoracic outlet fractures associated
with brachial plexus or vascular injuries 20
- 21. subclavian vascular injury should be suspected in patients
with fractures of first 3 ribs, clavicle and scapula, particularly
when associated with significant fracture displacement,
extrapleural haematoma, brachial plexus neuropathy or radiological
evidence of mediastinal haemorrhage fractures of sternum are rare
and require both lateral and oblique views of thorax for diagnosis.
The presence of a fractured sternum and an abnormal mediastinal
contour should prompt a search for injury to great vessels 21
- 22. - haemopericardium rapid accumulation of blood in
pericardial space often causes cardiac tamponade wthout altering
appearance of cardiac silhouette 22
- 23. CT Scan Valuable tool Aids in diagnosis and precise
location of numerous lesions. Contrast is useful particularly when
looking for mediastinal haemorrhage and periaortic haematomas.
23
- 24. Echocardiography ECG Cardiac wall motion abnormalities and
valve function and presence of pericardial fluid or blood. Most
common abnormality in thoracic trauma are S-T and T wave changes
and findings indicative of bundle branch block 24
- 25. Angiography BRONCHOSCOPY Angio- Remains the gold standard
for defining thoracic vascular injuries Bron- Indications include
evaluation of airway injury, haemoptysis, segmental or lobar
collapse, and removal of aspirated foreign bodies. 25
- 26. Management Immediate management - assure patent airway,
oxygenation and ventilation - exclude or treat pneumothorax
haemothorax cardiac tamponade 26
- 27. Extrathoracic Injuries - assess for extrathoracic injuries
- decompress stomach - provide pain relief - reconsider
endotracheal intubation, ventilation. In particular take into
account gross obesity, significant pre-existing lung disease,
severe pulmonary contusion or aspiration, need for surgery for
thoracic or extrathoracic injuries 27
- 28. General management Treatment of specific injuries
Monitoring Should include follow-up CXRs. Common for patients with
pulmonary contusion to deteriorate in first 24-48 hrs following
injury Not necessarily due to progression of contusion but is more
often due to development of pneumothorax, haemothorax, atelectasis
or pulmonary oedema. For this reason serial CXRs are necessary in
first 24 hrs Following are danger signs requiring full reassessment
28
- 29. resp rate > 20/min heart rate > 100/min systolic BP
< 100 mmHg reduced breath sounds on affected side Pao2 < 9
kPa on room air Paco2 > 8 kPa increased size of pneumothorax,
haemothorax or increased width of mediastinum on CXR 29
- 30. Deterioration Deterioration in any of these signs must be
followed by a search for evidence of blood loss, tension
pneumothorax, head injury, sepsis or fat embolism. Chest drains
should be checked for patency 30
- 31. Chest drains Indications for insertion of chest drains in
stable patients : pneumothorax > 10% in non-ventilated patient
(ie >1 intercostal space) haemothorax > 500 ml (ie above neck
of 7th rib) surgical emphysema confluent opacity of lung field in a
supine CXR suggesting haemothorax 31
- 32. Prophylactic Chest Drain There are arguments both for and
against the insertion of prophylactic chest drains in patients with
rib fractures who are to be ventilated for a GA. However without
air or fluid draining the drain is likely to become blocked at an
early stage. 32
- 33. In a series of patients with blunt chest trauma one
pneumothorax occurred per 79 days of ventilation when prophylactic
drains were used as opposed to one per 62 days when they were not.
Complication rate associated with insertion 6-9% 33
- 34. Theoretically, all that is required to drain pneumothorax
is a small-bore tube but this is more likely to become blocked.
When blood or pus is to be drained in an adult a 32 FG tube is
recommended Antibiotics use of prophylactic antibiotics
controversial. Some recommend them for patients treated
conservatively in whom a chest drain is inserted cefuroxime and
metronidazole for patients with perforated viscus (in addition to
exploration and drainage) 34
- 35. Clearance of secretions and prevention of atelectasis
General measures: pain relief (eg pleural block) physiotherapy
humidification bronchodilators (especially smokers or those exposed
to smoke, irritant chemicals or those with tracheobronchial burns)
consider cricothyroidotomy or "minitracheostomy" for those in whom
general measures are insufficient 35
- 36. Bronchoscopy Indications for flexible bronchoscopy: massive
air leak failure of lung to re-expand lobar collapse diagnosis and
assessment of tracheal burns bronchial toilet Rigid bronchoscopy
has less of a role in the trauma patient but may be used in cases
of persistent lobar collapse to aspirate a blood clot or plug of
sputum 36
- 37. Mechanical ventilation most centres use PCV or PSV to
reduce incidence of barotrauma - PCV and PSV also provide some
compensation for air leaks 37
- 38. Analgesia Of extreme importance in determining whether deep
breathing and coughing possible. Options IV analgesics in frequent
small doses or by continuous infusion Use of inhalor during
physiotherapy intercostal nerve block: 38
- 39. multiple individual nerve blocks (rptd as necessary) single
large volume (eg 20 ml 0.5% bupivicaine) into 1 intercostal space.
Spreads to block nerves above and below intrapleural bupivicaine
via intercostal catheters using intermittent injections or
continuous infusions epidural LA/opioids NSAIDs: fully resuscitated
patients with normal renal function 39
- 40. Post-operative intensive care following tracheobronchial,
lung or diaphragmatic repair high inflation pressures should be
avoided tracheal suction must be minimal where there is a
tracheobronchial suture line avoid fluid overload prevent gastric
distension 40
- 41. Specific injuries Classification Require immediate
intervention Tension pneumothorax Open pneumothorax Disruption of
major airway Cardiac tamponade Massive haemothorax Traumatic air
embolism Flail chest 41
- 42. Injuries with potential for threatening survival Lung
contusion Other pulmonary parenchymal injuries Myocardial contusion
Aortic rupture Oesophageal disruption Diaphragmatic rupture Rib
fractures Simple haemopneumothorax Traumatic asphyxia 42
- 43. Long term sequelae Clotted haemothorax Empyema Phrenic
nerve palsy Pericardial complications Fistulae Diaphragmatic hernia
Chylothorax 43
- 44. Others Sternal, clavicular, scapular injuries Subcutaneous
emphysema 44
- 45. Tension pneumothorax respiratory distress, tachycardia,
hypotension, tracheal deviation, unilateral absence of breath
sounds, distended neck veins. Cyanosis is a late manifestation may
be confused with cardiac tamponade but tension pneumothorax is more
common. Differentiation may be made by unilateral hyper-resonance
45
- 46. treat by immediate decompression: insert needle into 2nd
intercostal space in MidClavicularLine. Ability to easily aspirate
air confirms diagnosis. In event of failure to aspirate air,
withdraw needle but remember possibility of iatrogenic pneumothorax
now exists 46
- 47. Open pneumothorax sucking chest wound" if opening in chest
wall is approximately 2/3 the diameter of trachea air passes
preferentially through chest defect promptly close defect with
sterile occlusive dressing, large enough to overlap the wounds
edges and taped securely on 3 sides to provide a flutter-type valve
effect. As patient breathes in the dressing is sucked over wound
while the open end of the wound allows air to escape during
expiration place a chest drain in an area remote from the open
wound 47
- 48. Disruption of major airway clinical features vary with
level of rupture but usual picture is one of respiratory distress,
subcutaneous emphysema, haemoptysis pneumothorax invariable with
ruptured bronchus. Suspect bronchial rupture if pneumothorax
associated with a persistent large air leak after placement of
chest drain. Rupture usually occurs within 2.5 cm of carina
mediastinal emphysema common treatment of tracheal injuries:
immediate intubation with cuff positioned distal to tear. Drain
pneumothorax 48
- 49. Cardiac tamponade most commonly results from penetrating
injuries but may follow blunt trauma relatively small amounts of
blood (approx. 100 ml) required to restrict cardiac activity and
interfere with cardiac filling. Removal of small amounts of blood
or fluid (often as little as 15-20 ml) by pericardiocentesis may
have enormous beneficial effects diagnosis is often difficult:
49
- 50. volume of heart sounds difficult to assess in noisy
environment distended neck veins may be absent because of
hypovolaemia pulsus paradoxus may be absent and tension
pneumothorax may mimic tamponade consider possibility in patients
who do not respond to usual resuscitation and have a mechanism of
injury compatible with tamponade 50
- 51. pericardiocentesis pericardiocentesis blind
pericardiocentesis only if ultrasound/echo not available use
sub-xiphoid route and preferably a plastic sheathed needle for
pericardiocentesis. ECG monitoring is necessary to detect needle
induced arrhythmias 51
- 52. pericardial aspiration may not be diagnostic or therapeutic
if blood has clotted, which may be the case after rapid bleeding.
Open pericardiotomy may be life-saving but is indicated only when
an experienced surgeon is available even if pericardial tamponade
is strongly suspected volume resuscitation should continue while
preparations are made for pericardiocentesis aspiration of blood
alone may temporarily relieve symptoms because of the self sealing
qualities of the myocardium but all patients with positive
pericardiocentesis following trauma require open thoracotomy and
inspection of the heart 52
- 53. Massive haemothorax incidence of haemothorax and
haemopneumothorax ~50-60% in penetrating trauma and 60-70% in blunt
trauma. Majority are not massive massive haemothorax defined as
>1500 ml of blood in chest cavity clinical signs: unilateral
dullness to percussion shock unilateral absence of breath sounds
deviation of trachea neck veins may be flat due to severe
hypovolaemia or distended because of the mechanical effects of
intrathoracic blood blood loss complicated by hypoxia 53
- 54. Management manage initially by simultaneous restoration of
volume deficits and decompression of chest cavity. If auto-
transfusion device is available it should be used emergency
thoracotomy for massive haemothorax or haemothorax with ongoing
loss of >200 ml of blood per hour for 3-4 h 54
- 55. Systemic air embolism more common in penetrating injuries
immediately life-threatening usually due to broncho-pulmonary vein
fistula suspect if: focal neurological signs exist in the absence
of head injury circulatory collapse occurs on initiation of IPPV in
absence of tension pneumothorax froth is obtained in arterial blood
gas sample from a collapsed patient 55
- 56. Management Management If suspected: 100% O2 minimise
ventilation volumes and pressures emergency thoracotomy to clamp
ascending aorta, remove air source (by clamping pulmonary hilum)
and aspirate air from LV and ascending aorta 56
- 57. Flail segment major physiological insult is contusion of
underlying lung and decreased vital capacity occurs when 3 or more
consecutive ribs or costal cartilages are fractured bifocally.
these circumscribed segments, having lost continuity with the rigid
thorax, move inwards with inspiration and push outward with
exhalation, thus moving paradoxically. presenting symptoms of pain,
tachypnoea, dyspnoea, and thoracic splinting, along with chest wall
contusions, tenderness, crepitance, and palpable rib fractures are
suggestive, but paradoxical chest wall motion is the diagnostic
sine qua non. 57
- 58. may be difficult to diagnose if patient is already
mechanically ventilated, in pain, obese, or has large breasts or
subcutaneous emphysema. CXR is helpful in identifying multiple
fractured ribs, but will not reveal cartilaginous disruptions.
Major value of the CXR is in detecting associated injures (more
than 90% will have associated injuries-and 3 out of 4 require tube
thoracostomy for haemopneumothorax; extrathoracic injuries are
common: head injury in ~40%; major fractures in 40%, and
intraabdominal injuries in 30%. 58
- 59. Distribution of flail Anterior: typically secondary to
blows to the sternum, eg motor vehicle accident, CPR Lateral: due
to T-bone impacts or AP crush mechanisms Posterior: result from
direct blow to the back and are characterized by simultaneous
fractures along the midaxillary line and the rib neck. Splinting,
plus a supine position effectively limit paradoxical motion.
59
- 60. Management ~50% of cases can be managed without ventilation
others require ventilation for 1-3 weeks chest wall usually
stabilises in 1-2 weeks operative fixation is suggested by some
authors. Main benefit is to prevent deformity. weaning should not
wait till paradoxical movement improves, rather should be initiated
when gas exchange is adequate. in absence of systemic hypotension
control administration of IV fluids to prevent overhydration
60
- 61. ~50% of cases can be managed without ventilation others
require ventilation for 1-3 weeks chest wall usually stabilises in
1-2 weeks operative fixation is suggested by some authors. Main
benefit is to prevent deformity. weaning should not wait till
paradoxical movement improves, rather should be initiated when gas
exchange is adequate. in absence of systemic hypotension control
administration of IV fluids to prevent overhydration 61
- 62. Lung contusion essentially a bruise of the lung. Aetiology
controversial: probably a combination of shear stress (tearing
tissue) and bursting forces (popping the balloons) direct injury
causes pulmonary vascular damage with secondary alveolar
haemorrhage initially not much shunt as these alveoli are poorly
perfused subsequently tissue inflammation develops. Resultant
surrounding pulmonary oedema produces regional alterations in
compliance and airways resistance, leading to localised V/Q
mismatch atelectasis 62
- 63. diagnosis is radiological. classically see nonsegmental
pulmonary infiltrates-progress in first 12-24 hours of injury. Note
that CXR undestimates degree of contusion. CT more sensitive and
better method of assessing severity may be irregular nodular
densities that are discrete or confluent homogeneous consolidation
diffuse patchy pattern early CXR changes suggest more severe
contusion. Early pulmonary contusion infiltrates are due to
alveolar haemorrhage radiological differential diagnosis includes:
63
- 64. Aspiration Re-expansion of collapsed RUL following right
endobronchial intubation in most cases infiltrates associated with
pulmonary contusion are not visible till after fluid resuscitation.
contusions tend to worsen over 24-48 hours and then slowly resolve
unless complicated by infection, ARDS or cavitation 64
- 65. Management supplemental oxygen only about 25% of patients
require invasive ventilation good analgesia physiotherapy 65
- 66. Other pulmonary parenchymal injuries Pulmonary Laceration
Commonly associated with haemopneumothorax and haemoptysis Usually
managed with simple tube drainage Pulmonary Haematoma Uncomplicated
cases usually resolve in 3- 4 weeks 66
- 67. Posttraumatic Pulmonary Cavitary Lesions Posttraumatic
Pulmonary Cavitary Lesions Posttraumatic cysts, pseudocysts, or
pneumatoceles are cavitary lesions within the lung parenchyma
filled with fluid, blood, of air. CT is useful in diagnosis Most
resolve spontaneously Some can become infected requiring
antibiotics, CT guided aspiration, and in some cases surgical
resection 67
- 68. AV fistulas diagnosis by pulmonary angiography Torsion of
the lung XR signs: Opacification of affected hemithorax Mediastinal
shift toward the contralateral side Reversal of bronchoalveolar
markings of the affected side, with the major pulmonary vessels
coursing cephalad instead of caudad 68
- 69. Myocardial contusion Definition and epidemiology direct
traumatic myocardial damage without traumatic involvement of
coronary arteries common in blunt trauma but difficult to diagnose
tends to occur in acceleration/deceleration and crush/compression
injuries 69
- 70. Clinical features consider possibility in any patient with
a mechanism of injury that suggests likelihood of cardiac contusion
patients who are conscious may complain of dyspnoea or chest pain
may lead to significant physiological dysfunction and even death
but massive contusion leading to cardiogenic shock is rare. In
patients with chest trauma cardiogenic shock is usually due to
cardiac tamponade or ventricular akinesia 70
- 71. with compression in diastole valvular dysfunction may
occur; usually aortic valve in older patients and mitral in younger
pericardial rub, S3 gallop, cardiac failure serious damage to
virtually every cardiac structure has been reported most common
presentation is with asymptomatic ECG abnormalities although severe
contusion will produce cardiac failure. LAD damage may occur with
resulting anteroapical infarction 71
- 72. Investigations enzyme elevations, specifically CKMB
correlate poorly with contusion ECG changes: range from
non-specific T wave changes to pathological Qs. Multiple VPBs,
unexplained sinus tachycardia, AF, BBB (usually R) and ST segment
changes are most common ECG findings. Normal ECG at admission makes
cardiac contusion unlikely. TOE: +/- cardiac wall motion
abnormalities. Exclude lesions that will benefit from
revascularization or other cardiac surgery sternal # associated
with low incidence of cardiac contusion & arrhythmias 72
- 73. Management all patients with myocardial contusion should be
admitted to ICU for observation and cardiac monitoring (This view
is being challenged). Admit patients with arrhythmias or heart
failure to level 3 ICU non-urgent surgery should be postponed where
possible because of life threatening operative complications.
Consider invasive haemodynamic monitoring for patients who have to
undergo urgent surgery treat arrhythmias if life-threatening or
associated with cardiac failure; treat specific valve abnormalities
surgically. treat cardiogenic shock along usual lines with
optimization of preload, inotropes IABP. Exclude tamponade 73
- 74. Prognosis Prognosis resolution of wall motion abnormalities
in ~25% only (NB based on only 14 patients Ruptured aorta traumatic
aortic injuries are the second most frequent causes of death in
patients with chest injuries 74
- 75. Mechanism and types of injury Deceleration and traction-are
the classic wounding mechanisms of the thoracic arteries Horizontal
deceleration creates shearing forces at the aortic isthmus, the
junction between the relatively mobile aortic arch and the fixed
descending aorta. 90-98% of traumatic injuries of the thoracic
aorta occur at the isthmus 75
- 76. Vertical deceleration displaces the heart caudally and into
the left pleural cavity and acutely strains the ascending aorta or
the innominate artery. Sudden extension of the neck or traction on
the shoulder can overstrech the arch vessels and produce tears of
the intima, or complete rupture of the arterial wall dissection,
thrombosis, pseudoaneurysm or haemorrhage 76
- 77. Diagnosis circumstances may be only clue: head-on collision
at high speed, ejection from a vehicle, fall from great height one
characteristic shared by all survivors is that blood that leaks
from aorta is in a contained haematoma. Other than initial pressure
drop associated with loss of 500-1000 ml of blood, hypotension
responds to intravascular infusion. Persistent or recurrent
hypotension is usually due to another source of bleeding 77
- 78. Free rupture does occur but it is usually fatal unless
patient is operated on within minutes CXR essential - always
suspect ruptured aorta if mediastinum wide especially if associated
with any of following: L haemothorax depressed L main bronchus
blurred outline of arch or descending aorta (?) # 1st rib or L
apical haematoma displacement of mid-oesophagus to R 78
- 79. other suspicious CXR features: loss of aorticopulmonary
window, ant or lat deviation of trachea, loss of paraspinal
"stripe", calcium "layering" in aortic arch signs such as apical
pleural cap, mediastinal width > 8 cm, 1st & 2nd rib #s no
value in indicating major arterial injury further investigations
depend on CXR findings: further investigation not indicated if CXR
normal if CXR technically unsatisfactory or mediastinal contour
equivocally abnormal then perform thoracic CT first to look for
mediastinal haemorrhage 79
- 80. This often also demonstrates aortic pseudoaneurysm if
present. If mediastinal haemorrhage is present and aortic
pseudoaneurysm is not demonstrated then proceed to aortogram if
mediastinal contour on CXR clearly abnormal proceed directly to
aortography aortography is gold standard investigation although TOE
may supercede it. TOE may miss lesions of distal ascending aorta or
of arch vessels typical aortographic finding in patients with an
aortic tear is an irregular outpouching of aorta just distal to
left subclavian artery. 80
- 81. Outpouching may be circumferential with appearance of a
"sleeve" around aorta or may be localized, with abnormal area
present only along medial or lateral aspect of aorta NB there is
frequently a convexity or a bulge in region of embryonic ductus
arteriosus. This is usually smooth and symmetrical Treatment prompt
surgery. Often requires cardiopulmonary by 81
- 82. Injuries to aortic arch vessels Bleeding from an arch
vessel is usually contained, but in rare instances, the avulsion of
the origin of an arch artery causes massive bleeding into
pericardial or pleural cavity. Acute occlusion of the innominate or
subclavian may cause ischaemic symptoms of hand or arm (acute
ischaemia of the common carotid may lead to brain ischaemia)
Clinical features include cervical or supraclavicular haematomas,
bruits, diminished peripheral pulses 82
- 83. Oesophageal perforation Oesophageal perforation usually due
to penetrating injury but occasionally follows blunt trauma +/-
retrosternal pain, difficulty in swallowing, haematemesis, cervical
emphysema CXR: +/- pneumomediastinum, widened mediastinum,
pneumothorax, hydrothorax 83
- 84. consider diagnosis in any patient: with L pneumothorax or
haemothorax without a rib # who has received severe blow to lower
sternum or epigastrium and is in pain or shock out of proportion to
the apparent injury who has particulate matter appearing in the
chest tube drainage after the blood begins to clear definitive
investigation: gastrograffin swallow or endoscopy immediate
surgical repair with gastrostomy or feeding jejunostomy 84
- 85. Ruptured diaphragm - usually due to gross abdominal
compression causing large radial tears. Penetrating trauma tends to
produce small perforations that take some time to develop into
diaphragmatic hernias - rupture of L hemidiaphragm more common -
deterioration in respiratory status if MAST trousers are inflated -
CXR features listed above - 85
- 86. if rupture of L hemidiaphragm is suspected a NG tube should
be inserted. If this appears in thoracic cavity no further
investigations are required. Occasionally it is necessary to inject
contrast down NG tube to confirm diagnosis - if CT non-diagnostic
consider MRI in stable patients - significant risk of gut
strangulation with L rupture 75% of patient with ruptured diaphragm
have associated intra-abdominal injury - surgery should follow
basic resuscitation 86
- 87. Rib fractures Most common injury Extent of trauma and
mortality correlates directly with the number of ribs fractured
First three ribs fractured means a large amount of force caused the
injury ?recent study challenges this concept Ribs 10, 11, and 12
are associated with blunt injuries involving the spleen, liver,
kidneys and diaphragm. Fractures or three or more ribs are commonly
associated with pulmonary contusions 87
- 88. Chylothorax Injury to thoracic Duct Milky discharge from
the chest tube Coservative treatment for 2 weeks Thoracotomy and
ligation of Duct 88