Lecture 34: Chest Trauma and Pneumothorax II

Blunt Chest Trauma (BCT)

• Mechanism: force applied over relatively large area of chest wall

• Minor chest wall contusions to fatal intrathoracic injuries

• 25% of all trauma related deaths in U.S.

• Motor Vehicle Accident (MVA)

• Ejections from motorcycles

• Falls

• Violence & assaults

Most common mechanisms of BCT

Blunt Chest Trauma (BCT)

• Mild pain to severe dyspnea, hypotension, cardiac arrest

• Majority of injuries: chest wall contusions & rib fractures

-abrasions, swelling, seat belt marks, paradoxical motion

-distended neck veins, trachea position

1-7

True Ribs

8-12

false ribs

11-12

floating ribs

3-9

typical ribs

4-9

ribs that are most commonly fractured

1 and 2

Fracture of ribs ___________ suggest significant force

CT

-imaging that is more sensitive to rib fractures

-consider if significant trauma, multiple rib fx, intraabdominal or intrathoracic injury

Analgesics

treatment for a rib fracture with no pulmonary injury

Multiple rib fx

Elderly

Chronic lung disease

Severe co-morbidity

Intractable pain

Underlying lung, intrathoracic or intraabdominal injury

when would a rib fx cause you to be admitted?

Pulmonary Contusion

• Most common injury to pulmonary parenchyma in BCT

Pulmonary Contusion

• Damage to alveolar-capillary membrane, /\ membrane permeability

• Collection of blood & edema in alveoli

• V/Q mismatch

• Hypoxia, hypercarbia, acidosis

Pulmonary Contusion

Clinical Features

• Dyspnea, tachypnea, pain common

• Tenderness, ecchymosis, deformity, crepitus of chest wall

• Crackles on auscultation***

• Large - tachycardia, cyanosis, hemoptysis

Pulmonary Contusion

• Opacification / consolidation under area of BCT

• CXR findings lag behind clinical findings (coming and going!)

• Often not present initially - progress over 6-12 hrs

Pulmonary Contusion

-Oxygenation

-Pain control

-Admission

-Avoid Excessive IV fluid

treatment of a pulmonary contusion

Flail Chest

-3 or more adjacent ribs, each fractured in 2 or more places

• Chest wall unstable & segment lacks continuity with rest of thoracic cage

Flail Chest

-Severe disruption of normal chest wall movement

-asymmetrical & uncoordinated

-Not seen with PPV, only spontaneously breathing

Flail Chest

• Respiratory compromise related to degree of underlying lung injury - severe pulmonary contusion common

• Pain & mechanics can lead to hypoventilation, atelectasis & hypoxia

• Severe pain, tenderness, crepitus, bruising

• Paradoxical motion (sometimes) absence does NOT exclude the diagnosis

Contrast-enhanced CT

what imaging is usually indicated for a flail chest?

• Oxygenation, ventilation, pain control

• Manual stabilization initially

-CT Scan

• Positive pressure ventilation

• Pain Control

• Surgery to stabilize the flail segment

treatment for flail chest

Motor Vehicle Accident

most common cause of sternum fracture

Injury to Intrathoracic/Mediastinal Structures

biggest concern in regards to a sternum fracture

Lateral

which xrays have a higher sensitivity for sternum fractures

• Pain control, ice

• Displaced fractures may require reduction

treatment of sternal fractures

6-12 hour observation & 6-12 hour EKG

observation recommendations for a sternum fracture

-Brachial plexus injury

-Vascular injury

-Pneumothorax

-Non-union

possible complications of a clavicle fracture

Clavicle Fractures

• Swelling, ecchymosis & tenderness over site. +/- Crepitus

• Skin tenting; open fx possible

• Loss of normal contour of shoulder/clavicle

• Extremity held close to body, supported by other hand

-Sling, Ice, Pain control

-Surgery (possibly)

treatment of a clavicular fracture

Costoclavicular ligament

most important stabilizer of the sternoclavicular joint

Superior Mediastinum

-immediately posterior to sternoclavicular joint

-contains great vessels, trachea, and esophagus

Sternoclavicular Joint

least commonly dislocated major joint in body

1st degree (Grade I) & 2nd degree (Grade II) joint injury

Type of SC Joint Injury:

• Sprain or subluxation of SC joint

• Stretching, incomplete tears of the SC & CC ligaments or rupture of one ligament

• Clinical findings –swelling & tenderness over SC joint

• Treatment - Ice, analgesic, sling & follow-up

3rd degree (Grade III) joint injury

Type of SC Joint Injury:

• Rupture of SC & CC ligaments with complete dislocation of clavicle from manubrium

• Significant forces required - MVC, contact sports (rugby & football) are most common

• 2 types possible – anterior and posterior

Anterior Dislocations

mot common 3rd degree (Grade III) SC Joint Injury

Sternoclavicular Joint Injury

• Extremity may be foreshortened; usually supported across the trunk by opposite arm

• Shoulder appears shortened & rolled forward

• SCJ swollen & tender to palpation

Anterior Dislocation

Medial clavicle prominent & palpable anterior to sternum

Posterior Dislocation

-pain more severe

• Clavicular notch of sternum may be palpable

• Possible associated complaints**

• Hoarseness, dysphagia, dyspnea, weakness/ paresthesias of UE

• Intrathoracic or mediastinal injuries in 30%

• Airway complications rare

Posterior

in a __________________ dislocation, the neck is often flexed toward the injured side

With traction maintained, push clavicle into place by inward pressure over medial

describe reduction of SC joint with an anterior disolcation

-Clavicle grasped near medial border (towel clip) & pulled anteriorly

-Local anesthesia should be utilized

describe reduction of SC joint with a posterior disolcation