Year : 2018 | Volume
: 35 | Issue : 1 | Page : 1--4
Management of chest trauma
Al Ashry T Ghoneim1, Gamal E Saleh1, Refaat S Salama1, Mohammed K Zghloul2,
1 Department of General Surgery, Benha University, Benha, Egypt
2 Department of Cardiac Surgery, Damietta Cardiology and Gastroenterology Center, Damietta, Egypt
Mohammed K Zghloul
Department of Cardiac Surgery, Damietta Cardiology and Gastroenterology Center, Al Aaser Street, Damietta - 34512
Thoracic trauma is a major medical problem with high mortality. It is a life-threatening situation and frequently involves other anatomical areas that require simultaneous management. The typical management is supposed to be multidisciplinary and preferably started at the accident location and maintained during patient transport, through the arrival to the emergency department, through transport to surgical theatre, in the operation room and then in the ICU. Early management is the key to decrease morbidity and mortality. The aim of this study was to throw some light on the types of chest trauma with special reference to its recent management.
|How to cite this article:|
Ghoneim AT, Saleh GE, Salama RS, Zghloul MK. Management of chest trauma.Benha Med J 2018;35:1-4
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Ghoneim AT, Saleh GE, Salama RS, Zghloul MK. Management of chest trauma. Benha Med J [serial online] 2018 [cited 2018 Oct 18 ];35:1-4
Available from: http://www.bmfj.eg.net/text.asp?2018/35/1/1/226425
The incidence of the chest trauma increased lately due to the worldwide increase in violence and accidents. The ideal management should be multidisciplinary and should start before their arrival at the hospital and continued throughout transport, in the emergency department, the operating theatre and then in the ICU. Early diagnosis and early management are also important to reduce the morbidity and mortality rates .
The complex relationship of twelve paired ribs with the external and internal muscles, which form the chest wall, has both a structural and a functional role. The chest wall guards the heart, lungs and liver, grants a flexible skeletal frame to fasten the actions of the shoulder and arm, and supports respiratory movement, all while reliably delivering more than 20 000 breaths a day. Chest wall dysfunction is correlated with significant morbidity and fast life-threatening consequences .
The structures that cross the diaphragm are the inferior vena cava, the oesophagus, the right phrenic nerve at the eighth thoracic vertebra, vagi and the branches of the left gastric artery and vein at the 10th thoracic vertebra, the aorta, thoracic duct and azygos vein at the 12th thoracic vertebra. The left phrenic nerve passes into the diaphragm. The thoracic cage includes the lower respiratory tract as well, which consists of the trachea, bronchi and lungs .
A focus on the anatomy and blood supply of the chest wall has led to the development of muscle and musculocutaneous flaps and the increased use of prosthetic materials, wherein proper awareness of the functional anatomy and pathophysiology of the chest is crucial to the success of the reconstructive chest surgeon .
Types of thorax trauma injuries
The type of chest trauma injuries varies widely and basically depends on the violent environment or the kinematics and severity of the accidents in the various geographical regions all over the world. The injuries are divided into four groups:Thoracic wall injuries [e.g. rib fracture, sternal fracture and subcutaneous emphysema (SE)].Lung injuries (e.g. pneumothorax and haemothorax).Mediastinal injuries (e.g. myocardial injury, aortic injury and oesophageal tear).Diaphragmatic wounds .
Mechanism of injury
Chest trauma has an important role in the management of the polytraumatized patient. It is either blunt (e.g. falling from height or getting kicked) or penetrating (e.g. stabbing or gunshot) trauma. The penetrating injuries located between the nipple lines anteriorly or the scapulae posteriorly have the potential for great vessel or cardiac injury. The dangerous zone is between the epigastrium and the sternal notch and laterally within 3 cm of the sternum. Injuries below the level of the tip of the scapula posteriorly or the inframammary crease/nipple anteriorly have the possibility to traverse the diaphragm .
Blunt chest trauma frequently results in severe chest wall and lung injuries, including multiple rib fractures, flail chest and lung contusion. Most of the patients with such injuries are managed properly with pain control, aggressive respiratory management and mobilization. The prognosis for recovery is good, although chronic ache because of chest wall injury is common .
A minority of cases with chest wall or lung injuries will need endotracheal intubation and further invasive management such as surgical flail chest repair or pulmonary resection. A minority of rib fracture cases will develop a symptomatic nonunion that may be amenable to surgical resection or plating with or without bone grafting. Pneumatoceles are widespread among patients with large pulmonary contusion, but rarely need surgical intervention .
Imaging diagnosis of thoracic trauma
Various imaging techniques are necessary in the initial diagnosis of chest trauma patients. Although echocardiography has a significant role in the initial assessment of chest trauma patients, chest radiography is the typical choice in these patients. Rib fractures, pneumothorax, pleural effusion, pericardial effusion, blunt pulmonary lesions and foreign bodies such as knife or bullets are easily diagnosed .
Chest radiography is also helpful in the initial evaluation of cervicothoracic spine lesion. When plain radiographs are not enough to verify the clinical diagnosis or there is a doubt about the radiographic images, it is recommended that an ultrasound or computed tomography (CT) scan be performed. CT scan has a definite role in the diagnosis of chest trauma; images are more dependable compared with plain radiographs or ultrasound .
Chest trauma triage and resuscitation
A comprehensive and thorough examination of the patient and the assessment of injury severity must be carried out shortly. The main task of a surgeon is to evaluate the state of the patient to distinguish or prevent life-threatening conditions. The surgeon must complete a physical examination and must ensure fast resolution, when the situation is complex and laboratory tests and a chest radiograph are time consuming .
Resuscitation of the trauma patient with uncontrolled bleeding necessitates the early identification of bleeding sources followed by prompt action to reduce blood loss, to restore tissue perfusion and to accomplish haemodynamic stability. Thus, the management of chest injuries may require urgent thoracotomy for haemorrhage control, cavity decompression with chest tube drainage, and mechanical ventilation in case of respiratory insufficiency. Factors that may contribute to a favourable outcome include kinetic therapy and appropriate fluid management .
In the primary assessment of chest trauma patients, the process of diagnosis and prompt management should be started simultaneously, searching and managing life-threatening lesions such as airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest and cardiac tamponade .
Following are the minimal essential parameters that are regularly monitored in all patients with chest trauma, immediately upon their admission and later:Arterial blood pressure.Arterial pulse and heart rate.Central venous pressure (in patients with shock and mechanical ventilation).Volume of urine (in patients with shock).Cardiac index.Arterial PO2, PCO2 and pH.Haematocrit value .
Once the life-threatening injuries are identified and treated, a more extended and meticulous assessment must be carried out. The first step is to make a comprehensive and detailed review of the case. It is essential to obtain the patient’s medical history that can be relevant for the immediate complete management: diabetes, hypertension, heart disease, lung disease, possible pregnancy, drug addiction, medications, etc. .
It is also essential to collect data on the kinematics of trauma. We must review all chest wall, lung parenchyma, diaphragm, mediastinal silhouette and other extrapulmonary or thoracic injuries. If there is any diagnostic doubt and patient’s conditions allow, we may ask for a CT or CT angiography. Once the diagnosis is definitive, treatment is required .
Chest wall injury
In rib fractures, simple chest radiography should be routinely ordered and hospitalization is recommended when three or more ribs are fractured and as well as in the case of fracture of the first or second ribs and if there are serious injuries and associated complications. In lower rib fracture, the presence of abdominal lesions should be ruled out .
Several studies suggest a substantial benefit in patients with flail chest injuries requiring mechanical ventilation who undergo surgical stabilization. Hence, the surgical fixation is only recommended in cases in which the only cause for maintained mechanical ventilation is flail chest, when a thoracotomy is necessary for other causes or when there is traumatic thoracoplasty .
We should consider rib fracture open reduction and internal plating fixation in the pain managing algorithm of lesser injured blunt thoracic trauma patients who are suffering severe pain as a result of displaced rib fractures .
The patients who present with isolated fracture of the sternum without haemodynamic instability, dysrhythmia or history of ischaemic heart disease can be discharged home safely, provided that pain management is adequate . Sternal plating can be an efficient choice for the management of sternal dehiscence because it yields a steady sternum. Sternal plating is a safe and simple technique with no risks .
The SE can be classified into five grades. Several techniques can been used to treat SE, but a lot of these techniques are ineffective and not tolerable. We can use the infraclavicular incision to reduce the severity of SE; those incisions help in improving the status of the patients .
Pneumothorax is a widespread respiratory diagnosis and it is essential that it is promptly managed and in an appropriate way. Immediate management is principally determined by the degree of cardiorespiratory compromise, degree of symptoms and extent of pneumothorax and might involve observation only, needle aspiration or chest tube insertion .
Haemothorax is also a relatively common respiratory diagnosis. Quick recognition of the reason and beginning of treatment is important. In haemodynamically unstable cases, chest tube drainage and surgery is indicated. In haemodynamically stable cases, blood evacuation with chest drain with or without intrapleural fibrinolytic treatment should be performed. If this is not successful, surgical interference is indicated to avoid long-term complications and impaired respiratory functions .
Traumatic pulmonary parenchymal injuries reveal a distinguishing look in distribution, morphology and temporal evolution on the chest radiography and CT, which frequently presents a narrow differential or definitive diagnosis. This can significantly help the trauma surgeon/clinician in tailoring management and appropriate follow-up to optimize patient care with decrease in morbidity and mortality .
The emergency video-assisted thoracoscope surgery in haemodynamically stable patients after blunt chest trauma is secure and efficient, and we can perform it with some diagnostic benefits while patients are sedated during which the hazards of general anaesthesia are avoided .
Even though airway trauma is still extremely fatal, good results can be anticipated after surgical management. Fundamental requirements for this are an early diagnosis and early achievement of a safe and patent airway. Surgical primary repair to restore the airway integrity, minimize the pulmonary parenchymal loss, preserve vocal function and evade permanent tracheostomy should be the scope of every try to surgically manage an airway trauma .
It is very essential to make an early diagnosis of the diaphragmatic rupture for proper surgical management, decreasing the risks for visceral strangulation and its consequences. Surgical repair is the only curative treatment. Primary surgical repair with nonabsorbable sutures is the gold standard for small-to-moderate defects. Large defects may need patch closure with a mesh, but these can carry risks .
There is no gold standard for diagnosing the blunt cardiac injury (BCI) after chest trauma. Diagnostic investigations should be directed to identify the patients who are at the risk of developing cardiac complications as a consequence of BCI. If there are no abnormalities on the initial electrocardiography, there is no necessity to pursue the myocardial contusion with additional sophisticated investigations. Therapeutic interventions should be directed to manage the BCI complications .
One of the leading causes of death is the penetrating cardiac injuries. Prognosis of penetrating cardiac injuries differs widely dependent on the injury’s mechanism, anatomic site and physiologic status. Management of penetrating cardiac injuries needs a quick prehospital transfer, a yet careful systematic physical examination along with proficient surgical management; all should be performed in short time .
Several patients with traumatic aortic rupture or myocardial rupture can be saved with quick diagnosis and intervention. Pericardial tamponade can be precisely diagnosed before haemodynamic decompensation happens with standard echocardiography by emergency physicians. Chest CT should be considered in patients with mechanisms of injury, which increase concern as regards blunt injury of the aorta even when the chest radiographs are normal .
Oesophageal injury is relatively common in penetrating trauma of the neck or chest. Precise diagnosis and less invasive management are decreasing morbidity and mortality. Endoscope should be used with stable cases for small perforations, which are either enclosed or well drained through open or closed drains. Operative management is necessary for large uncontained perforations and widespread contamination. Hybrid methods that combine management modalities will be more common as the endoscopic and radiologic therapeutic techniques continue to develop .
Thoracic trauma is capable of causing immediate life-threatening injury, which we must recognize and manage through primary survey and resuscitation. Immediate deaths are frequently attributable to rupture of the myocardial wall or the thoracic aorta. Early deaths (in the first 30 min–3 h) resulting from chest trauma are frequently preventable.
Causes of these early deaths include tension pneumothorax, cardiac tamponade, airway obstruction and uncontrolled bleeding. As these problems are frequently reversible or may be temporized nonoperatively, it is crucial that emergency doctors be thoroughly familiar with their pathophysiology, clinical presentation and management.
Overwhelmingly, we can keep patient alive using simple emergency department procedures until aid arrives and/or definitive management for specific injuries can be initiated. Other injuries may not require immediate life-saving management, but still require identification and a management plan while the patient is in the emergency department to avoid mortality.
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Conflicts of interest
There are no conflicts of interest.
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