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recognizing and dealing with these emergencies is life saving
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EVALUATION & TREATMENT of THORACIC EMERGENCIES
Mr T Abbass
DR S Khizar
IMPORTANCE
Important public health problem
Common surgical emergency
Identify underlying mechanism of injury
Important cause of preventable deaths if recognized and treated early
Correlate history and physical exam to predict occult injuries
HISTORY
Injury mechanism
Prehospital events
Trends of events since injury
Obtain AMPLE (allergies,medications,past medical illnesses, last meal and events preceding)
PHYSICAL EXAM
Airway with cervical spine
Breathing
Circulation with haemorrhage control
Neck Veins
Breath Sounds, Subcutaneous emphysema
Cardiac sounds
Vitals
GCS
PHYSICAL EXAM
Consider conditions masking examination signs
Head trauma
Alcohol intoxication
Distracting multisystem injuries
RESUSCITATION
ATLS PROTOCOL;
Airway with cervical spine control
Breathing and ventilation
Circulation with haemorrhage control
Disability
Exposure
Secondary survey
RESUSCITATION
Intubation
IV fluids
O-ve blood transfusion
CVP measurement
Foley catheterisation
Tube thoractomy as discussed later
LAB INVESTIGATIONS
CBC
Arterial blood gases
Clotting
Blood group and cross match
RADIOLOGICAL INVESTIGATIONS
CXR
CLASSIFICATION
Respiratory Emergencies
Respiratory and Circulatory Emergencies
Circulatory Emergencies
RESPIRATORY EMERGENCIES
Tracheobronchial disruption
Open Pneumothorax
Flail Chest
TRACHEOBRONCHIALDISRUPTION
EVALUATION
Hypoxia
Chest not moving with ventilation
Haemoptysis
Subcutaneous emphysema
TRACHEOBRONCHIALDISRUPTION
TREATMENT
Intubate using flexible bronchoscope
Tracheostomy
OPEN PNEUMOTHORAX
EVALUATION
Hypoxia
Chest wound
Air passing in and out of chest wound
OPEN PNEUMOTHORAX
TREATMENT
Apply occlusive dressing using vaselinegauze and sponge
Chest drain insertion away from chest wound
FLAIL CHEST
EVALUATION
Hypoxia
Impaired ventilation
Paradoxical Chest movements
Multiple rib fractures at 2 or more places
FLAIL CHEST
TREATMENT
Consider ET intubation if respiratory compromise
Symptomatic treatment with observations and analgesia if no ventilatory compromise
CIRCULATORY&RESPIRATORY EMERGENCIES
Tension pneumothorax
Massive Hemothorax
TENSION PNEUMOTHORAX
EVALUATION
Dyspnoea
Hypoxia
Unilateral absence of breath sounds
Distended neck veins
Tracheal deviation to opposite side
Hypotension
Cyanosis
TENSION PNEUMOTHORAX
TREATMENT
Consider Thoracocentesis with 18G cannulain 2nd intercostal space at MCL
Chest drain insertion in 5th intercostal space if findings confirmed on needle thoracocentesis
MASSIVE HEMOTHORAX
EVALUATION
Dyspnoea
Hypoxia
Hypotension
Decreased breath sounds
Dull percussion note
Positive CXR
MASSIVE HEMOTHORAX
TREATMENT
Replace Blood Volume loss
Insert Chest tube
Consider thoracotomy if blood loss>1500mlinitially or >250ml per hour after initial evacuation
CIRCULATORY EMERGENCIES
Cardiac Tamponade
Aortic disruption
Myocardial contusion
CARDIAC TAMPONADE
EVALUATION
Hypotension
Tachycardia
Distended neck veins
Cyanosis
Presence of bilateral breath sounds
CARDIAC TAMPONADE
TREATMENT
Consider Pericardiocentesis as temporary measure
Thoracotomy as definitive measure for hemostasis
AORTIC DISRUPTION
EVALUATION
Blunt chest injury
Shock
CXR
CT Aortography/axial tomography
CXR SIGNS(Aortic Disruption)
Widened mediastinum
Fracture of 1st & 2nd ribs
Obliteration of aortic knob
Tracheal deviation to right
Elevation of right main stem bronchus
Depression of left main stem bronchus
Obliteration of space b/w pulmonary artery and aorta
Oesophageal deviation to right
AORTIC DISRUPTION
TREATMENT
Emergency Operative repair
MYOCARDIAL CONTUSION
EVALUATION
Blunt chest injury
Chest pain
Hypotension
Dysrrhythmia
MYOCARDIAL CONTUSION
EVALUATION
ECG
Echocardiography
Cardiac Enzymes
Consistent with myocardial injury
MYOCARDIAL CONTUSION
TREATMENT
Consider symptomatic treatment
Close cardiac monitoring
Serial clinical and enzymatic evaluation
Thanks for ATTENTION
