Chest injury

Chest injury

Chest injuries account for 10-12% of traumatic injuries. A quarter of chest injuries are severe injuries requiring urgent surgical intervention. In peacetime, closed injuries prevail over open ones and account for more than 90% of all chest injuries.

Classifications

• • The classification of chest injuries adopted in Russia divides them into closed wounds and penetrating wounds of the chest.
  • Classification of the Board of Traumatologists of the American Society of Surgeons. Chest injuries are divided into emergency conditions that directly threaten the life of the victim, and potentially life-threatening.

Immediate life threatening injuries can be fatal in minutes. Despite the significant variety of the nature and intensity of disorders, first of all, they will need to be attributed to: disorders of external respiration (respiratory), circulatory disorders (circulatory), shock.

• • Airway obstruction quickly leads to hypoxia, acidosis, and cardiac arrest. It is necessary to immediately ensure and maintain airway patency: remove secretions, blood, foreign bodies, perform tracheal intubation, cricothyroidotomy or tracheostomy (if indicated).
  • Pneumothorax and hemothorax.
  • Cardiac tamponade occurs when there is a rapid accumulation of blood in the pericardial cavity (under the cardiac shirt), accompanied by compression of the heart, a decrease in its filling in diastole and a decrease in cardiac output.
  • Clinical manifestations: arterial hypotension, a sharp weakening of the apex beat, expansion of the boundaries of the heart, a significant expansion of the veins of the neck. Localization of the wound in the projection of the heart allows you to suspect the injury of the pericardium and myocardium in a timely manner
  • Treatment: thoracotomy and rapid decompression of the pericardium. A left-sided anterior thoracotomy and pericardiotomy are performed, and the blood spilled into the pericardial cavity is evacuated. The myocardial injury is sutured. The pericardium is also sutured with separate sparse sutures to ensure free outflow of the contents of the pericardial cavity into the pleural cavity.
  • Pathological mobility of the chest wall – see. Rib fractures.

Injuries, potentially life-threatening, untimely treatment traditionally lead to death. However, the condition of the diseased allows within a few hours to make an accurate diagnosis and develop the necessary treatment tactics.

• • Tears of the trachea and main bronchi traditionally appear within 2 cm of the tracheal bifurcation. It is most commonly seen in blunt chest trauma. Injury to the trachea and bronchi does not often occur in isolation, traditionally in combination with damage to other organs of the mediastinum and chest cavity.
  • The diagnosis is established clinically, with radiography or bronchoscopy. Characteristic signs are severe respiratory failure, pneumothorax, mediastinal emphysema, subcutaneous emphysema, hemothorax and hemoptysis. A rupture should be suspected in the following cases:
  • Collapsed lung failed to expand after pleural drainage (decompression failure)
  • Continued flow of a large volume of air into the pleural cavity
  • Massive mediastinal and subcutaneous emphysema in the early periods after trauma (1-2 hours).
  • Treatment: restoration of the wall of the trachea and bronchus. If it is not possible to restore the integrity of the ruptured main bronchus with preserved vessels, both ends of the bronchus should be sutured tightly and the patient transferred to a specialized center for thoracic surgery.
  • Aortic rupture traditionally occurs with acute and blunt chest trauma or an abrupt stop in body movement (automobile accident). When large vessels of the chest are injured, less than half of the victims reach the hospital: there are few conditions for thrombosis, the wound traditionally gapes, which is accompanied by profuse bleeding. As a result, within 2/3 of the victims die.
  • Clinical manifestations are hemorrhagic shock, localization of injury in the upper half of the chest, intense pulsating hematoma, noise during auscultation above it, hemopneumothorax.
  • Radiography
  • Mediastinal expansion
  • Blurring of the contour of the aortic arch
  • Downward displacement of the left main bronchus
  • Shadow at the apex of the lung
  • Deviation of the trachea to the right
  • Fluid (blood) in the left pleural cavity.
  • Aortography: confirm the diagnosis.
  • Treatment. Emergency thoracotomy, restoration of the integrity of the aorta by suturing the wound or interposition of the graft. Usually carried out using a heart-lung machine.
  • Diaphragm injury traditionally occurs with open and closed injuries of the chest and abdomen. In this case, the pleural and abdominal cavities communicate with each other
  • Diagnosis is by x-ray showing displacement of the stomach or colon into the chest. All penetrating wounds of the chest below the level of the VII rib are dangerous with possible damage to the diaphragm. Therefore, with an unclear clinical picture, diagnostic thoracoscopy is indicated for these patients.
  • Treatment. Immediate insertion of a nasogastric tube (if not previously placed) prevents the significant expansion of the stomach traditionally accompanied by severe, life-threatening respiratory distress. Then, diaphragm ruptures are urgently sutured (by transabdominal access) and at the same time the combined injuries of the abdominal organs are eliminated. The pleural cavity is drained.
  • Esophageal ruptures often appear with penetrating wounds of the chest or with iatrogenic damage to it during esophagoscopy
  • Clinical manifestations: immediate development of subcutaneous emphysema in the neck and rapidly progressive mediastinitis
  • Treatment. Wide mediastinal drainage and closure of the tear should be performed as soon as possible. Access depends on the location of the rupture: either through the soft tissues of the neck, or by performing a thoracotomy. Sutures are traditionally covered and reinforced with surrounding tissues (pleura, intercostal muscles).
  • Contusion of the heart occurs with direct blows to the sternum. According to the severity of manifestations, contusion of the heart tissues ranges from minor subendocardial or subpericardial petechiae to damage to the entire thickness of the myocardium.
  • Clinical picture: pain in the region of the heart, not often stopped by validol, nitroglycerin, anxiety, fear, feeling of suffocation, weakness. The skin is earthy-gray in color, cold sweat, the pulse is weak filling, arrhythmic, tachycardia up to 140-150 per minute. Auscultation revealed dullness of tones, arrhythmia, arterial hypotension. On the ECG – a decrease in voltage, an increase, flattening, 2-phase or inversion of the T wave, deformation of the QRS complex.
  • Complications
  • Arrhythmias (including ventricular extrasystoles, supraventricular tachycardia and atrial fibrillation)
  • Myocardial wall ruptures
  • Ruptures of the interventricular septum
  • Left ventricular failure.

f Diagnosis is based on ECG and 2D echocardiography.

• • Treatment: constant monitoring of the activity of the heart and hemodynamics with the help of monitoring equipment, treatment of arrhythmias with appropriate products, with the development of cardiogenic shock – appropriate intensive therapy.
  • Pulmonary contusion is the most common injury that accompanies extensive chest trauma in 30-75% of cases.
  • The reasons. Closed trauma causing intra-alveolar hemorrhage, edema, and obstruction of the bronchioles
  • The diagnosis is established on the basis of chest X-ray data, arterial blood gas composition and clinical signs of respiratory failure.
  • Treatment: restriction of fluid intake, oxygen inhalation, physiotherapy, adequate pain relief (including epidural analgesia). In the event of complications (pneumo- and hemothorax) – emergency drainage of the chest cavity.
  • Mediastinal emphysema and subcutaneous emphysema
  • Subcutaneous emphysema most often occurs with tension pneumothorax and rupture of the parietal pleura, which corresponds to a typical injury – rupture of the lung with rib fractures or penetrating injury. With an intact parietal pleura, air enters the soft tissues of the chest from the mediastinum through the superior aperture.

chest. It is possible to develop extensive subcutaneous emphysema with a closed rupture of the bronchus or lung and preserved parietal pleura. It is necessary to distinguish between limited, widespread and total subcutaneous emphysema.

• • Mediastinal emphysema (pneumomediastinum) occurs when the bronchus (less commonly, the trachea) ruptures while maintaining the integrity of the mediastinal pleura (air spreads through the paratracheal and mediastinal spaces). Another root cause of pneumomediastinum is a complication of laparoscopy (when the insufflated gas instead of the abdominal cavity enters the preperitoneal tissue and then into the anterior mediastinum)
  • Clinical manifestations. Symmetrical swelling in the supraclavicular areas, rapidly spreading to the neck, face. Hoarseness of voice, extracardial tamponade of the heart. On palpation – a symptom of crisp snow (crepitus)
  • Treatment. With progressive mediastinal emphysema with dysfunction of the cardiovascular and respiratory systems, emergency suprasternal mediastinotomy is indicated: local anesthesia, novocaine is subsequently injected into the skin, subcutaneous tissue and retrosternal space. A horizontal incision is made above the handle of the sternum and, sliding along the posterior wall of the sternum, carefully penetrate the mediastinum. Then a drain is installed and suggestive sutures are applied.
  • Compression of the chest (traumatic asphyxia). With a long and strong compression of the chest, an almost complete or partial holding of the breath occurs, entailing an increase in intrathoracic pressure with a sharp increase in pressure in the intrathoracic blood vessels. The outflow of venous blood through the system of the superior vena cava to the right parts of the heart is disturbed
  • Clinical picture: consciousness is often disturbed, patients complain of chest pain, tinnitus, hoarseness, not often aphonia, bleeding from the nose and ears is possible. The appearance of the patient is characteristic: the skin of the head, neck, upper chest has a bright red color with multiple punctate hemorrhages spreading to the mucous membranes of the oral cavity, eardrums, conjunctiva and retina. There may be no hemorrhages on the skin in places where the clothes fit snugly. In severe cases, shortness of breath, weak frequent pulse, arrhythmias, arterial hypotension. On auscultation – a large number of moist rales, on the x-ray – all kinds of darkening of the lung fields
  • Treatment. With mild traumatic asphyxia – rest, cervical vagosympathetic novocaine blockade according to AV Vishnevsky, oxygen therapy. In severe traumatic asphyxia – mechanical ventilation, resuscitation, intensive care.

See also Hemothorax, Rib fractures, Pneumothorax, Cardiac Tamponade, Shock

ICD

• S20 Superficial injury of chest
• S21 Open wound of chest
• S22 Fracture of rib(s), sternum and thoracic spine
• S26 Injury of the heart
• S27 Injury of other and unspecified organs of thoracic cavity