Thoracic Injuries At A Glance

Chest trauma caused about 25% of traumatic deaths in the United States. Many chest injuries cause death in the first minutes or hours after the trauma; they can be treated at the bedside with permanent or temporary measures that do not require advanced surgical training often. Etiology chest injuries can be the result of blunt or penetrating trauma. Among the major thoracic injuries include the following: damage to the aorta (aortic tear (traumatic)) Blunt cardiac injury (blunt cardiac injury) pericardial tamponade (pericardial tamponade) Flatter chest (Flatter chest) hemothorax (hemothorax) pneumothorax (simple [pneumothorax], offnener [pneumothorax (Open)] and tense [pneumothorax (tension)] pneumothorax) pulmonary contusion (pulmonary contusion) Many patients have concurrent hemothorax and pneumothorax (hemopneumothorax). Bone injuries are common, usually ribs (rib fractures) and collarbone concerning (collarbone fractures), but fractures of the sternum and shoulder blade may occur. The esophagus and diaphragm (abdominal injuries at a glance) can also be damaged by chest trauma. Because the diaphragm can be located during exhalation at the same height as the nipples, penetrating injuries to the chest can lead to the nipple also to intra-abdominal injuries. Pathophysiology Most occur morbidity and mortality due to chest trauma because injuries interfere with breathing, circulation or both. Breathing can be impaired Direct damage to lungs or airways Altered respiratory mechanisms Among the violations that directly damage the lungs or airways, include pulmonary contusion and tracheobronchial disorder. Injuries that alter the mechanics of breathing are hemothorax, pneumothorax and flutter chest. Injuries to the lungs, the tracheobronchial tree or – rarely – the esophagus can allow air into the soft tissues of the chest and / or throat (subcutaneous emphysema) or the mediastinum (pneumomediastinum). The air itself has rarely significant physiological consequences; the underlying injury is the problem. Tension affects both breathing and circulation. The circulation may be impaired: Reduced bleeding the venous return direct cardiac injury bleeding as they occur during hemothorax may be solid, leading to shock (breathing is also affected if hemothorax is great). Reduced venous reflux affects the cardiac filling, which is caused hypotension. Reduced venous return flow can occur due to increased pressure in the chest cavity in the tension pneumothorax or by increased pressure in the intrapericardial cardiac tamponade. Heart failure and / or conduction defects may result from blunt cardiac injury that damages the heart muscle or the heart valves. Complications Because injuries of the chest wall usually make breathing very painful, patients often limit the inspiration (splinting). A common complication of splinting is atelectasis, which can lead to hypoxemia, pneumonia, or both. Patients being treated with thoracotomy, v. a. when a hemothorax is incomplete emptying, purulent intrathoracic infection (empyema) can develop. Symptoms and signs Symptoms include pain that worsen usually with breathing if the chest wall is injured and sometimes wheezing. Common findings include breast tenderness, ecchymosis and shortness of breath; Hypotension or shock may be present. An extension of the jugular vein may occur in tension pneumothorax or cardiac tamponade when patients have an adequate intravascular volume. Decreased breath sounds can be caused by pneumothorax or hemothorax; Percussion is dull at hemothorax in the affected areas and hyperresonant for pneumothorax. The trachea can be different from the side of a tension pneumothorax. When the stagger chest moves a segment of the chest wall paradoxical-d. h, in the opposite direction from the rest of the chest wall (outward during exhalation and inwardly during inhalation). the fluttering segment is often felt (Flatter breast). A subcutaneous emphysema causes crackling or crunching when it is scanned. Results may be localized to a small area or include a substantial part of the chest wall and / or spread to the neck. Most commonly, a pneumothorax is the cause; if extensive injuries to the tracheobronchial tree or upper respiratory tract should be considered. Air in the mediastinum can produce a characteristic crunch synchronously with the heart beat (Hamman characters or Hamman-crackling). A Hamman’s sign points to a pneumomediastinum and often violations of the tracheobronchial tree or no – rarely – on esophageal injury. Diagnosis Clinical examination chest X-ray Occasionally other imaging (. Eg CT, ultrasonography, aortic imaging) Clinical examination Five states are immediately life-threatening and must be corrected quickly: Massive hemothorax tension pneumothorax Open pneumothorax flutter chest cardiac tamponade diagnosis and begin treatment during the primary survey (handling trauma patients) and initially based on clinical findings. Depth and symmetry of the chest wall excursion are valued, listened to the lungs and the entire chest and neck inspected and palpated. Dyspnea patients should be monitored with serial assessments of clinical status and the oxygenation and ventilation (eg. As with pulse oximetry, BGA, Capnometry if intubated). Penetrating chest wounds should not be probed., However their position helps reduce the risk of injuries to predict. Wounds with a high risk are those that lie medial to the nipples or the shoulder blades and those which pass through the chest from side to side (i. E. Off by one half of the thorax and through the other exit). Such wounds can hurt the hilum or the great vessels, heart, tracheobronchial tree or rarely the esophagus. Patients with symptoms of partial or complete airway obstruction after a blunt trauma should be intubated to control the airway immediately. breathing with difficulty are in patients following the serious injuries that need to be considered during the primary survey: tension pneumothorax Open pneumothorax Massive hemothorax flutter breast There is a simplified, rapid approach to differentiate these injuries (A simple, rapid evaluation of patients with chest trauma and shortness of breath during the primary survey.). A simple, rapid evaluation of patients with chest trauma and shortness of breath during the primary survey. (Signs of shock) are in patients with chest trauma and impaired circulation serious injuries, which are checked during the primary survey following: Massive hemothorax Spannungspneumothorax Perikardtamponade other chest injuries (eg blunt cardiac injury, aortic tear.) Can cause a shock, but will not be primary survey dealt with. Simplified, fast approaches can help quickly between correctable causes of shock due to chest injuries to distinguish (A simple, rapid assessment of chest injuries in patients with shock during the primary survey.). However, should bleeding in all patients with shock after severe trauma, will be excluded regardless of whether a chest injury that could cause the shock is identified. A simple, rapid assessment of chest injuries in patients with shock during the primary survey. * Bleeding should be in all patients who are following a major trauma in a state of shock, excluded, regardless of whether a chest injury that could cause the shock is identified A † expansion of the jugular vein may be absent with hypovolemic shock in patients. The treatment of injuries affecting the airway, breathing or circulation starts during the primary survey. After the primary survey, patients are clinically accurate to other serious chest injuries and less severe manifestations of violations during the primary survey method untersucht.Bildgebende Imaging techniques are typically indicated in patients with significant chest trauma. A radiograph is almost always created. The results are diagnostic usually for certain injuries (z. B. pneumothorax, hemothorax, moderate or severe pulmonary contusion, clavicle fracture, some rib fractures) and suggestive of other (eg. As aortic tear, diaphragmatic rupture). However, it can take several hours until the findings are obvious (eg. As in pulmonary contusion and diaphragmatic injury). Plain radiographs of the shoulder blade or the sternum is sometimes performed when sensitivity is on these structures. In trauma centers, an ultrasound of the heart is usually performed during the resuscitation phase, to test for pericardial tamponade; some pneumothorax can also be seen. A CT of the chest is often in suspected aortic injury performed (aorta tear trauma ()) to diagnose and small pneumothorax, sternum fractures or mediastinal (eg, heart, esophagus, bronchi) injuries; Thoracic spine injuries will also be identified. Other tests for aortic injuries are aortography and transesophageal Echokardiographie.Labor and other tests A complete blood count is often created but is mainly valuable as a baseline for detecting a current circulation. ABG results help monitor patients with hypoxia or shortness of breath. Cardiac markers (eg. As troponin, CPK-MB) can help rule out blunt cardiac injury. An ECG is usually at chest trauma that is compatible with difficulty or with heart damage done. A cardiac damage may cause arrhythmias, conduction abnormalities, ST segment abnormalities, or a combination. Therapy Supportive treatment treat specific injuries immediately life-threatening injuries are treated at the bedside during diagnosis. Suspected Spannungspneumothorax: Nadeldekompression shortness of breath, shock and decreased breath sounds, “thoracotomy tube” (as is carried out pleural drainage). Shock with suspected cardiac tamponade: Perikardpunktion. Suspected hypovolemic shock: Fluid resuscitation (intravenous fluid replacement). Immediate Wiederbelebungsthorakotomie can be considered for trauma victims into consideration when the doctor ruled the process (be thoracotomy) has one of the following and the patient: Penetrating thoracic injury with a need for CPR of <15 min Penetrating non-thoracic trauma with a need for CPR <5 min Blunt trauma with a need for CPR <10 min Persistent systolic blood pressure <60 mm Hg due to suspected cardiac tamponade, bleeding or air embolism tips and risks In trauma patients with respiratory distress or shock, and decreased breathing sounds, a "tube thoracotomy be "carried out prior to imaging techniques Without one of these criteria a Wiederbelebungsthorakotomie is contraindicated, since the procedure involves substantial risks (eg. B. transmitting blood-borne diseases, injuries by doctors) and costs. The specific treatment depends on the injury. Supportive therapy typically includes analgesics supplementary O2 and sometimes artificial respiration.