chest trauma
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Haemothorax
Introduction
Three pathway of
bleeding into pleura:
Chest wall
Thoracic viscera
Abdomen
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Classification
According to cause:
Traumatic
Post operative (lung, cardiac, esoph..)
At the course of malignancies (pleura, lung…)
Aortic aneurism dissection
Spontaneously.
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According to amount of blood
Limited (up to 500 ml) under lower
angle of scapula
Moderate (500- 1000ml) at the level
of angle of scapula
Massive (>1000ml)
To close the angle need 500-700ml
blood
To fill one side of pleural cavity need
3.5-4 liters of blood
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
Massive one can cause death by:
Respiratory problems:
Lung collapse
Mediastinal shift which cause hemodynamic disorder
Hypovolemia and shock
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4-5 hours
(N) Aseptic
Blood in pleura exudation
inflammation
Cloth formation
(more in open vs
close haemothorax) Hemodilute
Macrophage
Absorption and aggregation
adhesion
Infection and
empyema
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Sign and symptom
Minimal:
Mild pain
Mild dullness at the left side
Massive:
Chest pain
Dyspnea
pale
Tachycardia
Hypotension
Even shock
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Cont…
No participation in respiration
Vocal fremitus can’t be felt
dullness
B/S absent or decreased
Radiography shows density
Level can be seen when air is present
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Treatment
Minimal: can be resolved or aspirate by syringe (8th
intercostals space)
Moderate: apply chest tube in safe triangle 5th
intercostal
Massive: large bore chest tube (7 or 8 space)
Great arteries damage need ER thoracotomy
If bleeding is >200ml /hr thoracotomy
Clothed: thoracotomy + chest drain
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Cardiac injury and tamponed
Introduction
Cardiac injuries
Cardiac tamponed
increase in venous pressure dec BP and decrease in cardiac
output can cause shock or death.
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Cont…
prepared by: Dr Shir Mohammad Mohammadi
signs
Increase dullness in cardiac area
Muffle heart sounds
Distended jugular veins
Paradoxical pulse
Droplet like heart by radiography
Need emergency pericordocentesis
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Pericardial aspiration
Procedure:
In semi sitting position, at 45 degree, toward left
shoulder
Benefit of epigastric intervention:
Needle doesn’t pass the pleura
Gravity
Low risk of coronary artery damage
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
Cont…
If the aspiration is negative and the signs are positive,
make 8 to 10cm incision and evacuate the clot.
In sever cardiac injuries
Anterolateral thoracotomy
Heart injury repair
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Emphysema of mediastinum
Introduction
Causes:
Trauma
Mediastinal pleura injury
In combine with pneumothorax
Diaphragm rupture
Tracheal damage
Rupture of esophagus
Inflammations (tracheal or bronchial ulcers or tumors perf..)
External factors (esophagoscopy ……)
Idiopathic (inc acute intra lungs pressure, straining
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Sign and symptom
No symptom in mild small amount of air.
In massive air: retrosternal and cardiac pain
Respiratory problems
Neck vein distention
Respiratory and circulatory arrest
Emphysema of neck, upper chest and supraclavicular
area
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Treatment
Related to its cause
Rest
Elevate the lower part of the chest
O2 therapy
Collar mediastinotomy
Thoracotomy
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Thoracotomy
Posterolateral thoracotomy is the standard
Indication:
Massive intrathorascic bleeding
Clotted Hemothorax
Massive air leak
Chronic empyema
Pathologies of lungs and bronches
Aortic diseases
Esophageal pathologies
Mediastinal pathologies
Heart surgery
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Cont…
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Short Break
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Anatomy of Diaphragm
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
Diaphragmatic
hernia:
80% congenital
hernias on the left.
Hernia of Morgagni:
Hernia of Bochdalek:
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Hiatus
hernia:
Sliding 85%
Rolling 5%
Mixed 10%. prepared by: Dr Shir Mohammad Mohammadi
Stomach Cardia Anatomy
• The valvular effects of the GE
junction
• Pressure of the right crus.
• The rosette-like folds of the
gastric mucous
• The presence of a length (2cm)
of intra abdominal esophagus.
• A band of muscle on the fundus
of the stomach; acting as a
sling, which accentuates the GE
junction
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
Mechanism of herniation
• Muscular degeneration by age
• Intra abdominal pressure due to pregnancy and …
• Fatty tissues in the hiatus which increase the
elasticity of the crus
• Reflux esophagitis which causes Esophageal
spasm and fibrosis
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Clinical features:
Over 40 years of age.
Symptoms are like reflux esophagitis
More in women
Radiography ( BM)
Esophagoscopy
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Complications of hiatus hernia:
Esophagitis
- Aspiration pneumonia
- Obstruction or strangulation
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Treatment of sliding hiatus hernia:
Medical treatment
. Sleep in a semi setting position.
. Avoid heavy work ، lifting weights and excessive bending.
. Six times ,non bulky meals.
. Antacids.
. H2 _ Receptor antagonist.
. Reduction of weight.
. Correction of anemia.
Surgical treatment
1-Replace the GE junction below the diaphragm.
2-Reduce the size of the hiatus.
3-Making of an anti reflux mechanism.
(Nissen & Belsey operations )
prepared by: Dr Shir Mohammad Mohammadi
.
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
Treatment of stricture due to reflux
esophagitis
• Bouginage.
• Dilatation and repair of hiatus hernia.
• Partial gastrectomy with or without repair of the
hiatus hernia.
• Vagotomy with or without repair of the hiatus
hernia.
• Hiatus hernia repair in various methods
• Resection of the stricture with replacement by
stomach, colon or jejunum
• Collis Gastroplasty
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Para esophageal (rolling) hernia
Clinical features:
. Intermittent dysphagia.
. Cardiac symptoms due to
pressure on the heart.
. Hiccup
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Treatment
The same to the sliding hernia
But no need for antereflux procidure
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Mixed hiatus hernia
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
prepared by: Dr Shir Mohammad Mohammadi
