Examination of trauma, chest wound
Injuries or injuries to the chest are a common surgical emergency group depending on the surgical facility, accounting for about 10, 15 percent.
The concept of injury, chest wound
Chest injury (or closed-chest injury): An injury to the chest but the chest wall remains closed, ie the pleural space is not ventilated to the outside air.
Chest wound (or open chest wound): This is an injury to the chest that causes a puncture of the chest wall, ie the pleural space is injured with the outside air.
Chest injury and injury is a common emergency surgery group (depending on the surgery facility), accounting for about 10-15% of the emergency operations at Viet Duc Hospital (a large surgical center with specialties in chest surgery - based on emergency surgeries for the last 6 months of 2003). Because trauma directly affects the circulatory apparatus, it can quickly lead to death, so it is the first priority type of emergency in diagnosis, transportation, and handling.
The causes of chest injuries are often traffic accidents, high falls, and occupational accidents. Age is most common from 20 to 50 years old, mainly in men (over 90%). There may be injuries of other organs, so when examining, always respect the principle of the comprehensive examination to avoid missing lesions.
The cause of the breast injury is usually a knife, sharp object, or fire, so it easily damages the organs in the chest such as the heart, diaphragm, blood vessels. The most common age is from 20 to 40 years old, most of them are men (over 90%).
Recall thoracic anatomy and respiratory physiology
Some of the following anatomical and physiological recalls have a very important application role in symptomology, diagnosis, and treatment of trauma and breast injuries.
Rigid frame: Sternum in front, spine at back, connected by ribs. Outside the ribs are covered by muscles and skin, close to the inside, there are pleural leaves.
Diaphragm: The chest-belly space. The right side is about 0.5 - 1.5 cm higher than the left. The diaphragm dome top reaches the intercostal space of the 5 medial axillary lines.
The internal organs:
The two sides have 2 lungs, the outer surface of the lung is covered by the pleural leaves adjacent to the leaves forming a virtual cavity with negative pressure (- 5 to - 10 cmH2O). Lungs have no muscle so they cannot contract on their own, but there are many elastic fibers that make the lungs always tend to contract toward the hilum.
Heart: Located just behind the sternum and left rib cartilage.
The mediastinum - upper has large blood vessels, main bronchial gas.
The posterior mediastinum has a thoracic aorta and esophagus.
And contains the most important component of the respiratory apparatus, the circulatory.
The inhalation and exhalation activity relies on the respiratory muscles, the elasticity of the chest - lungs, and is based on the principle that the air goes from a place of high pressure to a place where the pressure is low. The pressure in the alveoli is always close to the atmospheric pressure. Normally, the diaphragm guarantees 70% of the respiratory capacity. Specifically:
Then inhale and chest expands, the diaphragm is lowered and the lungs expand and the alveolar pressure decreases and the air enters the lungs.
Then you exhale, the chest falls, the diaphragm pushes up and the lungs collapse and increase the alveolar pressure and the air goes out.
Thereby, it can be seen that the guarantee of negative pressure in the pleural space, the integrity of the thorax, and the ventilation of the respiratory tract play a very important role in respiratory physiology.
In the presence of surgical lesions in chest wound injuries such as rib fractures, pleural perforation, or obstruction of the airways due to blood, foreign bodies, and phlegm will lead to respiratory physiology and respiratory distress.
The main pathological lesions
Damage to the chest wall
Include some of the following major lesions
Perforation of the chest wall:
The chest wall is penetrated from the skin into the pleural space by piercing sharp objects, causing the chest wound, leading to a general result of blood overflow - pleural airflow. A hole in the chest wall is large or small depending on the trauma agent. In addition to tearing - soft perforation, the rib can be fractured - fracture, if the wound crosses the lower ribs, it often breaks the intercostal bundle, causing heavy bleeding to the pleural cavity. Damage to internal organs in the chest, in addition to tears in the lung parenchyma in a simple chest wound, there may also be heart injuries, diaphragm perforation, tearing blood vessels - large bronchi ... creating different forms of the wound. chest.
Along with the movable rib array, the open chest wound (large wound, not self-sealing or not having received first aid, the pleural cavity is free to the outside) are two very serious lesions in chest trauma, due to severe pathophysiological disorders characterized by 2 reversible respiratory syndromes and swaying mediastinum:
Respiratory Reversal: The phenomenon of reversal of the physiology of the damaged lung. When inhaled, instead of the lungs expanding, the air will pass through the chest wound into the pleural cavity, causing the affected lung to collapse, pushing some of the residual air to the healing side. When exhaled, the air in the pleural cavity will pass out through the wound, causing the opposite effect, which causes residual air from the healing lung to enter the lesion. This respiratory reversal will lead to severe hypoxia.
Swaying mediastinum: When both pleural cavities still have negative pressure, the mediastinum stands in the middle. Due to chest wound, the negative pressure on one side is lost, causing the mediastinum to be drawn to the healing side. When inhaled, air enters the affected pleural space while the negative pressure on the benign side increases, increasing the level of pressure differential, so the mediastinum is drawn to the healthy side. On exhalation, the pressure difference is greatly reduced, causing the mediastinum to be pushed back to the affected side. The phenomenon of the mediastinum swing prevents blood from returning to the heart, reducing blood to the lungs, leading to a more severe lack of oxygen.
Because the lack of oxygen makes the patient breathe faster, the 2 above-mentioned syndromes are worse, leading to a vicious cycle and very easily fatal. Therefore, the first-aid rule in these cases is: seal the wound with an open chest wound or immediately immobilize the moving flank.
One or more bones may break. If it is caused by direct impact (which is a common mechanism), the broken head often penetrates inside causing a puncture and lung perforation. If it is caused by indirect pressure, the broken head is usually facing outwards.
Fractures (ruptures) of the ribs in a chest wound are often accompanied by a rupture of the intercostal artery causing heavy bleeding.
The degree of displacement of the two fractured ends can be a fracture, lateral displacement, overlap displacement. If there is a deviation, the fractured bone often punctures the pleura - lung by lying close to the surface of the bone.
Blood flowing from the fracture site forms a hematoma under the skin and into the pleural cavity if there is a pleural tear.
Mobile rib array:
Definition: An area of the chest that is constantly lost and moves in the opposite direction from the chest when breathing. The condition is that the ribs must be broken 2 places on an arc and on 3 adjacent ribs. Common in very strong injuries. Causes serious disorders of breathing and circulation.
Common types of ribs:
Lateral array: Most common, due to clear motion.
Posterior ribs: The region between the spine and the medial axillary line, less mobile.
Anterior ribs: Velvet causes severe respiratory distress.
The rib array can be either instantaneous or secondary
Fracture of the sternum:
Usually due to very strong trauma, directly to the sternum region. Causes severe respiratory failure and damage to the organs inside the chest, especially the heart.
Breakage (perforation) of the diaphragm:
Perforation of the diaphragm is common in the wound of the lower chest (usually from the intercostal space of 5 middle axillary lines), causing injury to the abdomen. You may experience an abdominal wound that goes up your chest through the diaphragm.
Diaphragm rupture is more common in trauma caused by pressure or a high fall. The left side is more common than the right. If left rupture, the organs in the abdomen and gastrointestinal fluid often pass the rupture into the pleural space causing a herniated diaphragm and infection of the pleural space. If the right-side rupture is often accompanied by liver damage, the blood is sucked up into the pleural cavity causing intense pleural hemorrhage.
Lesions in the pleural space
It should be noted that despite its simple anatomical structure, pleural manifestations are a common consequence of most of the lesions of the chest wall or the organs in the thorax, and it is this manifestation that produces many symptoms. clinical syndrome, and at the same time determines treatment attitude.
Due to the influx of air, the negative pressure is lost in the pleural space, the pulmonary parenchyma shrinks, the intercostal spaces expand and push the mediastinum to the opposite side. Air can enter the pleural space from 2 sources:
Outside: Through the chest wound.
In out: Due to tearing the lung parenchyma (alveoli, bronchi ...).
In a chest injury, if there is a lesion of the chest wall causing a tear to the pleural wall, the air from the pleural cavity can escape under the skin, forming an airflow under the skin.
Severe injury is overflow under pressure (due to the valve in the chest wall, in the large bronchial rupture), causing air to enter the pleural space in one direction but cannot escape, causing heavy pressure on lungs and mediastinum.
The blood flowing into the pleural space will compress, lose negative pressure, cause the lungs to contract and fill the mediastinum. Blood enters the pleural space from several sources:
Chest wall: From broken ribs, muscles, intercostal artery ...
Internal organs: From the lungs, heart, large blood vessels ...
When the amount of blood accounts for more than 10% of the pleural space - the equivalent on the radiograph shows the filling of the diaphragmatic angle, then the clinical symptoms appear:
Blood in the pleural space does not clot, usually black blood. When severe and acute bleeding (damage to blood vessels) occurs, both blood and blood clots are present.
Bleeding + pneumothorax:
The most common injury in trauma, chest wound. In terms of disease anatomy is the combination of the two lesions mentioned above.
Damage to the organs
Tearing of the alveoli or small bronchus (peripheral lung parenchyma):
Spillage - an overflow of air into the pleural space.
Tearing of the trachea, large bronchus:
Causing a lot of pneumothorax, easy to see gas under pressure.
Spillage under the skin neck - face - chest if tracheal damage.
There may be a gas spillway into the mediastinum.
Blood flows from the lesion into the airway - bronchitis causes early clinical coughing of blood.
Lung hematoma (crushing):
Uncommon, mainly in injuries caused by high falls. Pulmonary parenchyma tear and crushed plaques + bleeding in lung parenchyma à risk of severe atelectasis later, it is difficult to treat.
Atelectasis, two phenomena:
Pulmonary parenchymal shrinkage: After trauma, due to hemorrhage - gas causes loss of negative pressure in the pleural cavity, causing the lungs to shrink as described above.
This is the obstruction of the bronchi that causes the lungs to collapse, the main cause of bronchial obstruction is an increase in the secretion of phlegm (due to decreased pulmonary ventilation, parenchymal shrinkage) and crushing - bleeding into the lumen of the bronchi. injury.
Due to obstruction of the bronchi, the pulmonary parenchyma does not expand even though treatment returns the pleural negative pressure. Thus, this is a secondary consequence after other injuries, posing many problems in inpatient care after chest trauma.
Different from the "push" in the clinical and radiological manifestations of hemorrhage - pleural gas causes parenchymal shrinkage, the effect of atelectasis is a manifestation of "pull" such as chest collapse, pull the mediastinum to the side. injury, pulling the diaphragm up, deflating the intercostal space ...
Heart and pericardium:
In the chest wound (heart wound):
Tearing of the pericardium and heart caused by a sharp object.
Common when the wound is located in the dangerous triangle of the heart (top is the left nipple, the base is the sternum).
Bleeding out or into the pleural space, often fatal due to blood loss, is very rare in the clinical setting. Usually, the cause is a large foreign body that causes a large wound.
Bleeding into the pericardium, blood clots, increased pressure in the pericardium à temporarily sealing the wound, less blood loss but acute compression of the heart. This is the main clinical form.
In chest trauma (heart injury):
The damage can range from very mild pericardial hematoma to rupture of the chambers of the heart, structures in the heart, and most importantly, a rupture of the heart stem.
The mortality rate is very high, most of the time, only one chamber rupture causing bleeding and acute heart compression can be found clinically.
Usually due to trauma to the area of the sternum and rib cartilage.
Loops of the aorta:
Common in closed injury due to car accident, often causes tearing aortic contraction. Blood flow out often causes mediastinal hematoma, blood stasis above, anemia below.
Examination principle: always compare with the healthy chest to determine symptoms:
The most common muscle symptoms:
Chest pain: Usually occurs immediately after an injury with many different degrees, pain is continuous and increases with time.
Shortness of breath: Appears immediately after injury for severe forms, or later with mild forms. Also has a continuum and ascending nature.
Coughing up blood early: This is an uncommon symptom but has high diagnostic value. Appears right from the first hour after injury and only occurs in cases of severe (rare) crushed lung injury to the trachea or bronchus or lung parenchyma.
In addition, by questioning the disease, it is necessary to determine more about:
The cause, the agent, the mechanism of the injury, because it can help partially identify the level of injury.
History of heart disease and lung disease: For example, pleural effusion, tuberculosis, bronchial asthma, heart failure ... Because they will change the symptoms and clinical picture of chest injury.
Systemic symptoms mainly include symptoms of the general condition such as pulse, blood pressure, temperature, skin color and mucous membranes….
Systemic symptoms can vary depending on the disease form of the trauma or chest wound:
Conventional form: The circuit is usually fast. Blood pressure is normal. Skin and mucous membranes color is slightly pale and light purple.
There may be extensive blood loss: Rapid pulse. Blood pressure may remain normal or drop. Clear pale skin and mucous membranes. Limbs and limbs are cold, and may sweat on the face, forehead, or chest.
Severe respiratory failure: Rapid pulse. Blood pressure can drop in a late stage. Clear purple skin and mucous membranes. The lungs may be compatible with signs of excessive blood loss.
Possible acute cardiac compression syndrome: tachycardia, loss of peripheral vessels when inhaled deeply. Arterial blood pressure is dropped and blocked. Central venous pressure increased (> 15cmH2O). Cervical venous floating, hepatomegaly, positive hepatocellular response - cervical angioma. The lungs may be compatible with signs of massive blood loss or severe respiratory failure.
In addition, the full-body examination also allows the detection and evaluation of combined lesions, including severe injuries that create a multi-traumatic disease such as traumatic brain injury, abdominal injury, kidney injury, Pelvic fracture and complications, femoral fracture, spine fracture ...
Symptoms in the respiratory apparatus:
Chest deformity: the affected chest may bulge up (pneumothorax), collapse (pleural effusion), and decrease the amplitude of respiration compared to the healthy side.
Nasal bulging, breathing muscles in the neck - chest when breathing, clearly when there is severe respiratory failure.
In the chest wound:
There are wounds on the chest wall: In principle, the inlet hole of the wound can be from elsewhere (abdomen, neck ...), but most (over 95%) of the inlet are located on the chest wall. Through the wound, there are 2 possibilities:
Seeing an enlarged blood - gas through the wound: Uncommon because the majority of victims received first aid after being injured. But if it does, then this is a sure clinically confirmed sign of a chest wound.
Often no longer see blood-gas swelling, because the wound was first aid with a pressure bandage, suture...
Locate the wound: It plays a very important role in direction of examination and diagnosis. For example, the wound in the dangerous triangle of the heart à the risk of heart injury is high, or the wound from the intercostal space 5 or less middle axillary lines à the risk of chest-abdomen injury ...
Evaluate the length and nature (sharpness or roughness) of the wound to help identify the cause of the injury and the extent of the injury.
In chest trauma:
Skin abrasion, hematoma on chest wall: Common, suggestive of chest trauma. Assessing the position and magnitude of this skin rubbing area plays a guiding role in examination and diagnosis, for example in the anterior sternum region, the predisposing region of the breastbone and susceptible to a bilateral chest injury and heart injury; In the lower part of the left thoracic wall is easily accompanied by rupture of the spleen, or the right side is easily ruptured.
Inverted respiratory region of movable flank: Usually appears just above the rubbing zone - hematoma of the chest wall. Specifically, when you inhale, while the rib cage is bulging, the rib array area will recede and vice versa, when you breathe out, while the rib cage falls down, the area of the ribs rises.
Breathing: Usually shallow, frequency> 25 times/minute in case of respiratory failure.
Signs of painful rib fracture.
Subcutaneous airflow around the injured area: Very significant because it helps to confirm clinically that there is chest injury (mostly rib fractures, lung tears, blood flow - pneumothorax)
Compare with the healthy side will see:
Wine is more pronounced in highland areas when the pneumothorax is present.
Chisel lower in the presence of pleural hemorrhage or atelectasis.
Lung alveolar barrier: decreased or lost on the injured side.
Heart: blurred heart sound in cardiac compression syndrome.
Should be used only when there is no chest radiograph or symptoms are unclear. If the puncture is in a lying position:
When looking for air spill: Poke in the intercostal cavity 2 lines between the blow, find the air to easily pull out or the gas pushes the piston of the syringe.
When looking for blood spillage: Poking in the intercostal space 5 or 6 middle axillary lines shows blood, not clotting.
Pericardial puncture: Very little currently available. Often poked through Marfan, blood is not clotting
General subclinical symptoms
Chest X-ray straight
Roles and indications:
This is the main subclinical survey in chest trauma, helping to confirm the clinical diagnosis and accurately indicate the extent of many lesions (rib fracture, blood spill, air spill ...). Chest X-rays should be done for all patients if the emergency and patient's condition allows.
Common shooting positions:
Standing posture is the standard posture to take chest x-ray, for clear and typical images.
Backside scan: During injury, the patient is unable to stand. The images are often unclear and typical, so it is painful.
X-ray film standards:
Good film quality results in full clarity, requiring:
Full size: See the entire chest.
Correct posture: Spine straight, scapula out of the field, beam going perpendicular to chest.
Sufficient beam intensity; only visible 3 to 4 first thoracic vertebrae, and the trachea is located between the spine. If the rays are too hard you see all the thoracic vertebrae. If the rays are too soft, do not see the trachea.
The main symptoms:
Typically, when shooting standing.
Image of rib fracture. Number of fractures and degree of displacement. Note that only the posterior and lateral rib fractures can be seen, since the anterior arch is cartilage, so it does not obstruct the X-ray.
The image of pneumothorax: bright field, shrinking lung parenchyma makes the peripheral lung parenchymal contour on the opposite side, the mediastinum is pushed to the opposite side, the intercostal space expands, the diaphragm is pushed down.
The image of pleural hemorrhage: blurred field of the lung basal area creates a Damoiseau curve, the mediastinum is pushed to the opposite side.
Image of hemorrhage - pneumothorax: See the image of airflow above and the horizontal line separating from the blurred area of the hemorrhage at the bottom.
There are also images of pulmonary collapse (scattered cloudiness), atelectasis (blurred fields, enlarged pulmonary vein, collapsed intercostal space, diaphragm pulled up, mediastinum pulled to the injured side) effusion. pericardium (enlarged heart balloon, loss of the heart uterus, sharp edge of the heart), mediastinal airflow, diaphragmatic hernia ...
When taking the recumbent position: The picture is the same as above but of less quality. Note in the blood flow will see the entire field blurred; or in spill - overflow will see a bias of air if the gas is dominant, in favor of overflow if the blood is dominant, and there is no line separating blood from overflow.
Conventional blood test
Leukocytes usually increase. Red blood cells - the ratio of hemoglobin - hematocrit decreases with excessive blood loss.
Exploring special subclinical
Arterial blood gas test: To probe cellular respiration and acid-base balance. It gives parameters of: pH, PaO2, alkaline reserve ... Very useful in severe respiratory distress, but requires machinery and facilities.
Echocardiogram: To detect pericardial (blood) effusion, and damage in the heart when trauma is suspected - heart injury.
Bronchoscopy - bronchoscopy: Helps determine injury when a major air-bronchial injury is suspected and can be coordinated to suck blood with phlegm that obstructs the respiratory tract to prevent atelectasis.
Some major syndromes are common
By assembling the above groups of clinical and subclinical symptoms, it is possible to draw some of the main syndromes in trauma, trauma to the chest as follows:
Respiratory failure syndrome
Mechanical symptoms: Chest pain, difficulty breathing.
Systemic symptoms: tachycardia, skin - purple mucosa.
Symptoms of the respiratory apparatus: Fast shallow breathing> 25 l / min, the nose fluttering, the respiratory muscles contract.
Arterial blood gas tests reveal acidosis.
Usually, respiratory distress syndrome is associated with:
Systemic symptoms: rapid pulse, pale skin - mucosa, drop in blood pressure, cold hands and feet, sweating.
Symptoms of the respiratory apparatus: Chest deformation, decreased mobility amplitude. Signs of broken ribs or moving ribs. Type chisels, alveolar fencing reduced or lost ... Puncture the pleura to not clot blood.
X-ray shows pleural blood overflow, rib fracture ... Anemia is tested.
Often there is respiratory distress syndrome + respiratory tract symptoms such as: chest swelling, decreased mobility amplitude. You may see broken ribs or mobile ribs, spills under the skin. Type the wine. Alveolar barriers are reduced or lost. Puncture the pleura out the gas.
X-ray images of pneumothorax, rib fracture ...
Hemorrhagic syndrome - pneumothorax
This is the most common syndrome in trauma, breast injuries. It is the combination of the symptoms of the two above-mentioned syndromes. Detail:
Respiratory failure syndrome.
Pleural effusion syndrome
X-ray shows blood flow - pneumothorax, rib fracture ... Anemia is tested.
Respiratory failure syndrome.
The wound on the chest wall can see blood-gas swelling.
Hemorrhagic syndrome - pneumothorax.
Acute squeezing heart syndrome
Respiratory Impairment Syndrome: Characterized by a very strenuous patient, chest pain and difficulty breathing, but not commensurate with symptoms in the chest.
Hemothorax Syndrome: Left or right side. If there is often severe bleeding.
Systemic symptoms: As in the form of acute compression of the heart syndrome.
Blurred heart sound.
X-ray: Picture of pericardial effusion. There may be visual bleeding - pneumothorax.
Echocardiography with pericardial fluid.
A pericardial puncture does not clot.