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Grand Rounds

Case Presentation and Discussion on Chest Trauma


Benjamin C. Deveza, M.D.



General Data :

G.N., 55-year-old male
Paco, Manila





Chief complaint :

Chest trauma
History of Present Illness

Past Medical History
unremarkable

Family History
No history of disease

Physical Examination
Conscious, coherent, ambulatory, not in cardiorespiratory distress
BP 120/80 PR 70 RR 18 T 37
Pink palpebral conjunctiva, anicteric sclerae, supple neck, no CLAD
Symmetrical chest expansion, no retractions, clear breath sounds, (+) erythema and tenderness, 4th and 5th ribs, posterior axillary line, left
Physical Examination
Adynamic precordium, with regular rate, rhythm
Flat, normoactive bowel sounds, soft, non-tender
Pulses full and equal; no edema, cyanosis
Case Discussion
Salient Features
55-year-old male
heavy object fell on the back
pain on the back area, left
Symmetrical chest expansion, no retractions, clear breath sounds, (+) erythema and tenderness, 4th and 5th ribs, posterior axillary line, left


Chest Trauma

Chest Trauma

Chest Trauma

Chest Trauma


Do I need a Paraclinical Diagnostic procedure?
- Yes
- to increase my degree of certainty

Paraclinical Diagnostic Procedures

At the Emergency Room, chest x-ray was done :

Complete, Displaced Fracture, 3rd to 5th Ribs, posterior, left
No pneumohemothorax
Pre-Treatment Diagnosis
Treatment
Goals of treatment
Control of pain
Prevention of complications
Treatment options
Treatment options
Course in the Wards
On admission

DAT
IVF D5 LR 1L x KVO
IV Tramadol Drip started



Course in the Wards
On the 3rd Hospital Day
Repeat Chest X-ray done
- no interval changes
no pneumohemothorax
no contusion
IV analgesia discontinued
Started on oral analgesics

Course in the Wards
On the 4th Hospital Day

Patient was discharged improved
Without difficulty of breathing
With minimal pain

Final Diagnosis



Sharing of Information
Thoracic injury accounts for 25% of deaths due to trauma and is preceeded only by head injury
Chest wall trauma includes damage :
skin
fat
muscle
bone ( rib and sternum )
Sharing of Information
Short-term disability and death are usually due to associated injuries, long-term disability to chronic pain and pulmonary dysfunction

Sharing of Information
RIB FRACTURES
- diagnosis is primarily made from the mechanism of injury and P.E. findings

- point tenderness in a specific area related to a patient’s respiratory movement is a sensitive indicator

Sharing of Information
- treatment principles
control of pain
pulmonary toilet
prevention of pneumonia
- major morbidity arises from pulmonary complications
Sharing of Information
Associated Injuries
- most life-threatening complications from blunt and penetrating thoracic injury
hemothorax
pneumothorax
pneumohemothorax
- approximately 85% of these patients can be treated definitively with a chest tube
Sharing of Information
- indications for thoracotomy in blunt chest trauma
pericardial tamponade
tear of the descending aorta
rupture of a main bronchus
rupture of the esophagus




THANK YOU !!!
References
Cameron,J.L. Current Surgical Therapy 8th Ed; 2004: 663-664
Rhoads, J.E. Textbook of Surgery Principles and Practice 5th Ed; vol 1 :
Schwartz, S.I. Principles of Surgery 7th Ed; 1999 vol 1
Snell, Robert S. Clinical Anatomy. 4th Edition;1992
McKellar, D.P. Prognosis and Outcomes in Surgical Disease. 1999

MCQ : Choose the best answer


1. What is the most threatening occult injury in trauma surgery?
a. tear of the ascending aorta
b. tear of the descending aorta
c. tear in the diaphragm
d. tear to the subclavian artery

2. What is the thoracoabdominal region that is extremely difficult to evaluate in patient’s sustaining penetrating injuries and is considered a surgical “NO MAN’S LAND”?
a. area of the nipples to the costal margins
b. epigastric area
c. sternal area

MCR
Direction: Write
“A” if 1, 2, and 3 are valid statements.
“B” if only 1 and 3 are valid statements.
“C” if only 2 and 4 are valid statements.
“D” if only 4 is a valid statement.
“E” if all are valid statements.


3. What are ribs that are relatively protected by the shoulder girdle?
a. 1st rib
b. 3rd rib
c. 2nd rib
d. 4th rib


4. What are the indications for thoracotomy in blunt trauma?
a. pericardial tamponade
b. tear of the descending thoracic aorta
c. rupture of a main bronchus
d. rupture of the esophagus


5. What are the principles in the treatment of rib fractures?
a. CTT
b. pain control
c. thoracotomy
d. prevention of pneumonia
 

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