Breast Injury

The most common causes of chest injuries in peaceful conditions are car trauma, falling from a height, trauma with blunt objects, penetrating injuries of the chest. In wartime, the structure of chest injuries is dominated by gunshot wounds, by nature penetrating.

Closed chest trauma in combat conditions is represented by mine-explosive wounds, which, as a rule, have a combined injury character.

ICD-10 code

• S20 Superficial injury of the thorax
• S21 Open chest wound
• S22 Fracture of rib (ribs), sternum and thoracic spine
• S23 Dislocation, sprain and damage to the joints and the capsular-communicating apparatus of the thorax
• S24 Trauma of nerves and spinal cord in the thoracic region
• S25 Injury of the thoracic blood vessels
• S26 Injury of the heart
• S27 Injury of other and unspecified organs of thoracic cavity
• S28 Crush injury and traumatic amputation of part of the chest
• S29 Other and unspecified injuries of the thorax

Epidemiology of chest injuries

According to the Research Institute of First Aid to them. NV Sklifosovsky, chest injuries account for one in three cases of all injuries. In peaceful conditions, severe chest trauma, along with cranial injuries, occupies a major place among the causes of death of victims. Mostly they are people of working age, younger than 40 years. Trauma to the chest is considered the cause of every fourth case of death.

According to the data of the domestic bureau of forensic medical examinations (the analysis is based on expert conclusions and acts of forensic medical examination of corpses), closed chest trauma is the second most injured in other anatomical and physiological areas as the direct cause of death.

For the optimal and timely provision of care, the knowledge of the etiology and pathophysiology of injuries to the breast and the protocols of care is necessary.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]

Classification of chest injuries

Closed Damage

Without damage to the internal organs

• Without bone damage
• With bone damage (without paradoxical or paradoxical movements of the chest)

With damage to internal organs

• Without bone damage
• With bone damage (without paradoxical or paradoxical movements of the chest)

Injuries

• Non-penetrating wounds (blind and through)
  • without damage to bones,
  • with bone damage
• Penetrating wounds (through, blind)
  • With the injury of the pleura and lung (without hemothorax, with small, medium and large hemothorax)
    • without open pneumothorax,
    • with open pneumothorax,
    • with valve pneumothorax
  • With injury of the anterior mediastinum
    • without damage to organs,
    • with heart damage,
    • with damage to large vessels
  • With injury of the posterior mediastinum
    • without damage to organs,
    • with damage to the trachea,
    • with damage to the esophagus,
    • with damage to the aorta,
    • with injuries of the mediastinal organs in various combinations

[12], [13], [14], [15], [16], [17], [18]

The impact of injury mechanisms

The mechanism of getting a chest injury is of great importance, since closed and penetrating wounds have different pathophysiological and anatomical features. For most injuries, a blunt object does not require active surgical care, but rather conservative treatment (oxygen therapy and / or auxiliary non-invasive ventilation, drainage of the pleural cavity).

The diagnosis of "closed chest trauma" can cause difficulty, in which additional studies (CT of the thorax) are needed. With open chest trauma, emergency care is necessary, while additional diagnostic tests are performed according to strict indications.

Diagnosis of chest injuries

In some cases it is not difficult to diagnose a breast trauma, in others, if an anamnesis is not possible, the diagnosis is difficult. The severity is assessed on the ISS scale. The forecast for open and closed faults is determined by the TRISS system.

Penetrating chest wounds are often accompanied by damage to the diaphragm and abdominal organs. A thoracoabdominal injury is suggested if the wound is at the nipple level or lower. Damage to the diaphragm and abdominal organs is possible with a higher location of the inlet, if the wound is applied with a long object, and also with gunshot wounds due to the unpredictability of the bullet movement. When the chest trauma is closed, structures located at a considerable distance from the site of impact (large vessel, bronchus, diaphragm) can be damaged. Even small injuries (for example, isolated fracture of the rib) are dangerous. With all these injuries, serious bleeding complications, pneumothorax, infectious complications, pneumonia are possible.

To clarify the diagnosis, as well as the scope and nature of the injury, a qualitatively performed examination helps.

[19], [20], [21], [22], [23], [24], [25], [26]

Indications for hospitalization

For all chest injuries, including superficial injuries, care must be taken. Later treatment will lead to an increase in disability and an increase in complications.

Examination

The main purpose of the initial examination is to detect life-threatening violations:

• intense pneumothorax,
• massive hemothorax,
• open pneumothorax,
• tamponade of the heart,
• presence of a rib valve.

[27], [28], [29], [30], [31], [32], [33]

Monitoring

• Saturation of hemoglobin with oxygen (mandatory component).
• CO2 in the final portion of the exhaled mixture (if the patient is intubated).

Interventions

• Drainage of the pleural cavity.
• Thoracotomy.

Detailed inspection

A fuller examination is performed to diagnose all lesions and plan further treatment. During the inspection determine:

• rib fractures and rib valve,
• a bruise of the lungs, a clinical manifestation of which is possible in 24-72 h,
• pneumothorax,
• hemothorax,
• damage to the aorta,
• heart contusion.

[34], [35], [36], [37], [38], [39], [40]

Physical examination

With the proper organization of the examination and certain skills, a physical examination takes about 5 minutes.

On examination, pay attention to:

• Cyanosis is a sign of increasing hypoxemia due to respiratory failure. If the cyanotic color is only the face, neck and upper half of the chest ("decollete"), it is necessary to suspect a traumatic asphyxia that occurs when the chest is squeezed. It is characterized by pinpoint hemorrhages in the skin, mucous.
• Self-breathing - presence or absence, intercostal occlusion during inhalation (respiratory failure, airway obstruction), paradoxical breathing (final fracture of ribs with flotation of the thoracic wall), unilateral respiratory movements (rupture of the bronchus, pneumothorax, unilateral hemothorax), stridor (damage to the upper respiratory tract).
• Swelling of soft tissues, especially the eyelids and necks (subcutaneous emphysema) is a sign of damage to the lung or the main bronchus.
• Pay attention to unusual breathing noises, stridor, "sucking" wounds of the chest wall.
• When penetrating wounds necessarily examine the front and back surfaces of the trunk (on the back can be located outlet).

When palpation:

• Determine the deviation of the trachea.
• Evaluate the even participation of the chest in the act of breathing.
• Diagnose the soreness of the chest wall (sometimes broken ribs).
• Determine the presence of subcutaneous emphysema ("crunch of snow").

With auscultation:

• Assess the conduct of auscultatory respiratory noise during the act of breathing.
• Determine the performance of respiratory noise and their characteristics at all points of listening (it is considered the maximum diagnostic value with the correct auscultation).

With percussion:

• When percussion from both sides of the chest, dulling or resonance can be detected (when the study is performed in a noisy room, the results may be distorted).

Data of a classical lung examination

Syndrome	Trachea	Border	Auscultation	Percussion
Stressed pneumothorax	Displaced	Decreased Chest can be fixed in a state of	Noise is weak or absent	Dullness and tympanic sound
Hemotorax	Middle line	Decreased	Noise reduction at large and normal with moderate	Blunting, especially on the basal surface
Contusion of the lung	Middle line	Normal	Normal noise can have crepitus	Normal
Collapse of the lung	Toward a collapsed light	Decreased	Most likely reduced	Tympanic sound
Simple pneumothorax	Middle line	Decreased	Can be relaxed	Tympanic sound

Laboratory research

• A general blood test (hematocrit, hemoglobin, leukocytes counting the formula).
• COC, gas composition of blood (oxygenation index, CO2 content).
• For intubated victims - control of CO2 in the exhaled air.

Instrumental research

Perform a chest radiograph (if the patient's condition allows) in two projections and preferably in an upright position.

Conduct ultrasound (you can find hemo-, hydrothorax with a quantitative evaluation of the value and determination of the point of puncture).

The most promising methods are (not excluding the above methods and methods, but only complementing them):

• spectral analysis of auscultative phenomena (does not replace traditional auscultation),
• CT with the use of electron beam (Electron beam computer tomography), which makes it possible to assess pulmonary perfusion,
• computer evaluation of pulmonary perfusion using computer rheography,
• evaluation of pulmonary hemodynamics by the invasive method using the PICCO method.

Indications for consultation of other specialists

For successful therapeutic and diagnostic tactics, the joint work of the teams of resuscitation, thoracic and abdominal surgery departments, as well as diagnostic units (ultrasound, CT, angiosurgery, endoscopic surgeries) is necessary. Thus, in the treatment of breast trauma, an integrated approach is needed with the predominance of intensive care tactics.

Treatment of breast trauma

Treatment of breast trauma begins immediately in accordance with the general principles of intensive care (infusion therapy with reliable vascular access, recovery of airway patency, stabilization of hemodynamics). Associated lesions, of which fractures are most often met, head and abdominal injuries, are of a combined nature and are more dangerous than a chest trauma. Therefore, from the outset, it is necessary to determine priorities in the tactics of treatment.

After the resuscitation (if they are needed) and the diagnosis are determined the tactics of treatment. There are three possible options for therapeutic tactics for chest injuries - conservative therapy, drainage of the pleural cavity and surgery. In most cases, with closed trauma and penetrating wounds of the chest, conservative treatment (up to 80% according to the literature) separately or in combination with the installation of drains is sufficient. The number of emergency surgeries in the volume of thoracotomy does not exceed 5%

Medication

According to the systematic review of the Eastern Association for the Surgery of Trauma, a meta-analysis of 91 sources, Medline, Embase, Pubmed, and data of the Cochrane community for the period from 1966 to 2005, results were published in June 2006.

Level of Evidence I

• No sources of information were found that met this criterion.

Level of Evidence II

• Victims with a chest injury (bruised) of the lung are supported by a proper vollemic status. For the purpose of correct volemic load it is recommended to use the Swan-Hans catheter for invasive hemodynamics monitoring.
• The use of anesthesia and physiotherapy reduces the likelihood of respiratory failure and subsequent prolonged ventilation. Epidural analgesia is an adequate way of providing anesthesia in case of severe trauma.
• Respiratory support to victims is carried out with the obligatory condition of using a respirator in the shortest possible time, PEEP / CPAP should be included in the ventilation protocol.
• Steroids should not be used in the treatment of lung contusion.

Level of Evidence III

• The use of non-invasive masked auxiliary ventilation in the CPAP regime is the method of choice for those affected in consciousness with severe respiratory failure.
• One-lung ventilation is used for severe unilateral lung contusion, when it is impossible to eliminate bypass surgery in another way, because of the pronounced uneven ventilation.
• Diuretics (furosemide) are used to achieve the necessary vollemic status under the control of DZLK.
• Indications for carrying out respiratory therapy are not the trauma itself, but arterial hypoxemia due to respiratory failure.

The main components of treatment for victims with trauma to the chest

• Analgesia and analgesics. Inadequate anesthesia often leads (up to 65% in the elderly) to the development of pulmonary complications, while the lethality can reach 15%. For adequate analgesia, if there are no contraindications, perform epidural analgesia (level of evidence I). Its use reduces the hospital bed-day (level of evidence: II). Some sources (level of evidence I) indicate that paravertebral blockades and extrapleural analgesia reduce the subjective perception of pain and improve lung function (level of evidence II). With combined use of epidural analgesia and intravenous injection of narcotic drugs (fentanyl, morphine), maximum analgesia is achieved. Reducing the dose by the type of synergism reduces the severity of side effects of each drug (level of evidence II),
• Anxiolytics (benzodiazepines, haloperidol) have limited application. Assign with anxiety, development of psychotic conditions. The use is predetermined by the protocol of sedation and analgesia in patients in the ICU,
• antibacterial drugs,
• muscle relaxants are prescribed in situations where relaxation is necessary on the background of sedation to ensure adequate ventilation (medications are recommended by muscle relaxants of nondepolarizing action),
• respiratory therapy. There are no advantages to the choice of a particular mode of ventilation in patients with thoracic trauma, with the exception of the ARDS network study in the development of ARDS (see annex). In patients with this category of hypovolemia, the use of high PEER levels is not recommended (level D). Other methods of correction of gas exchange (prone position) have limited application, especially in patients with unstable thorax.

Other groups of drugs are used for symptomatic therapy. It should be noted that many of the drugs traditionally used have not proven to be effective in research.

The question regarding the timing of tracheostomy and indications for its performance in different categories of victims with a chest trauma has not been resolved.

Recommendations for antibacterial therapy (The EAST Practice Management Guidelines Work Group)

A Level I

According to the available evidence (Class I and II), data are recommended for pre-operative prophylaxis with antibacterial drugs with a wide spectrum (for aerobes and anaerobes) as a standard for victims with penetrating injuries. In the absence of damage to the internal organs, there is no need for further administration of the drugs.

In Level II

According to the available evidence (Class I and II), the data are recommended for prophylactic administration of antibacterial drugs for various injuries of the internal organs within 24 hours.

Class I is a prospective, randomized, double-blind study. Class II is a prospective, randomized, uncontrolled study. Class III retrospective study of clinical cases or meta-analysis.

C Level III

There are insufficient informative clinical studies to develop principles for reducing the risk of infection in patients with hemorrhagic shock. Because of the vasospasm, the normal distribution of antibiotics changes, which reduces their penetration into the tissues. To solve this problem, it is suggested to increase the dose of an antibiotic 2-3 times before stopping the bleeding. When hemostasis is achieved, antibacterial agents with high activity are selected for facultative anaerobic bacteria for a certain period, depending on the degree of infection of the wound. For this purpose aminoglycosides are used, showing suboptimal activity in victims with severe trauma, which is probably due to the pharmokinetics of the drug.

Anesthetics

Anesthesiologic allowance is performed according to all the rules of anesthesiology, observing the criteria of safety and effectiveness. It is recommended to install the epidural catheter at the required level (depending on the lesion) for subsequent analgesia in the postoperative period.

[41], [42], [43], [44], [45], [46], [47], [48], [49], [50], [51]

Surgical treatment of breast trauma

Selecting operational access

With damage to the heart and trunk vessels, longitudinal sternotomy is performed. Convenient and left-sided anterolateral access, the incision is made in the fourth to fifth intercostal space and (if necessary) widened laterally. However, with such access, the approach to the mouth of the main vessels is difficult. If the brachiocephalic trunk is damaged, sternotomy is produced with a transition to the neck along the sternocleidomastoid muscle or clavicle. With unilateral total hemothorax, an anterolateral or posterolateral thoracotomy is used on the side of the lesion. With right-sided hemothorax, the position of the patient on the back is preferred, since in the position on the left side of the CPR, if necessary, it is extremely difficult. Optimal access to the thoracic aorta is a left-sided posterolateral thoracotomy in the fourth intercostal space (the aortic arch is usually located here). If damage to the spine is not excluded, front access is used, and for the detection of the thoracic aorta, the apex of the lung is diverted or a single-lumen endotracheal tube with bronchial blocker is used, which can be used as a large diameter Fogarty catheter.

If suspicion of hemopericardia is performed, diagnostic subxyfoid pericardiotomy (either as an independent intervention or during surgery on the abdominal organs). Above the xiphoid process, a skin incision is made 5-7.5 cm long and the aponeurosis is cut through the white abdominal line. The xiphoid process is excised, the mediastinal tissues are bluntly peeled, the pericardium is exposed and dissected. When blood is detected in the pericardial cavity, sternotomy is performed, hemorrhage is stopped, the wound of the heart or trunk vessel is sutured. All this must be taken into account when preparing for surgery. Subxyfoidal access is used only for diagnostic purposes, it is not used for specialized operations.

Indication for surgical intervention:

Indications for surgery for chest injuries:

• cardiac tamponade,
• an extensive gaping wound of the chest wall,
• penetrating wounds of the anterior and superior mediastinum,
• a through wound of the mediastinum,
• continuing or profuse bleeding into the pleural cavity (discharge of blood by drainage),
• drainage of a large amount of air,
• a rupture of the trachea or major bronchus,
• rupture of the diaphragm,
• aortic rupture,
• perforation of the esophagus,
• foreign bodies of the chest cavity.

Life-threatening conditions, encountered with chest injuries, which require urgent care:

• Tamponade of the heart as a result of bleeding into the pericardial cavity (injury, rupture or bruise of the heart, damage to the mouth of the main vessel).
• Total hemothorax (damage to the heart or lung, rupture of the main vessel, bleeding from the intercostal vessels, abdominal trauma with damage to the diaphragm and bleeding into the pleural cavity).
• Tense pneumothorax (rupture of the lung, extensive damage to the bronchi, damage to the trachea).
• Rupture of the aorta or its major branch (blunt trauma as a result of a stroke with severe inhibition, less often penetrating chest injury).
• The final fracture of the ribs (or fracture of the ribs and sternum) with flotation of the chest wall (often accompanied by respiratory failure and hemothorax).
• Rupture of the diaphragm (blunt trauma is often accompanied by extensive rupture of the diaphragm with abdominal cavity falling into the thoracic cavity and respiratory disturbances).

Prevention of pulmonary complications (pneumonia and atelectasis)

The goal is to ensure that the airways are passable from sputum and deep breathing. Perform sputum aspirate through the tracheal tube, percussion and vibrating massage, postural drainage, spirotrenazher. Assign breathing with moistened oxygen (ultrasonic nebulizers), adequate anesthesia (see above in this section). All these activities are considered not mutually exclusive, but complementary. In the sanitation of the respiratory tract from sputum and blood after an injury, bronchoscopy can be of considerable help.

Forecast of a chest injury

According to the world data, the prognostic level is considered to be the level of scores on the TRISS scale. The degree of disability, the duration of the bed-day will be determined directly by the nature of the injury and the development of complications, both pulmonary and extrapulmonary. Conducting adequate and timely therapy is the key to successful treatment of this category of victims.

[52], [53], [54], [55]