Lecture By: DR. TAREK SILEM AL-NOGOMI Emergency Specialist General Surgery Acting Consultant

1. ER APPROACH TO A PATIENT WITH CHEST
EMERGENCIES
DR. TAREK SILEM AL-NOGOMI
Emergency Specialist
General Surgery Acting Consultant

2. CHEST TRAUMA
Chest trauma

3. This study includes all polytrauma patients
with chest injury treated between 1992 and 2002
at a major urban trauma center
Department of Traumatology, Medical
University of Vienna, Vienna, Austria
May 2005

4. 332 out of 501 polytrauma patients, 228 males and 104
females, had a coexisting chest injury. Mean age at the
time of injury was 37.7 years, and 258 patients were
intubated before admission. Average period on ICU was
15.4 days, and 35.9 days for total hospital stay. Regarding
the injury pattern in 143 patients a combined
hemo-/pneumothorax was seen, 109 patients had either a
hemothorax or a pneumothorax, in 155 patients a
unilateral and in 52 patients a bilateral serial rib fracture
was diagnosed, in 28 patients either sternal or singular rib
fractures were determined, in a total of 23 patients an
unstable thorax or a flail chest was seen, 105 patients had
a unilateral pulmonary contusion, and in 79 patients a
bilateral pulmonary contusion was diagnosed. Finally, a
total of eleven patients with a traumatic aortic disruption
were identified

6. Who Survive
85% Need conservative treatment
& or simple maneuvers
15% will need surgery

7. Types of Injury
Direct … blunt … penetrating … cruch •
•
Indirect … blast … deceleration •

11. TRAUMATIC CHEST PROBLEM
THREATENING LIFE NEEDS
IMMEDIATE MANAGEMENT
– ABCD
Dyspnea, tachypnea, hypotension,
ABG changes
Expose chest and neck completely,
observe, palpate and listen.
Cyanosis is a late symptom of
hypoxia.

12. ?? VITAL SIGNS
Hemodynamically instability
associated with chest
trauma represent
A life-threatening
emergency.

13. O2 INHALATION
ABG , if patient is desaturated.

14. SELECTIVE PHYSICAL
EXAMINATION
Pulse evaluation, regular, irregular, strong or
weak.
Neck, congested neck veins.
Heart sound .
Respirations … one side dullness or Hyper
resonance by percussion.

16. Trauma
Dysnea …. Desaturation

24. (TENSION PNEUMOTHORAX (TN
One way valve air leak occurs from lung or from
chest wall – complete collapse of lung, mediastinal
displacement to opposite sides compressing the
opposite lung with low venous rectum.
1. Penetrating chest trauma
2. Blunt chest trauma
3. Marked displaced thoracic spine fractures.
TN is a clinical diagnosis and treated without waiting
any investigation.
Patient with chest pain, tachypnea, tachycardia,
distended vein, absent breath sound affected side.
Hyper resonance to percussion.
Immediate decompression with second intercostals
space mid clavicular line needle no. 14 and then
ICT 5th ICS (nipple level) ant. to midaxillary line.

27. OPEN PNEUMOTHORAX
Large defect of chest wall.
If defect is 2/3, the diameter of
trachea, air passes through chest
wall with each respiration so
effective ventilation is impaired
with hypoxia and hypercarbia.

28. MANAGEMENT
Closing the defect with sterile
adhesive dressing taped on
three sides, then ICT &
surgical closure of the defect.

35. FLAIL CHEST
Two or more ribs fractured in two or more places.
Paradoxical movement will follow. This alone does not
cause hypoxia, but pain and underlying lung contusion.
Diagnosed by paradoxical movement ± palpation of
abnormal respiratory motion and crepitous of ribs or
cartilage fracture.
CXR (Multiple fracture ribs)
ABG
– Analgesics
– Adequate ventilation with humidified oxygen.
– Fluid resuscitation if hypotension.
Short period of intubation and ventilation may be
necessary.

46. MASSIVE HEMOTHORAX
Hypotension with the affected side
dullness to percussion.
Criteria:
- More than (1-1.5L) of blood
when inserting ICT.
- Continuing blood loss 200 ml/
hour for 2 – 4 hours.

47. MANAGEMENT
o ICT no. 38 F
o Management of hypovolemia
o Consider for thoracotomy

56. CXR - widening of upper
mediastinum and distortion of
aortic knuckles (60%).
Left side pleural effusion is
common.
CT scan is very helpful in
diagnosis.

57. Normal ECG

59. o Congested neck veins
o Decline in arterial pressure
o Muffled heart sounds
o Patient not respond to unusual measures of
resuscitation.
o Kussmaul’s sign
o PEA in the absence of hypovolemia and TN.
o

60. Echocardiogram (false
negative in 5%)
If monitor shows premature
ventricular contraction.
( Common dysrhythmia to
myocardial injury.)
Lidocaine bolus 1 mg/kg,
followed by lidocaine drip 2-4
mg/min.

62. CARDIAC TAMPONADE
Common in penetrating injuries
but may occur with blunt trauma.
Removal of as little as 15-20 ml by
pericardiocentesis, may result in
immediate hemodynamic
improvement.

63. INDICATION THORACOTOMY
1. Cardiac arrest or PEA in
hypovolemic patient with
penetrating chest trauma
(resuscitative thoracotomy).
2. Massive hemothorax
3. Penetrating chest trauma
anteriorly medial to the nipple line
and posteriorly medial to the
scapula with hypotension.

67. Tension pneumothorax
Open pneumothorax
Flail chest
Hemothorax
Cardiac tamponade

69. ‫) ومن يتقايجعل له مخرجا ويرزقه من‬
‫حيث ليحتسب ( صدقا م‬
‫العظي‬
AND WHOSOEVER FEARS ALLAH AND KEEPS
HIS DUTY TO HIM , GOD WILL MAKE A WAY
FOR HIM TO GET OUT (from ever difficulty).
AND WILL PROVIDE ( HIM l HER ) FROM
(SOURCES ) HE l SHE NEVER COULD
IMAGINE.
( THE NOBLE QURAN )