Oct. 29th & Nov. 19th, 2011

1. Thoracic
Trauma
By
Doctor Aram Baram

2. Thoracic Trauma
• Thoracic trauma is responsible for more than 25% of
trauma deaths.
• Blunt trauma accounts for 70% of chest injuries and more
than 70% of these injuries result from Motor Vehicle
Accidents.
•
• Penetrating injuries: 60 to 70% are due to stab wounds.
• Chest wall and soft tissue are the most common locations
for both blunt and penetrating trauma.
• Less than 10% of blunt injuries and only 15 to 30% of
penetrating injuries require thoracotomy
• One in four cases with cardiothoracic trauma,
regardless of etiology, requires hospital admission. 2

3. Types
•Blunt 70% of chest injuries
• Penetrating 60 to 70% are due
to stab wounds.
3

4. Penetrating Trauma
• Injuries are uncommon in either elderly or pediatric
patients, but they remain one of the most common
causes of death from trauma in persons up to 40 years
of age.
• Low-velocity handguns, seen primarily in the civilian
population, transmit very little damage to surrounding
tissues.
• Conversely, much more damage and energy is
conducted along the path of high-velocity missiles,
usually associated with the military, but now often
seen in violent assaults as well.
4

5. Blunt Trauma
Accounts for 70% of chest injuries and more
than 70% of these injuries result from Motor
Vehicle Accidents.
Less than 10% of blunt injuries and
only 15 to 30% of penetrating
injuries require thoracotomy
5

6. Initial Assessment and Management
Primary survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care
6

7. Pathophysiology of Chest Trauma
Is the derrangement in normal flow of air
and blood
hypovolemia
ventilation-
perfusion Inadequate oxygen
mismatch delivery to tissues
changes in
intrathoracic
pressure TISSUE
relationships HYPOXIA
7

8. THE PRIMARY SURVEY
Rapid and thorough performance of the “ABCs” is the standard.
This begins with traditional resuscitation as outlined by the American College
of Surgeons in the Advanced Trauma Life Support guidelines.
The airway must be controlled and breathing assessed and established
immediately if necessary.
Circulation must be supported through rapid establishment of reliable, large-
bore venous access and the initiation of fluid resuscitation.
The primary survey is performed to search for immediate life-threatening
injuries that could account for ventilation or hemodynamic instabilities,
which, if left uncorrected, could cause the acute demise of the patient.
These life-threatening injuries are listed in the table below:
8

9. Injuries Management
Tension pneumothorax Tube thoracostomy
Massive haemothorax Tube thoracostomy operative repair
Cardiac tamponade Pericardiocentesis operative repair
Deceleration aortic injury Operative repair
Massive flail chest with pulmonary
Intubation, pain control, fluid restriction
contusion
Upper and lower airway obstruction Intubation, airway, bronchoscopy
Tracheobronchial rupture Bronchoscopy, operative repair
Diaphragmatic rupture with visceral
Operative repair
herniation
Esophageal perforation Operative repair
9

10. The presentation depends on the mechanism of injury
and the organ systems injured.
• Thoraco-abdominal
injury
• Any wound below
nipples in front and
• Inferior scapula
angles dorsally
•Any penetrating wound such as this should be considered
to have an abdominal component until proven otherwise.
10

11. Diagnosing Thoracic Injuries
• The time of injury, mechanism of injury,
estimates of MVA velocity and deceleration,
and evidence of associated injury to other
systems (eg, loss of consciousness) are all
salient features of an adequate clinical history.
• Information should be obtained directly from
the patient whenever possible and from other
witnesses to the accident if available.
11

12. Inspection
• Chest Wall: look for signs of injury such as wounds
(sucking), contusions, abnormal movement (flail chest),
swellings, cyanosis, pallor, types of respiration…
• Neck: distended neck veins, subcutaneous
emphysema, swelling and cyanosis.
• Abdomen: scaphoid abdomen(diaphragmatic rupture)
or rocking horse ventilation(high cord injury).
Never forget the back
12

13. Physical Exam
• General examination: PR, RR, BP
• Palpation: tracheal position, tenderness, or
crepitus (surgical emphysema).
• Percussion: dullness for hemothorax and
hyperresonance for pneumothorax
• Auscultation: Equal breath sounds & air entry,
heart sounds, bowel sounds high in chest.
13

14. Imaging studies
• The chest radiograph (CXR) (PA& Lateral):
• ECG
• Focused Assessment for the Sonographic Examination
of the Trauma Patient (FAST).
• Chest CT scan
• Transthoracic echocardiography (TTE)
14

15. Angiography
Angiography remains the gold standard in the diagnosis of aortic transection or injuries to the
great vessels. Indications for Angiographic Studies for Potential Thoracic Injuries are:
1) High-speed deceleration injuries
2) Chest X-ray findings:
Widened mediastinum
Loss of aortic knob shadow
Tracheal or esophageal deviation to the right
Widening of paraspinal stripe and/or apical capping
Downward displacement of left mainstem bronchus
Obliteration of the aortopulmonary window
3) Fractured first rib, sternum, or scapula
4) Multiple rib fractures or flail chest
5) Massive hemothorax
6) Upper extremity hypertension
7) Unexplained hypotension
8) Pulse deficits or asymmetry
9) Systolic murmur
15

16. Pericadiocentesis:
Performed in the resuscitative
phase as a diagnostic or at
best a temporising modality
in cardiac tamponade.
Pericardiocentesis cannot be
relied on to diagnose cardiac
injuries in a trauma setting
because of high false positive
and false negative (10 to 20%)
rates. 16

17. Lab studies
• Blood type and cross match
• Arterial blood gas:
Arterial blood gas (ABG) analysis, though not as important in the initial assessme
of trauma victims, is important in their subsequent management.
• Serum chemistry profile: Urea , createnin, K,Na, Ca,…etc.
• Coagulation profile
The coagulation profile, including prothrombin time/activated partial
thromboplastin time, fibrinogen, fibrin degradation product, and D-dimer
analyses, can be helpful in the management of patients who receive massive
transfusions (eg, >10 U packed RBCs).
• Serum troponin levels
• Serum myocardial muscle creatine kinase isoenzyme levels.
• Serum lactate levels
17

18. Primary Survey
• Airway
• Breathing
• Circulation
18

19. Management
• Initial management
As always in trauma, management begins with establishing ABCs.
• Indications for emergency endotracheal intubation include apnea,
profound shock, and inadequate ventilation.
• Chest radiography is not indicated in patients with clinical signs of a
tension pneumothorax, and immediate chest decompression is
accomplished with either a large-bore needle at the second intercostal
space or, more definitively, with a tube thoracostomy.
• A sucking chest wound must be appropriately covered to permit
adequate ventilation and to prevent the iatrogenic development of a
tension pneumothorax.
19

20. Initial assessment and management
• Hypoxia is most serious problem - early
interventions aimed at reversing
• Immediate life-threatening injuries treated
quickly and simply - usually with a tube or a
needle
• Secondary survey guided by high suspicion for
specific injuries
20

21. SPECIFIC INJUERIES:
A. Chest wall Injuries
• 1. Fracture Ribs
• Fracture of the ribs is the most common blunt thoracic injury,
occurring in an estimated 39% of patients.
• Rib fractures represent an important indicator of trauma
severity. In general, the greater the number of ribs fractured,
the higher the patient’s morbidity and mortality.
• The number of ribs fractured has been significantly correlated
with the presence of hemothorax or pneumothorax, with
81% of patients having either condition if two or more ribs
were fractured.
• Fractures of the fourth through the ninth rib are associated
with injuries to the lung, bronchus, pleura, and heart,
whereas fractures below the ninth rib are indicative of
spleen, hepatic, or renal injuries.
21

22. Symptoms
• The main symptoms include pain, tenderness, and
possibly crepitus.
• An upright chest X-ray is the standard way to diagnose
fractures.
• After adjusting for severity of injury, comorbidity, and
presence of multiple rib fractures, elderly patients (>65
years old) with simple rib fractures still were five times
more likely to die compared with patients under age
65.
• First rib fracture has particular significance because of
the great force required for it to occur and the
likelihood that intrathoracic visceral injury also has
taken place
22

23. Treatment
• Once a haemopneumothorax and major skeletal
injuries are excluded, the management is mainly
for control of chest pain by
• Nalgesics mostly NSAIDS,
• intercostals blocks by local anesthesia, T.E.N.S
may be useful.
• Chest strapping or bed rest is no longer advised
and early ambulation with vigorous
physiotherapy (and oral antibiotics if necessary)
is encouraged
23

24. Flail Chest
• Free floating segment of ribs.
– 3 or more rib fractures broken in 2 places.
• Look for paradoxical chest wall motion
– Inhaleinward
– Exhaleoutward
• Decreased air entry.
24

25. Types of flail chest
• Anterior: Bilateral anterior fractures with
bilateral costochondral separation (15%) or
fractures of sternum with associated
costochondral separation (7%).
• Lateral: Multiple fractures on the same side
with or without costochondral separation
(73%) or fractures of several ribs with two or
more fracture points on the same side (5%).
25

26. Treatment:
• Approximately 50% of patients with flail chest can be managed without
mechanical ventilation with the use of epidural analgesia, chest
physiotherapy, bronchoscopy for mucus plugs, bronchodilators and
mucolytic agents and supplemental oxygen.
• Mechanical ventilation is used when signs of progressive hypoxia not
responding to simple oxygen therapy.
• In the more severe case, endotracheal intubation is required with
positive-pressure ventilation for up to 3 weeks, until the frac-tures
become less mobile.
• Thoracotomy with fracture fixation is occasionally appropriate if there is
an underlying lung injury to be treated at the same time.
• An anterior flail segment with the sternum moving paradoxically with
respiration can be stabilised by internal fixation but operative
management is not usual for either.
26

27. Sternal Fractures
• Most often in MVA.
• Incidence 3%.
• Normal vitals and normal EKG. Repeat EKG in
6 hrs and D/C if unchanged.
• Practice varies between institutions.
27

28. Subcutaneous Emphysema
• Air leak from lung parenchyma, or
tracheobronchial tree.
• Interstitial lung injury through hilum and
mediastinum.
• If extensive then suspect injury to
pharynx, larynx, or esophagus.
• Should be assumed that pt has
pneumothorax even if not visible on
chest x-ray.
28

29. Thanks for your
Attention
29

30. Traumatic Pneumothorax
• Traumatic injury causes
laceration of the lung
parenchyma &/or
tracheobronchial tree and
air enters the pleural
space.
• Negative pressure in
pleural space facilitates air
escape
30

31. Traumatic Pneumothorax
Trauma
Simple Open or sucking Tension
pneumothorax. pneumothorax. pneumothorax.

32. Simple Pneumothorax
• Clinically the breath sounds are
decreased on the affected side
with a hyper resonant percussion
note.
• An erect CXR aids the diagnosis.
• Pneumothoraces <2cm from the
inner rib surface could observed
• If these patients decompensate,
or if pneumothorax enlarges or if
the patient needs ventilation,
tube thoracostomy should be
performed.

33. Tension Pneumothorax
• Develops when a "one way
valve" air leak occurs either
from the lung or through the
chest wall (Sucking wound).
• The mediastinum is displaced
to the opposite side leading to
decrease venous return and
compression of the opposite
lung and impaired ventilation
and end with circulatory
collaps.
• This is a clinical diagnosis and
treatment should not be
delayed by waiting for
radiologic confirmation.

34. Inferior vena cava
34

35. Tension Pneumothorax
Tension pneumothorax is
characterised by
† air hunger,
† respiratory distress,
† tachycardia,
† hypotension,
† tracheal deviation to the
opposite side of injury,
† unilateral absence of breath Tension pneumothorax requires immediate
sounds, decompression and is managed initially by
† neck vein distention and rapid insertion of a large bore needle into the
2nd intercoastal space in the mid-clavicular
† cyanosis as a late line.
manifestation. Definitive treatment is tube thoracostomy via
a chest tube inserted in the safety triangle.

36. Chest Tube
Insertion:
should be in the “safe
triangle” is the triangle
bordered by the anterior
border of the latissimus
dorsi, the lateral border of
the pectoralis major muscle,
a line superior to the
horizontal level of the
nipple, and an apex below
the axilla.
36

37. Open Pneumothorax
A: Inspiration
Seen in patients with large chest wall
defects (Sucking wound), where the
area of the defect is 2/3 that of
tracheal diameter or is larger than the
area of glottic opening.
Air passes preferentially through the
chest defect with each respiratory
effort because air tends to follow the
path of least resistance through the
large chest wall defect.
B:Experation

38. Open Pneumothorax
38

39. Haemothorax
 Haemothorax is a collection of blood in the
pleural space and may be caused by blunt
or penetrating trauma.
 Most haemothoraces are the result of rib
fractures, lung parenchymal and minor
venous injuries, and as such are self-
limiting.
 Less commonly there is an arterial injury
(intercostal or internal mammary vessels)
which is more likely to require surgical
repair. 39

40. Haemothorax
• Diagnosis is made on clinical examination by the
decreased breath sounds and dullness to
percussion on affected side.
• Confirmation is by CXR which shows complete or
partial opacification of the affected side.
• Chest tube thoracostomy is performed in the
safety triangle for haemothorax by wide-bore
tube (> 28French).
• Bleeding is classified as minimal (<350 ml),
moderate (350 to 500ml)
massive (>1500 ml).

41. Massive Hemothorax
• Each hemithorax can hold 40-50% of blood
volume.
• Defined: 1500 mL or more intial drainge.
• Cause: Injury to lung parenchyma, intercostal
artery or internal mammary artery
41

42. Which exam to request?
Hematological: To detecte
blood loss
Chest x-ray:
• Upright film (PA & Lat):
200-300 mL of blood.
• Supine film: >1000mL of
blood
42

43. Management
Chet tube : In 85% of the patients, > 32F
About 5-15% of pts admitted with chest
trauma require thorocotomy.
Indications of Thoracotomy:
1) The initial blood drainage is >1500ml.
2) When bleeding persists at a rate of 200
to 300ml per hour over 3 to 4 hours.
3) When there is haemodynamic
instability. 43

44. Pulmonary Contusion
• Occurs in 50 to 60% of patients with blunt trauma.
• Intrusion of ribs after frontal or lateral impact can cause direct damage injury to alveolar
lining, capillaries and lung parenchyma cause hemorrhage and cellular disruption.
• Grossly involved lung becomes hemorrhagic consolidated and oedematous irregular
patches.
• The resulting hypoxemia occurs 24 to 36 hours after injury.
• Localised contusion usually resolves without major sequelae. This process usually takes 10
to 14 days.
• Alternatively this may progress to varying degrees of ARDS in some patients.
Treatment:
• Supplement oxygen.
• Chest physiotherapy.
• Bronchodilators and mucolytics.
• Limit fluid administration.
• Steroids - use controversial.
• Antibiotics also controversial.
• Mechanical ventilation if indicated.
• Analgesics are strongly indicated

45. Diaphragmatic rupture
• The mechanism for diaphragmatic rupture is high-
speed blunt abdominal trauma with a closed glottis.
• The incidence is 1-3% of all chest trauma cases.
• The sudden rise in intra-abdominal pressure breaches
the weakest part of the abdominal wall, namely the
diaphragm.
• The injury to left diaphragm is 4 times commoner than
the right due to protection afforded by the liver on the
right.

46. Diaphragmatic rupture
• Bowel sounds may be heard in the chest and the chest
radiograph may reveal bowel gas in the lung fields.
• A plain chest x-ray with a NG tube in the stomach can
confirm the diagnosis or a contrast study.
• But if the patient has signs of acute abdomen the
repair to be by a laperatomy to deal with any intra-
abdominal injuries.
• Whilst chronic injuries (more than one month) should
be approached through the chest due to adhesions.

47. Oesophageal injury
• It should be noted whether the presentation after
injury is delayed >24hours as this affects
management.
• The majority of cases occur in the cervical region.
• The clinical suspicion is heightened by the
association of fever, pain in the neck and
tachycardia (Makler’s triad), crepitus and a
“mediastinal crunch” may be heard on
auscultation.
• Contrast radiography could be performed by
Gastrografine.

48. Management
Early diagnosis :
An NG tube should be passed and IV prophylactic antibiotics
started. A right sided thoracotomy is used for the middle 1/3
oesophageal injury. The lower 1/3 is better approached via the
left side of the chest.
Delayed presentation:
Primary closure is often not possible due to florid sepsis. Options
open to a surgeon are:
• Tube drainage and oesophageal suction
• T-tube insertion in perforation
• Cervical oesophagostomy and distal ligation
• Oesophageal resection
The mortality for delayed presentation is +/-25%

49. Cardiac Tamponade
• Is impairment of ventricular filling due to
increased intrapericardial pressure due an
increase in the intrapericardial content such
as blood and/or effusions.
• Unless recognized and treated promptly
cardiac tamponade can be fatal.
• The pericardial space normally contains 20-50
mL of fluid.

50. Cardiac Tamponade
• Rapid accumulation of as little as 150 mL of
fluid can result in a marked increase in
pericardial pressure and can severely impede
cardiac output.
• Approximately 2% of penetrating injuries are
reported to result in cardiac tamponade

51. Diagnosis
• Beck’s Triad: (hypotension, jugular venous
distention, and muffled heart sounds) occurs in
only 10% to 40% of patients.
• Pulsus paradoxus also paradoxic pulse This is an
exaggeration (>12 mm Hg or 9%) of the normal
inspiratory decrease in systemic blood pressure..
• Kussmaul’s sign, or paradoxical inspiratory
distention of neck veins upon expiration, is
another classic sign attributed to pericardial
tamponade.
• FAST is rapid and accurate method of diagnosis

52. Cardiac Tamponade
• A clinical syndrome caused by the accumulation of
fluid in the pericardial space, resulting in reduced
ventricular filling and subsequent hemodynamic
compromise.
• The overall risk of death depends on the speed of
diagnosis, the treatment provided, and the
underlying cause of the tamponade.
52

53. Cardiac Tamponade
• Caused by blunt and penetrating trauma.
• Stab wounds to midchest most common cause.
• Pericardial sack has poor compliance.
• Normally it contains 20-50 mL of fluid.
Only 150-200 mL can result in tamponade.
53

54. Cardiac Tamponade
• History:
• Symptoms vary with the underlying cause and
the acuteness of the tamponade.
• Patients with acute tamponade may present
with dyspnea, tachycardia, and tachypnea.
• Cold and clammy extremities from
hypoperfusion are also observed in some
patients.
54

55. Treatment
• Pericardiocentesis or
• Subxiphoid
pericardiotomy or
• Left anterior thoracotomy

56. Pericardiocentesis
• Paraxiphoid approach
• Can direct needle toward
left scapula or right scapula
(less likely to damage
ventricle).
• Up and back at 45 degrees
for 4-5 cm.
• Aspirate every 1-2mm.
• Removal of 5-10 mL can
increase stroke volume by
25-50%. 56

57. COMPLICATIONS OF THORACIC TRAUMA
Pulmonary Pleural Space Vascular
Atelectasis Empyema Thromboembolism
Acute respiratory Bronchopleural Air embolism
distress fistula
syndrome/acute lung
injury
Pneumonia Organized Pseudoaneurysm
hemothorax
Infarction Chylothorax Great vessel fistula
Lung abscess Fibrothorax Vascular
Arteriovenous fistula Diaphragmatic Thromboembolism
hernias
Bronchial stenosis Pleural Space Air embolism