thoracic trauma

1. Management of
Thoracic Trauma
By
Dr.Imran Sadiq

2. Introduction
• Motor Vehicle Accidents/Road Traffic Accidents are one
of the leading cause of death among young age (16---
44yrs) in KSA.
• 17 persons are died daily due to MVA in KSA.
• Thoracic Trauma accounts for 25% of deaths related to
Trauma.
• 2/3rd of these deaths occur after reaching the hospital.
• Abdominal injuries are commonly associated with
Thoracic Trauma.
• About 70% of patients of Poly Trauma have Major
Thoracic Trauma.

3. Objective of Presentation
• To provide sufficient knowledge & information
that one can recognize and manage Thoracic
Trauma effectively and efficiently to minimize
that 2/3rds of deaths that occur after reaching
the Hospital.

6. Anatomy and Physiology of the Thorax
• Thoracic Skeleton
– 12 Pair of C-shaped ribs
• Ribs 1-7: Join at sternum with cartilage end-points
• Ribs 8-10: Join sternum with combined cartilage at 7th rib
• Ribs 11-12: No anterior attachment
– Sternum
• Manubrium
– Joins to clavicle and 1st rib
– Jugular Notch
• Body
– Sternal angle (Angle of Louis)
» Junction of the manubrium with the sternal body
» Attachment of 2nd rib
• Xiphoid process
– Distal portion of sternum

8. • Diaphragm
– Muscular, dome-like structure
– Separates abdomen from the thoracic cavity
– Affixed to the lower border of the rib cage
– Central and superior margin extends to the level of the 4th
rib anteriorly and 6th rib posteriorly
– Major muscle of respiration
• Draws downward during inspiration
• Moves upward during exhalation

9. • Associated Musculature
– Shoulder girdle
– Muscles of respiration
• Diaphragm
• Intercostal muscles
– Contract to elevate the ribs and increase thoracic diameter
– Increase depth of respiration
• Sternocleidomastoid
– Raise upper rib and sternum

11. • Physiology of Respiration
– Changing pressure assists:
• Venous return to heart
• Pumping blood to systemic circulation
– Inhalation
• Diaphragm contracts and flattens
• Intercostals contract expanding ribcage
• Thorax volume increases
– Less internal pressure than atmospheric
– Air enters lungs
– Exhalation
• Musculature relaxes
• Diaphragm & intercostals return to normal
– Greater internal pressure than atmospheric
– Air exits lungs

12. • Trachea, Bronchi & Lungs
– Pleura
• Visceral Pleura
– Cover lungs
• Parietal Pleura
– Lines inside of thoracic cavity
• Pleural Space
– POTENTIAL SPACE
» Air in Space = PNEUMOTHORAX
» Blood in Space = HEMOTHORAX
– Serous (pleural) fluid within
» Lubricates & permits ease of expansion

13. • Mediastinum
– Central space within thoracic cavity
– Boundaries
• Lateral: Lungs
• Inferior: Diaphragm
• Superior: Thoracic outlet
– Structures
• Heart
• Great Vessels
• Esophagus
• Trachea
• Nerves
– Vagus
– Phrenic
• Thoracic Duct

15. • Great Vessels
– Aorta
• Fixed at three sites
– Annulus
» Attaches to heart
– Ligamentum Arteriosum
» Near bifurcation of
pulmonary artery
– Aortic hiatus
» Passes through
diaphragm
– Superior Vena Cava
– Inferior Vena Cava
– Pulmonary Arteries
– Pulmonary Veins
• Esophagus
– Enters at thoracic inlet
– Posterior to trachea
– Exits at esophageal hiatus

16. Pathophysiology of Thoracic Trauma
• Blunt Trauma
– Results from kinetic energy forces
– Subdivision Mechanisms
• Blast
– Pressure wave causes tissue disruption
– Tear blood vessels & disrupt alveolar tissue
– Disruption of tracheobronchial tree
– Traumatic diaphragm rupture
• Crush (Compression)
– Body is compressed between an object and a hard surface
– Direct injury of chest wall and internal structures
• Deceleration
– Body in motion strikes a fixed object
– Blunt trauma to chest wall
– Internal structures continue in motion
» Ligamentum Arteriosum shears aorta
– Age Factors
• Pediatric Thorax: More cartilage = Absorbs forces
• Geriatric Thorax: Calcification & osteoporosis = More fractures

18. • Penetrating Trauma
– Low Energy
• Arrows, knives, handguns
• Injury caused by direct
contact and cavitation
– High Energy
• Military, hunting rifles &
high powered hand guns
• Extensive injury due to
high pressure cavitation

19. • Penetrating Injuries (cont.)
– Shotgun
• Injury severity based upon the distance between the victim and
shotgun & caliber of shot
• Type I: >7 meters from the weapon
– Soft tissue injury
• Type II: 3-7 meters from weapon
– Penetration into deep fascia and some internal organs
• Type III: <3 meters from weapon
– Massive tissue destruction

21. • Open Pneumothorax
– Free passage of air between atmosphere and pleural space
– Air replaces lung tissue
– Mediastinum shifts to uninjured side
– Air will be drawn through wound if wound is 2/3 diameter
of the trachea or larger
– Signs & Symptoms
• Penetrating chest trauma
• Sucking chest wound
• Frothy blood at wound site
• Severe Dyspnea
• Hypovolemia

25. • Hemothorax
– Accumulation of blood in the pleural space
– Serious hemorrhage may accumulate 1,500 mL of blood
• Mortality rate of 75%
• Each side of thorax may hold up to 3,000 mL
– Blood loss in thorax causes a decrease in tidal volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax
• Hemopneumothorax

26. • Pulmonary Contusion
– Soft tissue contusion of the lung
– 30-75% of patients with significant blunt chest trauma
– Frequently associated with rib fracture
– Typical MOI
• Deceleration
– Chest impact on steering wheel
• Bullet Cavitation
– High velocity ammunition
– Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar
tissue
• Progressive deterioration of ventilatory status
– Hemoptysis typically present

27. • Myocardial Contusion
– Occurs in 76% of patients with severe blunt chest trauma
– Right Atrium and Ventricle is commonly injured
– Injury may reduce strength of cardiac contractions
• Reduced cardiac output
– Electrical Disturbances due to irritability of damaged myocardial cells
– Progressive Problems
• Hematoma
• Hemoperitoneum
• Myocardial necrosis
• Dysrhythmias
• CHF & or Cardiogenic shock

28. Myocardial Contusion Signs &
Symptoms
• Bruising of chest wall
• Tachycardia and/or irregular rhythm
• Retrosternal pain similar to MI
• Associated injuries
– Rib/Sternal fractures
• Chest pain unrelieved by oxygen
– May be relieved with rest
– THIS IS TRAUMA-RELATED PAIN
• Similar signs and symptoms of medical chest pain

29. • Pericardial Tamponade
– Restriction to cardiac filling caused by blood or other fluid
within the pericardium
– Occurs in <2% of all serious chest trauma
• However, very high mortality
– Results from tear in the coronary artery or penetration of
myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of cardiac
contractions
– Removing as little as 20 ml can provide relief

30. Pericardial Tamponade Signs &
Symptoms
• Dyspnea
• Possible cyanosis
• Beck’s Triad
– JVD
– Distant heart tones
– Hypotension or
narrowing pulse
pressure
• Weak, thready pulse
• Shock
• Kussmaul’s sign
– Decrease or absence of JVD
during inspiration
• Pulsus Paradoxus
– Drop in SBP >10 during
inspiration
– Due to increase in CO2 during
inspiration
• Electrical Alterans
– P, QRS, & T amplitude
changes in every other
cardiac cycle
• PEA

31. • Traumatic Aneurysm or Aortic Rupture
– Aorta most commonly injured in severe blunt or penetrating trauma
• 85-95% mortality
– Typically patients will survive the initial injury insult
• 30% mortality in 6 hrs
• 50% mortality in 24 hrs
• 70% mortality in 1 week
– Injury may be confined to areas of aorta attachment
– Signs & Symptoms
• Rapid and deterioration of vitals
• Pulse deficit between right and left upper or lower extremities

32. • Other Vascular Injuries
– Rupture or laceration
• Superior Vena Cava
• Inferior Vena Cava
• General Thoracic Vasculature
– Blood Localizing in Mediastinum
– Compression of:
• Great vessels
• Myocardium
• Esophagus
– General Signs & Symptoms
• Penetrating Trauma
• Hypovolemia & Shock
• Hemothorax or hemomediastinum

33. • Traumatic Esophageal Rupture
– Rare complication of blunt thoracic trauma
– 30% mortality
– Contents in esophagus/stomach may move into
mediastinum
• Serious Infection occurs
• Chemical irritation
• Damage to mediastinal structures
• Air enters mediastinum
– Subcutaneous emphysema and penetrating trauma
present

34. • Tracheobronchial Injury
– MOI
• Blunt trauma
• Penetrating trauma
– 50% of patients with injury die within 1 hr of injury
– Disruption can occur anywhere in tracheobronchial tree
– Signs & Symptoms
• Dyspnea
• Cyanosis
• Hemoptysis
• Massive subcutaneous emphysema
• Suspect/Evaluate for other closed chest trauma

35. Traumatic Asphyxia
• Reddish-purple discoloration of the face and neck
(the skin below the face and neck remains pink).
• Jugular vein distention.
• Swelling of the lips and tongue.
• Swelling of the head and neck.
• Swelling or hemorrhage of the conjunctiva
(subconjunctival petechiae may appear).
• Hypotension results once the pressure is
released.

36. • Scene Size-up
• Initial Assessment
• Rapid Trauma Assessment
– Observe
• JVD, SQ Emphysema, Expansion of chest
– Question
– Palpate
– Auscultate
– Percuss
– Blunt Trauma Assessment
– Penetrating Trauma Assessment
• Ongoing Assessment

37. • Ensure ABC’s
– High flow O2 via NRB
– Intubate if indicated
– Consider RSI
– Consider overdrive ventilation
• If tidal volume less than 6,000 mL
• BVM at a rate of 12-16
– May be beneficial for chest contusion and rib fractures
– Promotes oxygen perfusion of alveoli and prevents atelectasis
• Anticipate Myocardial Compromise
• Shock Management
– Consider PASG
• Only in blunt chest trauma with SP <60 mm Hg
– Fluid Bolus: 20 mL/kg
– AUSCULTATE! AUSCULATE! AUSCULATE!

38. • Tracheobronchial Injury
– Support therapy
• Keep airway clear
• Administer high flow O2
– Consider intubation if unable to maintain patient airway
• Observe for development of tension pneumothorax and SQ emphysema
• Traumatic Asphyxia
– Support airway
• Provide O2
• PPV with BVM to assure adequate ventilation
– 2 large bore IV’s
– Evaluate and treat for concomitant injuries
– If entrapment > 20 min with chest compression
• Consider 1mEq/kg of Sodium Bicarbonate

39. • Traumatic Asphyxia
– Results from severe compressive forces applied to the
thorax
– Causes backwards flow of blood from right side of heart
into superior vena cava and the upper extremities
– Signs & Symptoms
• Head & Neck become engorged with blood
– Skin becomes deep red, purple, or blue
– NOT RESPIRATORY RELATED
• JVD
• Hypotension, Hypoxemia, Shock
• Face and tongue swollen
• Bulging eyes with conjunctival hemorrhage

46. FLAIL CHEST
Segment of chest wall that does not have
continuity with rest of thoracic cage
• Usually 2 fractures per rib in at least 2 ribs
• Segment does not contribute to lung
expansion
• Disrupts normal pulmonary mechanics
• Accompanied by pulmonary contusion in
50% of patients

47. MYOCARDIAL CONTUSION
• Physical bruising of
the cardiac muscle
• Associated with
fractures of the
sternum
• Any severe anterior
chest injury

48. MYOCARDIAL CONTUSION
DIAGNOSIS:
• Ectopy
• ST elevation
• Tachycardia
• Friction rub
• CPK enzymes, Troponin
Monitor in ICU & treat dysrhythmias
• Serial enzymes
• Analgesia

49. AORTIC RUPTURE
• CT with contrast
angiogram
• Contained injury
treat with BP control
• Operative repair

50. CARDIAC INJURY AND TAMPONADE
• Fatality rates > 80%
• Mostly ventricular, right > left
• Blood in pericardial sac causes
tamponade
• Occurs with penetrating injuries

51. DIAPHRAGM
RUPTURE
•Associated with
blunt trauma or
blast injury
•Can be due to
stab wounds

52. DIAPHRAGM RUPTURE
• Surgical repair to replace herniated
contents back into abdomen
• Close muscular diaphragm to
restore pulmonary function
• Chest tube to treat pneumothorax

53. ESOPHAGEAL INJURY
Most due to penetrating trauma
Difficult to diagnosis
If delayed or missed, rapid sepsis & high
mortality
Radiography
Endoscopy
Thoracoscopy
Treatment: surgical repair via thoracotomy