Thoracic trauma diagnosis and management

1. Presented by:
Dr.Mohammed Al siraj
MBBS,MRCS(ed )1,MRCS(ed(2
Surgery Resident

2.  Trauma is leading cause of :
 death,
 hospitalization,
 short and long-term disability for all ages from first –forty years.
 25% of all trauma death are due to chest injuries
 20-33% death risk can be reduced.
 Deaths occur within first 4 hours trauma
 Uncontrolled haemorrhage,
 Un corrected hypoxia or
 Delay in surgical interventions

3. Chest injuries may result
from:
 Gunshot wounds (GSW)
 Shrapnel
 Explosions
 Motor vehicle crashes
(MVC)
 Falls
 Crush injuries
 Stab wounds

4. Pathophysiology
Often life threatening injuries result in :
 Hypoxemia
 Hypovolemia
 Cardiac failure

5. Anatomy & Surface Anatomy
5

6. Determine the MOI
 Penetrating trauma.
 GSW or stab wounds
 Concentrates forces over
smaller area
 Bullet trajectories
unpredictable
 Crush injury
6
 Blunt trauma.
 Force distributed over
larger area
 Visceral injuries occur
from:
 Deceleration
 Compression
 Sheering forces
 Bursting

7. What are the significant pathophysiologic effect of
chest injury should I identify in the primary survey,
and when and how do I correct them?
What life-threatening chest injuries should I
recognize as causing major pathophysiologic
event?
What adjunctive tests are used during the secondary
survey to allow complete evaluation for potentially life-
threatening thoracic injuries?

8. Life threatening chest injuries:
Primary survey:
 Airway obstruction
 Flail chest
 Open pneumothoorax
 Tension pneumothorax
 Massive haemothorax
 Pericardial tamponade

9. Assess the Casualty
 Identify signs and
symptoms:
 Assess the Airway
 Assess the Breathing
 Assess the Circulation
9

10. Assess Respirations
 Respiratory rate and
effort:
 Tachypnea
 Bradypnea
 Labored
 Retractions
 Progressive respiratory
distress
CMAST 10

11. Assess the Neck
 Subcutaneous
emphysema.
 Position of trachea.
 JVD.
11

12. Assess the Chest Wall
 Contusions.
 Asymmetry.
 Open wounds or
impaled objects.
 Paradoxical movement.
 Tenderness.
 Crepitation.
12

13.  Lung sounds:
 Absent or decreased
Unilateral
Bilateral
 Location
 Bowel sounds in
chest?
 Heart sounds:
 Normal
 Muffled
13

14.  Percussion.
 Hyperresonance
Pneumothorax
Tension
pneumothorax
 Dull
 (hemothorax)
14

15.  Compare both sides of
the chest at the same
time when assessing for
asymmetry.
CMAST 15

16. Assess The back

17. Flail Chest
 2 or more adjacent rib
fractures in >2 places
 May be paradoxical chest
movement
 Pulmonary contusion
 Reduced respiratory volume
 Segment Fixation and
positive ventilation to restore
tidal volume

18. Open Pneumothorax
(Sucking Chest Wound)
 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

19. Petroleum Gauze

20. 20
"Asherman Chest Seal"

21. Heilmich valve

22. Tension Pneumothorax
 Dyspnea Tachypnea at first
 Hyperinflation of injured side of
chest
 Hyperresonance of injured side of
chest
 Diminished then absent breath
sounds on injured side
 Heart sounds normal
 Late signs:
 Cyanosis
 Diaphoresis
 AMS
 JVD
 Hypotension
 Hypovolemia
 Tracheal Shifting

23. Needle Decompression

24.  Secure catheter and
prevent reentry of air
into pleural space
 Monitor patient’s
respiratory status

25. Chest drain system Underwater seal

26. Massive Hemothorax
 Dyspnea Tachycardia at first
 Bulging/bruising/wound of injured
side of chest
 Stony Dullness percussion of
injured side of chest
 Diminished then absent breath
sounds on injured side
 Heart sounds normal
 Late signs:
 Cyanosis
 Diaphoresis
 AMS
 JVD
 Hypotension
 Hypovolemia
 Tracheal Shifting

27. Chest drain system Thorac0tomy if:
 > 1500 ml initially
 200 ml/hr for 4 hrs

28. Auto-transfusion

29. Pericardial Tamponade
 MOI Penetrating/severe
blunt injuries
 Dyspnea
 Hypotension
 Elevated CVP (JVD)
 Muffled Heart sounds
 Lung sounds normal
 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

30. confirm by Echo Pericardiocentesis

31. ER Thoracotomy

32. Evaluation and reassessment

33. Potentially life-threatening injuries:
Secondary survey:
 Simple pneumothorax
 haemothorax
 Pulmonar y contusion
 Tracheobronchial tree injury
 Blunt cardiac injury
 Traumatic aortic disruption
 Traumatic diaphragmatic
injury
 Blunt esophageal rupture

35. Normal CXR

36. Pulmonary Contusion
 Frequently manifests itself as Hypoxemia.
 Goals for treatment are to prevent it
 Oxygen therapy,
 Positive pressure either with a
CPAP mask
 Intubation and mechanical
ventilation with PEEP.
 Splinting from the pain associated with rib
fractures requires adequate pain management,
i.e.parenteral narcotics, interpleural local
anesthetics, or epidural narcotics/local
anesthetics.
 The contused lung is prone to capillary leak
and therefore careful fluid management is
indicated

37. Haemothorax
 blood in pleural space
 Part or total lung collapse
 Rib fx
 Chest pain, dyspnea,
tachypnea
 Chest drain system

38. Heamothorax ? Or pulmonary contusion ?

40. Closed (Simple) Pneumothorax
 Air in pleural space
 Part or total lung collapse
 Rib fx
 Paper bag effect
 Chest pain, dyspnea,
tachypnea
 Chest drain-underwater
seal system

42. Myocardial Contusion
(Blunt Myocardial Injury)
 Often MVC
 Sternal or rib fx common
 May have chest pain
 Dysrhythmias,
palpitations, murmur
 Oxygenate, monitor ECG
 Treat rhythm disturbance

43.  NO longer routinely subjected to
prolonged observation in a monitored
setting. If ECG and echocardiogram
are normal patient may go home after
12 hours if no other injuries are
present.
 Young patients rarely have cardiac
related complications even when
cardiac contusion is diagnosed.
 The Best test for diagnosis remains
controversial. ??
 ECG is unreliable- unless ST
elevation is present.
 CPK MB isoenzymes -may be
non diagnostic.
 Cardiac troponin I which may
be more specific for myocardial
damage has not been
adequately evaluated.
 Echocardiography is useful for
detecting wall motion
abnormalities, pericardial
effusions and in combination
with abnormal CPK MB may
predict complications.
 Radionuclide angiography may
also be predictive of
complication.
 Thallium scanning can detect
areas of decreased perfusion,
but cannot differentiate an
acute from preexisting lesion

44. Traumatic Aortic disruption
 80-90% of patients with thoracic aortic
rupture die in the pre-hospital setting.
Those who survive to to reach the
hospital may have minimal symptoms.
 CXR may give the first suggestion of
injury.
 The disruption is usually at the isthmus
just distal to the left subclavian artery.
 Control of blood pressure is critical to
avoid further dissection.
 Emergent surgery with poor
hemodynamic stabilization has high
mortality

45.  Loss of the aortic knob
contour,
 Depression of the Lt
mainstem bronchus
 Shift of the esophagus
(nasogastric tube) to
the right and
 Lt heamothorax
 An apical cap in
addition to mediastinal
widening indicate need
for further workup

47. Diaphragmatic injury
 Often on left
 could be missed
 Shortness of breath
 Dyspnea
 Abdominal/chest pain
 Bowel sounds in chest
 Elevation of Lt
hemidiaphragm
 Confirm by CT
 Operative intervention

48. Could be an Intra-operative finding

50. Tracheobronchial Injuries
 Rare but high mortality
 Haemoptosis/Tension
pneumo/SQ emphy
 Suspect when persistent
large air leak after tube
thoracotmy
 Confirmed by bronhoscopy
 Keep airway clear
 Administer high flow O2
 Consider intubation if
unable to maintain patent
airway
 Operative intervention

51. Esophageal Injuries
 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
 pneumomediastinum
 Subcutaneous emphysema and
penetrating trauma present
 Operative intervention

52. SQ emphysema
•May result from Air way,lung or blast injury
•No treatment required
•Underlying injury must be addressed
•If PPV required then consider chest tube on side of SQ emphysema

53. Rib Fractures
 Rib fractures should be taken in
context. Their presence indicate
a need for examining the
underlying lung
 for contusion,
 laceration,
 hemo or pneumothorax.
 Multiple or anterior and posterior
rib fractures may cause a flail
segment.
 Fracture of the relatively
protected first through third ribs
indicates severe impact and
mandates careful search for
associated injury

54. Sternal Fractures
 Associated with severe
blunt anterior trauma
 Typical MOI
 Direct Blow (i.e. Steering
wheel)
 Incidence: 5-8%
 Mortality: 25-45%
 Myocardial contusion
 Pericardial tamponade
 Cardiac rupture
 Pulmonary contusion

55. Traumatic Asphyxia
 Severe crush to chest and
compression of SVC
 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

56.  85 % of pt with life threatening injuries can be managed by
simple interventions easily mastered by physicians and ER
service personnel

57.  15 % operative intervention

58. Thank you