One of important topics in trauma. For surgical block and emergency medicine.

2. INTRODUC
TION
 Significant cause of mortality – many demise
before reaching the hospital
 Presentation of penetrating thoracic trauma can
vary widely;
stable patients with few complaints to
hemodynamically unstable patients requiring
immediate life-saving interventions.
 Apparently ‘stable’ patients can deteriorate
rapidly – all require rapid assessment for life
threatening conditions

3. EPIDEMIOL
OGY
Chest injuries are a relatively common cause of preventable death
among trauma patients
Most commonly from GSW and stab wounds.
Less common but more deadly than blunt chest trauma.
15-30% (minority) of penetrating chest injuries require operative
management - many managed with observation and serial
evaluation
4% Major vascular injury [Penetrating chest injuries]
30% Concurrent esophageal and major vascular injuries, 3%
cardiac injuries [Penetrating tracheobronchial injuries]
30% Diaphragmatic injuries (stab wounds) - 60% (GSW)
[Thoracoabdominal trauma]

4.  Chest wall
 Lungs
 Tracheobronchial tree
 Heart
 Great vessels
 Esophagus
 Diaphragm
 Spinal cord
 Thoracic vertebrae
 Thoracic duct

5.  Skin, bones (including the thoracic
spine, scapulae, clavicles, sternum
and ribs, costal cartilage), and
muscles of the chest and back
(including the pectoralis major and
minor, intercostals, trapezius,
latissimus, rhomboids, and
paraspinals)
 Neurovascular bundles composed of
an intercostal nerve, artery, and vein,
run along the inferior portion of each
rib.
 Usually lungs fill the thorax. Lined by
visceral pleura. Parietal pleura lines
the inside of the chest wall. Lungs
held to the chest wall by surface
tension between the pleural surfaces.

6.  Major vessels within the thorax -
aorta, the brachiocephalic trunk,
and the left subclavian, left
common carotid, and innominate
arteries.
 Injuries to major vessels are rarely
encountered in the emergency
department because most patients
with such wounds demise at scene
of injury

8.  Visceral compartment in the
midline of the thoracic cavity, that
is surrounded by the left and
right pleural sacs.
 Divided into
the superior and inferior
mediastinum at sternal angle
 The inferior mediastinum is further
divided into:
anterior, middle and posterior
mediastinum.
 Every compartment contains
many vital organs, vascular and
neural structures that are closely
related one to another.

9.  Thoracoabdominal injuries involve both
the thoracic and abdominal cavities
 Superior margin:
- Anterior: Nipple line/4th ICS
- Posteriorly: Tip of scapula/8th ICS
- Lateral: 6th ICS
 Inferior:
- inferior costal margin

10.  Penetrating trauma in this
zone indicates when a
patient is at higher risk for
cardiac injury.
 Superiorly:
- clavicles and sternal notch
 Inferiorly:
- costal margins
 Laterally:
- nipple line

11. Difficult to assess direction and extent of
injury from the physical examination (low
sensitivity and specificity)
The extent of internal injury from a
seemingly small external wound can
easily be underestimated
Penetrating wounds to “the box” = high
risk of injury to the heart and other
mediastinal structures
Gunshot wounds and other higher
velocity mechanisms have a less
predictable pattern of injury
Permanent cavity: tissues sustain
damage from the direct path of the
bullet
Temporary cavity: Tissue injury from
shock waves causes by bullet

12. Airway
Determine
patency
 Adjuncts if
needed
Assess for
intubation need
(Caution in
obstructive
shock)
Breathing
Inspection
Palpation
Percussion
Auscultation
Pulse oximeter
+-
Supplemental
O2
Circulation
Hypotension
Diminished
pulses
IV fluid
Blood replaced
by blood
(Permissive
hypotension)
Adjuncts
E-FAST
Aaccurately
detects the
presence of
hemopericardium,
pneumothorax,
hemothorax, and
peritoneal fluid
False negatives!

13.  A careful, head-to-toe secondary assessment is performed in all trauma
patients determined to be stable upon completion of the primary survey.
 Chest specific: Identification of subtle symptom and signs
- Assessment of posterior chest
- Phrenic nerve dysfunction can present as mild resp distress
- Examination for rib fractures, flail segments
 Continual reassessment of the primary survey and areas of potential injury is
essential.
 Patients with penetrating thoracic trauma can deteriorate rapidly, and neither
stable vital signs nor the absence of symptoms initially excludes the presence
of a life-threatening injury.

14. CXR
Stable: erect PA film and
lateral
Unstable: Supine AP
Contrasted CT chest - Base of skull to
adrenals
CT angiogram – suspect vascular injury
Penetrating object crosses
mediastinum
S+S for
tracheobronchial/vascular
injury (stable)
Symptoms consistent with
injury that is inconsistent
with CXR

15. Specific conditions
Life-threatening
Airway
oTracheobronchial
tree injury
Breathing
- Tension
pneumothorax
- Open pneumothorax
- Massive
haemothorax
Circulation
- Massive
haemothorax
- Cardiac tamponade
Potentially life-
threatening
-Simple pneumothorax
-Haemothorax
-Traumatic
diaphragmatic injury

16. • Hemoptysis, cervical subcutaneous emphysema, tension
pneumothorax, cyanosis.
• Incomplete expansion of lung and continued air leak after ICD
suspicious
Presentation
• Radiography (CXR, CT)
• Bronchoscopy
Diagnosis
• Fiber-optic intubation (anatomic distortion)
• Definitive treatment:
Selective nonoperative management (select few)
Surgical repair: Direct reapproximation and repair vs
resection with reconstruction (dependent on site, extent of
injury, concurrent injury)
Management

17.  Air entry the potential space
between visceral and parietal
pleura.
 Air in pleural space disrupts the
cohesive forces between the visceral
and parietal pleura – allowing lung
to collapse.
 One way valve air leak occurs from
lung or through chest wall.
 Air forced into lung with no means
of escape
 Progress to collapse of affected lung
 Mediastinum displaced to opposite
side
 decrease venous return
 compress opposite lung
 Further marked decrease in
venous return
 reduction in cardiac output
= obstructive shock

18. • Chest pain, dyspnoea, tachypnoea, tachycardia, hypotension,
decrease chest movements, neck vein distension , decreased sats
• Tracheal deviation away from side of injury
• Hyperresonance and absent breath sounds
Presentation
• CLINICAL – do not delay treatment awaiting radiological
confirmation
Diagnosis
• Immediate decompression: large needle 4th/5th ICS slightly ant to
MAL
• Definitive: ICD (28-32 French chest tube in 5th ICS slightly ant to
MAL)
Management

19.  Immediate equilibration between
intrathoracic pressure and
atmospheric pressure
 Air follows path of least
resistance
 When opening of chest wall
about 2/3 diameter of trachea or
more, air passes preferentially
through chest wall defect with
inspiration.

20. •As for simple pneumothorax
•Noisy movement of air through chest wall
Presentation
•CLINICAL – do not delay treatment
awaiting radiological confirmation
Diagnosis
•Immediate: 3-way dressing/Jelonet (use
as occlusive dressing)
•Definitive: ICD
Surgical closure of wound
Management

22.  Accumulation of >1500ml blood
in one side of chest
 Continuing blood loss >200ml/hr
for 4 hours
 Compress lung and prevent
adequate oxygenation and
ventilation
 Penetrating wound disrupts
systemic or hilar vessels

23. • Shock
• Dull to percussion
• Absent breath sounds
Presentation
• Clinical
• Radiography
Diagnosis
• Resus – blood products and IV fluids
• ICD
• Urgent thoracotomy: repair of systemic or hilar
vessels
Management

24.  Any patient with a penetrating wound
to the chest, back, neck, or abdomen
can develop pericardial tamponade.
 Bleeding sites: Intrapericardial region of
great vessels, chambers, coronary
arteries and veins.
 Compression of heart by accumulation
of fluid in pericardial sac.
 Pericardial sac – fixed fibrous structure.
Small amount of blood can restrict
cardiac activity
 Ultimately, tamponade physiology
causes diminished cardiac output due to
decrease inflow to the heart, leading to
a decrease in systolic blood pressure
and a narrowing of the pulse pressure.

25. •Stable initially (slow bleeding rate)
•Beck’s triad (hypotension, jugular venous distension (JVD), muffled heart
sounds) – Not always present/clear
•Kussmaul’s sign
•Bilateral breath sounds (differentiates from tension pneumo)
Presentation
•Clinical
•Ultrasound if immediately available (FAST 90-95% sensitive)
Diagnosis
•Resus – blood products and IV fluids
•Temporary: Ultrasound guided pericardiocentesis
•Urgent thoracotomy: open surgical drainage and repair
Management

27.  Cause of cardiac tamponade and demise on scene
 MANAGEMENT:
 RESUSCIATION
 STABLE
Echo to determine pre-operative plan - assess for site of injury, actively bleeding,
intraventricular defect, massive regurgitation.
If intracardiac lesion and stable, prefer to send to a cardiac centre for intervention
 UNSTABLE – Thoracotomy (Front room vs operative)

28. Intraoperative:
- Cell saver
- If clot has formed, do not dislodge.
- Suture technique:
1. Interrupted or continuous prolene sutures
2. Importantly, through and through sutures regardless of technique of suture
3. Use of pledgets:
Surgical pledgets are non-absorbable synthetic patches that reduce the possibility
of tearing of sutures through tissue. They are indicated for use as suture supports.

30. - Small defect – de bakey forceps/finger to stop bleeding and suture with prolene
around site
- Large defect – Insert Foley’s and blow up balloon to obtain control of bleeding.
Suture around and slowly deflate and remove.

31. Specific conditions
Life-threatening
Airway
oTracheobronchial
tree injury
Breathing
Tension pneumothorax
Open pneumothorax
Massive haemothorax
Circulation
Massive haemothorax
Cardiac tamponade
Potentially life-
threatening
Simple pneumothorax
Haemothorax
Traumatic
diaphragmatic injury

32.  Air entry the potential space
between visceral and parietal
pleura.
 Air in pleural space disrupts the
cohesive forces between the
visceral and parietal pleura –
allowing lung to collapse.
 A ventilation-perfusion defect
occurs – blood perfusing the non-
ventilated area is not
oxygenated.

33. •Chest pain, dyspnoea, tachypnoea, tachycardia, hypotension, decrease chest
movements, decreased sats
•Subcutaneous emphysema
•Hyperresonance and absent breath sounds
Presentation
•CXR
Diagnosis
•Definitive:
ICD in 5th ICS, just anterior to MAL
- Size 24G
– Direct tube upwards
•Conservative therapy in select cases
(Opt against in our setting due to poor monitoring and observations in ward)
Management

34.  A pneumothorax will slowly resolve over
time as the air is reabsorbed some
patients may be safely managed without
an immediate procedure to remove the
air.
 Indications:
1. Haemodynamically stable
2. Asymptomatic (No dysponea)
3. Less or equal to 2cm intrapleural
distance from hilum.
 Admit for high flow o2, monitor, repeat
CXR

35. • Dull to percussion
• Absent breath sounds
Presentation
• Clinical
• Radiography
Diagnosis
• Resus – blood products and IV fluids
• ICD – size 32-34G
- Direct tube downwards
Management

36.  More commonly on left as liver
obliterates /protects defect on right
 May produce perforations that remain
asymptomatic for years

37. • Asymptomatic
• Suspect in all thoracoabdominal injuries on left side
• Delayed presentation: abdominal pain, nausea, vomiting, bowel
obstruction features
Presentation
• HIGH LEVEL OF SUSPICION IN ALL LEFT
THORACOABDOMINAL INJURIES
CXR: appearance of elevated diaphragm; free air under diaphragm
• Gastric tube appears in chest cavity
• Diagnostic laparoscopy or explorative laporatomy
Diagnosis
• Operative: direct repair (Open or laparoscopically)
Management

38.  Primary repair: permanent monofilament suture (Size 0, 1) in a continuous or interrupted fashion.
 Gentle downward traction of the cardiac surface of the diaphragm away from the heart during the
placement of sutures to avoid cardiac injury (assuming left-sided repair)
 Use of mesh — if extensive debridement needed with much diaphragmatic tissue destruction = primary
repair is not possible. Nonabsorbable prosthetic materials (can be used, provided no colonic
contamination is present. When contamination is present, the abdomen is washed out and an autologous
tissue flap can be used.

39.  2018. ATLS - Advanced trauma life support. 10th ed. Chicago, Ill.: American
College of Surgeons, Committee on Trauma.
 Uptodate.com. 2022. Initial evaluation and management of blunt thoracic
Available at: <https://www.uptodate.com/contents/initial-evaluation-and-
trauma-in-
adults?sectionName=ANATOMY%20AND%20MECHANISM&search=penetrating
opicRef=13862&anchor=H3&source=see_link#H3> [Accessed 13 February
 Uptodate.com. 2022. Initial management of trauma in adults. [online]
<https://www.uptodate.com/contents/initial-management-of-trauma-in-
adults?search=penetrating%20chest%20trauma&topicRef=353&source=see_li
February 2022].

40.  2018. ATLS - Advanced trauma life support. 10th ed. Chicago, Ill.: American
College of Surgeons, Committee on Trauma.
 Uptodate.com. 2022. Initial evaluation and management of blunt thoracic
Available at: <https://www.uptodate.com/contents/initial-evaluation-and-
trauma-in-
adults?sectionName=ANATOMY%20AND%20MECHANISM&search=penetrating
opicRef=13862&anchor=H3&source=see_link#H3> [Accessed 13 February
 Uptodate.com. 2022. Initial management of trauma in adults. [online]
<https://www.uptodate.com/contents/initial-management-of-trauma-in-
adults?search=penetrating%20chest%20trauma&topicRef=353&source=see_li
February 2022].

41. QUESTION 1
 Clinical differences between tension
pneumothorax and simple
pneumothorax? (3)

42.  1. Shock
 2. Distended neck veins
 3. Mediastinal/tracheal shift

43. QUESTION
2:
 What would occur if an occlusive
dressing is applied to an open
pneumothorax wound with all four
edges taped?

44.  Taping all four edges of the dressing can
cause air to accumulate in the thoracic
cavity  create one way valve.

45. QUESTION
3:
 Diagnosis?

46. QUESTION
3:
Traumatic diaphragmatic
hernia

47. CXR
 Inferior arrows: pneumomediastinum
 Superior arrows: air tracking into soft tissue of
neck
CT