1) Chest injuries account for 20-25% of all trauma deaths and are a leading cause of death worldwide. Life-threatening conditions include tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and cardiac tamponade.
2) Tension pneumothorax requires immediate needle decompression without waiting for imaging if suspected clinically. Open pneumothorax is managed with an occlusive dressing.
3) Flail chest involves fractures of 3 or more ribs in two places, leading to paradoxical chest wall movement and impaired ventilation. Massive hemothorax involves over 1.5L of blood drained by chest tube or more than 200cc/hour
3. INTRODUCTION
• Trauma causes 100,000 deaths and more than 9 million disability
injury annually in worldwide (6th
leading cause of death).
• Chest injuries are responsible for 20-25% of all trauma death.
• The World Health Ranking 2011 has ranked Malaysia at number 20
with the most deaths caused by road accidents.
• An average of 18 people were killed on Malaysian roads daily.
* Malaysian Institute of Road Safety (MIROS)
4. CLASIFICATION
•Anatomy
• Lungs, pleura and ribs
• Cardiac injury
• Trachea , oesophagus & major vessels
• Diaphragm
•Mechanism of injury
• Blunt
• Penetrating
• Shearing / acceleration-decelaration injury
•Cause / Aetiology
• MVA / trauma
• Fall from height
• Gunshot / sharp or blunt object
7. TENSION PNEUMOTHORAX
Develops when air leak occurs
from the lung or through chest
wall.
Air is forced into thoracic
cavity without means of
escape
Creating a “one-way valve”.
Affected lung collapsed
Displaced mediastinum to
opposite site
Decrease venous return
Compressing the opposite
lung
13. OPEN PNEUMOTHORAX:
Pathophysiology
• Known as “sucking
chest wound.”
• Air allowed to enter
pleural space from the
outside.
• Ineffective ventilation
because air goes in and
out from the chest
wound, rather than
from trachea.
• Leading to hypoxia and
hypercarbia.
14. Open Pneumothorax
Clinical Findings
•A defect in the chest wall
with air coming in & out
•A sucking sound on
inhalation
•Tachycardia & tachypnea
•Respiratory distress
•Subcutaneous
emphysema
•Decreased breath sounds
on the affected side
22. FLAIL CHEST
Management
1. Initial management:
- adequate ventilation
fluid resuscitation
In absence of systemic hypotension, fluid
resuscitation should be carefully controlled to
prevent overhydration.
23. FLAIL CHEST
Management
2. Definitive management
Positive-pressure ventilation may be needed.
•Reverses the mechanism of paradoxical chest wall
movement
•Restores the tidal volume
Adequate analgesic
•Reduces the pain of chest wall movement
Assess for the development of a pneumothorax
•May need chest tube insertion
25. MASSIVE HEMOTHORAX
Defined as presence of
>1.5 liter
of blood drained from
the pleural space upon
chest tube insertion
or >200cc/hour in first
4 hours.
32. CARDIAC TAMPONADE
Pathophysiology
•A blunt or penetrating trauma may cause tears
in the myocardial walls, allowing blood to leak
from the heart.
If 150 to 200 mL of blood enters the pericardial
space acutely, pericardial tamponade can develops
36. Cardiac Tamponade
Management
•Airway and ventilation
•Circulation—IV fluid challenge
•Pericardiocentesis
•Prompt involvement of cardiothoracic team.
•Do not take out the penetrating object
38. OTHER CHEST INJURIES
1. RIB FRACTURE
2. SIMPLE PNEUMOTHORAX
3. HEMOTHORAX
4. PULMONARY CONTUSION
5. TRACHEOBRONCHIAL TREE INJURIES
6. CARDIAC CONTUSION
7. TRAUMATIC MAJOR VESSEL DISRUPTION
8. DIAPHRAGMATIC INJURIES
39.
40. *Hemorrhage should be excluded in all patients who are in shock after major trauma
†Neck vein distention may be absent in patients with hypovolemic shock.
41. GENERAL MANAGEMENT
•Primary & secondary survey
•Serial clinical assessment & SPO2 monitoring
•Adequate analgesia (pain control CPG)
•Oxygen therapy tailored to oxygenation status
•Chest tube insertion
•Intensive & vigorous chest physiotherapy, deep
breathing exercise & incentive spirometry
•Mucolytic & nebulizer
•Early referral to appropriate team (i.e. anaest, CTC)
•± Assisted ventilation or intubation
•± Thoracotomy / thorachoscopy and proceed
42. TAKE HOME MESSAGES
1. Life threatening condition in thoracic injury are
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax
• Flail chest
• Cardiac temponade.
2. Tension pneumothorax required emergent needle
thoracotomy without waiting for CXR if highly suspected
clinically
3. Do not remove the object causing the penetrating thoracic
injury
4. Open pneumothorax is managed with flutter-valve dressing or
three sided dressing
43. TAKE HOME MESSAGES
5. Flail chest is defined as segmental fractures in 2 or more
places of 3 or more consecutive ribs.
6. Massive hemothorax happen when
• more than 1.5 liters blood drained upon chest tube insertion
• Or more than 200cc/hour in 4 hours
5. All symptomatic traumatic pneumo/hemothorax require chest
tube insertion
6. Cardiac tamponade is recognized by presence of Beck’s Triad
which are
• Muffled heart sound
• Hypotension
• Distended neck veins
44. TAKE HOME MESSAGES
9. Key management in thoracic injury include
• Identifying the life threatening condition
• Resuscitation and oxygen therapy
• Chest tube insertion
• Adequate pain control and aggressive chest physiotherapy
• Ventilation and early associate team referral
45. REFERENCES
• ATLS for Doctors, 8th
Edition
• Bailey & Love Short Practice of Surgery, 25th
Editions
• Emergency Medicine Clinics of North America
- Volume 30, Issue 2 (May 2012)
• SRB’s Manual of Surgery 4th
edition
Editor's Notes
Indications for thoracotormy:
1. >1.5 liter of blood drained from the pleural space upon chest tube insertion
or >200cc/hour in first 4 hours.
2. Initial output less than 1.5 L, but continues bleed and need transfusion
3. Site: medial to nipple line/scapula
Indication for chest tube?
Removal of as little as 20 mL of blood may drastically improve cardiac output.