31-Chest Trauma

CHEST TRAUMA
CHEST TRAUMA
• MECHANISM OF INJURY TO CHEST
• Blunt versus penetrating trauma
• Injury dependent on mechanism
• Motor vehicle accident
• Fall from height
• Physical assault
• Explosive blast
• Gunshot wound
• Stab wound
Thoracic injury = 25% of all severe injuries.
In a further 25%= death of the patient.
The cause of death is haemorrhage.
About 80% of patients managed non-operatively.
Good outcome is correct diagnosis &resuscitation.
CHEST TRAUMA
Blunt force injuries from assault
or fall from height
Bony fractures
Lung injuries
Cardiac contusion
CHEST TRAUMA
Acceleration : Deceleration Injuries

CHEST TRAUMA
Penetrating injuries:
Gunshot wounds
Stabbing wounds
CHEST TRAUMA
• Improved field diagnosis and treatment of life

threatening conditions
• Rapid evacuation to higher level of care
• High risk of death despite acute intervention
• Need for prompt diagnosis and treatment
CHEST TRAUMA
ANATOMY
Chest wall and ribs
Lungs and pleura
Great and thoracic vessels
Heart and mediastinal
structures
Diaphragm
CHEST TRAUMA
Common Injuries
u Rib fractures
u Sternal fractures
u Open or Closed Pneumothorax
- unilateral / bilateral
u Hemothorax
u Hemopneumothorax
CHEST TRAUMA
u Airway obstruction
u Early intubation is very important, particularly
in cases of neck haematoma or possible
airway oedema.
u Airway distortion can be insidious and
progressive and can make delayed
intubation more difficult if not impossible.
CHEST TRAUMA
80% Blunt injuries managed non-operatively
Management of airway / oxygenation
Analgesia
Intubation and ventilator support if needed

Chest tubes if needed for heamothorax or
pneumothorax
CHEST TRAUMA
PENETRATING INJURIES
Trajectory across chest
Mechanism due to knife or gunshot
Type of bullet
CHEST TRAUMA
INITIAL MANAGEMENT
• Airway, Breathing, Circulation
• PRIMARY SURVEY
u Identify & treat immediately life threatening conditions along
with resuscitation
CHEST TRAUMA
Early intervention directed toward

diagnosing and treating:
uTension pneumothorax
uMassive hemothorax
uOpen pneumothorax
uCardiac tamponade
uFlail chest
CHEST TRAUMA INVESTIGATIONS
RADIOLOGIC TESTS
Chest X-ray, usually portable
Abdominal KUB
eFAST Ultrasound Exam (Extended focused assessment with

sonar for trauma)
CAT scan, and CT Angiogram if needed
Chest tube insertion(Therapeutic/diagnostic)

INVESTIGATIONS
Underwater chest drain
In the physiologically grossly unstable patient, where physical
examination is inconclusive and there is no time for radiological
investigations, insertion of an underwater chest drainage
tube can be a diagnostic procedure as well as a therapeutic
one, and the benefits of insertion often outweigh the risks.
Inves&ga&on of chest injuries

●● Directly or indirectly involved in >50% of trauma deaths
●● 80% can be managed non-operatively
●● A chest radiograph is the investigation of first choice
●● A chest drain can be diagnostic as well as therapeutic
●● A spiral CT scan provides rapid diagnoses in the chest and
abdomen
CHEST TRAUMA
Rib Fractures(most common site of bleeding)
Physical Diagnosis:
Deformity
Localized pain
Crepitus
Treatment:
Analgesia (PCA)
Pulmonary toilet
Observe for pneumothorax
CHEST TRAUMA
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
CHEST TRAUMA
Flail Chest Diagnosis:
• Paradoxical chest wall movement
• Poor air movement
• Hypoxia
Treatment :
• Pain control
• Pulmonary & physical therapy
• Intubation and ventilator support if needed
u Fluid restriction if possible
Voluntary splinting of the chest wall occurs as a result of pain, so
mechanically impaired chest wall movement and the associated lung
contusion all contribute to the hypoxia. There is a high risk of developing a
pneumothorax or haemothorax.
The CT scan, with contrast to display the vascular structures and a 3-D
reconstruction of the chest wall,is the gold standard for diagnosis of this
condition.
Traditionally, mechanical ventilation was used to ‘internally splint’ the chest,

but had a price in terms of intensive care unit resources and ventilation-
dependent morbidity.
Currently, treatment consists of oxygen administration, adequate

analgesia (including opiates) and physiotherapy.
If a chest tube is in situ, topical intrapleural local analgesia introduced via

the tube, can also be used.
Ventilation is reserved for cases developing respiratory failure despite

adequate analgesia and oxygen.
Surgery to stabilise the flail segment using internal fixation of the ribs may
be useful in a selected group of patients with isolated or severe chest injury
and pulmonary contusion.
CHEST TRAUMA
The clinical presentation of Tension pneumothorax
Restless with tachypnoea,

Dyspnoea and distended neck veins (similar to pericardial tamponade).
Tracheal deviation; a late finding
Hyper-resonance
Decreased or absent breath sounds over the affected hemithorax.
Tension pneumothorax
u is a clinical diagnosis and treatment should never be delayed
u by waiting for radiological confirmation (Figure 27.3).
u Treatment consists of immediate decompression, initially
u by rapid insertion of a large-bore cannula into the second
u intercostal space in the mid-clavicular line of the affected
u side, then followed by insertion of a chest tube through the
u fifth intercostal space in the anterior axillary line.
Open pneumothorax
(‘sucking chest wound’)
This is due to a large open defect in the chest (>3 cm),leading to
immediate equilibration between intrathoracic and atmospheric pressure.
If the opening in the chest wall exceeds about two-thirds of the diameter
of the trachea, then with each inspiratory cycle, air will be preferentially
drawn through the defect, rather than through the trachea. Air
accumulates in the hemithorax (rather than in the lung) with each
inspiration, leading to profound hypoventilation on the affected side and
hypoxia.
If there is a valvular effect, increasing amounts of air in the pleura will result
in a tension pneumothorax
uInitial management consists of promptly closing the defect

with a sterile occlusive plastic dressing (e.g. Opsite®), taped
on three sides to act as a flutter-type valve.
A chest tube is inserted as soon as possible in a site remote from the injury
site.
CHEST TRAUMA
Decompression of Tension Pneumothorax
u large bore needle
u2nd intercostal space
umidclavicular line
u Chest tube as definitive treatment
CHEST TUBE INSERTION
u The safest site for insertion of a drain (Triangle of safety)
u 1●● anterior to the mid-axillary line;
u 2… .behind pectoralis major (anterior axillary line)
u 3 ●● above the level of the nipple(T4 level); above 5th rib avoid
diaphragm
CHEST TUBE INSERTION
• Connect tube to
underwater seal and
suture in place
• Examine chest to
check effect
• CXR to check
placement and
position
PULMONARY CONTUSION
• Common with blunt trauma

• May be associated with laceration of
lung parenchyma
• Leakage of blood and fluid into interstitial
spaces of lung
• Significant inflammatory reaction to blood
components in the lung
PULMONARY CONTUSION
Parenchymal
infiltrate seen
on CXR
adjacent to
injured chest
wall
PULMONARY CONTUSION
Indications for Chest airway
intubation
uRespiratory distress
uHypoxia
uOther injuries which compromise
respiratory effort, such as
abdominal or neurologic
MYOCARDIAL CONTUSION
• Physical bruising
of the cardiac
muscle
• Associated with
fractures of the
sternum
• Any severe
anterior chest
injury
MYOCARDIAL CONTUSION
DIAGNOSIS:
u Ectopy
u ST elevation
u Tachycardia
u Friction rub
u CPK enzymes, Troponin
Monitor in ICU & treat dysrhythmias

u Serial enzymes
u Analgesia
MASSIVE HEMOTHORAX
• From blunt or penetrating injuries
• 200cc – 1L in chest cavity seen on CXR
• Treat with chest tube, if immediate
drainage is 1500 cc or if 250 cc/hr for 4
hours, then immediate thoracotomy
• Bleeding may be from ribs, lung, blood
vessels
AORTIC RUPTURE
• Abrupt deceleration or compression injury
• Sudden motion of heart / great vessels in chest
• Great vessel injury may occur in 0.3 => 10%
penetrating trauma
• Often rapidly fatal
• 10% survive to hospital
• 20% survive > 1 hour
• 90% who reach hospital will die
• Early diagnosis and treatment
AORTIC RUPTURE
• mechanism
of injury
• widened
mediastinum
on CXR
AORTIC RUPTURE
• CT with contrast
angiogram
• Contained injury
treat with BP
control
• Operative
repair/stent
CARDIAC INJURY AND TAMPONADE
• Fatality rates > 80%Mostly ventricular, right > left
• Blood in pericardial sac causes tamponade.It occurs with penetrating
injuries. u .
• Needle pericardiocentesis has been suggested. However,
u in penetrating injury to the heart there is usually a substantial
u clot in the pericardium, which may prevent aspiration. A dry
u pericardiocentesis proves only that there is a ‘clot’ on both
u ends of the needle!
u Pericardiocentesis has a high potential for iatrogenic injury to the heart
and it should, at the most,be regarded as a desperate temporising
measure in a transport situation (under electrocardiogram (ECG)
control).
u The correct immediate treatment of tamponade is operative, either via
a subxiphoid window, or by open surgery (sternotomy or left
thoracotomy), with repair of the heart in the operating theatre if time
allows or otherwise in the emergency room.
DIAPHRAGM RUPTURE
• Associated with blunt trauma or blast injury
• Can be due to stab wounds
DIAPHRAGM RUPTURE
• Surgical repair to replace herniated

contents back into abdomen
• Close muscular diaphragm to restore
pulmonary function
• Chest tube to treat pneumothorax
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
EMERGENCY THORACOTOMY
INDICATIONS OF ACUTE THORACOTOMY
• Cardiac tamponade (unrelieved by needle
pericardiocentesis)
• Vascular injury to thoracic outlet
• Massive air leak
• Endoscopic / radiographic evidence of
tracheal or bronchial injury
• Esophageal injury
• Chest tube output
u immediate evacuation of 1500ml blood
u or > 250cc/ hourI
ER THORACOTOMY
survival rates < 8%

ER THORACOTOMY(INTERNAL CPR)
• BLUNT injury with arrest

• Arriving without pulse/BP
• Penetrating injury with arrest
• High likelihood of isolated / correctable intra-
thoracic injury
• ER THORACOTOMY in presence of :
u pulse
u blood pressure
u organized cardiac activity
SUMMARY
• Chest trauma may be due to blunt,
penetrating or combination of causes
• Organs at risk include bony, hollow, as well

as cardiovascular structures
• Immediate life threatening conditions need

to be treated
• Maintenance of airway, oxygenation, and

control of hemorrhage are important goals

31-Chest Trauma

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CHEST TRAUMA

Acceleration : Deceleration Injuries

• Improved field diagnosis and treatment of life

Management of airway / oxygenation

Intubation and ventilator support if needed

Mechanism due to knife or gunshot

Early intervention directed toward

Chest X-ray, usually portable

eFAST Ultrasound Exam (Extended focused assessment with

CAT scan, and CT Angiogram if needed

Chest tube insertion(Therapeutic/diagnostic)

Inves&ga&on of chest injuries

●● A chest radiograph is the investigation of first choice

●● A chest drain can be diagnostic as well as therapeutic

●● A spiral CT scan provides rapid diagnoses in the chest and

Segment of chest wall that does not have

Traditionally, mechanical ventilation was used to ‘internally splint’ the chest,

Currently, treatment consists of oxygen administration, adequate

If a chest tube is in situ, topical intrapleural local analgesia introduced via

Ventilation is reserved for cases developing respiratory failure despite

Restless with tachypnoea,

uInitial management consists of promptly closing the defect

• Common with blunt trauma

Monitor in ICU & treat dysrhythmias

• Surgical repair to replace herniated

survival rates < 8%

• BLUNT injury with arrest

• Organs at risk include bony, hollow, as well

• Immediate life threatening conditions need

• Maintenance of airway, oxygenation, and

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