2. 2 major forces within chest which lead to
injury:
1. Compression and distraction.
Compression results in destruction of
vascular components, haemorrhage,
oedema and impairment of function.
2.Distraction injuries usually result in
shearing forces which destroy integrity of
intrathoracic viscera
2
3. Blunt trauma
• - mode of injury important
- where there has been massive deformity of a
car or a history of a fall of 5 metres or more
major intrathoracic injuries should always be
suspected.
• The physical nature of chest wall allows for
considerable elastic recoil, especially in young
patients and therefore degree of injury within
chest may need to be judged initially by
deformity to car rather than appearance of
patient
3
4. • Blunt injuries occur in 3 major directions:
1.AP
2 lateral and 3.transdiaphragmatic
• AP deformity results in relative backward
motion of heart. This may result in
disruption of aorta at level of ligamentum
arteriosum just below left subclavian.
• As heart swings back and up it may
cause so-called wishbone # of a proximal
bronchus
• - Injuries to heart occur in up to 1/2 of
patients after deceleration injuries
4
5. • deceleration with impact to back causes
relatively few intrathoracic injuries
- lateral compression of chest during
deceleration causes fractures typically of
lower ribs with risk of injury to liver, spleen
and kidneys
- when lateral compression results in flail
segments damage to thoracic cavity is
usually relatively small and most frequently
limited to contusion and laceration of lung
parenchyma
- lap belt of seat belts leads to rise in
intrabdominal pressure in massive
deceleration and this, combined with
shearing and twisting of upper trunk may
result in diaphragmatic rupture 5
6. Penetrating injuries
• result in parenchymal damage related to
track of missile or stabbing implement and
velocity
• more solid structures (eg heart and major
vessels) suffer greater injury where high-
velocity missiles are penetrating weapon
• most lethal complication is haemorrhage
• often associated with abdominal trauma
6
7. Crush injury
• occurs where elastic limits of chest and its
contents have been exceeded
• patients usually have AP deformity
• majority have flail chests with multiple
fractures, pneumothorax or haemothorax
• most have pulmonary contusion
• injuries of heart, aorta, diaphragm, liver ,
kidney and spleen are common
7
8. • another group of patients with crush
injuries are those with "traumatic
asphyxia" syndrome, where constrictive
forces are applied over a wide area for as
little as 2-5 mins. Profound venous
hypertension associated with relative
stasis is mechanism of injury. There is
widespread capillary dilatation and
rupture, subconjunctival haemorrhage and
retinal haemorrhage. Simultaneous
injuries (eg intracranial haemorrhage)
must be suspected
• severe crush injuries have a high mortality
8
10. Chest trauma hypoxia
Due to:
• reduced blood volume
• ventilatory failure
• contusion
• displacement of mediastinum
• pneumothorax
10
11. Clinical features:
• Initial history and examination are often
abbreviated
• Examination
• air hunger; use of accessory muscles; tracheal
deviation; cyanosis or distended neck veins;
(evidence of tension pneumothorax, or
tamponade);
• tracheal deviation (evidence of tension
pneumothorax)
• major defects in the chest (sucking chest
wounds
11
12. • unilaterally diminished breath sounds or
hyperresonance to percussion (evidence
of closed pneumothorax or tension
pneumothorax);
• decreased heart sounds (pericardial
tamponade);
• location of foreign bodies;
• location of entry and exit wounds
12
14. • Look in particular for the
- pneumothorax: ( up to 30% of
pneumothoraces missed on
supine CXR) air collects in
anterior-inferior pleural space
producing deep" costophrenic
sulcus”
14
15. - pneumomediastinum
• parietal pleura visible along left mediastinal
border. pleura descends below mid-
hemidiaphragm
• sharply defined edge to descending aorta which
can often be followed into upper abdomen
• "continuous diaphragm" sign under cardiac
shadow
• subcutaneous, retroperitoneal or intraperitoneal
emphysema
15
16. - pneumopericardium
• air around heart that does not rise above
level of pericardial reflection at root of
great vessels
• air shifts with position of patient (unlike
pneumomediastinum
16
17. - pleural effusion
• uniform increase in density over
hemithorax
• pleural cap
17
18. - pulmonary contusion
• homogenous infiltrates that tend to be
peripheral and non-segmental
• may be associated with adjacent rib
fractures
• air bronchograms are rare due to blood in
small airways
18
19. - ruptured hemidiaphragm:- more
commonly left sided
• non-specific signs include: apparent elevation of
hemidiaphragm, obliteration or distortion of
contour of hemidiaphragm, contralateral
displacement of mediastinum, pleural effusion
• presence of gas containing viscera in thorax,
particularly with a focal constriction across gas-
containing bowel is pathognomonic
• haemopneumothorax may be misdiagnosed
when dilated stomach gives horizontal air-fluid
interface on erect CXR
19
20. • in absence of right rib #s a small right
haemothorax with a "high R diaphragm"
suggestive of ruptured diaphragm
• findings may be absent in 25-50% initially
- chest wall injuries
- may give clues to associated injuries
• fractures of first 3 ribs in particular
indicates significant trauma
• thoracic outlet fractures associated with
brachial plexus or vascular injuries
20
21. • subclavian vascular injury should be
suspected in patients with fractures of first
3 ribs, clavicle and scapula, particularly
when associated with significant fracture
displacement, extrapleural haematoma,
brachial plexus neuropathy or radiological
evidence of mediastinal haemorrhage
• fractures of sternum are rare and require
both lateral and oblique views of thorax for
diagnosis. The presence of a fractured
sternum and an abnormal mediastinal
contour should prompt a search for injury
to great vessels
21
22. - haemopericardium
• rapid accumulation of blood in pericardial
space often causes cardiac tamponade
wthout altering appearance of cardiac
silhouette
22
23. CT Scan
• Valuable tool
• Aids in diagnosis and precise location of
numerous lesions.
• Contrast is useful particularly when
looking for mediastinal haemorrhage and
periaortic haematomas.
23
24. Echocardiography
ECG
• Cardiac wall motion abnormalities and
valve function and presence of pericardial
fluid or blood.
• Most common abnormality in thoracic
trauma are S-T and T wave changes and
findings indicative of bundle branch block
24
25. Angiography
BRONCHOSCOPY
• Angio-
• Remains the gold standard for defining
thoracic vascular injuries
• Bron-
• Indications include evaluation of airway
injury, haemoptysis, segmental or lobar
collapse, and removal of aspirated foreign
bodies.
25
27. Extrathoracic Injuries
• - assess for extrathoracic injuries
- decompress stomach
- provide pain relief
- reconsider endotracheal intubation,
ventilation. In particular take into account
gross obesity, significant pre-existing lung
disease, severe pulmonary contusion or
aspiration, need for surgery for thoracic or
extrathoracic injuries
27
28. General management
• Treatment of specific injuries
• Monitoring
• Should include follow-up CXRs. Common for
patients with pulmonary contusion to deteriorate
in first 24-48 hrs following injury Not necessarily
due to progression of contusion but is more
often due to development of pneumothorax,
haemothorax, atelectasis or pulmonary oedema.
• For this reason serial CXRs are necessary in
first 24 hrs
Following are danger signs requiring full
reassessment
28
29. • resp rate > 20/min
• heart rate > 100/min
• systolic BP < 100 mmHg
• reduced breath sounds on affected side
• Pao2 < 9 kPa on room air
• Paco2 > 8 kPa
• increased size of pneumothorax,
haemothorax or increased width of
mediastinum on CXR
29
30. Deterioration
• Deterioration in any of these signs must be
followed by a search for evidence of
• blood loss,
• tension pneumothorax,
• head injury, sepsis
• or fat embolism.
• Chest drains should be checked for patency
30
31. Chest drains
• Indications for insertion of chest drains in
stable patients :
• pneumothorax > 10% in non-ventilated
patient (ie >1 intercostal space)
• haemothorax > 500 ml (ie above neck of
7th rib)
• surgical emphysema
• confluent opacity of lung field in a supine
CXR suggesting haemothorax
31
32. Prophylactic Chest Drain
• There are arguments both for and
against the insertion of
prophylactic chest drains in
patients with rib fractures who are
to be ventilated for a GA.
However without air or fluid
draining the drain is likely to
become blocked at an early
stage. 32
33. In a series of patients with blunt
chest trauma one
pneumothorax occurred per 79
days of ventilation when
prophylactic drains were used
as opposed to one per 62 days
when they were not.
Complication rate associated
with insertion 6-9% 33
34. • Theoretically, all that is required to drain
pneumothorax is a small-bore tube but
this is more likely to become blocked.
When blood or pus is to be drained in an
adult a 32 FG tube is recommended
• Antibiotics
• use of prophylactic antibiotics
controversial. Some recommend them for
patients treated conservatively in whom a
chest drain is inserted
• cefuroxime and metronidazole for patients
with perforated viscus (in addition to
exploration and drainage) 34
35. Clearance of secretions and prevention of
atelectasis
• General measures:
• pain relief (eg pleural block)
• physiotherapy
• humidification
• bronchodilators (especially smokers or those
exposed to smoke, irritant chemicals or those
with tracheobronchial burns)
• consider cricothyroidotomy or
"minitracheostomy" for those in whom general
measures are insufficient
35
36. Bronchoscopy
Indications for flexible bronchoscopy:
• massive air leak
• failure of lung to re-expand
• lobar collapse
• diagnosis and assessment of tracheal burns
• bronchial toilet
• Rigid bronchoscopy has less of a role in the
trauma patient but may be used in cases of
persistent lobar collapse to aspirate a blood clot
or plug of sputum
36
37. Mechanical ventilation
• most centres use PCV or PSV to reduce
incidence of barotrauma
- PCV and PSV also provide some
compensation for air leaks
37
38. Analgesia
• Of extreme importance in determining
whether deep breathing and coughing
possible. Options
• IV analgesics in frequent small doses or
by continuous infusion
• Use of inhalor during physiotherapy
• intercostal nerve block:
38
39. • multiple individual nerve blocks (rptd as
necessary)
• single large volume (eg 20 ml 0.5%
bupivicaine) into 1 intercostal space.
Spreads to block nerves above and below
• intrapleural bupivicaine via intercostal
catheters using intermittent injections or
continuous infusions
• epidural LA/opioids
• NSAIDs: fully resuscitated patients with
normal renal function 39
40. Post-operative intensive care
• following tracheobronchial, lung or
diaphragmatic repair high inflation
pressures should be avoided
• tracheal suction must be minimal where
there is a tracheobronchial suture line
• avoid fluid overload
• prevent gastric distension
40
41. Specific injuries
• Classification
• Require immediate intervention
• Tension pneumothorax
• Open pneumothorax
• Disruption of major airway
• Cardiac tamponade
• Massive haemothorax
• Traumatic air embolism
• Flail chest
41
45. Tension pneumothorax
• respiratory distress, tachycardia,
hypotension, tracheal deviation, unilateral
absence of breath sounds, distended neck
veins. Cyanosis is a late manifestation
• may be confused with cardiac tamponade
but tension pneumothorax is more
common. Differentiation may be made by
unilateral hyper-resonance
45
46. • treat by immediate decompression: insert
needle into 2nd intercostal space in
MidClavicularLine. Ability to easily aspirate
air confirms diagnosis. In event of failure
to aspirate air, withdraw needle but
remember possibility of iatrogenic
pneumothorax now exists
46
47. Open pneumothorax
• sucking chest wound"
• if opening in chest wall is approximately 2/3 the
diameter of trachea air passes preferentially
through chest defect
• promptly close defect with sterile occlusive
dressing, large enough to overlap the wound’s
edges and taped securely on 3 sides to provide
a flutter-type valve effect. As patient breathes in
the dressing is sucked over wound while the
open end of the wound allows air to escape
during expiration
• place a chest drain in an area remote from the
open wound
47
48. Disruption of major airway
• clinical features vary with level of rupture but
usual picture is one of respiratory distress,
subcutaneous emphysema, haemoptysis
• pneumothorax invariable with ruptured
bronchus. Suspect bronchial rupture if
pneumothorax associated with a persistent large
air leak after placement of chest drain. Rupture
usually occurs within 2.5 cm of carina
• mediastinal emphysema common
• treatment of tracheal injuries: immediate
intubation with cuff positioned distal to tear.
Drain pneumothorax
48
49. Cardiac tamponade
• most commonly results from penetrating
injuries but may follow blunt trauma
• relatively small amounts of blood (approx.
100 ml) required to restrict cardiac activity
and interfere with cardiac filling. Removal
of small amounts of blood or fluid (often as
little as 15-20 ml) by pericardiocentesis
may have enormous beneficial effects
• diagnosis is often difficult:
49
50. – volume of heart sounds difficult to
assess in noisy environment
– distended neck veins may be absent
because of hypovolaemia
– pulsus paradoxus may be absent and
tension pneumothorax may mimic
tamponade
• consider possibility in patients who do not
respond to usual resuscitation and have a
mechanism of injury compatible with
tamponade
50
51. pericardiocentesis
• pericardiocentesis
– blind pericardiocentesis
• only if ultrasound/echo not available
• use sub-xiphoid route and preferably a
plastic sheathed needle for
pericardiocentesis. ECG monitoring is
necessary to detect needle induced
arrhythmias
51
52. – pericardial aspiration may not be diagnostic or
therapeutic if blood has clotted, which may be the
case after rapid bleeding. Open pericardiotomy
may be life-saving but is indicated only when an
experienced surgeon is available
– even if pericardial tamponade is strongly
suspected volume resuscitation should continue
while preparations are made for pericardiocentesis
– aspiration of blood alone may temporarily relieve
symptoms because of the self sealing qualities of
the myocardium but all patients with positive
pericardiocentesis following trauma require open
thoracotomy and inspection of the heart
52
53. Massive haemothorax
• incidence of haemothorax and haemopneumothorax
~50-60% in penetrating trauma and 60-70% in blunt
trauma. Majority are not massive
• massive haemothorax defined as >1500 ml of blood in
chest cavity
• clinical signs:
– unilateral dullness to percussion
– shock
– unilateral absence of breath sounds
– deviation of trachea
– neck veins may be flat due to severe hypovolaemia or distended
because of the mechanical effects of intrathoracic blood
• blood loss complicated by hypoxia
53
54. Management
• manage initially by simultaneous
restoration of volume deficits and
decompression of chest cavity. If auto-
transfusion device is available it should be
used
• emergency thoracotomy for massive
haemothorax or haemothorax with
ongoing loss of >200 ml of blood per hour
for 3-4 h
54
55. Systemic air embolism
• more common in penetrating injuries
• immediately life-threatening
• usually due to broncho-pulmonary vein fistula
• suspect if:
– focal neurological signs exist in the absence of head
injury
– circulatory collapse occurs on initiation of IPPV in
absence of tension pneumothorax
– froth is obtained in arterial blood gas sample from a
collapsed patient
55
56. Management
• Management
• If suspected:
• 100% O2
• minimise ventilation volumes and
pressures
• emergency thoracotomy to clamp
ascending aorta, remove air source (by
clamping pulmonary hilum) and aspirate
air from LV and ascending aorta
56
57. Flail segment
• major physiological insult is contusion of underlying lung
and decreased vital capacity
• occurs when 3 or more consecutive ribs or costal
cartilages are fractured bifocally.
• these circumscribed segments, having lost continuity
with the rigid thorax, move inwards with inspiration and
push outward with exhalation, thus moving paradoxically.
• presenting symptoms of pain, tachypnoea, dyspnoea,
and thoracic splinting, along with chest wall contusions,
tenderness, crepitance, and palpable rib fractures are
suggestive, but paradoxical chest wall motion is the
diagnostic sine qua non.
57
58. • may be difficult to diagnose if patient is already
mechanically ventilated, in pain, obese, or has large
breasts or subcutaneous emphysema.
• CXR is helpful in identifying multiple fractured ribs,
but will not reveal cartilaginous disruptions. Major
value of the CXR is in detecting associated injures
(more than 90% will have associated injuries-and 3
out of 4 require tube thoracostomy for
haemopneumothorax; extrathoracic injuries are
common: head injury in ~40%; major fractures in
40%, and intraabdominal injuries in 30%.
58
59. Distribution of flail
• Anterior: typically secondary to blows to the
sternum, eg motor vehicle accident, CPR
• Lateral: due to T-bone impacts or AP crush
mechanisms
• Posterior: result from direct blow to the back and
are characterized by simultaneous fractures
along the midaxillary line and the rib neck.
Splinting, plus a supine position effectively limit
paradoxical motion.
59
60. Management
• ~50% of cases can be managed without ventilation
• others require ventilation for 1-3 weeks
• chest wall usually stabilises in 1-2 weeks
• operative fixation is suggested by some authors. Main
benefit is to prevent deformity.
• weaning should not wait till paradoxical movement
improves, rather should be initiated when gas exchange
is adequate.
• in absence of systemic hypotension control
administration of IV fluids to prevent overhydration
60
61. • ~50% of cases can be managed without
ventilation
• others require ventilation for 1-3 weeks
• chest wall usually stabilises in 1-2 weeks
• operative fixation is suggested by some
authors. Main benefit is to prevent
deformity.
• weaning should not wait till paradoxical
movement improves, rather should be
initiated when gas exchange is adequate.
• in absence of systemic hypotension
control administration of IV fluids to
prevent overhydration 61
62. Lung contusion
• essentially a bruise of the lung. Aetiology controversial:
probably a combination of shear stress (tearing tissue)
and bursting forces (popping the balloons)
• direct injury causes pulmonary vascular damage with
secondary alveolar haemorrhage
• initially not much shunt as these alveoli are poorly
perfused
• subsequently tissue inflammation develops. Resultant
surrounding pulmonary oedema produces regional
alterations in compliance and airways resistance, leading
to localised V/Q mismatch
• atelectasis
62
63. • diagnosis is radiological.
– classically see nonsegmental pulmonary
infiltrates-progress in first 12-24 hours of
injury. Note that CXR undestimates degree of
contusion. CT more sensitive and better
method of assessing severity
– may be irregular nodular densities that are
discrete or confluent
– homogeneous consolidation
– diffuse patchy pattern
– early CXR changes suggest more severe
contusion. Early pulmonary contusion
infiltrates are due to alveolar haemorrhage
• radiological differential diagnosis includes:
63
64. • Aspiration
• Re-expansion of collapsed RUL
following right endobronchial
intubation
– in most cases infiltrates associated with
pulmonary contusion are not visible till
after fluid resuscitation.
• contusions tend to worsen over 24-48
hours and then slowly resolve unless
complicated by infection, ARDS or
cavitation
64
66. Other pulmonary parenchymal injuries
• Pulmonary Laceration
• Commonly associated with
haemopneumothorax and haemoptysis
• Usually managed with simple tube
drainage
• Pulmonary Haematoma
• Uncomplicated cases usually resolve in 3-
4 weeks
66
67. Posttraumatic Pulmonary Cavitary
Lesions
• Posttraumatic Pulmonary Cavitary Lesions
• Posttraumatic cysts, pseudocysts, or
pneumatoceles are cavitary lesions within the
lung parenchyma filled with fluid, blood, of air.
• CT is useful in diagnosis
• Most resolve spontaneously
• Some can become infected requiring antibiotics,
CT guided aspiration, and in some cases
surgical resection
67
68. • AV fistulas
• diagnosis by pulmonary angiography
• Torsion of the lung
• XR signs:
• Opacification of affected hemithorax
• Mediastinal shift toward the contralateral
side
• Reversal of bronchoalveolar markings of
the affected side, with the major pulmonary
vessels coursing cephalad instead of
caudad
68
69. Myocardial contusion
• Definition and epidemiology
• direct traumatic myocardial damage
without traumatic involvement of coronary
arteries
• common in blunt trauma but difficult to
diagnose
• tends to occur in acceleration/deceleration
and crush/compression injuries
69
70. Clinical features
• consider possibility in any patient with a
mechanism of injury that suggests likelihood of
cardiac contusion
• patients who are conscious may complain of
dyspnoea or chest pain
• may lead to significant physiological dysfunction
and even death but massive contusion leading
to cardiogenic shock is rare. In patients with
chest trauma cardiogenic shock is usually due to
cardiac tamponade or ventricular akinesia
70
71. • with compression in diastole valvular
dysfunction may occur; usually aortic
valve in older patients and mitral in
younger
• pericardial rub, S3 gallop, cardiac failure
• serious damage to virtually every cardiac
structure has been reported
• most common presentation is with
asymptomatic ECG abnormalities
although severe contusion will produce
cardiac failure.
• LAD damage may occur with resulting
anteroapical infarction 71
72. Investigations
• enzyme elevations, specifically CKMB correlate poorly
with contusion
• ECG changes: range from non-specific T wave changes
to pathological Qs. Multiple VPBs, unexplained sinus
tachycardia, AF, BBB (usually R) and ST segment
changes are most common ECG findings. Normal ECG
at admission makes cardiac contusion unlikely.
• TOE: +/- cardiac wall motion abnormalities. Exclude
lesions that will benefit from revascularization or other
cardiac surgery
• sternal # associated with low incidence of cardiac
contusion & arrhythmias
72
73. Management
• all patients with myocardial contusion should be admitted
to ICU for observation and cardiac monitoring (This view
is being challenged). Admit patients with arrhythmias or
heart failure to level 3 ICU
• non-urgent surgery should be postponed where possible
because of life threatening operative complications.
Consider invasive haemodynamic monitoring for patients
who have to undergo urgent surgery
• treat arrhythmias if life-threatening or associated with
cardiac failure; treat specific valve abnormalities
surgically.
• treat cardiogenic shock along usual lines with
optimization of preload, inotropes ± IABP. Exclude
tamponade
73
74. Prognosis
• Prognosis
• resolution of wall motion abnormalities in
~25% only (NB based on only 14 patients
• Ruptured aorta
• traumatic aortic injuries are the second
most frequent causes of death in patients
with chest injuries
74
75. Mechanism and types of injury
• Deceleration and traction-are the classic
wounding mechanisms of the thoracic arteries
• Horizontal deceleration creates shearing forces
at the aortic isthmus, the junction between the
relatively mobile aortic arch and the fixed
descending aorta. 90-98% of traumatic injuries
of the thoracic aorta occur at the isthmus
75
76. • Vertical deceleration displaces the heart
caudally and into the left pleural cavity and
acutely strains the ascending aorta or the
innominate artery.
• Sudden extension of the neck or traction
on the shoulder can overstrech the arch
vessels and produce tears of the intima, or
complete rupture of the arterial wall®
dissection, thrombosis, pseudoaneurysm
or haemorrhage
76
77. Diagnosis
• circumstances may be only clue: head-on
collision at high speed, ejection from a vehicle,
fall from great height
• one characteristic shared by all survivors is that
blood that leaks from aorta is in a contained
haematoma. Other than initial pressure drop
associated with loss of 500-1000 ml of blood,
hypotension responds to intravascular infusion.
Persistent or recurrent hypotension is usually
due to another source of bleeding
77
78. • Free rupture does occur but it is usually
fatal unless patient is operated on within
minutes
• CXR essential - always suspect ruptured
aorta if mediastinum wide especially if
associated with any of following:
– L haemothorax
– depressed L main bronchus
– blurred outline of arch or descending aorta
– (?) # 1st rib or L apical haematoma
– displacement of mid-oesophagus to R
78
79. • other suspicious CXR features: loss of
aorticopulmonary window, ant or lat deviation of
trachea, loss of paraspinal "stripe", calcium
"layering" in aortic arch
• signs such as apical pleural cap, mediastinal
width > 8 cm, 1st & 2nd rib #s no value in
indicating major arterial injury
• further investigations depend on CXR findings:
– further investigation not indicated if CXR normal
• if CXR technically unsatisfactory or mediastinal
contour equivocally abnormal then perform
thoracic CT first to look for mediastinal
haemorrhage
79
80. – This often also demonstrates aortic
pseudoaneurysm if present. If mediastinal
haemorrhage is present and aortic
pseudoaneurysm is not demonstrated then proceed
to aortogram
– if mediastinal contour on CXR clearly abnormal
proceed directly to aortography
• aortography is gold standard investigation although
TOE may supercede it. TOE may miss lesions of distal
ascending aorta or of arch vessels
• typical aortographic finding in patients with an aortic
tear is an irregular outpouching of aorta just distal to
left subclavian artery. 80
81. • Outpouching may be circumferential with
appearance of a "sleeve" around aorta or may
be localized, with abnormal area present only
along medial or lateral aspect of aorta
• NB there is frequently a convexity or a bulge in
region of embryonic ductus arteriosus. This is
usually smooth and symmetrical
• Treatment
• prompt surgery. Often requires
cardiopulmonary by 81
82. Injuries to aortic arch vessels
• Bleeding from an arch vessel is usually
contained, but in rare instances, the avulsion of
the origin of an arch artery causes massive
bleeding into pericardial or pleural cavity.
• Acute occlusion of the innominate or subclavian
may cause ischaemic symptoms of hand or arm
(acute ischaemia of the common carotid may
lead to brain ischaemia)
• Clinical features include cervical or
supraclavicular haematomas, bruits, diminished
peripheral pulses
82
83. Oesophageal perforation
• Oesophageal perforation
• usually due to penetrating injury but
occasionally follows blunt trauma
• +/- retrosternal pain, difficulty in
swallowing, haematemesis, cervical
emphysema
• CXR: +/- pneumomediastinum, widened
mediastinum, pneumothorax, hydrothorax
83
84. • consider diagnosis in any patient:
– with L pneumothorax or haemothorax without a
rib #
– who has received severe blow to lower sternum
or epigastrium and is in pain or shock out of
proportion to the apparent injury
– who has particulate matter appearing in the
chest tube drainage after the blood begins to
clear
• definitive investigation: gastrograffin swallow
or endoscopy
• immediate surgical repair with gastrostomy
or feeding jejunostomy
84
85. Ruptured diaphragm
• - usually due to gross abdominal
compression causing large radial tears.
Penetrating trauma tends to produce small
perforations that take some time to
develop into diaphragmatic hernias
- rupture of L hemidiaphragm more
common
- ± deterioration in respiratory status if
MAST trousers are inflated
- CXR features listed above
-
85
86. • if rupture of L hemidiaphragm is
suspected a NG tube should be inserted.
If this appears in thoracic cavity no further
investigations are required. Occasionally it
is necessary to inject contrast down NG
tube to confirm diagnosis
- if CT non-diagnostic consider MRI in
stable patients
- significant risk of gut strangulation with L
rupture
• 75% of patient with ruptured diaphragm have associated
intra-abdominal injury
- surgery should follow basic resuscitation
86
87. Rib fractures
• Most common injury
• Extent of trauma and mortality correlates directly
with the number of ribs fractured
• First three ribs fractured means a large amount
of force caused the injury ?recent study
challenges this concept
• Ribs 10, 11, and 12 are associated with blunt
injuries involving the spleen, liver, kidneys and
diaphragm.
• Fractures or three or more ribs are commonly
associated with pulmonary contusions
87
88. Chylothorax
• Injury to thoracic Duct
• Milky discharge from the chest tube
• Coservative treatment for 2 weeks
• Thoracotomy and ligation of Duct
88
