Dr Anil Kumar, Assistant Professor , AIIMS Patna.

1. Dr Anil Kumar
Assistant Professor
Department of Surgical Disciplines
All India Institute of Medical Sciences
25-11-2015

2. Objective:
 Burden of Chest Trauma.
 Types of chest trauma.
 Background & Consequences/effect of chest injury
 Basic Principle to manage chest Trauma.
 Life threatening chest injuries
 Role of X-Ray & E-FAST in chest trauma
25-11-2015

3. Burden of chest trauma:
 Chest trauma : 10- 15% of all the cases .
 Responsible for 25% of death
 The rising burden of serious thoracic trauma
sustained by motorcyclist in road traffic crashes
(Bambach MR,Mitchell RJ 2014 Jan;. Epub 2013 Oct 19)
 The high burden of injuries in South Africa
(WHO:Rosana Norman, Richard Matzopoulos, Pam
Groenewald, Debbie Bradshaw)
25-11-2015

4. Types of Chest Trauma:
 Blunt
 Penetrating
 Explosion related
25-11-2015

5. Background:
 Significant cause of mortality.
 Immediate cause of death: Myocardial injury, Aortic
rupture
 Can be preventable : Prompt Diagnosis & Treatment.
 Thoracotomy : < 10 % of BTC & only 15-30 % of PTC.
 Majority of Chest Trauma patient can be managed:
simple intervention.
25-11-2015

6. Issues in chest Trauma: Hypoxia,
Hypercarbia & Acidosis
 Hypoxia: Inadequate delivery of oxygen to the tissue.
(A)Hypovolemia(Blood Loss)
(B)- Pulmonary ventilation/Perfusion mismatch
e.g- Contusion, Hematoma & Alveolar collapse
(C)Change in ITP relationship
e.g - Tension Pneumothorax
- Open Pneumothorax
25-11-2015

7. Issues in chest Trauma : Hypoxia,
Hypercarbia & Acidosis
 Hypercarbia: Inadequate ventilation.
(A) Change in ITP relationship
e.g - Tension Pneumothorax
- Open Pneumothorax
(B) Dec Level of consciousness
 Metabolic Acidosis: Hypo-perfusion of the tissu(Shock).
25-11-2015

8. Basic principle of Management:
 Primary survey
 Resuscitation of vital functions
 Adjunct of primary survey including CXR & E-FAST
 Detailed secondary survey
 Definitive care.
25-11-2015

9. Primary Survey
 Airway with cervical spine protection
 Breathing and ventilation
 Circulation with Hemorrhage control
 Disability: GCS
 Exposure(Undress)/Events with Hypothermia control
25-11-2015

10. Inspection Palpation Percussion Auscultation Diagnosis
Restricted
Chest move
CCT=+/- Hyper-
resonant
B.S= Dec/ - Tension
Pneumothorax.
Open wound CCT=+/- Hyper-
resonant
B.S=Dec/- Open
Pneumothorax
Restricted
chest move
CCT=+/- Dullness B.S=Dec/- Massive
Haemothorax
Paradoxical
movement
Asymetry
CCT=+ Dull/Hyper B.S=Dec/- Flail Chest with
pulmonary
contusion
Life threatening chest injuries:
25-11-2015

11. Tension Pneumothorax
 One-way valve air leak
 Air is forced to enter into the
thoracic cavity without any
means of escape
 Completely collapsing the
affected lung
 Mediastinal shift &
compressing the opposite
lung
25-11-2015

12. Tension Pneumothorax: Etiology
 Mechanical Ventilation with PPV in patients with
visceral pleural injury.
 CVP Insertion
Iatrogenic
 Esophageal Endoscopy
 Thoracic Spine #
 Chest Trauma (15-50% of severe chest trauma)
25-11-2015

13. Tension Pneumothorax:
 Dx – Absolutely clinical
-Restricted Chest Movement
-Absent Breath Sound
-Hyper-resonant note on Percussion
 Don't wait for radiological confirmation
 Immediate do the needle thoracostomy/ICD
( Definitive t/t)
25-11-2015

14. T/t of Tension Pneumothorax:
Needle
Thoracostomy in
2nd I.C.S in M.C.L.
Chest tube insertion in 5th
I.C.S in M.A.L.
25-11-2015

15. CXR - Pneumothorax.
JPNATC, AIIMS
25-11-2015

16. How to read CXR: ABCDEF
 Airway- Trachea
 Broncho alveolar Marking
 Cardiac Shadow
 Diaphragm
 External cage i.e the Bony
Area
 Foreign Bodies like
ET tube, Chest tube,
Central line, Nasogastric tube
25-11-2015

17. Open Pneumothorax
(Sucking chest wound)
25-11-2015

18. Open Pneumothorax
(Sucking chest wound)
Sucking wound
25-11-2015

19. T/t of open Pneumothorax:
 Apply Sterile Occlusive dressing over the defect
 Taped securely on 3 sides
 Provide Flutter -TypeValve
effect.
 Breath in- Dressing occlu-
des the wound & prevent
air to enter from out &
vice versa
25-11-2015

20. T/t of open Pneumothorax:
 Don’t put ICD through the defect
 Site of ICD – Remote from the wound
 Definitive surgical closure of the
defect after ICD insertion, when
pneumo subsides
Open wound
25-11-2015

21. Flail Chest & Pulmonary Contusion:
 If 2 or more ribs fractured in
2 or more places.
 Flail segment don't have
bony continuity.
 Paradoxical movement of flail
segment with underlying
normal chest movement .
 High association with Pulmonary
Contusion
25-11-2015

22. Flail Chest & Pulmonary Contusion
 Asymmetrical & uncoordinated chest movement
 Pain , Tenderness & Crepitation.
 CXR
 ABG
 CT
25-11-2015

23. Flail Chest & Pul. Contusion -M/n
 Better to admit- ICU ( Intubation & Ventilation)
 Administration of Humidified Oxygen.
 Fluid Resuscitation judiciously
 Analgesia- IV Narcotics/ Intercostals nerve block/
Epidural Anesthesia(Prefered)
 ICD (If A/w Pneumo/Haemo)
25-11-2015

24. Massive Haemothorax:
 Rapid accumulation of more than 1500 ml of blood in
the chest cavity
 Mainly caused by Penetrating wound- Disruption of
systemic & hilar vessels.
25-11-2015

25. Massive Haemothorax: Dx
 Restricted Chest Movement(Inspection)
 Breath Sound = Absent
 Dullness to Percussion
 Chest X-Ray
 ABG
 CT.
25-11-2015

26. Massive Haemothorax: M/n
 Follow the ABC.
 ICD (In Safety Triangle )
 IV Fluid – Infused 2 lit warmed RL very fast.
 5-10 ml blood for grouping & cross matching to start Blood
Transfusion at earliest.
 Auto transfusion from the ICD Bag.
 Plan- Thoracotomy (If indicated)
25-11-2015

27. Indication of Thoracotomy
 1500 ml blood collected immediately in ICD bag
 Blood loss @200ml/hr for 2-4 hrs.
 Persistent need of BT.
 Penetrating Injury -medial to the nipple line ( Over
anterior chest wall ) & medial to the scapula(Over
posterior chest wall)
25-11-2015

28. Penetrating Chest Trauma:
25-11-2015

29. Operative finding: Lacerated Lung
25-11-2015

30. E-FAST
 Lung USG is more sensitive than CXR for
Pneumothorax
 Perform rapidly at bed side by Surgeon, don't wait for
radiologist.
 Safe, fast & effective for detecting the pneumo
 Very easy to learn
25-11-2015

31. To detect Pneumothorax??
 A Line
 B Line
 Seashore sign
 Barcode sign
 Lung Point.
25-11-2015

32. E-FAST in Chest Trauma
25-11-2015

33. Bat’s Sign: Normal Finding: B Mode
25-11-2015

34. E-FAST in Chest Trauma: B mode
25-11-2015

35. Seashore sign & Barcode sign
Normal Lung
Pneumothorax- Find
the lung point
Seashore sign
Barcode sign
25-11-2015

36. Lung Point: Pneumothorax
25-11-2015
Barcode sign
Lung Point

37. Chest Trauma- Follow ABC
Nn
Bat’s Sign, Pleural Line
& Lung Sliding
Lung Sliding=
Absent
Bar Code Sign
Scan laterally &
Find the Lung
Point
Seashore sign
Put needle or Chest
tube
Switch to M Mode Normal Lung
25-11-2015
Pneumothorax
Bar code
Lung Point

38. Home Message!!!!!!!!!!!
 Thoracic trauma is a significant cause of mortality.
 Hypoxia, Hypercarbia & Acidosis- main concerned.
 Basic principle of m/n is the primary survey ( ABCDE)
 Life threatening injuries should be managed during
Primary survey.
 > 90% of BTC & > 70 % of PTC - simple intervention.
 E-FAST- Rapid, accurate & easily deployed and can be
lifesaving
25-11-2015

39. 25-11-2015