2. Trauma is predominantly blunt, and primarily result
of MVA and falls 8-10% chest trauma is penetrating
Chest wall trauma is most frequent injury after blunt
thoracic trauma
Chest trauma is predictor of more serious injury
elsewhere
Most chest injuries managed with observation,
analgesia, thoracentesis, and respiratory support
15-20% require thoracotomy
Operation rate <5% in blunt trauma and has poorer
outcome
Overall thoracic trauma mortality 10%
Accounts for ¼ trauma deaths
3. GOLDEN HOUR
Early deaths (within golden hour) caused by;
.Airway obstruction
.Tension pneumothorax
.Massive haemothorax
.Cardiac tamponade .
Open pneumothorax .
.Flail chest
8. PRIMARY SURVEY
AIRWAY MAINTENANCE
.Chin lift
.Jaw thrust
.Oropharyngeal airway
.Nasopharyngeal airway .Definitive
airway - ETT - Surgical airway
.Prehospital ETT confers no survival
advantage over BVM and slightly increases
prehospital time .
9. PRIMARY SURVEY
C-SPINE
CT significantly out performs, plain X-ray as
screening tool for very high risk C-spine injury
CT should be initial screening tool in those with
significantly depressed mental status Plain x-
ray still recommended as initial screening test
for low risk patients
10. PRIMARY SURVEY
BREATHING
Look – symmetrical chest movements
asymmetry or splinting or flail
Listen – breath sound both sides
Feel : abnormalities
.Oxygen
.Suction
.Pulse oximetry
11. PRIMARY SURVEY
BREATHING
Sensitivity physical examination in trauma
Auscultation 100% sensitive in detecting HPX in blunt chest
trauma, and only 50% sensitive in penetrating trauma, but 100%
specific
In presence of unequal BS, CXR unnecessary to confirm HPX,
and ICC can be inserted on basis of auscultation. Auscultation
poor screening tool for HPX in penetrating trauma .Blunt chest
trauma patients who are stable with normal physical
examination do not need routine CXR
All victims penetrating trauma require CXR because many will
have hemothorax in absence of clinical findings.
13. Clinical diagnosis
May arrive in ER dead or dying
Most easily treatable life-threatening surgical
emergency in the ER
Characterized by chest pain, air hunger,
respiratory distress, tachycardia, hypotension,
tracheal deviation to contralateral side,
ipsilateral side decreased BS and percussion
tympany, neck vein distention, cyanosis
Treatment should not be delayed for radiology
Requires immediate needle decompression
MCL 2nd ICS followed by ICC 5th ICS
14. OPEN PNEUMOTHORAX
If opening in chest wall 2/3 diameter
trachea, air passes preferentially through
defect with each respiratory effort
16. 2 or more # ribs in 2 or more places
Severe disruption normal chest wall movement with paradoxical
movements
If significant underlying lung injury exists, serious hypoxia may result
Diagnosis made by clinical examination, CXR, CT
ABG required to assess need for mechanical ventilation
TREATMENT
humidified O2, analgesia, judicious fluids, mechanical ventilation
(PEEP, SIMV, PSV), bronchoscopic aspiration, chest physiotherapy,
+/- IV Atb
Indication for mechanical ventilation; Pa02<60mmHg,
PaC02>50mmHg, assoc severe trauma with LOC +/- shock, airway
obstruction or repeated atelectasis
Surgical stabilization – indicated if prolonged ventilatory assistance
expected; benefits include - less ventilatory support and pneumonia,
shorter ICU stay, cost effective, improved FVC, faster return to work
18. >1500ml blood in chest cavity, or
<1500ml initially, but 200ml/h for 2-4hr
Signs; shock, absence breath sounds +/- dullness percussion on
one side chest, ventilatory embarrassment, shift mediastinum
Management; restoration blood volume (crystalloids +
blood/autotransfusion), decompression chest cavity (#38F ICC
5th ICS) – may need to clamp tube and consider autotransfusion
Do not wait for CXR to confirm diagnosis
Indication for urgent thoracotomy, esp. if ongoing
transfusion requirements
85% cases due to injured systemic vessel; intercostal or internal
mammary artery, less commonly hilum of lung or myocardium
15% cases due to deep pulmonary lacerations – treated by
oversewing or resection segment or lobe
Beware penetrating wounds medial to nipple anteriorly, or
scapula posteriorly as may require ER or urgent thoracotomy for
possible damage to great vessels, hilar structures, or heart, with
potential for cardiac tamponade
Definition
20. Pericardium fills with blood from heart,
pericardial vessels, or great vessels
15-20ml may be enough to cause
haemodynamic compromise
Most commonly from penetrating injuries
Any patient with penetrating thoracic injury
has cardiac injury until proven otherwise
Wounded heart will follow on of two courses;
exsanguination or tamponade (80%)
Exsanguination group - most die in field or in
ER – if survive show signs hemorrhagic
shock
Definition
21. PRESENTATION
Beck’s triad (over 90% cases)
.venous pressure elevation •
.decline arterial pressure •
.muffled heart sounds
(hypotension may be due to hypovolaemia, neck veins
may not be distended due to hypovolaemia) May be
restless and anxious and refuse to lie supine Pulsus
paradoxis >10mm Hg (10% cases) Kusssmaul’s sign
– rise in venous pressure with inspiration
PEA in absence of hypovolaemia or tension
pneumothorax suggest cardiac tamponade
22. Pericardiocentesis indicated if high index suspicion and
failure to respond to resuscitation for hemorrhagic shock
All patients with positive pericardiocentesis require open
thoracotomy.
Management
24. ER THORACOTOMY
Dismal survival
Best outcomes with ;
• Isolated chest injury
• Single vs multiple chest injuries
• Penetrating injury
• Stab rather than gunshot
• Right sided, single chamber heart injuries
• Major factor in outcome is presenting physiology - Better
outcome if vital signs present on admission
• If BP present on arrival ER – survival advantage if
thoracotomy performed in theatre
• Prehospital intubation
• Cardiac tamponade
• Presence mentation in field or on arrival in ER
25. ER THORACOTOMY
Six potential therapeutic goals;
Control bleeding (cardiac or thoracic)
Effective cardiac compressions
Relief pericardial tamponade
Cross clamp lung hilum after suspected air
embolism
Cross clamp descending aorta for lower torso
hemorrhage control
Confirm ETT placement
26. URGENT THORACOTOMY
INDICATIONS;
Massive hemothorax
>1500ml blood from ICC immediately >200-
300ml blood from ICC after initial drainage
persistent blood transfusion requirements
Penetrating injury to anterior chest with cardiac tamponade
Cardiac arrest (resuscitative thoracotomy)
Large open wounds of thoracic cage
Major thoracic vascular injuries with hemodynamic instability
Major trachiobronchial injury
Evidence osophageal perforation Bullet embolism to
heart/pulmonary artery ? Mediastinal traverse with
penetrating object .
30. Second most common injury from chest trauma after #ribs
Upto 50% occult and not seen on initial CXR 20% have
accompanying hemothorax From both penetrating and
blunt trauma Signs; decreased BS on affected side
hyperesonance on affected side Erect CXR required for
diagnosis Managed by ICC 5th ICS (28Fr)
ICC is safest option, irrespective of size, because unpredictable
progression to tension pneumothorax
Observation +/- aspiration risky! and 10% fail conservative Rx
Always needs ICC if undergoing transport, GA, or PPV( 40%
increase size)
Small bore pleural catheters assoc with increased incidence
recurrence and complications
32. Blunt or penetrating trauma
Bleeding from; lung laceration, intercostal
vessel, internal mammary artery, T-spine #
Usually self-limiting
if large enough to appear on CXR needs ICC
ICC reduces late incidence of empyema or
fibrothorax.
34. Most common potentially lethal chest injury
Damage to parenchyma from passage shock wave
through tissue
CXR – may be normal, but usually shows opacity in lung
field, lags 12-24hr behind clinical picture
Respiratory failure subtle and develops over time. ABG
worsens at day 2-3 as oedema increases, careful
monitoring and reevaluation. Intubation and ventilation
if Sao2<90% especially if co- morbidities, or being
transported
In multi-injured trauma patient pulmonary contusion may
be superimposed by sepsis, SIRS, MODS, ARDS
Definition
36. TRACHEOBRONCHIAL TREE INJURY
Uncommon injury (<2% major thoracic injuries)
Often overlooked on initial assessment In blunt
trauma the majority injuries occur within 2.5cm
carina
Most die at scene
If survive - high mortality from associated injuries
SIGNS;
hemoptysis, subcutaneous emphysema, tension
pneumothorax with mediastinal shift, progressive
mediastinal air
Suspect if persistent large air leak after tube
thoracostomy or if surgical emphysema
37. TRACHEOBRONCHIAL TREE INJURY
Mor than one ICC may be needed to overcome leak
and expand the lung.
Confirmed on bronchoscopy
Opposite main stem bronchial intubation may be
temporarily required
TREATMENT;
Distal bronchus – usually close with chest tube drainage
alone within days
Proximal bronchus – posterolateral thoracotomy – repair
bronchus with monofilament if possible, otherwise
segmentectomy or lobectomy required
39. BLUNT CARDIAC INJURY
Suspect in any patient who sustains high energy impact to
thorax
May cause; myocardial contusion, cardiac chamber rupture,
valvular disruption
Assoc injuries common – sternal #, #ribs, flail chest, seatbelt
sign over precordium
May be asymptomatic
Chamber rupture – most die in field, typically presents with
cardiac tamponade (mostly R side) – presentation and treatment
similar to penetrating injuries
Myocardial contusion may present with chest discomfort,
hypotension, conduction abnormalities, valvular dysfunction,
papillary muscle rupture, raised CVP (due to RV dysfunction)
40. BLUNT CARDIAC INJURY
DIAGNOSIS – goal is to identify patients who need treatment (few)
ECG
variable, multiple PVC’s, sinus tacchycardia, AF, BBB usually R, ST
segment ∆ (ST or T-wave ∆ more specific than arrhythmia) negative
ECG predicts absence of contusion, and even more strongly suggests
patient not likely to suffer cardiac complication Troponin
no correlation with level and severity injury, reports vary as to
whether it adds any more info to ECG
Transthoracic Echo
as part of FAST in all patients with truncal trauma in some centres
indicated if clinical, biochemical, ECG abnormality, wall motion
abnormality, thrombi, pericardial effusion
Less commonly – radionuclide angiography, TOE
41. BLUNT CARDIAC TRAUMA
If ECG, Troponin, and FAST normal, and no clinical
signs or cardiac dysfunction – do not pursue diagnosis
further
Second troponin and ECG 8hr after injury required to
reliably exclude significant myocardial injury
If clinical, ECG, or chemical evidence of cardiac
contusion, then monitor in HDU/CCU/ICU until resolution
clinical signs and return ECG/Troponin to normal
Unstable patients admitted to ICU
Overall prognosis after cardiac contusion is good
43. Common cause of sudden death after MVA or fall from height –
80-85% mortality before reaching hospital
If survive tend to have incomplete laceration near ligamentum
arteriosum at aortic isthmus (95%), just distal to LSCA – fixed
nature at this point
All survivors have contained hematoma -intact adventitial layer
or contained mediastinal hematoma prevent immediate death If
survive to hospital – 30% mortality in 6hr, 40-50% mortality in
24hr
Persistent or recurrent hypotension is usually due to other cause
If ruptures into L chest is fatal within minutes
Specific signs and symptoms frequently absent Diagnosis
made by high index suspicion, mechanism injury
(deceleration), characteristic radiological findings, TOE, CT
angiogram, arteriography
44. Signs on CXR;
Widened mediastinum (>8cm, or M/C ratio >0.3)
Obliteration aortic knob
Deviation trachea to Rt
Obliteration space between pulmonary artery and
aorta
Depression L main stem bronchus
Deviation esophagus to R (NGT)
Widened paratracheal stripe
Widened paraspinal interfaces
Presence of pleural or apical cap
Left hemothorax
#1st or 2nd rib or scapula
Angiography should be performed liberally
45. 1-2% cases have normal CXR
If suspicion exists, patient should be evaluated at facility
capable of repairing injury
Angiography is gold standard Multi-
detector row CT Angiogram – • faster
time to diagnosis than angiogram • non-
invasive
• emerging as gold standard
• Normal mediastinum with no hematoma, and regular aorta
surrounded by normal fat has 100% NPV for aortic injury • most
authors recommend abnormalities on CT be followed by
angiogram
47. TRAUMATIC DIAPHRAGMATIC
INJURY
Diaphragmatic injury most common injury requiring
surgery after blunt trauma
More commonly diagnosed on L, but near equal
incidence
Diagnosed by physical examination, CXR – elevated
or indistinct hemidiaphragm, bowel, stomach, NGT in
chest (20% CXR normal)
CT scan, US
Liver obliterates defect or protects it on R side – more
difficult to detect initially, 75% delayed diagnosis, MRI
helpful in R sided injuries
Elevated R hemi diaphragm may be only finding on
CXR
48. TRAUMATIC
DIAPHRAGMATIC INJURY
Blunt trauma produces radial tears that lead to herniation
Penetrating trauma produces small perforations that
often take time, even years to develop
If injury suspected on left side – NGT should be inserted
Upper GIT contrast study necessary if diagnosis unclear
Laparoscopy or Thoracoscopy may be useful if diagnosis
unclear
Laparotomy for other causes may reveal diaphragmatic
injury
49. TRAUMATIC
DIAPHRAGMATIC INJURY
TREATMENT
All diaphragmatic injuries should be repaired even if
small and of no apparent importance, due to risk
herniation and incarceration
Preferred closure is direct repair with interrupted non-
absorbable sutures
Synthetic materials may be required to close large
defects
50. MEDIASTINAL TRAVERSING
WOUNDS
Penetrating objects that traverse mediastinum may
injure heart, great vessels, tracheobronchial tree,
esophagus
Diagnosis made when examination or CXR reveals
entrance wound in one hemithorax and exit wound or
missile lodged in opposite side or mediastinum If
hemodynamically abnormal consider exsanguinating
thoracic hemorrhage, tension pneumothorax,
pericardial tamponade Bilateral ICC’s necessary
Indications for urgent thoracotomy similar for massive
hemothorax
Both sides may need thoracotomy but start with side
with most blood
52. OSOPHAGEAL RUPTURE
Most commonly penetrating
Blunt trauma causes forceful expulsion stomach contents into
esophagus – linear tear in lower esophagus which may leak into
mediastinum
Mediastinitis with immediate or delayed rupture into pleural
space causes empyema
Mortality >20%
Prompt recognition and initiation treatment mandatory
Delays in treatment assoc with higher morbidity and mortality
Primary closure within 24hr best outcome
Needs to be excluded in all patients with traversing mediastinal
injuries
May present with painful swallowing, hematemesis,
subcutaneous emphysema, SOB, fever
53. OESOPHAGEAL RUPTURE
Consider in all patients with;
• L pneumothorax or hemothorax without rib #
• Blow to sternum or epigastrium with pain +/- shock inconsistent with
apparent injury
• Food or particulate matter in ICC
• Mediastinal air on CXR
• Persistent pneumothorax
Confirm with esophagogram or esophagoscopy
Esophagogram difficult in intoxicated, combative, unprotected
airway, poor view cervical esophagus if intubated Endoscopy
– sens and spec 90-100%, performed in ER or at bedside
Endoscopy all patients with signs and symptoms or suspicious
nature of injury
May be role for VAT in diagnosis and treatment
55. Most common injured part of chest
Pain impairs ventilation and effective coughing which
may lead to atelectasis and pneumonia especially
with pre-existing lung disease
# scapula, 1st or 2nd rib may have severe associated
injuries with mortality up to 35%
Ribs 4-9 sustain majority of blunt trauma
More force required in younger patients
# ribs 10-12 should raise suspicion for hepatosplenic
injury
56. Likelihood of hepatosplenic injury;
10-16% rib #’ have concomitant intra-abdominal
injury to liver or spleen
Liver injury increased with low rib # (8-12), R
sided rib #
Splenic injury increased with low rib #.lt sided.
57. IMAGING
CXR has poor sensitivity, and rarely influences management #
anterior cartilages or separation costochondral junctions may
not be seen on CXR
Special rib view Xrays unnecessary as may not ∆ management
Ultrasound reveals rib # more accurately than X-ray and clinical
acumen, specificity 85%
USS superior to CT scan without radiation dose Follow-up
USS at 3/52 post injury is gold standard May impact on
patients with higher levels of activity such as manual
workers or athletes wrt return to work and physical activity
58. SIGNS
localized pain, tenderness, and crepitus
TREATMENT
Goal of treatment is to exclude underlying more serious injury, and
ensure adequate analgesia
Analgesia with; PO and IV analgesics, PCA, intercostal block,
epidural
Oxygen
Physiotherapy
SURGERY
Surgical stabilization may reduce pain and ventilator requirements
Methods ; fixator plates, intramedullary wires or nails, struts
Indications ; select group with flail chest not weaning from
mechanical ventilation after 5-7/7 with only moderate extrathoracic
injuries and no HI, pulmonary contusion, or ARDS.
60. Usually result of direct blow May be
accompanied by pulmonary
contusion
Consider blunt cardiac injury with all
sternal #
Does not necessarily require monitoring
Operative repair needed . posterior
sternoclavicular dislocation may cause
SVC obstruction needs reduction.
