Lecture on chest trauma delivered during Basic Life Support 2018 course in Sibu Hospital. Encompasses basic sciences, classifications, principles and tips on management.

1. Chest Trauma
Chea Chan Hooi
Surgeon
Sibu Hospital
BTLS Sibu Hospital
14/08/2018

2. Content
• Introduction
• Anatomy
• Classification
• Injuries
– Rib fracture
– Lethal Dozen
• Conclusion
• Q&A

3. Introduction
• Common
• Significant contribution to the trimodal
distribution of trauma deaths
• “Lethal dozen”
• Only 15% need surgical intervention
• Rib fracture is the most common

4. Anatomy

5. Classification
• Etiology
– Blunt vs. penetrating
• Severity
– Immediate vs. potentially life-threatening

6. Rib fracture
• The most common
• Beware of pathological fracture, NAI
• Majority do not need operative treatment
• Non-operative treatment
– Supplemental O2
– Adequate analgesia
• Oral, IV, rib block, thoracic epidural
– Expectorant
– Chest physiotherapy
• Admission
– Elderly
– Underlying lung disease
– >2 ribs
– Involve 1st & 2nd ribs
– Suspect other chest or abdominal injuries, NAI

8. Lethal dozen
Immediate life-threatening
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Pericardial tamponade
Potentially life-threatening
• Thoracic aortic disruption
• Tracheobronchial injury
• Esophageal injury
• Blunt myocardial injury
• Pulmonary contusion
• Diaphragmatic injury

9. Immediate life-threatening

10. Airway obstruction
• Upper airway
• Etiology
– Laryngo-tracheal injury
– Foreign body aspiration
– Inhalational injury (flame burn)
• Beware of c-spine injury
• When to suspect?
– All neck trauma
– Cough, hoarseness, stridor
– Agitated
– Respiratory distress
• Confirm diagnosis
– Flexible or rigid endoscopy
– Direct laryngoscopy
• Management
– Sweep or Heimlich maneuver
– Nasotracheal or endotracheal intubation
– Cricothyroidotomy (needle or open)
– Tracheostomy

12. Tension pneumothorax
• Progressive build up of air within pleural space
d/t one-way-valve effect
• When to suspect?
– Trachea deviated away
– Hyperexpanded chest with hyperresonance
– Distended neck veins
• Clinical diagnosis
• Management
– Needle thoracocentesis
– Chest tube

14. 5th ICS, slightly anterior
to mid-axillary line
(ATLS 10th ed)

15. Open pneumothorax
• Accumulation of air within pleural space from
chest wall wound
• When to suspect?
– Open chest wound + reduced breath sounds
– Sucking sound
• Management
– Occlusive dressing
– Chest tube insertion

17. Massive haemothorax
• Rapid, massive accumulation of blood within pleural space
• IC vessels, lung parenchyma or IMA
• When to suspect?
– Patient in shock
– Stony dullness on percussion
– Trachea deviated away
• Confirm diagnosis
– eFAST
– CXR (>500ml)
• Management
– Chest tube insertion
– Surgical exploration
• Indications
– >1.5L blood upon insertion
– Continued bleeding >200ml/hr, >2 hrs
– Repeated transfusions to maintain hemodynamics
• Open thoracotomy or video-assisted thoracoscopy

19. Flail chest
• Fractures of ≥3 ribs at 2 points of each ribs
• Paradoxical movements
• Significant force over a large area
• Problems
– Pain limits breathing movement
– Loss of chest wall integrity
– Pulmonary contusion
• Management
– Supplemental O2
– Adequate analgesia
– Chest tube to drain any pleural effusion
– Mechanical ventilation

21. Pericardial tamponade
• Accumulation of blood within pericardial space 
restricting cardiac filling  reducing cardiac output
• Beck triad
– Distended neck veins
– Soft/muffled heart sounds
– Hypotensive
• Diagnosis
– FAST
• Management
– Pericardiocentesis

23. Potentially life-threatening

24. Thoracic aortic injury
• Those who survive and reach hospital
• When to suspect?
– Discrepancy of BP left & right UL
– Discrepancy of BP UL & LL
– Widened pulse pressure
– Chest wall contusion
– Widened mediastinum on CXR
• Confirm diagnosis
– CT aortography
– Echocardiography
• Treatment
– Operative repair (open or endovascular)
– Non-operative
• Keep SBP ~100mmHg
• Only in selected cases

26. Tracheobronchial injury
• When to suspect?
– Extensive subcutaneous emphysema ± respiratory distress
– Hoarseness of voice
– Haemoptysis
– Chest tube bubbling ferociously
– Failure of collapsed lung to re-expand despite adequate pleural
drainage
– Pneumothorax, pneumomediastinum on CXR
• Confirm diagnosis
– Bronchoscopy
– CECT scan
• Treatment
– Operative repair (stenting preferred)
– Non-operative
• Intubation
• Tracheostomy

28. Esophageal injury
• Usually from penetrating injury
• High index of suspicion
– Odynophagia
– Subcutaneous or mediastinal emphysema, retro-oesophageal
air
– Pleural effusion
– Unexplained fever
• Confirm diagnosis
– CECT esophagogram
– OGDS
• Treatment
– Operative repair <24 hrs
– Non-operative >24 hrs

29. Myocardial injury
• Blunt, rarely symptomatic
• When to suspect?
– ECG abnormalities
– Raised cardiac enzymes?
• Confirm diagnosis
– ECG
– Echo – wall motion abnormalities
• Treatment
– Close observation for at least 24 hours + ACLS

30. Pulmonary contusion
• Bleeding into lung parenchyma
• A/with significant chest wall injury
• When to suspect?
– All high impact chest trauma
– Haemoptysis, blood in ETT
– Worsening hypoxaemia within 24 - 48 hours.
• Confirm diagnosis
– Serial CXR
– CECT scan
• Treatment
– Supplemental O2
– Adequate analgesia
– Chest tube to drain pleural effusion
– Mechanical ventilation
– Avoid further physiological insults

32. Diaphragmatic injury
• Mechanism depends on etiology of chest trauma
• Commonly missed as a/with other significant injuries
• When to suspect?
– Penetrating injury below nipple line
– All upper abdominal blunt trauma
• CXR
– Raised hemidiaphragm
– Ryle’s tube, bowels within thoracic cavity
• Management
– Non-operative vs. operative

34. Conclusion
• Chest trauma are relatively common
• Trivial – life-threatening
• Vigilance & high index of suspicion
• Prompt & timely intervention is crucial
• Application of BTLS and ATLS protocols and
knowledge

35. Thank you!
Q&A?