This was presented as part of CME at King Faisal hospital , Kigali

1. Chest trauma
Presentation by Dr Fidele Havugimana
COSECSA-MCS Candidate
Supervisor: Dr Maurice Musoni, Consultant CT Surgeon

2. Content
 Introduction
 Chest anatomy
 Immediately life-threatening chest injuries
 Potentially life-threatening chest injuries
 Takehome message

3. INTRODUCTION
 The chest is anatomically/physiologically rich that it contains the 2 organs(heart&lungs) whose
lack of function traditionally used to define death before including brain activity as an important
criterion .
 Thoracic trauma is the 3rd most common cause of deaths after abdominal injuries and head
trauma in polytrauma pts(Morris et al, 2020-World Journal of Em Surgery)
 Thoracic trauma comprises 20-25% of all trauma worldwide, It accounts for 25% of trauma-
related death and is a contributing factor in another 25% of polytrauma pts
 A third of RTA’s have significant chest trauma
 Rwanda?

4. Thorax is the 4th most common(10%)
anatomical site of traumatic injuries
following craniofacial,LLs, ULs .
If such a rare case
happened in Rwanda, how
about the common
presentations?

5. Anatomy of the chest
Thoracic inlet connects the root of the
neck to the thoracic cavity
Thoracic wall

6. Anatomy of the chest----

7. BLUNT VS PENETRATING
BLUNT
PENETMA

8. Blunt Chest trauma
 Aceleration/Deceleration injury:
 MVA
 Fall > 3m
 Sports
 Compression(AP& transverse)
 Blast injuries
< 10% of BCT require surgical
interventions as opposed to 15-
30% in PCT

9. Penetrating Chest trauma
 High velocity:
 Gunshot
 Missile fragments
 Low velocity:
 stab

10. Initial management- Primary Survey (
ATLS Protocol)
 Airway/C-spine stabilization
 Trachea,bronchial disruption
 Breathing
 Chest wall integrity,pneumothorax, flail chest
 Pulmoray contusion
 Circulation
 Tamponade, hemothorax,tension pneumothorax
 Cardiac, great vessel injury
 Disability
 Exposure

11. The deadly Dozen !
Blunt, penetrating
Immediately life- Potentially life-threatening
1.Airway obstruction 1.Tracheobronchial disruption
2.Tension pneumothorax 2.Aortic disruption
3.Open pneumothorax 3.Diaphragmatic disruption
4.Massive haemothorax 4.Esophageal disruption
5.Cardiac tamponade 5.Cardiac contusion
6.Flail chest 6.Pulmonary contusion

12. Immediately life-threatening
……………..Primary Survey………………….

13. Airway obstruction
 Most common cause of Early preventable trauma related deaths
 Unconcious pt: tongue ! But also: dentures,teeth, secretions , blood clot
 Bilateral mandibular fractures, expanding neck haematoma.
Mgt
 BLS
Early intubation if:
 Severe TBI
 Neck heamatoma
 Possible airway oedema

14. Tension pneumothorax

15. Open pneumothorax ‘‘ Sucking chest
wound’’
 Hole in the chest wall due to blunt
or penetrating trauma
 Air moves freely in & out of the
pleural space
 Negative pressure is lost in the
pleural space causing the lungs to
passively collapse
 Lung tissue usually remains intact
 Sucking sound or bubbling at the
wound site on inspiration
 Dyspnea/tachypnea
 Unequal chest rise and fall
 Possible subcut air
 Signs of hypoperfusion

16. Open pneumothorax -management
 O2, monitor
 IV en routes
 Spinal immobilization as indicated
 Three-sided occlusive dressing
 Chest tube
 Observe for S&S of tension
pneumothorax
 If tension pneumothorax remove the
occlusive dressing & needle
thoracostomy

17. Massive haemothorax
 Blood accumulates in the pleural space
 Injury to the heart,great vessels ,intercostal
arteries
 More common to see hypotension before
resp distress
 Needs thoracotomy if:
 Initial drainage of more than 1500ml
 Ongoing haemorrhage of 200ml/hr over 3-
4 hrs
 Caution if drainage of 500ml and
persistence of dullness or radiographic
opacification

18. Cardiac tamponade
 Accumulation of fluid(blood) in the
pericardial space
 Reduced ventricular filling
 Pressure backs up and results in
o Decreased Veinous return
o Decreased stroke volume
o Decreased cardiac output
 Beck’s triad( Distended neck veins,
hypotension,muffled heart sounds)
 CXR:enlarged heart shadow
 HUS: pericardial effusion
 TTT: Pericardiocentesis

19. Flail chest
Two or more consecutive rib fractures at 2 or more
places
 Paradoxical motion of the flail segment
 Segment moves :
• in on inspiration
• Out on expiration
 Dyspnea
 Localized chest pain
 s/o poor perfusion, oxygen exchange
 Risk of pneumothorax, haemothorax & lung
contusion
 Massive force needed to cause this injury so think
about other injuries

20. Flail chest------ treatment
 Internal pneumatic stabilization---
unnecessary
 Adequate pain control
 Proper oxygenation
 ICU—supportive ventilation
 Generally operative fixation is
reserved for patients requiring
thoracotomy for other reasons
Operative vs conservative
management
Slobogean et al 2013, retrospective meta-
analysis , 11 studies,753 patients
 Surgical fixation offers better outcome:
 Substantial decrease in vent days(8
days,95% CI 5-10 days)
 Decreased ICU days(5 days 96%CI,2-8
days)
 Less risk of developing pneumonia
 Septicemia
 Mortality
 tracheostomy

21. Potentially life-threatening
………………………Secondary Survey…………………………….

22. Tracheo-bronchial disruption
 Blunt or penetrating trauma
 Presents with:
 Air leak, massive and sometimes uncontrollable
 Acute resp distress
 Neck & upper chest subcut empysema, sometimes massive
and disfiguring
 Rx-bronchoscopy-deep intubation(beyond injury) sometimes
tracheostomy

23. Aortic disruption
Aortic rupture
 Thoracic aortic rupture is a common cause of
sudden death after MVA and fall from height(1/3
fatality on site due to free rupture)
 80-90% fatality rate within 1st hour
 Exsanguination
 Usual site: distal aortic arch
 1:6 who die in MVA sustain AR
 Early recognition is a key to salvageability
Think about it if:
o Widened pulse pressure
o Rt , LT arm BP discrepancy
o UL,LL BP discrepancy
o Widened mediastinum on CXRmassive
o Haemothorax
o Fractures of 1st and 2nd rib
Confirm with:
o Aortography
o Contrast Spiral CT/mediastinum
Mgt
o Emergency surgery

24. Contained aortic rupture
 Contained injuries carry a good
prognosis
 Not the source of hypotension
 Salvageable tear-haematoma
contained
 1/3 die in 24 hrs w/o treatment
 Widened mediastinum unreliable on
portable x-ray
 TEE, contrast CT,aortogram

25. Diaphragmatic disruption
 Loss of thoraco-abdominal
separation
 80-90% occur from MVA
 L>R rupture----liver protection, 80-
90% occur on the Lt
 Respiratory distress
 Bowel sound in the chest
 Pre-op diagnosis in only 40-50%
 Operative repair in all cases

26. Esophageal disruption
 Mostly from PCT
 Odinophagia, subcut& mediastinal emphysema
 Unexplained fever within 24 hrs of injury
 Mortality raises exponentially if treatment delayed (12-24hrs)
 Esophagogram & esophagoscopy
 Management is mainly operative

27. Cardiac contusion
 Common steering wheel injury
 Range from minor to MI
 Must be suspected in any patient with
significant BCT who develops EKG
abnormalities in resuscitation room
 May be asymptomatic up to 8 hrs
 Can present in cardiogenic shock
 Possible dysrhythmia
 EKG
 Treatment may include amiodarone-
ventricular tachydysrythmias
 Mandatory monitoring for 24 hrs

28. Pulmonary contusion
 Hemorrhage into the lung
parenchyma
 Potentially lethal injury(mortality 6-
25%)
 risk factor for PNA&ARDS
 Worsening hypoxemia
 Hemoptysis in the ETT
 CT is the confirmatory imaging of
first choice
 Treatment: Oxygenation,physio and
analgesia

29. And…………….
RIB FRACTURES

30. RIB FRACTURES
 Very common
 Rare in children , common in elderly
 Rarely life –threatening in
themselves
 RIB 1,2 Vs RIB 8-12
 Mgt: strong analgesia, incentive
spirometry
 Admission if unable to cough and
clear secretions

31. Takehome message
 Significant proportion of deaths from chest trauma occur immediately
 Strict adherence to ATLS protocol is needed to identify and treat the deadly chest
injuries( simple and effective techniques like chest tube insertion by any medical
practitioner !)------85%.........
 Targeted and focused assessment is needed to detect and treat the potentially
life threatening chest injuries

32. References
 Gabin Mbanjumucyo,Naomi George, Alexis Kearney et al. Epidemiology of injuries and
outcomes among trauma patients receiving prehospital care at a tertiary teaching hospital in
Kigali, Rwanda, AFJEM Open Access, Oct 2016
 Herbert Butana, Laurance Ntawunga, Desire Rubanguka, and Isaie Sibomana. Tension
Viscerothorax In A Patient With Missed Traumatic Diaphragmatic Hernia. A Case Report.
EJMED ,April 2020
 Slobogean GP,Macpherson CA,Sun T. Surgical fixation vs non operative management of flail
chest, a meta-analysiss, J Am Coll Surg Feb 2013
 Herbert cubasch,Elias Degiannis. The deadly dozen of chest trauma,CME july 2004 Vol.22 No.7
 Hussein Elkhayat,MD Chest trauma refreshment for emergancy doctors, presentation July 2004
 Tony Melendez, RN BS, MICN EMS Educator Chest & Abdomen Trauma:Understanding &
Responding Appropriately ppt ,2013