This Presentation was made during MS surgery Residency at Department of Cardiothoracic and Vascular Surgery, MMCVTC, Institute of Medicine( IOM) TUTH

1. CHEST TRAUMA
DR SANTOSH DEV
MS, General Surgery Resident
Department of GI & General Surgery
IOM, TUTH

2. OUTLINE
• Introduction
• Initial Evaluation
• Emergency department Thoracotomy(EDT)
• Secondary evaluation & definitive Diagnosis
• Indications of Urgent Operative interventions
• Chest Wall injuries(Ribs #, Sternal #, Flail chest)
• Lung Injuries(Contusions, laceration)
• Cardiac Injuries(Penetrating, blunt, myocardial contusion)
• Other injuries(Tracheobronchial, Esophageal, Great vessels,
Traumatic Aortic aorta)
• Retained Hemothorax & Posttraumatic Empyema

3. INTRODUCTION
• The concept of a “golden hour” following trauma is widely attributed
to R. Adams Cowley, founder of Baltimore’s Shock Trauma Institute,
who in 1975 stated “the first hour after injury will largely determine a
critically injured person’s chances for survival.”
• Based on Research Data, Patients with severe hemorrhage from
significant thoracic injuries likely have far less than a 60-minute
window for definitive therapy before their outcome and survival are
compromised.

4. • 42% deaths – brain injury
• 39% death-Major bleeding,
mainly torso
• Successful resuscitation with
techniques such as “damage
control resuscitation” and
“damage control surgery” –
improved survival
DEMOGRAPHY

5. • Accounting for 1,40,000 deaths annually, leading cause of death in
patients younger than 40 years of age
• Primary or contributing cause of death in up to 50% of all trauma-
related deaaths
• Fortunately, majority can be treated effectively by simple maneuvers,
however 10 to 15 % have severe, life threatening injuries require
Definitive operative repair.
CHEST TRAUMA

7. • Thorax term refers to the area between the neck and abdomen
enclosed by the ribs, sternum, and vertebrae radially, the thoracic
inlet superiorly; and the diaphragm inferiorly
Significance:
• Negative inspiratory force –initiate ventilation
• Positive expiratory force for vocalization, creates a frame for the neck,
upper extremities, thoracic structures and abdomen.
ANATOMY

8. THORACIC CAGE

10. INITIAL EVALUATION

11. EMERGENCY DEPARTMENT THORACOTOMY(EDT)
• Goals: -Hemorrhage control -Cardiac compression
-Crossclampingof Hilum/aorta -Cardiactamponade
• Indications: Isolated penetrating chest injury
with
i) greatest chance of survival & the absence
of life- absent pulse/ gag reflexes
ii) Asystole at presentation
• Standard Incision: LT ANTEROLATERAL
THORACOTOMY

12. CHOICE OF INCISION

13. SECONDARY EVALUATION & DEFINITIVE DIAGNOSIS
• Physical examination & simple Chest xray
• After Stable- CT better to detect:
-simple rib #, -Flail chest segments,
-pneumothorax, -hemothorax,
-pulmonary contusion -tracheobronchial &
-esophageal injuries
• CTA- for aortic/ great vessels injuries
• ECHO- for assessing proximity wound to the heart

14. INDICATION OF URGENT OPERATIVE INTERVENTION

15. AIRWAY OBSTRUCTION

16. Presentation
• Three Possible Presentations:
1. asymptomatic
2. wheezing (from airway narrowing) with a persistent
cough and signs of obstructive emphysema;
3.pyrexia with a productive cough from pulmonary
suppuration.

17. Treatment
• Early Intubation-Important, Part Neck hematoma or possible
airway edema(Delayed intubation- Difficult)
• Treatment of the underlying cause
Sometimes- Tracheostomy
Chest radiograph
• If foreign body- Endoscopic removal

18. TENSION PNEUMOTHORAX
• “one-way valve” air leak occurs
either from - lung or the chest wall
• Most common cause-Penetrating
chest trauma, blunt chest trauma
with a parenchymal lung injury & air
leak, iatrogenic lung injury &
mechanical positive pressure
ventillation

19. Presentation
• Tachypnea, dyspnea, Distended neck veins
• Clinical examination-Tracheal deviation, not necessary, late
• Percussion-Hyperresonance
• Auscultation- Decreased/Absent Breath sound

20. Treatment
• Immediate decompression(large
bore cannula) 2nd ICS mid-
clavicular line fb
• Chest tube-5th ICS in anterior
axillary line

21. PERICARDIAL TAMPONADE
• Any Penetrating injury near the
heart+ shock-cardiac injury until
proven otherwise
• Presentation- CVP elevation,
decreased BP, Muffled heart sound
(Beck)
• Neck may be flat- if massive bleeding
occurred
• eFAST-Diagnostic
• Chest radiography

22. PERICARDIAL TAMPONADE

23. Treatment
• Needle pericardiocentesis-Suggested
often “Dry tap”
(Penetrating injury-clot in the
pericardium)
High potential of iatrogenic injury
• Definitive TT- Oerative; Subxiphoid
window or Open surgery (sternotomy
or lt thoracotomy) with repair of heart

24. Crucial 1° Survey Differential Dx: Cardiac
Tamponade vs Tension Pneumothorax
Clinical Sign Cardiac
T
amponade
Tension Pneumothorax
Blood Pressure Low (PEA) Low
Cardiac Tones Muffled Normal
Breath Sounds Normal Absent - collapsed side
Neck Veins Distended (flat in
hypovolemia)
Flat
Respirations ± Normal Tachypnea
Treatment Needle/drain
pericardium
Needle/tube chest

25. MASSIVE HEMOTHORAX
• Most common cause-Blunt injury from
torn intercostal vessels or IMA 2 to # of
ribs
• Significantly compromise resp efforts
• Presentation is with haemorrhagic shock,
flat neck veins, unilateral absence of
breath sounds and dullness to percussion

26. Management
Aimed at -correcting the hypovolaemic shock, insertion of an
intercostal drain and, in some cases, intubation
urgent thoracotomy Indication:
1. Initial drainage of more than 1500 mL of blood or
2. ongoing haemorrhage of more than 200 mL/h over 3–4
hours

27. OPEN PNEUMOTHORAX
• “Sucking Chest wound”
• d/t Large open defect in the
chest(>3 cm)
• Opening in the chest wall exceeds
2/3rd the diameter of the trachea-air
build up
• Closing the defect-Sterile occlusive
plastic dressing, taped on 3
sides(flutter type valve)
• EMERGENCY ICCT insertion

28. Occlusive Dressing

29. CHEST WALL INJURIES
RIBS FRACTURES
• Most common, from blunt trauma
• Consequences-Pain, splinting,
prevention of adequate cough
• Confirmed by anterior- posterior or
lateral-lateral manual compression.

30. Management of Ribs #
• Routine chest radiograph vs CT, high sens and spec
• Conservative-Adequate pain management-Oral analgesics,
Thoracic epidural anesthesia, encouraging good pulmonary
Toilet
• Operative repair-flail chest, painful moveable rib fractures
that are refractory to conventional management, chest wall
deformity/defect, rib fracture nonunion, and during
thoracotomy.

31. STERNAL FRACTURES
• Mainly MVA, assosc with
underlying thoracic and abdominal
injuries
• Diagnosis- Severe pain, instability
on sternal palpation
• Mostly Transverse fractures,
majority occurring near
sternomanubrial joint.

32. Management of Sternal #
• Identification or exclusion of other life threatening injuries
with ECG, chest radiograph.
• Conservative- mostly managed by adequate oral analgesics
on OPD basis
• Operative- ORIF for unstable fracture or displacement by
more than 1 cm of overlap

33. FLAIL CHEST
• Most serious, mainly blunt trauma
• Fracture of adjacent ribs, each of
which is fractured in two or more
places
• A panel of chest wall moves
independently of, and in the
opposite direction to, the
remainder of the chest(i.e
paradoxical motion)

34. Management of Flail Chest
• Early and aggressive pain control with Oral analgesics and
parenteral narcotics with PCA device. Thoracic epidural
anesthesia is the mainstay
• Ambulation and frequent coughing Encouraged
• Operative repair of rib fracture- Most beneficial
Excellent outcomes for patients with flail chest of > 3 ribs
“A reduction in ventilator days, pneumonia, ICU days, analgesic use, and other
morbidities has inconsistently been demonstrated when rib fixation is undertaken”

35. CHEST TRAUMA
(cont……)
DR SANTOSH DEV
MS, General Surgery Resident
Department of GI & General Surgery
IOM, TUTH

36. OUTLINE
• Introduction
• Initial Evaluation
• Emergency department Thoracotomy(EDT)
• Secondary evaluation & definitive Diagnosis
• Indications of Urgent Operative interventions
• Chest Wall injuries(Ribs #, Sternal #, Flail chest)
• Lung Injuries(Contusions, laceration)
• Cardiac Injuries(Penetrating, blunt, myocardial contusion)
• Other injuries(Tracheobronchial, Esophageal, Great vessels,
Traumatic Aortic aorta)
• Retained Hemothorax & Posttraumatic Empyema

37. LUNG INJURIES
• More common in penetrating vs blunt
injury
• Majority- pneumothorax/hemothorax-
chest tube & full reexpansion of the
lung.
20-40% of penetrating injury and 15-
20% of blunt injury requiring
thoracotomy will need some form of
lung resection.

38. BLUNT TRAUMA VS
PENETRATING
• Blunt, more severe & difficult lung
injury, worse outcomes as difficult
to treat surgically
• If profuse lung bleeding-hilar
control
• Pneumonectomy-if both artery and
vein injured, assosc with 50 -100 %
mortality rates

39. LUNG CONTUSIONS
• V/Q mismatch- SOB,
Respiratory failure req
mechanical ventilation
• Chest xray vs CT, size of
contusion α post traumatic
ARDS risk
• Contused lung- Risk factor for
pneumonia

40. Investigations
• Chest Xray- Initial Test.
(At least24-48 hrs-Contusions, Severe)
• CT- valuable for Pulmonary
contusion identification
(High density lesions)

41. • Most contusion resolve by 3 to 5 days( If adequately resuscitated and
not complicated by Superinfection)
• Mainly supportive care - Aggressive Pulmonary Toilet,
- Adequate Pain Control -ventilation (If necessary)
• Monitor for Respiratory Decompensation:
- ↑RR -Agitation -Hypoxemia
(Avoid Steroid- Flare up infection, no role in resolution of contusion)
Management

42. OPERATIVE MANAGEMENT
• Indications:
i)Hemorrhage(>1500 mL initially or >300 mL/hr for >_3hrs
ii) Persistent air leak impairing ventilation
• Common procedures-
i) simple suture repair or
ii)wedge resection using a stapling device
• Incision- 5Th ICS Posterolateral of the involved side
(Mostly -lung sparing techniques such as non-anatomic stapled
resections or tractotomies)

43. TRACTOTOMY
Deeper laceration-
Resection/ Tractotomy
Mortality:
∞ amt of lung tissue
resected
• 9% - suture repair
13%- tractotomy
• 30%-Wedge resection
43%-lobectomy
• 50%-Pneumonectomy

44. CARDIAC INJURIES
• 10-70% mortality
• Pericardium- Poor compliance, as
little as 50 ml of blood- cause
tamponade.
• Sensitivity of USG in detection of
hemopericardium- diminished in
the presence of Hemothorax

45. Management
• Pericardial window vs EDT,
(depending upon
hemodynamic status)

46. • 20% clinically silent, subsequently
diagnosed at OR or imaging
• 50% Pericardial Tamponade
• Remaining 30%-Hemorrhagic shock
develops, bleeding due to atrial or
ventricular wound into one/both
hemithoraces.
PENETRATING CARDIAC INJURIES

47. Diagnosis
• High index of suspicion for- area
bounded sup by clavicles, laterally by
mid clavicular lines and inferiorly by
the costal margins
• 2D-cardiac Usg, sensitivity 96 to
100% and specificity of 100%
• Subxiphoid Pericardial window-Gold
standard for diagnosis of cardiac
injury
Cardiac Box (described initially)

48. • Approaches-
Median sternotomy-access
to all four chambers, suitable
for most precordial stab,
gunshot wound low caliber
Left thoracotomy-if cross
clamping of the thoracic
aorta, assosciated thoracic
visceral injuries

49. Treatment:
• Atrial wound, Rt/LT ventricular free wall injuries(away from
coronary arteries)- finger pressure, vasc clamp, oversewing,
hor mattress suture under the wound and continuous
epicardial suture
• Ventricular injuries(adjacent to coronary arteries), - CPB
often required
• LT ventricular- repaired with felt-pledgetted or pericardial
plegetted sutures (vs Rt- without Pledgets)
• Intracardiac injuries- feel for pulmonary thrill for vsd, digital
palpation through atrial wounds for ASD, AV insufficiency;
Repaired after Hemodynamically Stable

50. BLUNT CARDIAC INJURIES
• Usually MVA or a fall, assoc with
sternal or rib #
• Most common location-Anterior
heart, Right ventricle primarily
• Direct impact-myocardial cell death,
mechanical dysfunction,
dysrhythmias, right atrial perforation
followed by LA perforation, RV
perforation, Atrial Septic perforation,
VS perforation.

51. MYOCARDIAL CONTUSION
• Clinically sequelae- myocardial dysrhythmias and pump failure
• If 12 Lead ECG- nonspecific ST-T wave changes, Monitored
observation for 12 hours. If most serious , Observation 24 to 48
hours, further testing
If Hemodynamically Unstable-Prompt ECHO
(Cardiac Enzymes, Nuclear medicine studies- Has No role)
Management- Ionotropic support, RT ventricular afterload
reduction, Dysrhythmia treatment, etc

52. • <2% incidence, mostly within
2.5 cm of the carina
• 86%-Mainstream bronchial
injuries
• 9%-Distal bronchial injuries
• 8%- Complex injuries
TRACHEOBRONCHIAL INJURIES

53. Presentation
• A) With pleural communication-
Pneumothorax; (Persists after chest
tube placement, continuous air
leak)
• B) Extrapleural communication-
Massive pneumomediastinum
• C) Nonspecific- SC Emphysema &
Hemoptysis

54. Diagnosis
• CT sensitivity 100%, initially screening tool
• However, gold standard- diagnostic bronchoscopy(Rigid or flexible),
not done initially r/o cervical spinal injury
TREATMENT
Ensure/establish adequate ventilation
• Avoided Blind intubation/PPV during initial evaluation
• RPL thoracotomy-most of the injuries except LT mainstream
bronchial injuries>3 cm from the carina-LT postlat thoracotomy

55. Management:
A) Non-operative: Lesions < 1/3rd of the bronchial wall, well opposed
edges, minimal tissue loss
B) Operative:
• Thoracotomy fb repair, knots outside of the lumen.
• Limited tracheal resection, upto 2 cm of trachea can be easily &
safely excised and primary repair performed.
• Postop- Adequate pain control, adequate pulmonary toilet
• Routine use of PPI recommended

56. • Rare, cervical, gunshot/iatrogenic trauma
• Only 1% of gunshot injury to chest-
intrathoracic esophageal injuries
• Blunt esophageal injuries- typically occur
in the neck (increased intraluminal
pressure)
• Symptoms- asymptomatic, odynophagia,
dysphagia, hematemesis, etc
ESOPHAGEAL INJURIES

57. Diagnosis
• Chest xray- small amount of
mediastinal emphysema or
small pleural effusion
• Definitive diagnosis-surgical
exploration, endoscopy, or
esophagoscopy
• Esophagogram with
barium(vs water soluble
contrast) recommended –
increased sensitivity, image
quality, decreased
pneumonitis

58. Early and aggressive.
•Primary repair- if within 24 hours
•If delayed, depending on local inflammation, contamination,
severity, primary – not feasible then Temporizing techniques
to control sepsis include:
- Esophageal diversion -Esophageal exclusion
-Esophagectomy -T-tube drainage
Treatment

59. Approach
Thoracic injuries involving:
• Upper 1/3, middle 1/3- RT posterolateral thoracotomy
(4th/5th ICS)
• Distal 1/3rd – LT posterolateral thoracotomy (6th ICS)
Later- Definitive repair
Contrast study (to evaluate integrity of the anastomosis)
Initiate diet

60. • Incidence 4%, H/O wound at the
base of the neck or transmediastinal
gunshot wound
• Pulseless/Moribund presentation
• Diagnosis confirmed by- EDT/Urgent
thoracotomy
Proximal inuries - massive
hemothorax -pericardial
tamponade, or -
external bleeding.
GREAT VESSELS INJURIES

61. • Stable patients- Chest xray- Apical
cap/Widened mediastinum
• Angiography/CTA- for confirmation
• Operative approach:
#Dual lumen ET tube- facilitates
exposure of these injuries
#Median sternotomy vs Left
thoracotomy Incision
INVESTIGATIONS

62. • End-to-end anastomosis via primary or
interposition grafts(PTF, knitted Dacron)
• Percutaneous endovascular control-stable
patients
• Assoc venous inuries-SVA, IJV, Innominate- tt
by lateral repair or patch venography
• Internal jugular or innominate can be ligated
with little ill effect in pts with closed head
injury
• Vena cava injuries – can be shunted if repair is
not feasible, ligation-last resort
TREATMENT

63. TRAUMATIC AORTIC RUPTURE
• 10-15% of all traffic fatalities, majority are fatal at scene
• Mechanism:
#Rapid deceleration-rotation of heart-torsion/shearing effect-
mobility of aorta
#Most thoracic disruption in survivors-Aortic isthmus just distal to
the origin of the LT subclavian artery.

64. PRESENTATION
• High speed MVA, multiple injuries with no signs/symptoms on
examination
• However, most- interscapular pain/hoarseness, diff in BP/PR
between Upper & lower extremities or between Rt & LT upper
extremities.
• Screening Chest xray- Mediastinal Hemorrhage(mediastinal
widening), obsc of aortic knub, etc
• High speed CT with IV contrast- Diagnostic study of choice

66. Management of traumatic Aortic Rupture
Adequate airway, control of external / cavitary hemorrhage &
evacuation of intracranial mass/hemorrhage(Craniotomy precedence
over repair of the torn thoracic aorta)
If intraabdominal bleeding is present, Laparotomy is indicated before
repair of the torn thoracic aorta.
Preop: IV B-blockade to prevent Hypertension (Esmolol- Best, short
half-life for risk of hypotension)
Goals of Therapy: HR <100 Bpm, SYSTOLIC BP: 100-120 mmHg
(decreases risk of rupture)
Mainstay of management– Medical for- Low grade/ minimal aortic
injuries.

67. Treatment
• Direct/ interposition graft placement via LT thoracotomy
• Excellent reults- Clamp-and-sew technique
• However most guidelines recommend use of Distal aortic
perfusion(eg, Lt atrial-distal aortic bypass or partial CBP with
femoral cannulation)
• Endovascular stent graft
#Results of multiple studies indicate endovascular repair- superior to
open repair in terms of mortality, renal injury, graft infection,
incidence of spinal cord ischemia)

68. • Presence of persistent opacification
in the pleural space in a patient with
a previous known hemothorax.
• Causes: -
1. Improper positioning/contamination
chest tube
2. obstruction of the chest tube
RETAINED HEMOTHORAX & POST TRAUMATIC EMPYEMA

69. Treatment
• Retained blood-Nidus for infection & empyema
• Placement of additional chest tube- rarely effective in
removing clotted blood from the pleural space
• If Early(<5 days after injury)- VATS, cost effective
• If ongoing bleeding, dense adhesion due to long time
hemothorax- Posterolateral Thoracotomy affected side(5th
ICS) required
• Decortication- If the clotted hemothorax has a fibrous peel

71. CONCLUSION
• Thoracic trauma-contributing factor for Majority of trauma related
deaths
• Early identification & appropriate management possible with
thorough physical examination and Appropriate radiographic
evaluation
• Most thoracic injuries- treated with simple bedside procedures
• Many variables most be considered when considering surgical
intervention
• Location & nature of injury guides appropriate surgical approach for
surgical intervention

72. References
• Bailey & Love's Short Practice of Surgery 27th Edition
• Josef Fischer - Fischer’s Mastery of Surgery-LWW (2018)
• Courtney M. Townsend Jr. JR MD (editor) - Sabiston Textbook of
Surgery_ The Biological Basis of Modern Surgical Practice-Elsevier
(2021)
• Google

73. THANK YOU
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