Thoracic Injury and Trauma - Surgery

1. Thoracic Injury & Trauma
By: Alyaa Akma binti Azman

2. Introduction
Thoracic injury accounts for 25% of all injuries.
In a further 25%, it may be a significant contributor to the
subsequent death of the patient.
In most of these patients, the cause of death is haemorrhage.
Chest injuries are often life-threatening, either in their own right or
in conjunction with other system injuries.

3. Investigation of chest injuries
80% can be managed non-operatively
A chest radiograph is the investigation of first choice
A spiral CT scan provides rapid diagnoses in the chest and
abdomen
A chest drain can be diagnostic as well as therapeutic

4. Management
Most patients who have suffered penetrating injury to the chest can
be managed with appropriate resuscitation and drainage of
haematoma.
Closed management of chest injuries:
■ About 80% of chest injuries can be managed closed
■ If there is an open wound insert a chest drain
■ If bleeding persists, the chest will need to be opened

5. Immediate life-threatening injuries
1) Airway obstruction
Early preventable trauma deaths are often due to lack of or delay in
airway control.
Dentures, teeth, secretions and blood can contribute to airway
obstruction in trauma. Laryngeal trauma such as thyroid or cricoid
fractures and tracheal injury are other causes of airway obstruction.
These patients need intubation (with simultaneous protection of the
cervical spine). Early intubation is very important, particularly in
cases of neck haematoma or possible airway oedema.

6. Tension pneumothorax
It develops when a lung or chest wall injury is such that it allows air
into the pleural space but not out of it (a one-way valve).
Most common causes :
• penetrating chest trauma,
• blunt chest trauma with parenchymal lung injury and
• air leak that did not spontaneously close,
• iatrogenic lung punctures (e.g. due to subclavian central
venepuncture)

7. Treatment
Rapid insertion of a large-
bore needle into the 2nd
intercostal space in the
mid-clavicular line of the
affected hemithorax.
This is immediately followed
by insertion of a chest tube
through the 5th intercostal
space in the anterior
axillary line.

8. Cardiac Tamponade
Most commonly the result of
penetrating trauma.
•The correct immediate
treatment is operative
(sternotomy or left
thoracotomy),with repair of the
heart in the operating theatre if
time allows or otherwise in the
emergency room.

9. Open pneumothorax (‘sucking chest wound’)
• Due to large open defect in
the chest (> 3 cm)
• Leading to equilibration
between intrathoracic &
atmospheric pressure.
• Air accumulates in the
hemithorax with each
inspiration, leading to
profound hypoventilation on
the affected side and hypoxia.

10. Treatment
Promptly closing the defect with a sterile occlusive plastic
dressing (e.g. Opsite), taped on 3 sides to act as a flutter-
type valve.
• A chest tube is inserted ASAP in a site remote from the
injury site.
• Definitive treatment may warrant formal debridement and
closure, preferably in the operating room
• If the lung does not reinflate, the drain should be placed on
low-pressure (5 cm water) suction;
• Physiotherapy and active mobilisation should begin ASAP
OPSITE

11. Massive haemothorax
• The most common cause of massive haemothorax in blunt injury is
continuing bleeding from torn intercostal vessels or occasionally the
internal mammary artery
• Accumulation of blood in a hemithorax can significantly compromise
respiratory efforts by compressing the lung and preventing adequate
ventilation
• Presents as haemorrhagic shock with flat neck veins, unilateral absence
of breath sounds and dullness to percussion.
• The treatment consists of correcting the hypovolaemic shock, insertion
of an intercostal drain and, in some cases, intubation.

12. Flail chest
• Usually results from blunt
trauma associated with multiple
rib fractures,
• Three or more ribs fractured in
two or more places
• The diagnosis is made clinically,
not by radiography.
•On inspiration the loose segment
of the chest wall is displaced
inwards

13. Treatment
•Currently, treatment consists of oxygen administration, adequate
analgesia (including opiates) and physiotherapy.
• If a chest tube is in situ, intrapleural local analgesia can be used as well.
•Ventilation is reserved for cases developing respiratory failure despite
adequate analgesia and oxygen
• Surgery to stabilise the flail chest is currently in use again;
• It may be useful in a selected group with isolated or severe chest injury
and pulmonary contusion who have been shown to benefit from internal
operative fixation of the flail segment.

14. Potentially life-threatening injuries
1) Thoracic aortic disruption- Traumatic aortic rupture is a common
cause of sudden death after an automobile collision or fall from a great
height.
• The diagnosis is confirmed by aortography or a contrast spiral CT scan
of the mediastinum and to a lesser extent by
transoesophagealechocardiography.
•Initially, management consists of control of the systolic arterial blood
pressure (to less than 100 mmHg).

15. Other potentially life-threatening injuries
2) Diaphgrammatic injury - Any penetrating injury to or below the fifth
intercostal space should raise the suspicion of diaphragmatic penetration.
3) Oesophageal injury
4) Tracheobronchial injuries - damage to the tracheobronchial tree It
can result from blunt or penetrating trauma to the neck or chest, inhalation
of harmful chemical.
5) Pulmonary Contussion - caused by haemorrhage into the lung
parenchyma, usually underneath a flail segment or fractured ribs.