slides for medical students

1. THORACIC INJURY
By; Desalegn F. [MD, Assit. proffesor of Surgery)
9/21/2022 1

2. Outline
Introduction
Classification of chest injury
Pathophysiology
Specific Injury associated with
penetrating & blunt thoracic trauma
with their management:-
Chest Wall Injury
Pulmonary Injuries
Cardiovascular Injuries
Esophageal Injuries 2

3. OBJECTIVES
Major thoracic injuries grouped together as the “fatal 14”.
(1) Identifying & initiate treatment during the primary survey:
“lethal six”
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Flail chest and pulmonary contusion
• Massive hemothorax
• Cardiac tamponade
(2 )Identify & initiate treatment potentially life-threatening
injuries during the secondary survey: “hidden eight”
9/21/2022 3

4.  Simple pneumothorax
 Hemothorax
 Pulmonary contusion
 Tracheobronchial tree injury
 Blunt cardiac injury
 Traumatic aortic disruption
 Traumatic diaphragmatic injury
 Blunt esophageal rupture
(3 )Describe the significance and treatment of the following
injuries:
 Subcutaneous emphysema
 Thoracic crush injuries
 Sternal, rib, and clavicular fractures
9/21/2022 4

5. INCIDENCE
 Thoracic injury is common in the polytrauma
Patient and can pose lifethreatening Problems
if not promptly identified during the primary
survey.
 Trauma kills 150,000 Americans every year. It is
the most common cause of death in the
population <40 years of age.
9/21/2022 5

6.  One-fourth of deaths are occurring in the prehospital setting.
 Thoracic injuries account for 25% of immediate trauma-
related deaths, second only to head and spinal cord injuries.
 For those who survive the initial trauma, an additional 25% will
die within the first year from complications.
9/21/2022 6

7. 80-85% -managed by simple measures.
Only 15-20% require major Surgery
< 10% of blunt chest injuries and
only 15% to 30% of penetrating chest injuries require
operative intervention (typically thoracoscopy or
thoracotomy).
9/21/2022 7

8.  Early deaths (within the golden hour) are caused by:-
-airway obstruction,
-tension pneumothorax or
-massive hemothorax, and
-cardiac tamponade (major respiratory ).
 Chest wall trauma is most frequent after blunt thoracic
trauma
9/21/2022 8

9. DIAGNOSIS
 Hx ;
 P/E:-
 Specific Physical Findings in Chest Trauma
Neck veins
Distended in tamponade or tension pneumothorax
Collapsed in hypovolemia
Chest wall motion abnormalities
Decreased due to rib fractures
Paradoxical due to flail chest
Palpation
Crepitus due to subcutaneous emphysema
Chest percussion
Hyperresonance in tension pneumothorax
Dullness in hemothorax
Breath sounds
Decreased in pneumothorax or hemothorax
Ix: -CBC & Bg, CXR, US, ECG , 9

10. Classification of thoracic injuries
1. Chest wall
2. Pleural space
3. Pulmonary parenchyma
4. Mediastinal structures
a. Aerodigestive structures
 Trachea & bronchi
 Esophagus
b. Vascular structures
9/21/2022 10

11. Mechanism of Injury
1. Blunt
• direct blow
• deceleration injury
• compression injury
2. Penetrating:
 Stab, Fire-arms, Goring . .
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12. I) Blunt Trauma
 Results from kinetic energy forces
 Subdivision Mechanisms:
 Blast
 Pressure wave causes tissue disruption
 Tear blood vessels & disrupt alveolar tissue
 Disruption of tracheobronchial tree
 Traumatic diaphragm rupture
 Crush (Compression)
 Body is compressed between an object and a hard surface
 Direct injury of chest wall and internal structures
9/21/2022 12

13. 2)Penetrating Trauma
 Low Energy
 Arrows, knives, handguns
 Injury caused by direct contact and cavitation
 High Energy
 Military & high powered hand guns
 Extensive injury due to high pressure cavitation
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14. Shotgun
Injury severity based upon the distance between the victim and
shotgun & caliber of shot
 Type I: >7 meters from the weapon
 Soft tissue injury
 Type II: 3-7 meters from weapon
 Penetration into deep fascia and some internal organs
 Type III: <3 meters from weapon
 Massive tissue destruction
9/21/2022 14

15. Pathophysiology
Of chest trauma includes three factors: Hypoxia, hypercarbia, and acidosis often
result from chest injuries.
Hypoxia- inadequate delivery of oxygen to the tissues
 -airway obstruction,
 -changes in intrathoracic pressure, (tension pneumothorax and open pneumothorax)
 -ventilation-perfusion mismatches, and
 - hypovolemia.

16. Hypercapnia – caused by respiratory acidosis
 Inadequate ventilation as a result of the presence of either a
collapsed lung, associated head injuries with altered mental
status, or exogenous intoxication (drugs and alcohol).
Acidosis is due mainly to hypoperfusion from blood
loss→metabolic acidosis or Pump problems- by distended neck
veins & caused by one of four conditions:
T. pneumothorax,P.tamponade,coronary air
embolism,cardiac contusion or MI
9/21/2022 16

17. SPECIFIC CHEST INJURIES
Airway obstruction
–Laryngeal injury - accompany major thoracic trauma
-with posterior dislocation of the clavicular head, which causes
upper airway obstruction
-Inhaled foreign body
 Assessed by listening for air movement at pt’s nose,mouth; stridor
 Voice quality, if the patient is able to talk
 inspecting the oropharynx for foreign-body obstruction; and
 Look - intercostal and supraclavicular muscle retractions.
Rx-cricothyroidotomy ; Tracheostomy,FB removal ;closed
reduction

18. Pneumothroax
 One of most common traumatic injuries, 20%;
 Traumatic vs spontaneous
Traumatic; Three types : simple, open, and tension.
 Simple pneumothorax - air leaking into the pleural space as a
result of a parenchymal lung injury.
 Open pneumothorax -wounds of the chest wall allow air to
enter the pleural space from the outside.
 Tension pneumothorax - air collects in the pleural space
under pressures exceeding atmospheric pressure

19. 9/21/2022 19

20. Simple pneumothorax
 air entering the potential space between the visceral and parietal pleura
 Lung laceration with air leakage is the most common from blunt trauma.
 Air in the pleural space disrupts the cohesive forces between the visceral and
parietal pleura, which allows the lung to collapse
 patient with a pneumothorax -should undergo chest decompression before transport
via air ambulance due to the expansion of the pneumothorax at altitude
Rx :All traumatic pneumothorax- ICT

21. Tension Pneumothorax(TP)
 develops when a “one-way valve” air leak occurs
from lung or through chest wall
 Air is forced into the pleural space without any
means of escape, eventually completely collapsing
the affected lung.

22. Causes
 blunt & penetrating trauma but differs in mechanism .
 Following blunt trauma may occur from:
a. sudden ↑in intrathoracic pressure leading to ruptured alveoli &
air leak,
b. rib #s lacerating the lung,
c. deceleration injuries tearing the lung, or
d. blunt forces directly crushing & disrupting alveoli.
 In penetrating trauma, the etiology is the direct laceration of
lung parenchyma.

23.  commonest cause T.Pneumothorax is mechanical
ventilation with positive-pressure ventilation(PPV) in
patients with visceral pleural injury.
 It can complicate a simple pneumothorax
 traumatic defects in the chest wall if incorrectly covered
with occlusive dressings or if the defect itself constitutes
a flap-valve mechanism.
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24. Tension pneumothorax
- clinical diagnosis
characterized by:
Chest pain,
Air hunger,
Respiratory distress ,
Tachycardia,
Hypotension,
Tracheal deviation away from the side of injury,
Unilateral absence of breath sounds ,
Elevated hemithorax without respiratory movement ,
Neck vein distention
,Cyanosis (late manifestation)

25. Rx
 Immediate decompression -
by a large-caliber needle with 5 cm
reach the pleural space >50% of the
time, whereas an 8 cm reach the
pleural space >90% .
2nd IC MCL
 Definitive treatment -
insertion of a chest tube into the
fifth intercostal space

26. Open Pneumothorax (Sucking Chest Wound)
 Occurs with full-thickness loss of the chest wall,
permitting free communication between the pleural space
and the atmosphere . (size)
 This compromises ventilation due to equilibration of
atmospheric and pleural pressures, which prevents lung
inflation and alveolar ventilation, and results in
hypoxia and hypercarbia.
 Complete occlusion of the chest wall defect without a
tube thoracostomy may convert an open pneumothorax
to a tension pneumothorax.
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27.  If the opening of the chest wall is at least two-thirds the
circumference of the trachea, air passes preferentially through
the chest wound with each breath rather than down the
tracheobronchial tree.
 Ventilation is thus compromised leading to significant hypoxia
and hypercarbia
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28. TREATMENT
The defect temporarily managed with an occlusive
dressing that is taped on three sides, allowing
accumulated air to escape from the pleural space &
thus prevents a tension pneumothorax.
Repair of the chest wall defect and tube thoracostomy remote
from the wound is definitive treatment.
9/21/2022 28
. Promptly close the defect
with a sterile occlusive
dressing that is large enough
to overlap the wound’s edges.
Tape it securely on three
sides to provide a flutter-
type valve effect.

29. Flail Chest and Pulmonary Contusion
 when a segment of chest wall does not have bony continuity
with the rest of the thoracic cage results from multiple rib
fractures at 3 or more adjacent ribs fractured in at least two
or more places.
 after costochondral disruption separation

30. Con…
-Occurs in 10% to 15% in major chest trauma.
-common after blunt thoracic trauma & may occur as an
isolated finding, but it is usually associated with other significant
injuries.
-Closed head injury is the most frequently associated
extrathoracic injury, and it contributes to higher morbidity and
mortality rates.
- Isolated flail chest carries a low mortality rate in younger
patients

31. Cont..
 results in disruption of normal chest wall movement
 instability lead to paradoxical motion of the chest
wall during inspiration and expiration,
 this defect alone does not cause hypoxia
 If injury to the underlying lung (pulmonary contusion)
& Restricted chest wall movement associated with
pain is significant →serious hypoxia

32. Pathophysiology of flail chest
 Inspiratory phase:
 chest wall collapses inward,
causing air to move out of the
bronchus of the involved lung
into the trachea and
bronchus of the uninvolved
lung →causing a shift of
mediastinum to the
uninvolved side

33. Expiratory phase:
 chest wall balloons outward
so that air is expelled from the
lung on the uninvolved side
and enters the lung on the
involved side with an
associated shift of
mediastinum to the involved
side.

34. pathophysiology
1)Alteration of chest wall mechanics impairs adequate tidal volume or an
effective cough
2)Underlying pulmonary contusion( In vast majority of serious flail chest
injuries)extravasation & accumulation of blood & fluid in the alveolar air space,
which results in sufficient shunting to produce hypoxia
3)extreme pain of multiple rib fractures  profound splinting and diminution of
tidal volume and prevents adequate coughing and pulmonary toilet
 combination of depressed tidal volume and in adequate coughing leads to
hypoventilation, atelectasis, and often pneumonia
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35. treatment
Initial treatment adequate ventilation, humidified oxygen, and fluid resuscitation.
The definitive treatment ensure adequate oxygenation, administer fluids judiciously, and
provide analgesia to improve ventilation.
options of local anesthetic - intermittent intercostal nerve block(s) &
intrapleural,extrapleural, or epidural anesthesia.
So , adequate LA analgesia → prevent the need for intubation.
A careful assessment of the respiratory rate, arterial oxygen tension, and work of
breathing will indicate appropriate timing for intubation and ventilation.

36. Hemothorax
--Blood b/n visceral& parietal pleura
--Bleeding from:
 Intercostal arteries
 Internal mammary artery
 Lung laceration
 Effects: Hypovolemia and lung
compression
9/21/2022 36

37. Clinically:
 Hypovolaemia
 Absence of breath sounds
 Dullness to percussion
 CXR: (300-350 ml is required to blunt the costophrenic angle)
 A volume of 300 mL is needed for hemothorax to manifest on an upright
CXR
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38. Treatment
1. IV Fluid resuscitation ;transfusion
2.Tube thoracostomy [large-caliber (36 or 40 French]
3. Thoracotomy
 Massive heamothorax (1500ml at a time during ICT, 15-
20ml/kg/hr)
 Bleeding of >200ml/hr for 3- 4hours (3-4ml/kg/hr)
 Bleeding of >100ml/hr for 8hours
9/21/2022 38

39. Pulmonary Contusion
 Occurs in both blunt (More frequently )&
penetrating injuries
 Pathologic state in which hemorrhage and
edema of the lung parenchyma occur without
parenchymal disruption
 Radiologic findings may not be present on
admission and may develop 24 to 48 hours after
the initial injury
 Pneumonia is the most frequent complication,
9/21/2022 39

40. Pathophysiology
-decreased lung compliance
- development of a ventilation-perfusion mismatch
-leading to hypoxemia & increased work of
breathing.
-Respiratory failure occurs more often in patients with;
- large contusions, in the elderly, and
- underlying chronic lung disease aggravated by
inadequate pain control
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41. Diagnosis
C/F :
Confirmed by low PaO2
 Manifests with respiratory distress, cough and
hemoptysis(frequent)
CXR
 Pul. Contusion + heamothorax
Rx
 Chest tube insertion + supportive care (antipain &
chest physiotherapy)
9/21/2022 41

42. PULMONARY HEMATOMA
 Difficult to differentiate from pulmonary contusion because of
the surrounding intraparenchymal hemorrhage.
 24 to 48 hours after the injury, a hematoma typically develops
into a discrete mass with distinct margins.
 CT scans can distinguishing b/n contusion & hematoma.
 Mostly, hematoma itself does not interfere with gas exchange
& is reabsorbed in time.
 Only rarely may hematoma become 2ry infected & present as
an abscess requiring drainage
9/21/2022 42

43. Tracheobronchial injuries
 Are uncommon, 0.2% to 8%
 In < 1% with blunt thoracic trauma
 Most patients who sustain such injuries die at the
scene
Mechanisms
 Penetrating
 Blunt trauma: with in 2.5 cm of the carina,> 80%
9/21/2022 43

44. Diagnosis
Difficult and often delayed
Hx : -patients typically present with hemoptysis, subcutaneous
emphysema, or T. pneumothorax
- Incomplete expansion of lung after placement of chest tube
suggests TBI
Investigation
 CXR, ( Pneumothorax, Pneumomediastinum, Air in the
soft tissue of the neck, abnormal migration of
endotracheal tube tip, balloon distension beyond tracheal
diameter
 Definitive diagnosis- made in operating room or by
bronchoscopy (Look directly)
9/21/2022 44

45. Treatment
 Airway
 Intubation over flexible bronchoscope
 Tube thoracostomy
 Non operative management
Asymptomatic tears found incidentally
 < 1/3 of the circumference
 Fully expanded lungs with tube thoracostomy
 No air leak
 No associated injury
 No need for positive pressure ventilation
 Operative management….the rest
9/21/2022 45

46. Ribs fracture
 Simple rib fractures account for more than 50% of non-penetrating trauma
 Ribs break at point of impact or posterior angle (weakest structural point)
 Ribs 1-3 are relatively protected – high energy - severe intrathoracic injury
 Ribs 9-12 are more mobile - associated with intraabdominal injury
 Right side rib fractures 3X risk of hepatic injury
 Left side rib fractures 4X risk of splenic injury
9/21/2022 46

47.  Fractures more common in adults due to inelasticity of the chest wall
 Rib fractures - high potential for penetratinginjury to pleura, lung, liver or spleen
 Multiple rib fractures(2 or more) is associatedwith higher incidenceof internal injury
20% mortality in the elderly(5x), Less common in children
1st rib fracture: Severe injury ;30% mortality
9/21/2022 47

48. Clinical Features
 Clinical suspicion with tenderness, bony crepitus, ecchymosis and muscle spasm over
the rib
 Compression over the site of injury typically causes pain
Diagnosis
 CXR is mainstay of diagnosis to evaluate for associated injuries
 Fracture of ribs 1-2 hallmark of severe chest trauma
9/21/2022 48

49. Management;
 Rib fracturesheal in 3-6 weeks
 Strong analgesics -Pain control (PO Narcotics, IV Narcotics, Intercostal Nerve Blocks)
 Maintenance of pulmonary function
 Encourage breathing
Prophylactic antibiotics
Treat associated injuries
Displacedrib fracturesshouldbe monitoredand repeat CXR at 3-4 hoursafter
presentationto evaluate for delayedpneumothorax development
9/21/2022
49

50. STERNAL FRACTURES
 rare , Up to 4% after MVA
 Usually transverse fracture, majority at the sterno-manubrial junction
or in the midbody
 Facture may be simple (two fragments) or
comminuted (multiple fragments), displaced or
aligned, or stable or unstable
 Associated injuries:
myocardial contusion, cardiac chamber rupture, transaction of the
aorta
 Dx: X-ray (lateral)
50

51. Treatment
 Initial management of sternal fracture is directed toward
resuscitation and identification or exclusion of other life-
threatening injuries
Non operative management –most patient
 Exclude life treatening injuries (ECG, CXR)
 Pain control
 Chest physiotherapy
 Reduce fracture manually- most
9/21/2022 51

52. Open reduction -Plate or wire
-Unstable fracture
-Displacement >1cm
-Associated lower extremity injury who requires crutches
for ambulation experiences such disabling sternal pain
during ambulation that fracture repair is necessary
For flail sternum:
-Internal or external
9/21/2022 52

53. Subcutaneous Emphysema;
Pathophysiology
Subcutaneous emphysema in the presence of chest trauma is indicative
of a more serious thoracic injury
Extrapleural
tracheobronchial tree injury →allows air to leak into mediastinum
→up to the soft tissues of anterior neck
Intrapleural
Intrapleural leakage→ air leaks through parietal pleura →into the
thoracic wall
9/21/2022 53

54. Location
Adjacent to penetrating wound - indicate localized infiltration from external environment (5cm)
Localized subcutaneous air over chest wall - indicates presence of traumatic pneumothorax
Localized over supraclavicular area and anterior neck - indicates pneumomediastinum
Massive subcutaneous air of the face and neck - indicates ruptured of bronchus
9/21/2022 54

55. Diagnosis
-Palpationof chest wall and neck revealscrepitance
-CXR may show subcutaneousair tracking through soft tissue
Management
-Mostly subcutaneous air is benign and self limited
-Can be treated with high flow oxygen
-Identify underlying injury and treat
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56. Cardiac injuries
Blunt cardiac injuries (BCI)
 Encompasses contusion of the cardiac wall to cardiac chamber or valvular
rupture.
 Most patients do not reach the hospital alive.
 right ventricle is most frequently involved .
BCI occurs ;
- often from MV crashes where rapid deceleration occurs
- direct blow to the precordium
Several forces may involved
o shearing from rapid deceleration,
o compression of the heart b/n the spine & sternum,
o abrupt pressure fluctuations in the chest and abdomen in blast injury
9/21/2022 56

57. Myocardial contusion
 Occur in less severe chest trauma
 It is collapse of cardiac muscle
 CF: no specific sign or symptom
 Ix: no universal diagnostic criteria
 ECG monitored for 8 to 24 hrs.
 If the initial ECG is normal, no further workup is generally
necessary.
-most frequent arrhythmias are ST-segment & T-waves
changes and sinus tachycardia.
-Right bundle branch block is common 57

58.  Echocardiography - demonstrate a wall motion
abnormality,
 ECG & serum troponin I levels at admission and 8
hours after injury can rule out the diagnosis of
significant blunt cardiac injury.
 normal results at both time points can be safely
discharged from the hospital
 Creatinine kinase
Treatment
 Based on clinical presentation
 Treat arrhythmias(Supraventricular and ventricular ) in ICU
9/21/2022 58

59. Cardiac Tamponade
 Blood in the pericardial sac
 Most frequently after penetrating injuries
 Classically, Beck’s triad: 30-40%:-
 Distended neck veins
 Muffled heart sounds
 Hypotension
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60. Diagnosis
 P/ E is often unreliable in detecting pericardial
tamponade.
 CXR- pericardial effusion, CM due to a massive
pericardial effusion (At least 200 mL before the cardiac
silhouette enlarges)
 Ultrasonography
9/21/2022 60

61. 61
 Echocardiography
- presence of a pericardial effusion is diagnostic ,but absence
does not necessarily rule out injury
-because of associated left pleural effusion
obscuring the pericardium or
escape of blood from the pericardium into the pleural
space→ pericardial sac may be empty

62. Rx
 Volume resuscitation
 Pericardiocentesis
 Pericardiocentesis
- a pericardial drain is placed using ultrasound
guidance.
- successful in decompressing tamponade in ~80% of
cases;
 Removing as little as 15 to 20 mL of blood will often
;
- temporarily stabilize pt's hemodynamic status,
- prevent subendocardial ischemia & associated lethal 62

63.  Drawbacks of pericardiocentesis include;
o high rate of false positives & false negatives and
o potential for iatrogenic cardiac injuries.
o limited use in treating tamponade because blood within
the pericardial sac often is clotted and is not amenable to
removal through a needle.
9/21/2022 63

64. o pericardial window-
- The subxiphoid pericardial window remains the gold
standard for diagnosis of cardiac injury
 10 cm vertical midline incision that is made over the
xiphoid, slightly favoring the epigastrium.

 Xiphoid is grasped with a clamp & dissected away from
the abdominal fascia & diaphragmatic fibers &
substernal plane is accessed.
9/21/2022 64

65.  As the inferior portion of the sternum is being
elevated, the prepericardial adipose tissue is
dissected to provide exposure of the acute margin of
the pericardium.
 The pericardium is then retracted inferiorly into the
wound & incised sharply.
- blood or clot within the pericardial sac indicates
a positive result, necessitating immediate repair of
the injury
9/21/2022 65

66. Ruptured diaphragm
 Often - by penetrating injuries below nipples & above
costal margins(small opening & hernation slow progressive
 After blunt trauma, opening is large & at risk for hernation
early  Sx RD
-↑abdominal pressure from forceful impact that causes
stretching with avulsion or, more commonly, lacerations; or
- fractured ribs -perforate the muscle
 Tears tend to be in a radial orientation along the posterolateral aspect of the
diaphragm.
 More on the left side (following blunt trauma) L>R ,9:1,
 Severe associated injuries occur in greater than 50%
9/21/2022
66

67. Clinical feature
 Asymptomatic
 may be associated with epigastric and abdominal
pain, referred shoulder pain, shortness of breath, or
shock.
Diagnosis
 Diagnosis is easiest on the left when herniated bowel
enters into the chest
 CXR with NGT in place seen during hernation
 Initial chest radiography may be non diagnostic,
particularly if the patient is on positive-pressure
ventilation; Distortion of contour, Apparent elevation,
Mediastinal shift
 Laparascopy- Gold standard
9/21/2022 67

68.  Lateral chest film showing
herniation of the stomach into
the left pleural cavity
9/21/2022 68

69. Treatment
 Acute diaphragmatic rupture is generally repaired through a
midline abdominal incision
 Chronic defects discovered months or years after the initial
injury can be treated through a transthoracic, an abdominal, or
a combined approach
 Diaphragmatic injuries are repaired with interrupted
horizontal sutures.
 Larger defects may eventually require the use of
prosthetic material
9/21/2022 69

70. Penetrating Cardiac Injuries
 Area determined by midclavicular line bilateraly , a line
at level of clavicles , & a line at level of costal margins
potentially have a cardiac injury until proved
otherwise.
 Generally present in one of three ways
o clinically silent-20%
o pericardial tamponade-50% one or more of beck`s
triad
o hemorrhagic shock –the remaining =30% 70

71. Diagnosis
 Clinical
 CXR –Can identify other injuries & to determine trajectory of
the missile in the case of gunshot wounds.
 Echocardiography- identify abnormal amounts of pericardial
fluid,
 subxiphoid pericardial window.
If the result is positive, median sternotomy is performed for
definitive cardiac repair.
 Treatment
 Hemodynamically unstable patients should be taken to the
operating room for emergency thoracotomy.
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72.  Stable patients should have a chest radiograph
 The presence of shock or hemodynamic instability has
been cited as an important determinant of mortality
 The survival rate is greater than 70% if vital signs are
present on admission
 Mortality rates vary from 8.5% to 81.3%.
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73. Esophageal injury
 very rare, lethal if unrecognized
 Most esophageal injuries are secondary to Penetrating
trauma-0.7%
 All mediastinum-traversing gunshot wounds or stab wounds
near the posterior midline should be evaluated for possible
esophageal injury.
 Blunt trauma: distal third ,uncommon
-Tear or perforation of esophagus after forceful expulsion of
gastric contents
-direct blow
Dx: c/f- B/n 60% & 80%sn& sm , location, size , degree of contamination,
length of time elapsed after injury
9/21/2022 73

74. Rx:
Non-operative therapy
 Criteria ((Cameroon Criteria)
 No evidence of pleural contamination
 Walled-off extravasation
 Minimal or no symptoms
 No evidence of systemic infection
Operative
 Esophageal perforation associated with intrinsic disease,without the above
criteria
 early débridement, Primyar Repair
 Tissue buttressing with viable muscle flap & drainage, if identified
within 24 hours after injury
 With large destructive injuries or delayed presentation of injuries, esophageal
exclusion with wide drainage, diverting loop esophagostomy, and placement of a
gastrostomy tube
74

75. Elderly patients
 Conservative management
 Feeding jejunostomy
 Gastrostomy to prevent gastroesophageal reflux
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76.  Indication Thoracotomy:
Massive hemothorax/continued bleeding
Massive air leak
Perforation of intrathoracic esophagus
Rapidly recurring P.temponade
Valvular/septal injury of heart with CHF
Mediastinal widening ass’d with hemothorax
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77. Current indications and contraindications for emergency department thoracotomy
Indications
 Salvageable postinjury cardiac arrest:
 Patients sustaining witnessed penetrating trauma to the torso with <15 min
of prehospital CPR
 Patients sustaining witnessed blunt trauma with <10 min of prehospital CPR
 Patients sustaining witnessed penetrating trauma to the neck or extremities
with <5 min of prehospital CPR
 Persistent severe postinjury hypotension (SBP ≤60 mmHg) due to:
Cardiac tamponade
 Hemorrhage—intrathoracic, intra-abdominal, extremity,cervical
 Air embolism
Contraindications
 Penetrating trauma: CPR >15 min and no signs of life (pupillary response,
respiratory effort, motor activity)
 Blunt trauma: CPR >10 min and no signs of life or asystole without
associated tamponade
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78. Thoracic Great Vessel injuries
 Aorta SVC, IVC, Azigous vein, hemiazigous vein pulmonary
artery & vein, bronchial vessels
 Physical clues
 Significant chest wall trauma
 Massive heamothorax
 Excessive entry site bleeding
 Expanding apical chest heamatoma / neck mass
General Principles of Mx
 I.V access
 Arresting the bleeding
 Investigate only on stable pts
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79. Traumatic Asphyxia
 Cause severe blunt thoracic trauma.
 Mechanism of development
Thoracoabdominal compression during deep inspiration against
a closed glottis causes venous hypertension in the valveless
cervicofacial system.
 Clinical manifestation is excessive venous pressures.
Characteristic signs include ;
o facial and upper chest petechiae,
o subconjunctival hemorrhages, cervical cyanosis, and
o temporary loss of vision due to retinal edema.
 Treatment
 self-limited.
 Supportive treatment,associated injuries must be treated . 79

80. Reference;
 Advanced Trauma Life Support,10th edition
 General thoracic surgery ,Thomas W. Shields
 Sabiston –surgery 20th ed
 ACS, Surgery 2007
 Schwartz’s principles of Surgery 10th e
 Sheild’s General thoracic Surgery 7th e
 Internet & Surgical Journals
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