SPECIAL THANKS TO SADRU MOHAMED FOR MAKING THESE SLIDES AVAILABLE HERE sadru12@gmail.com +255759212578

1. THORACIC TRAUMA
Dr Phillipo Leo ChalyaDr Phillipo Leo Chalya
M.D. [Dar]; M.MED surg [Mak]M.D. [Dar]; M.MED surg [Mak]
Surgeon Specialist - BMCSurgeon Specialist - BMC
11

2. 22
OUTLINE
 DefinitionDefinition
 EpidemiologyEpidemiology
 EtiologyEtiology
 Mechanism of injuryMechanism of injury
 ClassificationClassification
 PathophysiologyPathophysiology
 Clinical presentationClinical presentation
 WorkupWorkup
 ManagementManagement
 ComplicationsComplications
 SummarySummary

3. 33
DEFINITION
Thoracic trauma is not a single entityThoracic trauma is not a single entity
It refers to as injuries of the thoracicIt refers to as injuries of the thoracic
cage and its internal and associatedcage and its internal and associated
structuresstructures
It is one of the surgical emergenciesIt is one of the surgical emergencies

4. 44
EPIDEMIOLOGY
IncidenceIncidence
Morbidity / mortalityMorbidity / mortality
AgeAge
SexSex
RaceRace

5. 55
Incidence
Varies both geographically and withVaries both geographically and with
SESSES
In the US, S/America, Africa and AsiaIn the US, S/America, Africa and Asia
incidence of penetrating injuries isincidence of penetrating injuries is ↑↑
due to criminal or military activitiesdue to criminal or military activities
In Europe blunt injuries isIn Europe blunt injuries is ↑↑ mainlymainly
due to RTAdue to RTA

6. 66
Morbidity / mortality
Thoracic trauma is associated with significantThoracic trauma is associated with significant
mortality and morbiditymortality and morbidity
Chest trauma accounts for 25% of all traumaChest trauma accounts for 25% of all trauma
deathsdeaths
2/3 of deaths occur after reaching hospital2/3 of deaths occur after reaching hospital
Serious pathological consequences:Serious pathological consequences: --
HypoxiaHypoxia
HypovolaemiaHypovolaemia
Myocardial failureMyocardial failure

7. 77
Age
Trauma including chest trauma isTrauma including chest trauma is
the leading cause of deaths amongthe leading cause of deaths among
people between 1-44 years of agepeople between 1-44 years of age

8. 88
Sex
Male are more affected thanMale are more affected than
females [M>F]females [M>F]

9. 99
Race
Studies reported no racialStudies reported no racial
predilection to thoracic injuriespredilection to thoracic injuries

10. 1010
AETIOLOGY
 Road traffic accidentRoad traffic accident
 AssaultAssault
 War injuriesWar injuries
 FallsFalls
 Sport injuriesSport injuries
 Aircraft accidentAircraft accident
 Stab woundStab wound
 Bullet injuriesBullet injuries
 etcetc

11. 1111
MECHANISM OF
INJURY
Blunt thoracic injuriesBlunt thoracic injuries
Penetrating thoracic injuriesPenetrating thoracic injuries

12. 1212
Blunt thoracic injuries
 Direct trauma to the chest cageDirect trauma to the chest cage
The victim is struck in the chest by a moving objectThe victim is struck in the chest by a moving object
→→fractures of the ribs, contused lungs etcfractures of the ribs, contused lungs etc
 Compression thoracic injuriesCompression thoracic injuries
The chest is injured by compressionThe chest is injured by compression →→ diaphragmaticdiaphragmatic
rupture, cardiac & lung contusionrupture, cardiac & lung contusion
 Deceleration thoracic injuriesDeceleration thoracic injuries
These are injuries resulting from rapid deceleration of theThese are injuries resulting from rapid deceleration of the
body with continuing moving of the internal thoracicbody with continuing moving of the internal thoracic
organsorgans→→ aortic rupture (tear), cardiac and pulmonaryaortic rupture (tear), cardiac and pulmonary
contusioncontusion

13. 1313
Penetrating thoracic injuries
 The degree of tissue damage is proportional toThe degree of tissue damage is proportional to
the Kinetic Energy [K.E.] of the penetratingthe Kinetic Energy [K.E.] of the penetrating
objectobject
 K.E. = 1/2mvK.E. = 1/2mv22
, therefore K.E., therefore K.E. αα mvmv22
 The velocity of the penetrating object is theThe velocity of the penetrating object is the
major determinant of tissue damage than themajor determinant of tissue damage than the
mass of an objectmass of an object
 The high the velocity the more energy generatedThe high the velocity the more energy generated
and therefore more tissue damageand therefore more tissue damage

14. 1414
Penetrating injuries [cont]
The mechanism of injury in penetratingThe mechanism of injury in penetrating
thoracic injuries can categorized as:-thoracic injuries can categorized as:-
 Low velocity thoracic injuriesLow velocity thoracic injuries
E.g. stab woundsE.g. stab wounds
Velocity < 1200ft/s injuriesVelocity < 1200ft/s injuries
 Medium velocity thoracic injuriesMedium velocity thoracic injuries
 E.g. Most handgunsE.g. Most handguns
 Velocity 1200-2000ft/sVelocity 1200-2000ft/s
 High velocity thoracic injuriesHigh velocity thoracic injuries
E.g. most war weapons eg riflesE.g. most war weapons eg rifles

15. 1515
CLASSIFICATIONS
Classified according to:-Classified according to:-
Mechanism of injuryMechanism of injury
Site of injuries/anatomicalSite of injuries/anatomical
classificationclassification

16. 1616
Mechanism of injury
Blunt thoracic injuriesBlunt thoracic injuries
Penetrating thoracic injuriesPenetrating thoracic injuries

17. 1717
Site of injuries/anatomical
classification
Chest wall injuriesChest wall injuries
Pleural injuriesPleural injuries
Pulmonary injuriesPulmonary injuries
Mediastinal injuriesMediastinal injuries

18. 1818
Chest wall injuries
Soft tissue injuriesSoft tissue injuries
Bony injuriesBony injuries
Rib #sRib #s
Flail chestFlail chest
Sternum #Sternum #
Clavicle #Clavicle #
Thoracic spine injuryThoracic spine injury

19. 1919
Pleural injuries
PneumothoraxPneumothorax
Closed pneumothoraxClosed pneumothorax
Open pneumothoraxOpen pneumothorax
Tension pneumothoraxTension pneumothorax
HemothoraxHemothorax
PneumohemothoraxPneumohemothorax

20. 2020
Pulmonary injuries
LacerationLaceration
ContusionContusion
HaematomaHaematoma
Crush injury with fragmentation ofCrush injury with fragmentation of
the lungthe lung

21. 2121
Mediastinal injuries
Cardiac injuryCardiac injury
Tracheo-broncheal injuryTracheo-broncheal injury
Cardio-pulmonary injuryCardio-pulmonary injury
Thoracic duct injuryThoracic duct injury
Diaphragmatic injuryDiaphragmatic injury

22. 2222
PATHOPHYSIOLOGY
Thoracic injury results into threeThoracic injury results into three
pathophysiological consequencespathophysiological consequences
These are:-These are:-
HypoxemiaHypoxemia
HypovolaemiaHypovolaemia
Myocardial failureMyocardial failure

23. 2323
Hypoxaemia
Refers toRefers to PaOPaO22 oror  O2 contents in arterial bloodO2 contents in arterial blood
Results from any injury that disturbs airway orResults from any injury that disturbs airway or
ventilation including:-ventilation including:-
Airway obstructionAirway obstruction
PneumothoraxPneumothorax
Flail chestFlail chest
Lung contusionLung contusion
Tracheobroncheal injuryTracheobroncheal injury
Diaphragmatic ruptureDiaphragmatic rupture
Each of these injuries limits the physiologic functionEach of these injuries limits the physiologic function
of air exchangeof air exchange

24. 2424
Hypovolaemia
Refers to asRefers to as  in blood volumein blood volume
Results from intrathoracicResults from intrathoracic
haemorrhage secondary tohaemorrhage secondary to rib #s,rib #s,
injury to the lung parenchyma orinjury to the lung parenchyma or
intercostal vesselsintercostal vessels

25. 2525
Myocardial failure
Refers to as failure of the heart to pump bloodRefers to as failure of the heart to pump blood
to the general circulationto the general circulation
May be caused by eitherMay be caused by either bluntblunt oror penetratingpenetrating
thoracic injurythoracic injury
Causes of myocardial failure include:-Causes of myocardial failure include:-
Cardiac contusionCardiac contusion
Pericardial effusionPericardial effusion
Rupture of ventricular septum or vulvular muscleRupture of ventricular septum or vulvular muscle
Coronary air embolusCoronary air embolus

26. 2626
CLINICAL PRESENTATIONS
HistoryHistory
Physical examinationPhysical examination
General examinationGeneral examination
Systemic examinationSystemic examination
Local examinationLocal examination

27. 2727
History
History of chest traumaHistory of chest trauma
Chest painChest pain
Difficulty in breathingDifficulty in breathing
±Haemoptysis±Haemoptysis
±Cough±Cough

28. 2828
Physical examination
General examinationGeneral examination
DyspnoeaDyspnoea
CyanosisCyanosis
AnemiaAnemia
ShockShock
Level of consciousnessLevel of consciousness
Puffy appearance of surgical emphysemaPuffy appearance of surgical emphysema
Restless and gaspingRestless and gasping

29. 2929
Physical examination [cont]
Local examinationLocal examination
Open Chest woundOpen Chest wound →→assess theassess the
depthdepth
Bruises and lacerations on the chestBruises and lacerations on the chest
wallwall
Thoracic spine tendernessThoracic spine tenderness

30. 3030
Physical examination [cont]
Systemic examinationSystemic examination
Respiratory systemRespiratory system
Cardiovascular systemCardiovascular system
Abdominal examinationAbdominal examination
CNS examinationCNS examination

31. 3131
WORKUP
Laboratory studiesLaboratory studies
Imaging studiesImaging studies
Endoscopic studiesEndoscopic studies
Diagnostic proceduresDiagnostic procedures
OthersOthers

32. 3232
Laboratory studies
Non- specificNon- specific
Adds little informationAdds little information
Hemoglobin estimationHemoglobin estimation
Blood grouping and cross-matchingBlood grouping and cross-matching
Blood gaseous analysisBlood gaseous analysis
PaCO2PaCO2
PaO2PaO2

33. 3333
Imaging studies
Plain CXR to rule out:-Plain CXR to rule out:-
Rib fracturesRib fractures
HaemothoraxHaemothorax
PneumothoraxPneumothorax
HaemopneumothoraxHaemopneumothorax
Cardiac temponadeCardiac temponade

34. 3434
Imaging studies [cont]
Abdominal USS [FAST]Abdominal USS [FAST]
To rule out associated abdominalTo rule out associated abdominal
visceral injury and pleural effusionvisceral injury and pleural effusion
CT scan –CT scan – chest, brain, abdomenchest, brain, abdomen
Aortogram –Aortogram – to rule out aortato rule out aorta
rupturerupture

35. 3535
Endoscopic studies
BronchoscopyBronchoscopy
OesophagoscopyOesophagoscopy

36. 3636
Diagnostic procedures

37. 3737
MANAGEMENT
The mgt is divided into 5 phasesThe mgt is divided into 5 phases
according to ATLS (Advanced Traumaaccording to ATLS (Advanced Trauma
Life Support)Life Support)
 Phase I: Primary survey phasePhase I: Primary survey phase
 Phase II: Resuscitation phasePhase II: Resuscitation phase
 Phase III :Secondary survey phasePhase III :Secondary survey phase
 Phase IV: Supportive care phasePhase IV: Supportive care phase
 Phase V: DefinitivePhase V: Definitive treatment phasetreatment phase

38. 3838
Phase I: Primary survey phase
 Aim: to identify life threatening conditionsAim: to identify life threatening conditions
 The life threatening conditions include:-The life threatening conditions include:-
 A=AirwayA=Airway
 B=BreathingB=Breathing
 C=CirculationC=Circulation
 D=DisabilityD=Disability
 E=ExposureE=Exposure
 This should go hand in hand with the phase IIThis should go hand in hand with the phase II

39. 3939
Phase II. Resuscitation phase
 Aim: to treat the immediately lifeAim: to treat the immediately life
threatening conditionthreatening condition
 Airway –secure airway & Immobilize theAirway –secure airway & Immobilize the
cervical spinecervical spine
 Breathing – optimize ventilationBreathing – optimize ventilation
 Circulation- establish i.v. accessCirculation- establish i.v. access
 Disability- assess neurological deficitDisability- assess neurological deficit
 Expose the patient to avoid missed injuryExpose the patient to avoid missed injury

40. 4040
Airway
A clear patent and functional airwayA clear patent and functional airway
should be establishedshould be established
This can be achieved by:-This can be achieved by:-
Use of airwaysUse of airways
Proper position of the patientProper position of the patient
Endotracheal intubationEndotracheal intubation
AmbubagsAmbubags
TracheostomyTracheostomy

41. 4141
Breathing / Ventilation
 Achieved by:-Achieved by:-
 Make sure the patient is breathingMake sure the patient is breathing
properlyproperly
use of oxygen masksuse of oxygen masks
Mechanical ventilatorsMechanical ventilators

42. 4242
Circulation
Patients with thoracic trauma may bePatients with thoracic trauma may be
associated with massive blood loss leadingassociated with massive blood loss leading
to hemorrhagic shockto hemorrhagic shock
A functional i.v. fluid should be establishedA functional i.v. fluid should be established
to restore blood volume and preventto restore blood volume and prevent
irreversible shockirreversible shock
During the shock state use crystalloid fluidDuring the shock state use crystalloid fluid
BT should be given in case of hemorrhagicBT should be given in case of hemorrhagic
shockshock

43. 4343
Dysfunction of CNS
Neurologic evaluation should beNeurologic evaluation should be
assessed as follows:-assessed as follows:-
Levels of consciousness using GCSLevels of consciousness using GCS
Pupil size and response to lightPupil size and response to light
Motor activity and tactile sensationMotor activity and tactile sensation
Oculocephalic [doll’s eye]Oculocephalic [doll’s eye]

44. 4444
Exposure of the patient
TheThe patient should be fullypatient should be fully
exposed/ undressed to avoidexposed/ undressed to avoid
missed injuriesmissed injuries

45. 4545
Phase III :Secondary survey phase
 Not started until phase I &II areNot started until phase I &II are
completecomplete
 This include:-This include:-
 HistoryHistory
 Physical examinationPhysical examination
 InvestigationsInvestigations

46. 4646
History
Take history from relatives, friends,Take history from relatives, friends,
ambulance staff, police etcambulance staff, police etc
Mechanism of injuryMechanism of injury
When was the injuryWhen was the injury
Mechanism of impactMechanism of impact
Type of weaponType of weapon

47. 4747
History [cont]
AMPLE historyAMPLE history
A= history of allergiesA= history of allergies
M= medicationsM= medications
P= pre-morbid illnessP= pre-morbid illness
L= last mealL= last meal
E= events surrounding injuryE= events surrounding injury

48. 4848
History [cont]
 Associated injuriesAssociated injuries
 HeadHead
 Abdominal injuriesAbdominal injuries
 Major long bone fracturesMajor long bone fractures
 SpinesSpines
 Pelvic fracturesPelvic fractures

49. 4949
History [cont]
 Other symptomsOther symptoms
 Loss of consciousnessLoss of consciousness
 Bleeding from the ENTBleeding from the ENT

50. 5050
Physical examination
 General examinationGeneral examination
 Local examinationLocal examination
 Systemic examinationSystemic examination

51. 5151
General examination
 DyspnoeaDyspnoea
 CyanosisCyanosis
 AnaemiaAnaemia
 ShockShock
 Level of consciousnessLevel of consciousness
 etcetc

52. 5252
Local examination
 Look for:-Look for:-
 Open chest wound- assess the depthOpen chest wound- assess the depth
 Bruises and lacerations on the chestBruises and lacerations on the chest
wallwall
 Thoracic spines tendernessThoracic spines tenderness

53. 5353
Systemic examination
 Respiration examinationRespiration examination
 Cardiovascular examinationCardiovascular examination
 Abdominal examinationAbdominal examination
 etcetc

54. 5454
Respiration examination
 InspectionInspection
 Look for:-Look for:-
 Decreased chest movementDecreased chest movement
 Paradoxical respirationParadoxical respiration

55. 5555
Respiration examination [cont]
 PalpationPalpation
 Feel for:-Feel for:-
 Tracheal / Mediastinal shiftTracheal / Mediastinal shift
 Tenderness over the chest wallTenderness over the chest wall
 Creptus of rib fracturesCreptus of rib fractures → do→ do
compression test to rule out rib #scompression test to rule out rib #s
 SternumSternum
 Crackly feeling of surgical emphysemaCrackly feeling of surgical emphysema

56. 5656
Respiration examination [cont]
 PercussionPercussion
 Should be done gentlyShould be done gently
 Dullness – haemothorax/lung collapseDullness – haemothorax/lung collapse
 Hyper-resonant- pneumothoraxHyper-resonant- pneumothorax
 Increased cardiac dullness-Increased cardiac dullness-
hemopericardiumhemopericardium

57. 5757
Respiration examination [cont]
 AuscultationAuscultation
 Note the following:-Note the following:-
 Clicking sounds from rib #Clicking sounds from rib #
 Course creptations of surgical emphysemaCourse creptations of surgical emphysema
 or absence of breath sounds on the affected sideor absence of breath sounds on the affected side
indicating fluid or air in the pleural cavity or collapsedindicating fluid or air in the pleural cavity or collapsed
lunglung
 High pitched breath sounds suggesting tensionHigh pitched breath sounds suggesting tension
pneumothoraxpneumothorax
 Presence of breath sounds suggesting rupturedPresence of breath sounds suggesting ruptured
diaphragmdiaphragm

58. 5858
Cardiovascular examination
 Look for:-Look for:-
 PulsePulse
 Blood pressureBlood pressure
 JVPJVP
 Apex beatApex beat
 ↑↑ cardiac dullnesscardiac dullness
 Pulsus paradoxicusPulsus paradoxicus

59. 5959
Abdominal examination
 Look for:-Look for:-
 Evidence of haematomaEvidence of haematoma
 Distended abdomenDistended abdomen
 Tenderness over the epigastrium /LtTenderness over the epigastrium /Lt
hypochondriumhypochondrium

60. 6060
Investigations
Lab investigationsLab investigations
Hb, Blood grouping & X-matching,Hb, Blood grouping & X-matching,
blood gaseous analysisblood gaseous analysis
Imaging investigationsImaging investigations
CXR, CT scan, abdominal USCXR, CT scan, abdominal US
Aspiration tapAspiration tap

61. 6161
Phase IV: Supportive care phase
AnalgesicsAnalgesics
AntibioticsAntibiotics
Toxiod prophylaxisToxiod prophylaxis
Urethral catheterizationUrethral catheterization
Monitor:-Monitor:-
Vital signsVital signs
Input/outputInput/output

62. 6262
Phase V: Definitive treatment phase
Depends on the type of injuryDepends on the type of injury
 Open chest woundOpen chest wound
Treatment: surgical toilet, closure of theTreatment: surgical toilet, closure of the
woundwound
 Simple rib#Simple rib#
Treatment: bed rest, analgesics,Treatment: bed rest, analgesics,
antibiotics, physiotherapy as soon as painantibiotics, physiotherapy as soon as pain


63. 6363
Phase V: Definitive treatment phase
[cont]
 Flail chestFlail chest →→internal Pneumaticinternal Pneumatic
Fixation ±intubation or tracheostomyFixation ±intubation or tracheostomy
 Pneumothorax,Pneumothorax, haemothorax,haemothorax,
pulmonary injuriespulmonary injuries →→UWSD ±UWSD ±
pneumonectomypneumonectomy
 Cardiac injuryCardiac injury →cardiac surgery,→cardiac surgery,
pericardiocentesispericardiocentesis

64. 6464
Phase V: Definitive treatment phase
[cont]
 Diaphragmatic ruptureDiaphragmatic rupture →→ RepairRepair
 Esophageal ruptureEsophageal rupture →→ RepairRepair
 Associated injuriesAssociated injuries →→ should beshould be
managed accordinglymanaged accordingly

65. 6565
CompliCations
General complicationsGeneral complications
Local complicationsLocal complications

66. 6666
General complications
 Haemorrhagic shockHaemorrhagic shock
 Cardiopulmonary failureCardiopulmonary failure
 Cerebral hypoxiaCerebral hypoxia
 HypercapnoeaHypercapnoea
 Neurogenic shockNeurogenic shock

67. 6767
Local complications
 Thoracic wall complicationsThoracic wall complications
 Rib #sRib #s
 Flail chestFlail chest
 Clavical / thoracic spines /sternal #sClavical / thoracic spines /sternal #s
 Surgical emphysemaSurgical emphysema

68. 6868
Local complications [cont]
 Pleural complicationsPleural complications
 PneumothoraxPneumothorax
 HaemothoraxHaemothorax
 HaemopneumothoraxHaemopneumothorax
 EmpyemaEmpyema thoracisthoracis

69. 6969
Local complications [cont]
 Pulmonary complicationsPulmonary complications
 Lung contusionLung contusion
 Lung lacerationLung laceration
 Lung fibrosisLung fibrosis

70. 7070
Local complications [cont]
 Mediastinal complicationsMediastinal complications
 Cardiac temponadeCardiac temponade
 Pericardial effusionPericardial effusion
 Myocardial failureMyocardial failure
 Cardiopulmonary injuriesCardiopulmonary injuries
 Diaphragmatic ruptureDiaphragmatic rupture
 Esophageal injuriesEsophageal injuries
 Sub-diaphragmatic injuriesSub-diaphragmatic injuries eg ruptured spleen,eg ruptured spleen,
liverliver

71. 7171
Chest trauma- Summary
 CommonCommon
 SeriousSerious
 Primary goal is to provide oxygen to vital organsPrimary goal is to provide oxygen to vital organs
 RememberRemember
AAirwayirway BBreathingreathing
CCirculationirculation
DDysfunction of CNSysfunction of CNS
EExposure to avoid missed injuryxposure to avoid missed injury
Be alert to change in clinical conditionBe alert to change in clinical condition

72. 7272

73. 7373

74. 7474
SPECIAL THANKS TO
SADRU MOHAMED
FOR MAKING THESE SLIDES AVAILABLE
HERE
sadru12@gmail.com
+255759212578