Thoracic injuries can be immediately life-threatening, potentially life-threatening, or non-life-threatening. Immediately life-threatening injuries include tension pneumothorax, massive hemothorax, and cardiac tamponade which require urgent treatment to prevent death. Potentially life-threatening injuries like aortic injury or cardiac injury may not initially present severe symptoms but can worsen without treatment. The majority of thoracic injuries are non-life-threatening such as rib fractures and pulmonary contusions which are managed with pain control, pulmonary toilet, and observation.

2. Introduction
• Thoracic injuries account for ~ 25% of all trauma
deaths
– Immediate (within seconds to minutes),
• disruption of the heart or great vessel injury
– Early (minutes to hours)
• Airway obstruction, tension pneumothorax,
pulmonary contusion, or cardiac tamponade
– Late (days to weeks) after injury
• Pulmonary complications, sepsis, and missed injuries

3. • Most patients with thoracic injury are managed
nonoperatively( 85% )
– analgesia,
– pulmonary hygiene,
– endotracheal intubation, and
– tube thoracostomy.
• Only 10% to 15% of patients with chest trauma will
require thoracotomy or sternotomy

4. Indications for Urgent Thoracotomy
• Chest drainage >1,500 mL initial or >200 mL/hr for 4
consecutive hrs
• Large unevacuated clotted hemothorax
• Developing cardiac tamponade
• Chest wall defect
• Massive air leak or incomplete lung expansion despite
adequate drainage
• Great vessel injury
• Esophageal injury
• Diaphragmatic laceration
• Traumatic septal or valvular injury

5. Indications for ED Thoracotomy
– Acute pericardial
tamponade unresponsive
to cardiac massage
– Exsanguinating
intrathoracic hemorrhage
– Need for internal cardiac
massage
• Approach :
– left anterolateral
thoracotomy

6. Identifying a Pneumothorax
CXR
• Upright
– most pleural gas
accumulates in an
apicolateral location
– As little as 50mL of pleural
gas may be visible
• Lateral decubitus
– most pleural gas
accumulates in the non-
dependent lateral location
– As little as 5 mL of pleural
gas may be visible

7. IDENTIFYING A PNEUMOTHORAX…
• CT Scan
– most accurate imaging modality for the detection
of pneumothorax
– complex pleural pathology can be optimally
displayed

8. • ultrasound
– highly accurate , extremely quick to be performed at
bedside and much more sensitive than CXR
– absence of lung sliding and B lines (comet tail) allows for
the diagnosis of pneumothorax

9. Thoracic Injury
 immediately life threatening
 Cause death in a minute
airway obstruction
Tension pneumothorax
Open pneumothrax
Hemothorax
Cardiac tamponade
Flail chest
Potentially life-
threatening
 If left untreated would
result in death
traumatic rupture of
aorta
blunt cardiac injury
Tracheobroncial injury
Diaphragmaticinjury
Esophagealperforation
pulmonarycontusion

10. Immediately life-threatening injuries (“lethal six”)
– Causes
• The tongue most commonly causes airway
obstruction in the unconscious patient.
• Bilateral mandibular fracture.
• Expanding neck hematomas.
• Laryngeal trauma

11. • Clinical presentation
– stridor
– hoarseness
– subcutaneous emphysema
– accessory muscle use
– air hunger, apnea, and cyanosis
• Management
– Directed to the causes
– Intubate early, especially in cases of neck hematoma or
possible airway edema
– emergency cricothyroidotomy if endotracheal intubation
fails.

12. • air enters the pleural space without a means
of exit.
• The affected lung collapses, with subsequent
mediastinal shift and kinking of the SVC and
IVC,
– impaired venous return, and decreased cardiac
output.
– Ventilation of the contralateral lung is also
decreased

13. • Most common causes
– Penetrating injury to the chest
– Blunt trauma with parenchymal lung injury
– Mechanical ventilation with high airway pressure
– Spontaneous pneumothorax with blebs that failed to
seal

14. • Diagnosis
• Hx and P/E
– Severe respiratory distress
– Hypotension
– absence of breath sounds
– Hyperresonance to percussion
– Neck vein distention (absent in hypovolemic pt)
– Tracheal deviation (late finding)
– Cyanosis

15. treatment
 Immediately decompress by
inserting a 12- or 14-gauge
i.v. canula into the 2nd ICS in
the MCL
 this converts the tension
pneumothorax into a simple
pneumothorax
 Follow immediately with
tube thoracostomy

16. • caused by stab injury or destructive penetrating
wound (shotgun)
• Large open defect >3 cm cause equilibration b/n
intrathoracic & atmospheric pressure
• If the opening >2/3rd of the Ø of the trachea, then
air follows the path of least resistance through the
chest wall with each inspiration
• Signs and symptoms are usually proportional to the
size of the defect.

17. • Mediastinal flutter
– Swinging of the mediastinum
• Pendulum air
– Expiratory air from the normal lung filling the
collapsed lung

18. • Management
 Close the chest wall defect with occlusive dressing
taped on three sides to act as a flutter-type valve.
Followed by tube thoracostomy
Large defects may require flap closure.

19. • is defined as >1500 mL of blood or, in the pediatric population, 1/3rd
of the pt's blood volume in the pleural space
• Common in penetrating trauma with hilar or systemic vessel
disruption
• Intercostal and internal mammary vessels are most
commonly injured
• Each hemithorax can hold up to 3 L of blood
• Hilar or great vessel disruption will present with severe shock.

20. Diagnosis
• Hemorrhagic shock
• Unilateral absence or diminution of breath sounds
• Unilateral dullness to percussion
• CXR will show unilateral “white out” (opacification)

21. • Treatment
– Establish large-bore i.v. access and have blood available
for infusion before decompression
– tube thoracostomy with a large tube (36F or 40F) in 5th
ICS
– A second chest tube is occasionally necessary to
adequately drain the hemothorax.

22. • Thoracotomy is indicated for:
– 1,500 mL blood evacuated initially or drainage of ≥20
mL/kg
– Ongoing bleeding of >200 mL/hr for 4 hrs(generally >3
mL/kg/hr)
– Failure to completely drain hemothorax, despite at least
two functioning and appropriately positioned chest
tubes
– Pt presents after a delay may be observed if output
ceases & the lung is re-expanded

23. – when ≥2 consecutive ribs are #d in two or more
locations
– leads to paradoxical motion of that chest wall segment
– flail segment classically involves anterior (costochondral
cartilage) or lateral rib
– Morbidity and mortality are generally related to the lung
parenchymal injury rather than the chest wall injury

24. Diagnosis
• is clinical, not radiographic
• Chest wall must be observed for several respiratory
cycles and during coughing
• flail segment, underlying pulmonary contusion, and
chest splinting due to pain
– all exacerbate hypoxemia….severe RD

25. Management
• Admit patient to ICU
• Immediately intubate for shock or signs of RD,
like:
– RR >35/minute or <8/minute
– Sao2 <90%, PaO2 <60 mmHg2PaCO2 >55 mmHg2
• Control pain ,Control pain !!!!
• Provide aggressive pulmonary hygiene
• Rarely chest wall stabilization
•Patient going for thoracotomy
•Failure to wean from ventilator
•extensive flail chest segments

26. • is commonly the result of penetrating trauma, but it
can also be seen in blunt chest trauma.
• Mostly ventricular, right > left
• pericardial sac does not acutely distend; 75 to 100
mL of blood can produce tamponade physiology in
the adult.

27. Diagnosis
• Classic signs:
– Increase in JVP,
– hypotension, and Beck's triad are present in only 33% of pts
– muffled heart sound
• Pulsus paradoxus
• Kussmaul's sign
– is a hard and true sign
• shock or ongoing hypotension without blood loss suggest this injury
• FAST , ECHO cardiography, chest CT,
• Pericardial window

28. Treatment
• Assess the need for intubation, oxygenate, and
start volume resuscitation.
• Pericardiocentesis can be used as a temporizing
maneuver .
– prevent subendocardial ischemia and lethal arrhythmias.
• emergent left anterolateral thoracotomy
• urgent sternotomy

29. Potentially life-threatening injuries (“hidden six”)
Traumatic rupture of the aorta
• defined as a tear in the wall of the aorta that is contained
by the adventitia of artery and the parietal pleura
• The mechanism of injury :
– rapid deceleration, such as falls from significant height, high-
speed motor vehicle crashes
• Laceration is usually located near the ligamentum
arteriosum (85%), distal to the left subclavian artery

30. • Diagnosis
• Clinical signs
• Asymmetry in upper extremity BP and upper extremity HTN
• Widened pulse pressure
• Chest wall contusion
• 50% pts with great vessel injury from blunt trauma have no
external signs of blunt chest injury.

31.  CXR
Widened mediastinum (supine CXR >8 cm; upright CXR >6 cm)
this is the most consistent finding
Aortography
Gold standard
2% to 3% are falsely negative
Chest CT
Mediastinal hematomas
Negative scans rule out aortic injury with a 92% sensitivity
Transesophageal echocardiogram
excellent alternative for unstable patients

32. • Management
• Control and prevent hypertension
– goal for SBP should be ~100mm/Hg and HR<100
beats/minute
– Beta blockade
• repair

33. • Most pts with major AW injuries die at the scene
as a result of asphyxia.
• Those who survive to reach the hospital are
usually in extremis.
• Of major bronchial injuries,
– 80% occur within 2.5 cm of carina
– Main stem 86%
– More common in right side

34. Diagnosis
– Intrapleural laceration (more distal airway injuries)
• massive pneumothorax that does not reexpand with chest tube
• Severe RD
– Extra pleural rupture into the mediastinum (thoracic
trachea and proximal bronchi)
• pneumomediastinum and subcutaneous emphysema
• RD may be minimal
– Imaging
• CXR
• Bronchoscopy

35. Management
• Surgical
– Extra thoracic - collar incision
– Intrathoracic- thoracotomy
– Injuries <1/3rd of the luminal circumference may be
considered for nonoperative management if
• pneumothorax and associated air leak that were present
resolve after insertion of a chest tube and
• the lung expands completely
• pts don’t require ppv

36. • only 3.8% of cases of blunt
chest trauma
• asymptomatic myocardial
muscle contusion to
clinically significant
dysrhythmia, septal defects
or valvular injury

37. Cardiac injuries…
diagnosis
• FAST
• CXR
• ECG
• ECHO
CARDIOGRAP
HY
treatment
• Treat dysrhythmias and put the pt on
continues monitoring

38. • Blunt trauma.
– classically large (~10 cm), radial, and located
posterolaterally
– herniation of the abdominal viscera typically occurs
acutely~ 66%
– The left hemidiaphragm is involved in 65% to 80% of
cases.
– are markers for severe intraabdominal injuries

39. • Penetrating trauma.
– Wounds are smaller (~3 cm) but tend to enlarge
over time
–herniation of the abdominal viscera typically
occurs after acute setting
–Left-sided injuries still predominate

40. • Diagnosis
• Hx and P/E
• CXR is diagnostic in only 25% to 50% of cases of blunt
trauma.
– elevated, obscured, or irregular diaphragmatic dome, and a
blunted CP angle
• CT scan
• Barium meal or SB follow through
• FAST
• Thoracoscopy, laparotomy, VATS

41. Treatment
• operative repair
– do not heal spontaneously & produce herniation
• Via laparotomy,
– Acute repair (<7-10days)
• Via thoracotomy
– in chronic herniation.
– posterolateral injury to the right hemidiaphragm
• Prosthetic material or flaps are rarely needed to
close the defect.

42. • Most injuries result from penetrating trauma.
• Blunt injury is rare (<0.1% incidence)
– caused by a rapid elevation in intraluminal pressure
during compression of the chest or abdomen
• more commonly injured in the neck
• Clinical presentation
– Odenophagia, subcutaneous emphysema, mediastinitis

43. Diagnosis
• Any possibility of injury need aggressive
investigation
• Esophagoscopy
– disruption of the mucosa both studies will detect
almost all injuries
• esophagogram
– extravasation of contrast
• CT scan may have a role in determining trajectory
in stable patients.
• Thoracentesis
– exudate with a high amylase.

44. Treatment
• Injuries identified within 24hrs
– Debridement and Primary repair + mediastinal drainage
• More than 24hrs
– Primary repair buttressed with vascularized autologous
tissue(parietal pleura & intercostal muscle)
– cervical esophagostomy , distal part stapled, gastrostomy and
feeding jejunostomy , mediastinal drainage for
• Critical pts and advanced mediastinitis or
• severe associated injuries
– T-tube drainage
• in critical pt and friable esophagus
– Esophagectomy for destructive injuries & gastric pull-up

45. • It is the most common potentially lethal chest injury
with mortality rate of 22% -30%
• Caused by h’ge into alveolar & interstitial spaces
and tissue damage
• Commonly, this accompanies multiple ribs # due to
blunt chest trauma
• It can also accompany a penetrating injury esp.
blast injuries from high-velocity missiles.
• Children may have it in the absence of rib # b/s of the resilience of
the chest wall.

46. Diagnosis
– Hemoptysis or blood in
the endotracheal tube
– CXR findings are
typically delayed in
appearance and
nonsegmental
– CT

47. • Treatment
• Largely supportive
– supplemental O2, pulmonary toilet, and analgesia
– Judicious fluid administration
– intubate and mechanically ventilate
• pulmonary resection
– is required in anatomic or nonanatomic patterns to
manage larger segments of injured lung tissue

48. Other thoracic injuries
• Rib Fractures
– most common major thoracic injuries…40%
– Factors that have the most impact on outcome of a pt is
• number of ribs fractured,
• age of the patient, and
• underlying pulmonary status
– One should always keep in mind that mortality from isolated rib fractures can
be as high as 5% in children and 20% in the elderly
– Diagnosis
• pain exacerbated by deep breathing
• CXR
• Bone scans

49. Rib Fractures….
• presence of ≥3 ribs # suggests the need for
hospitalization
– Management is directed at pain control
– repeat CXR at 6hrs after presentation to look for delayed
pneumothorax development (7%)
• There has been renewed interest in the operative fixation of rib
#
– optimal indications remains incompletely defined
– associated benefit

50. Pulmonary Hematoma
• difficult to differentiate from pulmonary contusion
• 24 to 48 hrs after the injury, it typically develops into a
discrete mass with distinct margins
• does not interfere with gas exchange and is reabsorbed
in time
• Treatment
– observation
– rarely it may become secondarily infected and present as an
abscess requiring drainage

51. Sternal Fracture
• Associated with severe blunt anterior trauma
• Mortality: 25-45%
– Myocardial contusion
– Pericardial tamponade
– Cardiac rupture
– Pulmonary contusion
• Treatment
• Pain control
• Plating
– severely displaced fractures

52. Mediastinal and Subcutaneous Emphysema
• Type of air entry
– Extrapleural( upper airway, tracheobronchial tree, esophagus)
• allows air to leak into mediastinum and then up to the soft tissues of
anterior neck
– Intrapleural (lung parenchyma)
• leakage typically creates a pneumothorax and then air leaks through the
parietal pleura and into the thoracic wall
– Source undetermined in 15%
• Typically, the more distal the injury, the more likely it is to
cause decompensation
• bronchoscopy , esophagoscopy and CXR

53. Mediastinal and Subcutaneous Emphysema…
• Management
– Mostly they are benign and self limited and can be treated with high flow
oxygen
• Facilitates re-absorption of nitrogen from tissues
– Key is identifying underlying injury
– Massive accumulations may be uncomfortable to a patient
• Decompression incisions in the skin are rarely if ever indicated

54. THANK YOU!!