Dr. Anil Kumar presented on the management of chest trauma. He discussed that chest trauma accounts for 10-15% of trauma cases and 25% of trauma deaths. The main issues in chest trauma are hypoxia, hypercarbia, and acidosis due to problems like tension pneumothorax, open pneumothorax, pulmonary contusion, and massive hemothorax. Basic management principles include the primary survey, resuscitation, adjuncts like chest X-ray and E-FAST ultrasound, and definitive care. Life-threatening injuries identified in the primary survey like tension pneumothorax require immediate needle decompression.

1. Dr Anil Kumar
Assistant Professor
Department of Surgical Disciplines
All India Institute of Medical Sciences
25-11-2015

2. Objective:
 Burden of Chest Trauma.
 Types of chest trauma.
 Background & Consequences/effect of chest injury
 Basic Principle to manage chest Trauma.
 Life threatening chest injuries
 Role of X-Ray & E-FAST in chest trauma
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3. Burden of chest trauma:
 Chest trauma : 10- 15% of all the cases .
 Responsible for 25% of death
 The rising burden of serious thoracic trauma
sustained by motorcyclist in road traffic crashes
(Bambach MR,Mitchell RJ 2014 Jan;. Epub 2013 Oct 19)
 The high burden of injuries in South Africa
(WHO:Rosana Norman, Richard Matzopoulos, Pam
Groenewald, Debbie Bradshaw)
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4. Types of Chest Trauma:
 Blunt
 Penetrating
 Explosion related
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5. Background:
 Significant cause of mortality.
 Immediate cause of death: Myocardial injury, Aortic
rupture
 Can be preventable : Prompt Diagnosis & Treatment.
 Thoracotomy : < 10 % of BTC & only 15-30 % of PTC.
 Majority of Chest Trauma patient can be managed:
simple intervention.
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6. Issues in chest Trauma: Hypoxia,
Hypercarbia & Acidosis
 Hypoxia: Inadequate delivery of oxygen to the tissue.
(A)Hypovolemia(Blood Loss)
(B)- Pulmonary ventilation/Perfusion mismatch
e.g- Contusion, Hematoma & Alveolar collapse
(C)Change in ITP relationship
e.g - Tension Pneumothorax
- Open Pneumothorax
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7. Issues in chest Trauma : Hypoxia,
Hypercarbia & Acidosis
 Hypercarbia: Inadequate ventilation.
(A) Change in ITP relationship
e.g - Tension Pneumothorax
- Open Pneumothorax
(B) Dec Level of consciousness
 Metabolic Acidosis: Hypo-perfusion of the tissu(Shock).
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8. Basic principle of Management:
 Primary survey
 Resuscitation of vital functions
 Adjunct of primary survey including CXR & E-FAST
 Detailed secondary survey
 Definitive care.
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9. Primary Survey
 Airway with cervical spine protection
 Breathing and ventilation
 Circulation with Hemorrhage control
 Disability: GCS
 Exposure(Undress)/Events with Hypothermia control
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10. Inspection Palpation Percussion Auscultation Diagnosis
Restricted
Chest move
CCT=+/- Hyper-
resonant
B.S= Dec/ - Tension
Pneumothorax.
Open wound CCT=+/- Hyper-
resonant
B.S=Dec/- Open
Pneumothorax
Restricted
chest move
CCT=+/- Dullness B.S=Dec/- Massive
Haemothorax
Paradoxical
movement
Asymetry
CCT=+ Dull/Hyper B.S=Dec/- Flail Chest with
pulmonary
contusion
Life threatening chest injuries:
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11. Tension Pneumothorax
 One-way valve air leak
 Air is forced to enter into the
thoracic cavity without any
means of escape
 Completely collapsing the
affected lung
 Mediastinal shift &
compressing the opposite
lung
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12. Tension Pneumothorax: Etiology
 Mechanical Ventilation with PPV in patients with
visceral pleural injury.
 CVP Insertion
Iatrogenic
 Esophageal Endoscopy
 Thoracic Spine #
 Chest Trauma (15-50% of severe chest trauma)
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13. Tension Pneumothorax:
 Dx – Absolutely clinical
-Restricted Chest Movement
-Absent Breath Sound
-Hyper-resonant note on Percussion
 Don't wait for radiological confirmation
 Immediate do the needle thoracostomy/ICD
( Definitive t/t)
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14. T/t of Tension Pneumothorax:
Needle
Thoracostomy in
2nd I.C.S in M.C.L.
Chest tube insertion in 5th
I.C.S in M.A.L.
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15. CXR - Pneumothorax.
JPNATC, AIIMS
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16. How to read CXR: ABCDEF
 Airway- Trachea
 Broncho alveolar Marking
 Cardiac Shadow
 Diaphragm
 External cage i.e the Bony
Area
 Foreign Bodies like
ET tube, Chest tube,
Central line, Nasogastric tube
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17. Open Pneumothorax
(Sucking chest wound)
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18. Open Pneumothorax
(Sucking chest wound)
Sucking wound
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19. T/t of open Pneumothorax:
 Apply Sterile Occlusive dressing over the defect
 Taped securely on 3 sides
 Provide Flutter -TypeValve
effect.
 Breath in- Dressing occlu-
des the wound & prevent
air to enter from out &
vice versa
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20. T/t of open Pneumothorax:
 Don’t put ICD through the defect
 Site of ICD – Remote from the wound
 Definitive surgical closure of the
defect after ICD insertion, when
pneumo subsides
Open wound
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21. Flail Chest & Pulmonary Contusion:
 If 2 or more ribs fractured in
2 or more places.
 Flail segment don't have
bony continuity.
 Paradoxical movement of flail
segment with underlying
normal chest movement .
 High association with Pulmonary
Contusion
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22. Flail Chest & Pulmonary Contusion
 Asymmetrical & uncoordinated chest movement
 Pain , Tenderness & Crepitation.
 CXR
 ABG
 CT
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23. Flail Chest & Pul. Contusion -M/n
 Better to admit- ICU ( Intubation & Ventilation)
 Administration of Humidified Oxygen.
 Fluid Resuscitation judiciously
 Analgesia- IV Narcotics/ Intercostals nerve block/
Epidural Anesthesia(Prefered)
 ICD (If A/w Pneumo/Haemo)
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24. Massive Haemothorax:
 Rapid accumulation of more than 1500 ml of blood in
the chest cavity
 Mainly caused by Penetrating wound- Disruption of
systemic & hilar vessels.
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25. Massive Haemothorax: Dx
 Restricted Chest Movement(Inspection)
 Breath Sound = Absent
 Dullness to Percussion
 Chest X-Ray
 ABG
 CT.
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26. Massive Haemothorax: M/n
 Follow the ABC.
 ICD (In Safety Triangle )
 IV Fluid – Infused 2 lit warmed RL very fast.
 5-10 ml blood for grouping & cross matching to start Blood
Transfusion at earliest.
 Auto transfusion from the ICD Bag.
 Plan- Thoracotomy (If indicated)
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27. Indication of Thoracotomy
 1500 ml blood collected immediately in ICD bag
 Blood loss @200ml/hr for 2-4 hrs.
 Persistent need of BT.
 Penetrating Injury -medial to the nipple line ( Over
anterior chest wall ) & medial to the scapula(Over
posterior chest wall)
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28. Penetrating Chest Trauma:
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29. Operative finding: Lacerated Lung
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30. E-FAST
 Lung USG is more sensitive than CXR for
Pneumothorax
 Perform rapidly at bed side by Surgeon, don't wait for
radiologist.
 Safe, fast & effective for detecting the pneumo
 Very easy to learn
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31. To detect Pneumothorax??
 A Line
 B Line
 Seashore sign
 Barcode sign
 Lung Point.
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32. E-FAST in Chest Trauma
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33. Bat’s Sign: Normal Finding: B Mode
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34. E-FAST in Chest Trauma: B mode
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35. Seashore sign & Barcode sign
Normal Lung
Pneumothorax- Find
the lung point
Seashore sign
Barcode sign
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36. Lung Point: Pneumothorax
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Barcode sign
Lung Point

37. Chest Trauma- Follow ABC
Nn
Bat’s Sign, Pleural Line
& Lung Sliding
Lung Sliding=
Absent
Bar Code Sign
Scan laterally &
Find the Lung
Point
Seashore sign
Put needle or Chest
tube
Switch to M Mode Normal Lung
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Pneumothorax
Bar code
Lung Point

38. Home Message!!!!!!!!!!!
 Thoracic trauma is a significant cause of mortality.
 Hypoxia, Hypercarbia & Acidosis- main concerned.
 Basic principle of m/n is the primary survey ( ABCDE)
 Life threatening injuries should be managed during
Primary survey.
 > 90% of BTC & > 70 % of PTC - simple intervention.
 E-FAST- Rapid, accurate & easily deployed and can be
lifesaving
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39. 25-11-2015