Chest Injuries

1. APPROACH TO A PATIENT OF
CHEST INJURY
DR TAJAMUL RASHID

2. THORACIC/CHEST INJURIES
• 25% OF ALL SEVERE INJURIES.
• 25% - DEATH.
• CAUSE OF DEATH  HEMORRHAGE.
• 80% OF PATIENTS - MANAGED NON-OPERATIVELY.

3. MECHANISM OF INJURY
Acceleration/deceleration (motor vehicle accident)
Body compression (crush injury)
High-speed impact (gunshot wound)
Miscellaneous
Low- velocity penetration ( stab wound)
Airway obstruction (suffocation)
Caustic injury ( poisoning)
Burns
Electrocution

4. ASSESSMENT

5. A. AIRWAY
Assess for airway patency
and air exchange - listen
at nose & mouth
Assess for intercostal and
supraclavicular muscle
retractions
Assess oropharynx for
foreign body obstruction

6. B. Breathing
Assess respiratory movements and
quality of respirations - look,
listen, feel.
Slow respirations are early indicator
of distress
Cyanosis is late.

7. C. CIRCULATION
Skin - look and feel for color,
temperature, capillary refill-
Look for cyanosis.
Assess pulses for
quality, rate,
regularity
Look at
neck
veins -
flat vs.
distended
- fluid
deficit or
decrease
d supply
to body
from
heart due
to
compress
ion.
Assess the B.P.

8. DEADLY DOZEN

10. CLINICAL FEATURES

12. TENSION PNEUMOTHORAX
• TACHYPNOEA, DYSPNOEA AND DISTENDED NECK VEINS
• TRACHEAL DEVIATION - LATE FINDING
• HYPER-RESONANCE AND DECREASED OR ABSENT
BREATH SOUNDS

13. PERICARDIAL TAMPONADE
• CENTRAL VENOUS PRESSURE ELEVATION
• DECLINE IN ARTERIAL PRESSURE
• TACHYCARDIA
• MUFFLED HEART SOUNDS

14. MASSIVE HAEMOTHORAX
• FLAT NECK VEINS
• UNILATERAL ABSENCE OF BREATH SOUNDS
• DULLNESS TO PERCUSSION

15. FLAIL CHEST
• PARADOXICAL MOTION OF A CHEST WALL SEGMENT.
• ON INSPIRATION, THE LOOSE SEGMENT OF THE CHEST
WALL IS DISPLACED INWARDS AND THEREFORE LESS
AIR MOVES INTO THE LUNGS.
• ON EXPIRATION, THE SEGMENT MOVES OUTWARDS
(PARADOXICAL RESPIRATION)

16. THORACIC AORTIC DISSECTION
• GROSS ASYMMETRY IN SYSTOLIC BLOOD PRESSURE
(BETWEEN THE TWO UPPER LIMBS, OR BETWEEN
UPPER AND LOWER LIMBS)
• WIDENED PULSE PRESSURE
• CHEST WALL CONTUSION.

17. DIAPHRAGMATIC INJURIES
• ANY PENETRATING INJURY BELOW THE FIFTH INTERCOSTAL
SPACE SHOULD RAISE SUSPICION OF DIAPHRAGMATIC
PENETRATION
• MOST DIAPHRAGMATIC INJURIES ARE SILENT AND THE
PRESENTING FEATURES ARE THOSE OF INJURY TO THE
SURROUNDING ORGANS.

18. OESOPHAGEAL INJURIES
• PENETRATING TRAUMA
• PATIENT CAN PRESENT WITH ODYNOPHAGIA (PAIN ON
SWALLOWING SALIVA, FOODS OR FLUIDS), SUBCUTANEOUS
OR MEDIASTINAL EMPHYSEMA, PLEURAL EFFUSION, AIR IN
THE PERIOESOPHAGEAL SPACE
• UNEXPLAINED FEVER.

19. INVESTIGATIONS

20. CHEST X-RAY

21. PERICARDIAL TAMPONADE

22. HEMOTHORAX

23. FLAIL CHEST

24. DIAPHRAGMATIC INJURY

25. AORTIC DISRUPTION

26. OESOPHAGEAL INJURIES

27. ULTRASOUND – EXTENDED FOCUSED
ASSESSMENT
WITH SONAR FOR TRAUMA
• CARDIAC TAMPONADE
• PLEURAL EFFUSION

28. CT SCAN

29. TREATMENT

30. INTERCOSTAL CHEST TUBE DRAINAGE

31. INTERCOSTAL CHEST TUBE DRAINAGE
• USED IN
TENSION PNEUMOTHORAX
OPEN PNEUMOTHORAX
MASSIVE HEMOTHORAX

32. NEEDLE DECOMPRESSION

33. PERICARDIOCENTESIS

34. FLAIL CHEST
• OXYGEN ADMINISTRATION, ADEQUATE ANALGESIA (INCLUDING
OPIATES) AND PHYSIOTHERAPY.
• CHEST TUBE IS IN SITU - TOPICAL INTRAPLEURAL LOCAL
ANALGESIA INTRODUCED VIA THE TUBE.
• VENTILATION - RESPIRATORY FAILURE DESPITE ADEQUATE
ANALGESIA AND OXYGEN.
• SURGERY - INTERNAL FIXATION OF THE RIBS -ISOLATED OR
SEVERE CHEST INJURY AND PULMONARY CONTUSION.

35. THORACIC AORTIC DISRUPTION
• CONTROL OF THE SYSTOLIC ARTERIAL BLOOD
PRESSURE (TO LESS THAN 120 MMHG).
• ENDOVASCULAR INTRA-AORTIC STENT
• TEAR CAN BE OPERATIVELY REPAIRED BY DIRECT
REPAIR OR EXCISION AND GRAFTING USING A DACRON
GRAFT.

36. DIAPHRAGMATIC INJURY
• OPERATIVE REPAIR IS RECOMMENDED IN ALL CASES.
• PENETRATING DIAPHRAGMATIC INJURY REPAIRED VIA
THE ABDOMEN AND NOT THE CHEST, TO RULE OUT
PENETRATING HOLLOW VISCUS INJURY.

37. OESOPHAGEAL INJURY
• OESOPHAGOGRAM IN THE DECUBITUS POSITION AND
OESOPHAGOSCOPY CONFIRM THE DIAGNOSIS
• TREATMENT IS OPERATIVE REPAIR OF ANY DEFECT AND
DRAINAGE.

38. TRACHEOBRONCHIAL INJURIES
Intubation of the unaffected
bronchus followed by operative repair
PULMONARY CONTUSIONS
Mild contusion-oxygen administration, pulmonary toilet and adequate analge
Severe cases- mechanical ventilation

39. EMERGENCY THORACIC SURGERY
EMERGENCY DEPARTMENT THORACOTOMY PLANNED EMERGENCY THORACOTO

40. ●Immediate thoracotomy in the ED for the control of
haemorrhage, cardiac tamponade or internal cardiac massage
●Emergency sternotomy for anterior mediastinal structures
and heart
●Planned thoracotomy for definitive correction of the
problem – this usually takes place in the more controlled
environment of the operating theatre.

41. EMERGENCY DEPARTMENT THORACOTOMY
INTERNAL CARDIAC MASSAGE
CONTROL OF HAEMORRHAGE FROM INJURY TO THE
HEART OR LUNG
CONTROL OF INTRATHORACIC HAEMORRHAGE FROM
OTHER SOURCES;
CONTROL OF MASSIVE AIR LEAK
CLAMPING OF THE THORACIC AORTA TO PRESERVE THE
BLOOD SUPPLY TO THE HEART AND BRAIN

42. • PENETRATING INJURY IN WHOM SIGNS OF LIFE ARE
STILL PRESENT
• EDT IS CONSIDERED FUTILE:
CPR IN THE ABSENCE OF ENDOTRACHEAL INTUBATION
FOR MORE THAN 5 MINUTES
CPR FOR MORE THAN 10 MINUTES (DESPITE
ENDOTRACHEAL INTUBATION)
BLUNT TRAUMA WHEN THERE HAVE BEEN NO SIGNS OF
LIFE AT THE SCENE

44. PLANNED EMERGENCY THORACOTOMY

45. SUMMARY

46. CHEST TRAUMA