Chest injuries pathology.

1. CHEST TRAUMA
Dr. Msokwa, E K

2. Introduction
• Chest injury is one of the commonest causes
of trauma related deaths, second to brain and
spinal injuries.
• It accounts for about 25% of trauma related
deaths.
• About 33% of patient with chest injury require
admission.
• Most patients with significant chest injury die
at scene of accident.

3. Classification of chest injury
1. Blunt chest injuries.
2. Penetrating chest injuries.

4. Blunt chest injuries
• Blunt chest injuries lead to thoracic wall
injuries of varying degrees and intra thoracic
organ injuries.
• Such injuries are common in motor vehicle,
motor cycle accidents, fall from height and
assault by blunt objects.

5. Mechanisms of injury
• Intra thoracic organ injury can involve any of
the following mechanisms.
Sudden compression of intra thoracic organs,
 Sudden change in intro thoracic pressure,
Deceleration/acceleration shearing forces
 Direct impact on rib cage or a combination of
any of the mechanisms.

6. • BCI usually include rib fractures which may
present with pain on respiration, tenderness and
creptus over the affected rib and hemothorax.
• Sternal fractures (common in drivers) can present
with ecchymosis or displacement of/over the
sternum, and bleeding into the mediastinum.
• Clavicular fractures may present with pain,
displacement and creptus.

7. Penetrating chest injuries
• Penetrating injuries to chest are due sharp
objects such as knives, arrow or due to high
velocity objects such as gunshots.
• May be minimal or absent visible external
evidence of thoracic injury, severe internal
damage may exist.
• Therefore no thoracic injury should be considered
as small injury.
• Thoracic injury is commonly, associated injuries to
other parts of the body.

8. General principles of resuscitation in
chest injury
• The initial resuscitation follows the ABCDE
principles of advanced trauma life support.
• Quick short history on causes of trauma and
the possible complication is taken.
• The quick review and treatment through the
ABCDE system.

9. Airways
• Airways checked for patency or presence of
obstruction.
• Common cause of obstruction include;
secretions, back falling off the tongue, oral
pharyngeal edema, blood clots, foreign body,
altered consciousness, traumatic airway
disruption.

10. Airways
• Signs for air way obstruction include stridor,
hypoxia and intercostals retraction.
• Then appropriate measure implemented such
as chin lift and/or jaw thrust with suction,
then placement of airway
• To some patient‘s endotracheal intubation
may be required.
• This can be achieved by oral tracheal or
nasotracheal tubes.

11. Airways
• Sometimes placement of a bypass system,
through cricothyroidotomy or tracheostomy
may be needed in patients with oral
pharyngeal or laryngeal obstruction.
• During manipulation of the airways care must
be taken to check for and avoid exacerbation
of cervical spine injury, en bloc movement is
usually advocated.

12. Breathing and ventilation
• Ventilation can be compromised by tension
hemopneumothorax, open chest injury, flail chest
and unconsciousness.
• Ambu bag ventilation can be offered and
mechanical positive pressure ventilation, if
prolonged ventilation is required.
• Positive pressure ventilation should be instituted
careful, because it can lead to or exacerbate
tension pneumothorax, which cause rapid
cardiopulmonary compromise.

13. Circulation
• Circulatory insufficiency may be due to
external and internal hemorrhage, heart injury
and tamponade, and massive
hemopneumothorax.
• Evaluation of continuing hemorrhage, or
cardiac tamponade or injury must be done
through assessment of hemodynamic status.
• Additional evaluation may include radiological
investigations such as X-rays, and Ultrasound.

14. Circulation
• Interventions to such patients include; placement
of an intravenous line, using a large
bore canula.
• At the initial puncture blood samples for
emergency investigation (such as grouping and
cross matching, hemoglobin and hematocrit
estimation, blood and gases analysis) is taken.
• The need for intravenous fluids or blood depends
on hemodynamic parameters.

15. Disability
• Assessment of possible neurological damage is
done; neurological evaluation may include
assessment of spine injuries, head injury and
peripheral nerve injuries.

16. Exposure
• The patient is fully exposed and then
evaluated for other injuries.
• Avoiding hypothermia which may result from
prolonged exposure.
• After resuscitation a primary survey and
secondary survey are then done to identify
further diagnostic and therapeutic
interventions.

17. • Emergency interventions may include;
• placement of underwater seal drainage tube,
emergency room thoracotomy,
• pericardiocentesis or pericardiotomy. The
choice depends on the cause and mechanism
of trauma, hemodynamic status and
competence of the surgeon.

18. Subsequent Ix
• CXR
• CT SCAN
• FAST Vs eFAST
• Echocardiography

19. Subsequent Treatment
• Severe pain may interfere with respiration,
therefore one of the main stay of treatment
for chest wall injuries is pain relief.
• Commonly rib, sterna and clavicular fractures
don‘t need surgical reduction,
• In frail chest internal fixation may be tried.

20. Frail chest
• Chest wall injury occurs when there is
segmental fracture of three or more
consecutive ribs
• Common sides involved are anterior and
lateral sides.
• Frail chest injuries may be accompanies by
internal organs injuries such as lung
contusion.

22. • The free floating segment contributes
impairment of chest wall movements.
• Lung contusion associated with lung edema,
micro hemorrhage and arterial venous
shunting leads to poor oxygen exchange cause
hypoventilation, hypercapnia, hypoxia,
respiratory failure and death.

23. Treatment
• Strong analgesia in form of parenteral
analgesics or epidural block.
• Stabilization of the chest wall with manual
pressure or open fixation of the ribs.
• Endotracheal intubation with positive
pressure mechanical ventilation for
about 4 to 5 days is recommended.

25. Pneumothorax
• Pneumothorax results from an abnormal
communication between pleural space and
atmospheric air either through the broncho-
pulmonary tree or through the chest wall.
• If a hole allows air flow in one direction (one
way valve) it is called tension pneumothorax.
• This lead to lung collapse on the affected side.

26. Pneumothorax
• Communication between bronchus through the
lung to pleural space is called bronchopleural
fistula.
• When a small defect exists through the chest wall
it is also called sucking wound.
• When the defect is larger than two third of the
trachea it is called open pneumothorax.
• Common cause includes severe blast injuries,
severe avulsion injury and close range short gun
injuries.

27. Mechanism
• This can be caused by rib fragment piecing
through the lung parenchyma or high pressure
rupture of the lung when the chest is
compressed against a closed glottis or direct
injury to the chest wall as may occur in
penetrating injuries.
• Positive pressure ventilation can also lead to
tension pneumothorax.

28. • If not attended the high pressure causes
mediastinal shift which in turn compromises
ventilation of the contralateral lung.
• Therefore this should be considered as
emergency condition.

29. Clinical signs
• Respiratory distress, reduced or absence of
respiratory movements on the affected side.
• Reduced or absence of tactile vocal fremitus
and resonance, tracheal deviation to opposite
direction, reduced or absent breath sounds to
the ipsilateral hemithorax.

30. Clinical signs
• Tachycardia with reduced pulse volume and
hypotension, distant heart sound, hyper
resonant percussion note on the affected side.
• In open pneumothorax sucking wound is
evident.

31. Mgt
• For simple pneumothorax,
observation and follow up
by chest X rays films can be
employed if
cardiorespiratory
compromise is minimal.
• Under water seal drainage
should be inserted in safety
triangle

32. Treatment
• In tension pneumothorax, an immediate
decompressing needle (12 or 14G) should be
placed.
• Subsequent UWSD.

34. Hemothorax
• Hemothorax is the presence of blood in the
pleural space commonly occurs concurrently
with pneumothorax.
• When amount of blood in pleural space
exceeds 1500mls it is considered as massive
hemothorax.

35. Clinical signs
• Breathlessness, reduced chest expansion and
movement on the affected side,
• Reduced tactile phremitus and vocal
resonance on the affected side contra lateral
tracheal deviation dull percussion note,
reduced breath sound.
• Tachycardia,reduce pulse volume and
hypotension may occur

36. Mgt
• CXR
• CT Scan
• Early placement of underwater seal drainage
with large calibre.

37. Pulmonary contusion
• Bruising injury of the lung tissue caused by
variety of injurious mechanisms.
• It can be caused by acceleration deceleration
injury, directly chest wall blunt trauma, blast
injuries and sometimes by shock wave injuries
as may occur in bomb blasts.
• Lung contusion occurs in about half of patients
with severe chest injury.

38. Pathophysiology
• In pulmonary contusion, there is injury and
disruption of alveoli and microvasculature
within the lung tissue, which in turn causes
micro hemorrhages into lung tissue.
• capillary fluid leakage leads to pulmonary
interstitial edema and later into fluid
accumulation in the alveoli and subsequent
consolidation of the lung tissue.

39. Pathophysiology
• Pulmonary injury also leads to migration and
activation of inflammatory cells.
• They releases inflammatory mediators. Affect
the other parts of the lung leading to edema
and respiratory dysfunction.

40. Clinical features
• It depends on severity of damage.
• May include breathlessness, fast breathing
and increased heart rate
• Cough -initially dry, then wet or frothy,
hemoptysis, and central cyanosis.

41. Clinical features
• Auscultation may reveal course crepitations
and or bronchial breathing due to lung
consolidation.
• Chest X-ray may reveal patchy opacities with
or without subpleural blood.
• Blood gas analysis is important to assess
adequacy of oxygenation.

43. Treatment
• Pulmonary contusion is usually self limiting
condition.
• Treatment is mainly supportive. Treatments
options include; analgesics, balanced fluids
with or without diuretics to prevent
exacerbation of edema.

44. • The role of steroid is controversial, some
studies advocate use of steroids while other
do not.
• In some setting, steroids are commonly used
in patients with severe pulmonary contusion.