Chest injury is one of the common condition in road traffic accident and other injuries including falling from height, blunt trauma and others, which can include fracture of ribs, or penetrating of objects to the lung the open pneumothorax, so this slide will enable you to know how to deal with this injury because mostly this patient are emergency need remediate help

1. CHEST INJURIES
Dr Phillipo L. Chalya M.D. ; M.Med (Surg)
Senior Lecturer- Department of Surgery
CUHAS-Bugando

2. DEFINITION
 Chest injuries can be defined as injuries of
the thoracic cage and its internal and
associated structures

3. HISTORICAL BACKGROUND

4. Historical background cont’d
 Chest injury is one of the oldest known forms of trauma
 One of the earliest writings of chest injury was noted in the
Edwin Smith Surgical Papyrus, written in 3000 BCE
 In 1635, Labeza de Vaca first described operative removal
of an arrowhead from the chest wall of an American Indian
 Rehn performed the first successful human cardiorrhaphy
in Germany in 1896
 In 1934, Alfred Blalock was the first American surgeon to
successfully repair an aortic injury

5. EPIDEMIOLOGY

6. Incidence
 Varies both geographically and with socio-
economic status
 In the US, S/America, Africa and Asia, the
incidence of penetrating injuries is higher
due to criminal or military activities
 In Europe, the incidence of blunt injuries is
high mainly due to RTA

7. Mortality/morbidity
 Chest trauma is associated with significant
mortality and morbidity
 Chest trauma account for 25% of all trauma
deaths
 2/3 of deaths occur after reaching hospital
 Serious pathological consequences include:-
 Hypoxia
 Hypovolaemia
 Myocardial failure

8. Age
 Trauma including chest trauma is the
leading cause of deaths among people
between 1-44 years of age

9. Sex
 Male are more affected than females
 Reasons ? Involvement of males in risk taking
activities and crimes

10. Race
 Studies reported no racial predilection to
thoracic injuries

11. ETIOLOGY

12. Etiology cont’d
 Road traffic accident
 Assault
 War injuries
 Falls
 Sport injuries
 Aircraft accident
 Stab wound
 Bullet injuries
 etc

13. MECHANISM OF INJURY
 Chest injuries occurs through 2
mechanisms namely:-
 Blunt chest injuries
 Penetrating chest injuries

14. Blunt chest injury
 Induces injuries through 3 distinct mechanisms:-
 Direct trauma to the thoracic cage i.e. a moving
object struck on the victim’s chest
 These usually cause rib #s, contused lungs
 Compression thoracic injuries
 In this case the chest is injured by compression e.g.
trapped in a landslide, building collapse→
diaphragmatic rupture, cardiac and pulmonary
contusions
 Deceleration thoracic injuries
 These are injuries resulting from rapid deceleration of
the body with continuing moving of the internal
thoracic organs → aortic rupture, pulmonary and
cardiac contusions

15. Penetrating chest injury
 The degree of tissue damage in penetrating
thoracic injuries is proportional to the
Kinetic Energy [K.E.] of the penetrating
object
 K.E. = 1/2mv2, therefore K.E.  mv2
 The velocity of the penetrating object is the
major determinant of tissue damage than
the mass of an object
 The high the velocity the more energy
generated and therefore more tissue
damage

16. Penetrating chest injury cont’d
 The mechanism of injury in penetrating thoracic
injuries can categorized as:-
 Low velocity thoracic injuries
 E.g. stab wounds
 Velocity < 1200ft/s injuries
 Medium velocity thoracic injuries
 E.g. Most handguns
 Velocity 1200-2000ft/s
 High velocity thoracic injuries
 E.g. most war weapons eg rifles
 Velocity > 2000ft/s

17. CLASSIFICATION
 According to its underlying mechanism of
injury
 According to the site of injury

18. According to mechanism of injury
 Blunt chest injuries
 Penetrating chest injuries

19. According to the site of injury
 Chest wall injuries
 Pleural injuries
 Pulmonary injuries
 Mediastinal injuries

20. Chest wall injuries
 Soft tissue injuries
 Bony injuries

21. Soft tissue injuries
 Open chest wound
 Stab wounds
 Bullet wounds
 Bruises, lacerations

22. Bony injuries
 Rib fracture
 Flail chest
 Sternum fracture
 Clavicle fracture
 Thoracic spine injury

23. Pleural injuries
 Pneumothorax
Simple pneumothorax
Tension pneumothorax
 Hemothorax
 Pneumohemothorax

24. Pulmonary injuries
 Laceration
 Contusion
 Haematoma
 Crush injury with fragmentation of the lung

25. Mediastinal injuries
 Cardiac injury
 Tracheo-broncheal injury
 Cardio-pulmonary injury
 Thoracic duct injury
 Diaphragmatic injury

26. PATHOPHYSIOLOGY

27. Pathophysiology cont’d
 Thoracic injury results into three
pathophysiological consequences
 These are:-
Hypoxemia
Hypovolaemia
Myocardial failure

28. Hypoxemia
 Refers to PaO2 or  O2 contents in arterial blood
 Results from any injury that disturbs airway or ventilation
including:-
 Airway obstruction
 Pneumothorax
 Flail chest
 Lung contusion
 Tracheo-broncheal injury
 Diaphragmatic rupture
 Each of these injuries limits the physiologic function of
air exchange

29. Hypovolaemia
 Refers to as  in blood volume
 Results from intrathoracic hemorrhage secondary to
rib fractures, injury to the lung parenchyma or
intercostal vessels

30. Myocardial failure
 Refers to as failure of the heart to pump blood to
the general circulation
 May be caused by either blunt or penetrating
thoracic injury
 Causes of myocardial failure include:-
 Cardiac contusion
 Pericardial effusion
 Rupture of ventricular septum or vulvular
muscle
 Coronary air embolus

31. CLINICAL PRESENTATION
 History
 Physical examination

32. History
 History of chest trauma
 Chest pain
 Difficulty in breathing
 ±Haemoptysis
 ±Cough

33. Physical examination
 General examination
 Local examination
 Systemic examination

34. General examination
 Dyspnoea
 Cyanosis
 Anemia
 Shock
 Level of consciousness
 Puffy appearance of surgical emphysema
 Restless and gasping

35. Local examination
 Open Chest wound →assess the depth
 Bruises and lacerations on the chest wall
 Thoracic spine tenderness

36. Systemic examination
 Respiratory system
 Cardiovascular system
 Abdominal examination
 CNS examination

37. WORK UP
 Laboratory investigations
 Imaging investigations
 Endoscopic studies
 Diagnostic procedures
 Others

38. Laboratory investigations
 Non- specific
 Adds little information
 Hemoglobin estimation
 Blood grouping and cross-matching
 Blood gaseous analysis
 PaCO2
 PaO2

39. Imaging investigations
 Plain CXR to rule out:-
 Rib fractures
 Haemothorax
 Pneumothorax
 Haemopneumothorax
 Cardiac temponade
 Abdominal USS [FAST]
 To rule out associated abdominal visceral injury and
pleural effusion
 CT scan – chest, brain, abdomen
 Aortogram – to rule out aorta rupture

40. Endoscopic studies
 Bronchoscopy
 Oesophagoscopy

41. Diagnostic procedures
 Aspiration tap
 Diagnostic peritoneal lavage (DPL) in case
associated hemoperitoneum is suspected

42. Others
 Electrocardiogram (ECG) in case of cardiac injury

43. MANAGEMENT

44. Goals of management
 Primary goal is to provide oxygen to vital
organs
 Relief of airway obstruction with cervical
spine protection
 Restoration of the mechanics of breathing
 Control of haemorrhage and restoration of
circulating blood volume

45. Management criteria
 The management is divided into 6 phases
according to Advanced Trauma Life
Support (ATLS) guidelines

46. Phases of management
 Phase I. Primary survey phase
 Phase II. Resuscitation phase
 Phase III. Secondary survey phase
 Phase IV. Tertiary survey phase
 Phase V. Supportive care phase
 Phase VI. Definitive care phase

47. Phase I. Primary survey phase
 Aim: to identify life threatening conditions
 The life threatening conditions include:-
 A=Airway
 B=Breathing
 C=Circulation
 D=Disability
 E=Exposure
 This should go hand in hand with phase II

48. Phase II. Resuscitation phase
 Aim: to treat the immediately life threatening
condition
Airway –secure airway & Immobilize the
cervical spine
Breathing – optimize ventilation
Circulation- establish i.v. access
Disability- assess neurological deficit
Expose the patient to avoid missed injury

49. Airway
 A clear patent and functional airway should
be established
 This can be achieved by:-
Use of airways
Proper position of the patient
Endotracheal intubation
Ambubags
Tracheostomy

50. Breathing / ventilation
 Make sure the patient is breathing properly
 Achieved by:-
 use of oxygen masks
Mechanical ventilators

51. Circulation
 Patients with thoracic trauma may be associated
with massive blood loss leading to hemorrhagic
shock
 A functional i.v. fluid should be established to
restore blood volume and prevent irreversible
shock
 During the shock state use crystalloid fluid
 BT should be given in case of hemorrhagic shock
 Any bleeding should be arrested

52. Dysfunction of CNS
 Neurological evaluation should be assessed
as follows:-
Levels of consciousness using GCS
Pupil size and response to light
Motor activity and tactile sensation

53. Exposure of the patient
 The patient should be fully exposed/ undressed
to avoid missed injuries

54. Phase III. Secondary survey phase
 Not started until phase I &II are complete
 This include:-
History
Physical examination
Investigations

55. History
 Take history from relatives, friends, ambulance
staff, police etc
 Mechanism of injury
 When was the injury
 Mechanism of impact
 Type of weapon
 AMPLE history
 A= history of allergies
 M= medications
 P= pre-morbid illness
 L= last meal
 E= events surrounding injury

56. History cont’d
 Associated injuries
 Head
 Abdominal injuries
 Major long bone fractures
 Spines
 Pelvic fractures
 Other symptoms
 Loss of consciousness
 Bleeding from the ENT

57. Physical examination
 General examination
 Local examination
 Systemic examination

58. General examination
 Look for:
 Dyspnoea
 Cyanosis
 Anemia
 Shock
 Level of consciousness
 etc

59. Local examination
 Look for:-
 Open chest wound- assess the depth
 Bruises and lacerations on the chest wall
 Thoracic spines tenderness

60. Systemic examination
 Respiration examination
 Cardiovascular examination
 Abdominal examination
 etc

61. Respiration examination
 Inspection
 Look for:-
 Decreased chest movement
 Paradoxical respiration
 Palpation
 Feel for:-
 Tracheal / Mediastinal shift
 Tenderness over the chest wall
 Creptus of rib fractures → do compression test to rule out
rib #s
 Sternum
 Crackly feeling of surgical emphysema

62.  Percussion
 Should be done gently
 Dullness – Hemothorax/lung collapse
 Hyper-resonant- pneumothorax
 Increased cardiac dullness- hemopericardium
 Auscultation
 Note the following:-
 Clicking sounds from rib #
 Course creptations of surgical emphysema
 or absence of breath sounds on the affected side indicating
fluid or air in the pleural cavity or collapsed lung
 High pitched breath sounds suggesting tension pneumothorax
 Presence of breath sounds suggesting ruptured diaphragm

63. Cardiovascular examination
 Look for:-
 Pulse
 Blood pressure
 JVP
 Apex beat
 ↑ cardiac dullness
 Pulsus paradoxicus

64. Abdominal examination
 Look for:-
 Evidence of haematoma
 Distended abdomen
 Tenderness over the epigastrium /Lt
hypochondrium

65. Investigations
 Lab investigations
 Hb
 Blood grouping & X-matching
 blood gaseous analysis
 Imaging investigations
 CXR
 abdominal US
 CT scan
 Aspiration tap

66. Phase IV. Tertiary survey phase
Aim: To identify any injuries missed during
primary and secondary survey phases

67. Phase V: Supportive care phase
 Analgesics
 Antibiotics
 Toxiod prophylaxis
 Urethral catheterization
 Monitor:-
 Vital signs
 Input/output

68. Phase VI: Definitive treatment phase
 Non surgical treatment
 Surgical treatment

69. Non surgical treatment
 Pharmacological treatment
 Analgesics
 Antibiotics
 TT injections in case of open chest wounds
 Non pharmacological treatment
 Bed rest
 Physiotherapy
 Immediately needle decompression by inserting a large bore
canula (14-gauge) into the MCL, 2nd ICS, on the affected side in
case of tension pneumothorax
 Pericardiocentesis in case of cardiac tamponade

70. Surgical treatment
 These include:-
 Under water seal drainage (UWSD)
 Usually inserted in the 4th or 5th ICS between the MCL and the
anterior axillary line using large bore chest tube (36F or 40F)
 Approximately 85 % of these patients can be treated definitively
with a chest tube alone
 Thoracotomy
 Done in approximately 15% of chest injury patients

71. Indications for thoracotomy
 Indications for thoracotomy in blunt chest
trauma include:-
 pericardial tamponade
 tear of the descending thoracic aorta
 rupture of a main bronchus
 rupture of the esophagus

72.  Indications of thoracotomy in penetrating chest
trauma include:-
 All transmediastinal penetrating wounds
 Large air leak with inadequate ventilation or
persistent collapse of the lung
 Drainage of more than 1500 mL of blood
when chest tube is first inserted
 Esophageal perforation
 Pericardial tamponade

73. COMPLICATIONS
 General complications
 Local complications

74. General complications
Haemorrhagic shock
Cardiopulmonary failure
Cerebral hypoxia
Hypercapnoea
Neurogenic shock

75. Local complications
Thoracic wall complications
 Pleural complications
 Pulmonary complications
 Mediastinal complications
 Sub-diaphragmatic injuries

76. Thoracic wall complications
Rib #s
Flail chest
Clavical / thoracic spines /sternal #s
Surgical emphysema

77. Pleural complications
 Pneumothorax
 Haemothorax
 Haemopneumothorax
 Empyema thoracis

78. Pulmonary complications
Lung contusion
Lung laceration
Lung fibrosis

79. Mediastinal complications
Cardiac temponade
Pericardial effusion
Myocardial failure
Cardiopulmonary injuries
Diaphragmatic rupture
Esophageal injuries

80. Sub-diaphragmatic injuries
 Ruptured liver
 Ruptured spleen

81. PREVENTION
 Primary prevention
 Secondary prevention
 Tertiary prevention

84. SUMMARY- CHEST INJURIES
Common
Serious
Primary goal is to provide oxygen to vital organs
Remember
Airway
Breathing
Circulation
 Dysfunction of CNS
 Exposure to avoid missed injury
Be alert to change in clinical condition