Chest trauma, especially blunt chest trauma, can cause many serious injuries from rib fractures to life-threatening conditions like tension pneumothorax. It is the second leading cause of trauma deaths. Immediate life-threatening injuries include tension pneumothorax, massive hemothorax, flail chest, and cardiac tamponade which must be quickly diagnosed and treated to prevent death. Other potential injuries include pulmonary contusions, pneumothorax, and aortic disruption which require close monitoring and treatment.

1. CHEST TRAUMA-
BLUNT
Dr.B.Selvaraj MS;Mch;FICS;
Professor of surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia
AN OVERVIEW
Dr.B.Selvaraj MS;Mch;FICS;
Professor of Surgery
Melaka Manipal Medical College
Melaka 75150 Malaysia

2. CHEST TRAUMA-Blunt

3. CHEST TRAUMA-Blunt
INTRODUCTION:
1.Second leading cause of trauma deaths
2. 65-70% of Chest injuries are due to RTA
3. 25% of trauma deaths are due to chest injury
4. 50% of patients who die from multiple trauma have
significant chest injury
5. Jagged edges of the broken ribs due to blunt trauma
can cause penetrating injuries to underlying structures

4. CHEST TRAUMA-Blunt
Mechanism of chest injury:
1.Body acceleration and deceleration (organ inertia lags
behind skeletal acceleration or deceleration) Eg: RTA
2.Body compression (force > the strength of skeleton) Eg:
Crush injury and falls
3.Penetrating wounds (open pneumothorax and organ
injury) Eg: Assaults- Stab and Missile injuries

5. CHEST TRAUMA-Blunt
Types of Chest Injury:
1.Blunt Chest Injury (Closed Chest Injury)
-Eg. RTA, Fall, Crush injury
- Associated with multiple injuries such as
head, limb, abdomen
2. Penetrating chest injury (Open chest injury)
- mostly by assault
- Associated with chest wall damage, open
pneumothorax and organ injury

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Mode of death:
1.Death
- can be immediate within seconds to minutes
- Can be early within few minutes to hours
- can be late within few days to weeks
2. Immediate deaths
- disruption of heart or great vessels injury
3.Early deaths
- airway obstruction, tension pneumothorax, pulmonary
contusion, or cardiac tamponade
4.Late deaths
- pulmonary complications, sepsis, and missed
injuries

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Classification:
-Immediate Life Threatening Injuries( Lethal Six)
-Potential life Threatening injuries ( Hidden Six)

8. CHEST TRAUMA-Blunt
Immediate life threatening injuries(Lethal Six)
Fatal if they are not recognized and treated immediately
-Airway obstruction
- Tension Pneumothorax
- Open Pneumothorax- “ Sucking chest wound”
- Massive hemothorax
- Flail chest
- Cardiac tamponade

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Potential Life Threatening injuries(Hidden Six)
Primary or Secondary survey may reveal one of eight
potentially life-threatening chest injuries
1.Cardiac contusion
2.Aortic disruption
3.Diaphragmatic rupture
4.Esophageal injury
5.Pulmonary contusion
6.Tracheo-bronchial injuries

10. CHEST TRAUMA-Blunt
Clinical Approach
The most common injuries to the chest wall—fractures of the
ribs, sternum, and clavicle—are rarely life threatening
They may portend more significant underlying visceral or
neurovascular injury.
The primary survey (ABCs) of the ATLS algorithm will direct
you to evaluate for the six conditions that results from
immediate life threatening injuries- Lethal Six.
Only after assessment of hemodynamic stability and
stabilization of airway, breathing, and circulation, you have
to proceed to the secondary survey

11. CHEST TRAUMA-Blunt
Clinical Approach
Chest radiography assists in the dx of pneumothorax,
hemothorax, chest wall injuries, or pulmonary contusions.
Focused assessment sonography in trauma (FAST)
examination will rule out cardiac tamponade and will assist
in the dx of associated abdominal injury.
Once primary and secondary surveys are completed, obtain
chest, abdominal, and pelvic CT scans in stable patients.
Unstable patients may need urgent operative intervention,
but ED thoracotomy in blunt trauma is virtually never
successful.

12. CHEST TRAUMA-Blunt
History/Symptoms
What was the mechanism of injury?
If a motor vehicle collision, what details can be obtained from
paramedics? VS in the field and en route?
Patient’s complaints; localization of pain?
AMPLE (Allergies; Medications; Past medical hx; Last meal;
Events leading to presentation)

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Physical Exam/Signs
Head-to-toe physical examination (secondary survey)
Evaluate and re-evaluate the VS and pulse oximetry. Look
for JVD and observe chest wall motion, flail segments, or
sucking wounds. Check for pulsus paradoxus.
Interrupt the physical examination if a life-saving procedure
such as airway or chest tube placement is needed.
Evaluate and re-evaluate areas of ongoing blood loss,
including open wounds and fractures. Are there associated
abdominal, pelvic, or extremity injuries that could account
for blood loss?

14. CHEST TRAUMA-Blunt
Investigations
CXR: Evaluate for pneumothorax, tension pneumothorax,
hemothorax, chest wall fractures, and pulmonary contusions.
FAST examination: Evaluate for cardiac tamponade.
CT of chest, abdomen, and pelvis (for stable patients only):
Perform with IV contrast. Rapid, reliable imaging of
lacerations and contusions.
CT angiography: Can be performed at the same time as
routine CT on many high-speed spiral scanners.
Catheter angiography: Remains the gold standard for
evaluation of aortic injury.

15. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-With excessive
energy transfer
during blunt
trauma, any of the
thoracic bones may
potentially fracture
—ribs, sternum,
clavicle,
or scapula.
-Simple rib
fractures are the
most common
injuries and,
although rarely life
threatening, may
be indicators of
more
significant
underlying injury.
- Pain and tenderness
over the fractured area
and discomfort with
deep breathing
- Local tenderness,
swelling or ecchymosis
around the fracture.
-A palpable defect or
fracture-related
crepitus may be
present.
-Respiratory insuffi
ciency seen in more
severe cases and can be
identified by observing
for tachypnea, use of
accessory muscles, and
cyanosis.
-AP chest films
are used routinely
in the initial
assessment
-CT of
the chest may
provide more
specific
information
regarding
location and
extent of specific
injury.
-Pain control and
observation for
patients with simple
chest wall fractures
-Analgesic agents,
intercostal
nerve blocks, and
epidural analgesia all
have been used
-Aggressive
pulmonary toilet to
prevent
atelectasis and
pneumonia.
-Operation is rarely
needed for simple
fractures but required
for significant
comminution,
hemorrhage from
fractures that lacerate
vessels, or
chronic non-union.
CHEST WALL FRACTURES

16. CHEST TRAUMA-Blunt
Chest Wall Fractures
Chest x-ray with fractures of the upper
ribs. These cases should always be
evaluated for thoracic inlet vascular
injuries, especially the subclavian
vessels.
Plain radiographs of multiple mid rib fractures,
with underlying lung contusion . Adequate
analgesia with intercostal block, epidural or
patient-controlled analgesia should be
considered early, especially in elderly patients.

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Chest Wall Fractures
(A) Radiograph showing fractures of the right lower ribs (arrows) (left). Injuries to intra-
abdominal solid organs are common and CT scan evaluation should be considered. (B)
Intraoperative photograph of the associated liver injury
in the same patient.

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Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
- Flail chest is an injury
that involves 3 or more
consecutive rib fractures
in two or more locations,
producing a
comminuted fracture
with a free-floating,
unstable bony segment
that is detached from the
remainder of the chest
wall.
-Associated injuries
are common and should
be aggressively sought.
-Pulmonary
contusion is the most
common local
disturbance in
association with flail
segment. Mortality is
significant.
-Respiratory distress is
the most common initial
presentation.
Dyspnea, tachycardia,
tachypnea, pain, and
tenderness usually
are present.
-The flail segment often
moves in a paradoxical
motion, opposite to that
of the remainder of the
hemithorax.
-Respirations may be
labored. As the acute
condition progresses,
pulmonary function
worsens.
-Auscultation virtually
always demonstrates
decreased breath
sounds over the affected
area.
-Dx is made by
physical
examination and
CXR.
-CT may help in
identification of
early pulmonary
contusion.
-Hypoxemia may be
present and should
be assessed with
pulse oximetry and
blood gas
analyses.
-The tx modalities
described for patients
with chest wall fractures
are appropriate for flail
chest.
-Pain control, pulmonary
toilet, and
supplemental oxygen are
the primary therapies for
pulmonary
contusions.
-The severity of flail
injuries and associated
contusions frequently
require endotracheal
intubation and
positive pressure
mechanical ventilation-
IPPV.
-Optimal ventilatory
management is crucial
-Judicial IV fluids to
avoid fluid overload.
FLAIL CHEST

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Flail Chest
Flail Chest: Paradoxical movement

20. CHEST TRAUMA-Blunt
Flail Chest
Flail chest. (A) Double fractures of at least three adjacent ribs are required in
order to produce a flail chest.
(B) Chest x-ray showing a left flail chest with underlying lung contusion.

21. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
- Simple
pneumothorax is
accumulation
of air within the
pleural space
producing
a collapsed lung.
-Air leak is
secondary to a
fractured rib
penetrating the
lung or stab wound
through the
parietal and
visceral pleura.
-Hyper resonance on
the affected side on
percussion
-Decreased
breath sounds on the
affected side on
auscultation
-Dx is made by
CXR, provided
hemodynamics
are stable.
-Chest tube
placement is
appropriate
Simple Pneumothorax

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Simple Pneumothorax

23. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-Though more common
in penetrating wounds,
open pneumothoraces
may occur with blunt
thoracic trauma also
-Pathophysiology is
similar to that of a
tension pneumothorax
however, the chest wall
is compromised, and the
pleural cavity
is in communication with
the atmosphere.
-Since the negative
intrathoracic pressure is
lost, all dynamic lung
mechanics are
affected.
-Intrathoracic pressures
rise and can shift
mediastinal
components to the
opposite side and
ultimate cardiovascular
decompensation.
-Patients typically
present with
respiratory distress due
to collapse
of the lung on the
affected side. Physical
examination should
reveal an obvious chest
wall defect.
-Auscultation reveals
complete or near-
complete loss of breath
sounds.
-Dx is made by
physical
examination and
CXR
-Sucking chest wound
is treated by placing a
three-way occlusive
dressing over the
wound to allow outfl
ow of air with
exhalation
while preventing
continued inflow of air
with inhalation.
-Intent is to prevent
the rise of
intrathoracic
pressures in the
affected hemithorax.
-A chest tube is then
placed. After initial
stabilization, most
patients undergo
operation for defi
nitive chest
wall closure.
Open Pneumothorax

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Open Pneumothorax

25. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-A tension
pneumothorax is
created when
ongoing air leak
allows continual
ingress of air into
the pleural space
but not the egress.
This accumulation
of air compresses
the lung and
mediastinal
structures.
-Early findings include
anxiety, dyspnea,
tachypnea, tachycardia.
-Diminished breath
sounds and
hyperresonance of the
chest wall
on the affected side may
be present.
-The typical patient will
have hypoxia related to
collapse of the
ipsilateral lung and
hypotension related to
shifting of the
mediastinum
-The trachea may be
deviated away
from the side of the
pneumothorax. JVD
may be present.
-Dx should be
made by physical
examination.
Chest radiography
should not be
needed to identify
a tension
pneumothorax,
and
therapeutic
intervention
should not be
delayed.
-Immediate needle
decompression of
the chest with a 16-
gauge angiocath in
the second
intercostal space,
midclavicular line
should be
performed when a
tension
pneumothorax is
suspected
-Once
accomplished, a
chest tube is placed
in a standard
location
Tension Pneumothorax

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Tension Pneumothorax

27. CHEST TRAUMA-Blunt
Tension Pneumothorax
Chest x-ray showing a
large tension
pneumothorax on the left
side, mediastinal shift to
the opposite side, and
downward displacement
of the left
hemidiaphragm. Arrows
point to tension
pneumothorax.
Tension pneumothorax on the CT
scan (arrow). Note the deviation of
the heart to the right.

28. CHEST TRAUMA-Blunt
Tension Pneumothorax

29. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-Hemothorax
following a blunt or
penetrating wound
to the chest can be
caused
by bleeding from
any structure in the
thorax: the
intercostal
arteries, the lung,
the great vessels, or
the heart.
-Initial findings
include anxiety,
dyspnea, tachypnea,
and tachycardia.
-Diminished breath
sounds and dullness
to percussion
are found over the
affected hemithorax.
-Massive hemothorax
can produce signifi
cant hemodynamic
instability secondary
to hemorrhagic
shock.
-By physical
examination and
CXR
-When confronted
with decreased
breath sounds,
place a chest tube.
-Findings of 1,500
mL of blood
initially, or more
than 200 mL/hour
for 2 to 4 hours,
generally
mandate a
thoracotomy to
control bleeding.
-Witnessed loss of
vital signs in the
ED is an indication
for ED thoracotomy
-The possibility of
subdiaphragmatic
injury must also be
considered
HEMOTHORAX

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Hemothorax

31. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-Pericardium is a two-
layered membrane
surrounding the heart
that normally
contains 20 to 50 mL
of fluid. Rapid
accumulation
of as little as 150 mL
of fluid after trauma
can produce cardiac
tamponade and
hypotension.
-Traumatic sources of
intrapericardial
blood include chamber
rupture, usually right-
sided, because of
the anterior
orientation, or
coronary artery
laceration.
-increasing pericardial
pressures cause reduction
in systemic venous return,
diastolic filling, and
cardiac output
-If untreated, cardiac
tamponade can produce
cardiovascular collapse and
death. Beck’s triad
(arterial hypotension,
venous hypertension, and
muffled heart tones) is the
classic presentation of
tamponade.
-Narrowing of pulse
pressures and pulsus
paradoxus, a change of
greater than 10 mmHg in
the systolic pressure
between inspiration and
expiration, may also be
seen
-Patients with acute
tamponade may present
with dyspnea, tachycardia,
and tachypnea.
-Dx is made by vital
signs and by
physical
examination.
-FAST scan may
reveal pericardial
fluid.
-Echocardiography
may used in stable
patients. A surgical
pericardial window
may be
required for
diagnosis.
-Cardiac tamponade is
treated by
pericardiocentesis if it
is due to blunt trauma
- If it is due to
penetrating trauma
operative exploration
and repair of the
source of bleeding
should be done
immediately
-. Fluid resuscitation
is needed to maintain
preload and
sustain cardiac output
during transport to
the OR.
Cardiac Tamponade

32. CHEST TRAUMA-Blunt
Cardiac Tamponade

33. CHEST TRAUMA-Blunt
Cardiac Tamponade

34. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-Rapid deceleration or
severe compression
applied directly to the
tracheobronchial tree
are the usual causes
of tracheobronchial
Disruption
-The viscera are
crushed between the
anterior chest
wall and the posterior
vertebrae
-Most patients with
severe
tracheobronchial
injuries die from
airway obstruction or
associated injuries
before reaching the
hospital.
-Respiratory distress
is the most notable
finding in these
patients, who are
stridorous and
unable to phonate
-If a chest tube has
been placed, there is
usually a massive air
leak. Pneumothorax
and subcutaneous
emphysema are
almost universally
present.
-If the patient
survives the
initial
assessment, CXR
and/or CT will
usually identify
this major injury.
-Bronchoscopy
may be required
in the subacute
setting to evaluate
less pronounced
injury.
-Laboratory
studies are rarely
useful.
- Surgical tx is
required since blunt
tracheal injuries are
immediately life
threatening and will
not heal without
repair.
-If the airway is
compromised,
endotracheal
intubation should be
performed. Flexible
bronchoscopy may
permit the tube to be
guided distal to the
site of injury.
-An emergent surgical
airway
may be needed if
conventional
endotracheal tube
placement fails.
Tracheo-Bronchial Tree Disruption

35. CHEST TRAUMA-Blunt
Tracheo Bronchial Tree Disruption
Tracheobronchial tree showing complete
transection of the right intermediate bronchus
(two-way arrow). (Courtesy of Dr Montserrat
Bret, University Hospital La Paz, Madrid)

36. CHEST TRAUMA-Blunt
Rib Fractures
Etiopathogenesis Clinical Features Diagnosis Treatment
-Traumatic rupture of
the aorta should be
suspected in any
patient sustaining
blunt chest trauma in
association with
deceleration injury.
-Although the
proximal
descending aorta is
most commonly
involved at the
ligamentum
arteriosum where it is
fixed, other areas may
be involved as well by
mechanisms such as
compression between
bony
fragments or
temporary brief
intraluminal
hypertension.
-Physical
findings may include
infrascapular murmur,
upper extremity
hypertension, and
unequal blood pressure
or pulses in the
extremities.
-Findings on CXR
include mediastinal
widening greater
than 8 cm, obliteration
of the aortic knob,
depression of the left
main-stem bronchus,
apical pleural cap, or
simply “a funny
Looking mediastinum
-a normal CXR does not
r/o the injury.
-CT, CT
angiography, MRI,
are all variants of
screening
modalities and will
show a mediastinal
hematoma. These
tests have not been
validated for areas
of the thoracic aorta
other than the
proximal descending
portion
-Aortography
remains the
gold standard for dx.
In a
patient with an
obvious mediastinal
hematoma on
CXR,aortography
should be
performed.
- Hemodynamically
unstable patients with
a dx established by
aortography require
prompt surgical
attention if attempts
at resuscitation have
not stabilized VS.
-In stable patients,
permissive
hypovolemia and
aggressive
minimization of the
dP/dT are important
principle of care
-In selected
patients, stent
grafting of aortic tears
may be preferred over
open surgical repair
Traumatic Rupture Of Aorta

37. CHEST TRAUMA-Blunt
Traumatic Rupture Of Aorta

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