Chest injuries are the second leading cause of trauma deaths each year. The majority of chest trauma can be managed without surgery. Common causes include blunt trauma from force to the chest, penetrating trauma from projectiles entering the chest, and compression injuries. Injuries include rib fractures, flail chest, pneumothoraces, pulmonary contusions, and others. Tension pneumothorax is a life-threatening condition where air builds up in the pleural space with no way to escape, resulting in collapsed lungs and compressed heart and blood vessels. Needle decompression is immediately needed to relieve pressure in the chest and prevent further deterioration.

1. Chest Trauma
H.R.Kadkhodaei MD.
Associated professor of ThoracicSurgery
Rasoul Akram Medical Complex

2. Statistics
Chest injuries are the second leading cause of
trauma deaths each year.
 Most thoracic injuries (90% of blunt trauma and
70% to 85% of penetrating trauma) can be
managed without surgery.


3. Main Causes of Chest Trauma

Blunt Trauma- Blunt force to chest.

Penetrating Trauma- Projectile that enters
chest causing small or large hole.

Compression Injury- Chest is caught
between two objects and chest is
compressed.

4. Injuries of chest





Rib Fractures
Flail Chest
Simple/Closed
Pneumothorax
Open Pneumothorax
Tension
Pneumothorax



Traumatic Asphyxia
Diaphragmatic
Rupture
Pulmonary contusion

5. Rib Fractures

Incidence
– Infrequent until adult life
– Significant force required
– Most often elderly patients

7. Rib Fractures
Pathophysiology





Most often caused by blunt trauma
Ribs 3 to 8 are fractured most often (they are thin
and poorly protected)
Respiratory restriction as a result of pain and
splinting
Intercostal vessel injury
Associated complications
– First and second ribs are injured by severe
trauma
– Tracheobronchial tree injury
– Vascular injury

8. Rib Fractures

Assessment findings
– Localized pain
– Pain that worsens with movement, deep
breathing, coughing
– Point tenderness

Most patients can localize the fracture by pointing
to the area (confirmed by palpation).
– Crepitus or audible crunch

9. Rib Fractures
Management

Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation
– Encourage coughing and deep breathing

Pharmacological
– Analgesics
– Intercostal block
– Epidural block

10. Rib Fractures
Complications
Splinting, which leads to atelectasis and
ventilation-perfusion mismatch
 Pneumonia can leads to empyema


11. Flail Chest
Pathophysiology

Two or more adjacent ribs fractured in two
or more places producing a free-floating
segment of chest wall
Flail chest usually results from direct impact.

13. Flail Chest

14. Flail Chest
Pathophysiology (2 of 2)

Respiratory failure due to:
– Underlying pulmonary contusion

The blunt force of the injury typically
produces an underlying pulmonary
contusion.
– Associated intrathoracic injury
– Inadequate bellows action of the chest

16. S/S of Flail Chest








Chest wall contusion
Respiratory distress
Paradoxical chest wall movement
Pleuritic chest pain
Crepitus
Pain and splinting of affected side
Tachypnea
Tachycardia

17. Flail Chest is a True Emergency

18. Flail Chest
Management

Airway and ventilation
– High-concentration oxygen.
– Positive-pressure ventilation may be needed.
» Reverses the mechanism of paradoxical
chest wall movement
» Restores the tidal volume
» Reduces the pain of chest wall movement
» Assess for the development of a
pneumothorax
– Evaluate the need for endotracheal intubation.
– Stabilize the flail segment (controversial).

19. Bulky Dressing for splint of Flail
Chest

Use Trauma bandage
and Triangular
Bandages to splint
ribs.

20. Flail Chest
Morbidity/Mortality
Significant chest trauma
 Mortality rates 20% to 40% due to
associated injuries
 Mortality increased with

–
–
–
–
–
Advanced age
Seven or more rib fractures
Three or more associated injuries
Shock
Head injuries

21. Simple/Closed Pneumothorax



Opening in lung tissue
that leaks air into chest
cavity
Blunt trauma is main
cause
Usually self correcting

22. Closed (simple) pneumothorax
– Incidence
» 10% to 30% in blunt chest trauma
» Almost 100% with penetrating chest trauma

23. Closed (Simple) Pneumothorax
Pathophysiology

May occur in the absence of rib fractures from:
– A sudden increase in intrathoracic pressure
generated when the chest wall is compressed
against a closed glottis (the paper-bag effect)
» Results in an increase in airway pressure and
ruptured alveoli, which lead to a
pneumothorax

Small tears self-seal; larger ones may progress.

Ventilation/perfusion mismatch.

25. Closed Pneumothorax
Assessment Findings









Tachypnea
Tachycardia
Respiratory distress
Absent or decreased breath sounds on the affected side
Hyperresonance
Decreased chest wall movement
Dyspnea
Chest pain referred to the shoulder or arm on the affected
side
pleuritic chest pain

26. Closed Pneumothorax
Management

Airway and ventilation
– High-concentration oxygen.
– Positive-pressure ventilation if necessary.
– If respiration rate is <12 or >28 per minute,
ventilatory assistance with a
bag-valve mask may be indicated.

27. Open Pneumothorax

Incidence
– Usually the result of penetrating trauma
» Gunshot wounds
» Knife wounds
» Motor vehicle collisions
» Falls

28. Open Pneumothorax



Opening in chest cavity that allows air to enter
pleural cavity
Causes the lung to collapse due to increased
pressure in pleural cavity
Can be life threatening and can deteriorate
rapidly

30. Open Pneumothorax
Pathophysiology (1 of 2)

An open defect in the chest wall (>3 cm)
– If the chest wound opening is greater than twothirds the diameter of the trachea, air follows the
path of least resistance through the chest wall
with each inspiration.
– As the air accumulates in the pleural space, the
lung on the injured side collapses and begins to
shift toward the uninjured side.

31. Open Pneumothorax

32. Open Pneumothorax
Inhale

33. Open Pneumothorax
Exhale

34. Open Pneumothorax
Inhale

35. Open Pneumothorax
Exhale

36. Open Pneumothoarx
Inhale

37. Open Pnuemothorax
Inhale

38. S/S of Open Pneumothorax
Dyspnea
 Sudden sharp pain
 Subcutaneous Emphysema
 Decreased lung sounds on affected side
 Red Bubbles on Exhalation from wound
( Sucking chest wound)


39. Open Pneumothorax
Management (1 of 2)

Airway and ventilation:
– High-concentration oxygen.
– Positive-pressure ventilation if necessary.
– Assist ventilations with a bag-valve device and
intubation as necessary.
– Monitor for the development of a tension
pneumothorax.

Circulation—treat for shock with crystalloid
infusion.

40. Open Pneumothorax
Management (2 of 2)

Nonpharmacological
– Occlude the open
wound—apply an
occlusive petroleum
gauze dressing (covered
with sterile dressings)
and secure it with tape.

41. Occlusive Dressing

Asherman Chest Seal

42. Plus Care
Monitor Heart Rhythm
 Establish IV Access and Draw Blood
Samples
 Airway Control that may include Intubation
 Monitor for Tension Pneumothorax


43. Tension Pneumothorax
Air builds in pleural space with no where
for the air to escape
 Results in collapse of lung on affected side
that results in pressure on mediastium,the
other lung, and great vessels


44. Tension Pneumothorax
Pathophysiology



Occurs when air enters the pleural space from a
lung injury or through the chest wall without a
means of exit.
Results in death if it is not immediately recognized
and treated.
When air is allowed to leak into the pleural space
during inspiration and becomes trapped during
exhalation, an increase in the pleural pressure
results.

45. Tension Pneumothorax Pathophysiology
(2 of 2)
Increased pleural pressure produces
mediastinal shift.
 Mediastinal shift results in:

– Compression of the uninjured lung
– Kinking of the superior and inferior vena cava,
decreasing venous return to the heart, and
subsequently decreasing cardiac output

46. Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

47. Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

48. Tension Pneumothorax
The trachea is
pushed to
the other side
Heart is being
Compressed and
Decrease CO

49. Tension Pneumothorax Assessment
Findings (1 of 3)






Extreme anxiety
Cyanosis
Increasing dyspnea
Difficult ventilations while being assisted
Tracheal deviation (a late sign)
Hypotension

50. Tension Pneumothorax Assessment
Findings (3 of 3)
Bulging of the intercostal muscles
 Subcutaneous emphysema
 Jugular venous distention (unless
hypovolemic)
 Unequal expansion of the chest (tension
does not fall with respiration)
 Hyperresonnace to percussion


51. Tension Pneumothorax
Physical Findings

52. Tension Pneumothorax Management
Emergency care is directed at reducing the
pressure in the pleural space.
 Airway and ventilation:

– High-concentration oxygen
– Positive pressure ventilation if necessary

Circulation—relieve the tension
pneumothorax to improve cardiac output.

53. Tension Pneumothorax Management (2 of 5)

Nonpharmacological
– Occlude open wound
– Needle thoracostomy
– Tube thoracostomy—in-hospital management

54. Tension Pneumothorax Management (3 of 5)

Needle thoracostomy

55. Tension Pneumothorax Management (4 of 5)

Tension pneumothorax associated with penetrating
trauma
– May occur when an open pneumothorax has been
sealed with an occlusive dressing.
– Pressure may be relieved by momentarily
removing the dressing (air escapes with an audible
release of air).

56. Tension Pneumothorax Management (5 of 5)

Tension pneumothorax associated with closed
trauma
– If the patient demonstrates significant dyspnea and
distinct signs and symptoms of tension pneumothorax:
» Provide thoracic decompression with either a large-bore needle
or commercially available thoracic decompression kit.
» Insert a 2-inch 14- or 16-gauge hollow needle or catheter into
the affected pleural space.

Usually the second intercostal space in the midclavicular line
Insert the needle just above the third rib to avoid the nerve, artery, and
vein that lie just beneath each rib.

57. Needle Decompression





Locate 2-3 Intercostal space midclavicular line
Cleanse area using aseptic technique
Insert catheter ( 14g or larger) over the top of the
3rd rib( nerve, artery, vein lie along bottom of rib)
Place Flutter valve over catheter
Reassess for Improvement

58. Needle Decompression

59. Flutter Valve



Asherman Chest Seal
makes good Flutter
Valve .
Also can use a Finger
from a Latex Glove
Or A Condom works
also

60. Pulmonary Contusion

A pulmonary contusion is the most common
potentially lethal chest injury.
» Incidence
 Blunt trauma to the chest
– The most common injury from blunt thoracic
trauma.
– 30% to 75% of patients with blunt trauma
have pulmonary contusion.
 Commonly associated with rib fracture
 High-energy shock waves from explosion
 High-velocity missile wounds
 Rapid deceleration

61. Pulmonary Contusion
Assessment Findings









Tachypnea
Tachycardia
Cough
Hemoptysis
Apprehension
Respiratory distress
Dyspnea
Evidence of blunt chest trauma
Cyanosis

62. Pulmonary Contusion
Management

Airway and ventilation:
– High-concentration oxygen
– Positive-pressure ventilation if necessary
Circulation—restrict IV fluids (use caution
restricting fluids in hypovolemic patients).
 Transport considerations.


63. Pulmonary Contusion
Morbidity/Mortality

May be missed due to the high incidence of
other associated injuries
Mortality—between 14% and 20%

64. Hemothorax (2 of 2)

Incidence
– Associated with pneumothorax.
– Blunt or penetrating trauma.
– Rib fractures are frequent cause.

65. Hemothorax
Occurs when pleural space fills with blood
 As blood increases, it puts pressure on heart
and other vessels in chest cavity
 Each Lung can hold 1.5 liters of blood


66. Hemothorax
Pathophysiology

Accumulation of blood in the pleural space
caused by bleeding from
– Penetrating or blunt lung injury
– Chest wall vessels
– Intercostal vessels

67. Hemothorax
Where does the blood come from.

68. Hemothorax

69. Hemothorax

70. Hemothorax

71. Hemothorax

72. Hemothorax

73. Hemothorax
May put pressure on the heart

74. Hemothorax
Assessment Findings (1 of 2)
Tachypnea
 Dyspnea
 Cyanosis

– Often not evident in hemorrhagic shock

Diminished or decreased breath sounds on
the affected side

75. Hemothorax
Assessment Findings (2 of 2)
Hyporesonance (dullness on percussion) on
the affected side
 Hypotension
 Narrowed pulse pressure
 Tracheal deviation to the unaffected side
(rare)
 Pale, cool, moist skin


76. S/S of Hemothorax
Anxiety/Restlessness
 Tachypnea
 Signs of Shock
 Frothy, Bloody Sputum
 Diminished Breath Sounds on Affected Side
 Tachycardia
 Flat Neck Veins


77. Hemothorax Physical Findings
Bledsoe et
al., Essentials of

78. Hemothorax
Management

Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation if necessary
– Ventilatory support with bag-valve mask, intubation, or
both

Circulation
– Administer volume-expanding fluids to correct
hypovolemia
– Nonpharmacological—tube thoracostomy (in-hospital
management)
– Transport considerations
» Appropriate mode
» Appropriate facility

79. Treatment for Hemothorax




ABC’s with c-spine control as indicated
Secure Airway assist ventilation if necessary
General Shock Care due to Blood loss
RAPID TRANSPORT

80. Hemothorax
Morbidity/Mortality


A life-threatening injury that frequently requires
urgent chest tube placement and/or surgery
Associated with great vessel or cardiac injury
– 50% of these patients will die immediately.
– 25% of these patients live 5 to 10 minutes.
– 25% of these patients may live 30 minutes or longer.

81. Traumatic Asphyxia

Incidence
– A severe crushing injury to the chest and
abdomen
» Steering wheel injury
» Conveyor belt injury
» Compression of the chest under a heavy object

82. Traumatic Asphyxia
Pathophysiology
A sudden compressional force squeezes the
chest.
 An increase in intrathoracic pressure forces
blood from the right side of the heart into
the veins of the upper thorax, neck, and
face.
 Jugular veins engorge and capillaries
rupture.


83. S/S of Traumatic Asphyxia
Severe Dyspnea
 Distended Neck Veins
 Bulging, Blood shot eyes
 Swollen Tounge with cyanotic lips
 Reddish-purple discoloration of face and
neck
 Petechiae


84. Traumatic Asphyxia
Assessment






Reddish-purple discoloration of the face and neck
(the skin below the face and neck remains pink).
Jugular vein distention.
Swelling of the lips and tongue.
Swelling of the head and neck.
Swelling or hemorrhage of the conjunctiva
(subconjunctival petechiae may appear).
Hypotension results once the pressure is released.

85. Traumatic Asphyxia
Management

Airway and ventilation
– Ensure an open airway.
– Provide adequate ventilation.

Circulation
– IV access.
– Expect hypotension and shock once the compression is
released.

86. Diaphragmatic Rupture
Incidence
 Penetrating trauma

– Blunt trauma
– Injuries to the diaphragm account for 1% to 8%
of all blunt injuries.
» 90% of injuries to the diaphragm are associated with
high-speed motor vehicle crashes.

87. Diaphragm Rupture

88. Diaphragmatic Rupture

Rupture can allow intra-abdominal organs
to enter the thoracic cavity, which may
cause the following:
– Compression of the lung with reduced
ventilation
– Decreased venous return
– Decreased cardiac output
– Shock

89. Diaphragmatic Rupture
Pathophysiology
Can produce very subtle signs and
symptoms
 Bowel obstruction and strangulation
 Restriction of lung expansion

– Hypoventilation
– Hypoxia

Mediastinal shift
– Cardiac compromise
– Respiratory compromise

90. Diaphragmatic Rupture Assessment
Findings





Tachypnea
Tachycardia
Respiratory distress
Dullness to percussion
Scaphoid abdomen (hollow or empty appearance)
– If a large quantity of the abdominal contents are displaced into the
chest



Bowel sounds in the affected hemithorax
Decreased breath sounds on the affected side
Possible chest or abdominal pain

91. S/S of Diaphragmatic Rupture
Abdominal Pain
 Shortness of Air
 Decreased Breath Sounds on side of rupture
 Bowel Sounds heard in chest cavity


92. Diaphragmatic Rupture Management

Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation if necessary
– Caution: positive pressure may worsen the injury



Circulation—IV access
Nonpharmacological—do not place patient in
Trendelenburg position
Transport considerations
– Appropriate mode
– Appropriate facility

93. Plus Care






Cardiac Monitor
Establish IV access and draw blood samples
Airway management including Intubation
Observe for Pneumothorax due to compression on
lung by abdominal contents
Possible insertion of NG tube to help decompress
the stomach to relieve pressure
Rapid transport

94. Summary
Chest Injuries are common and often life threatening
in trauma patients. So, Rapid identification and
treatment of these patients is paramount to patient
survival. Airway management is very important and
aggressive management is sometimes needed for
proper management of most chest injuries.