This document provides an overview of chest trauma, including: - Common injuries like pneumothorax, hemothorax, flail chest and their signs and symptoms. - Assessment involves clinical exam, chest x-ray and ultrasound to detect injuries. Chest tube insertion can be both therapeutic and diagnostic. - "Deadly dozen" life-threatening injuries from chest trauma include tension pneumothorax, cardiac tamponade, aortic disruption and others that often require emergency procedures or surgery. - Management involves airway control, ventilation, chest tube drainage, analgesia and monitoring for complications like respiratory failure. Operative treatment is indicated for severe injuries or those not responding to initial management.

1. Dr Mukhilesh R MS PG

2. CHEST
TRAUMA

3. Salient Features of Chest Trauma
• Most commonly missed injury
• Most common cause of death in thoracic injury is hemorraghe
• Clinical examination + chest radiography – to detect chest injury
• USG supplements the diagnosis
• Resuscitation to be done , without waiting for radiological
investigations.
• Chest drain – therapeutic as well as diagnostic

4. Chest Anatomy
• 12 pair of ribs with intercostal muscles.
• The lungs occupy the majority of the
thoracic volume.
• Mediastinum - heart and great vessels.
• Diaphragm
Mechanisms of Injury
– Blunt Injury
• Deceleration
• Compression
– Penetrating Injury
– Both

5. Red flag signs of chest injury
 Hemoptysis.
 Chest wall contusion.
 Flail chest.
 Open wounds.
 Jugular vein distention
(JVD).
 Subcutaneous empysema.
 Tracheal deviation.
Respiratory rate and effort: Lung sounds:
Tachypnea Absent or
Bradypnea decreased
Labored Unilateral
Retractions Bilateral
Progressive respiratory Bowel sounds in
distress
chest.

6. Assess the Chest Wall
 Contusions.
 Tenderness.
 Asymmetry.
 Open wounds or
impaled objects.
 Crepitation.
 Paradoxical movement.
 Compare both sides of the chest at the
same time when assessing for asymmetry.
Lung sounds – Percussion.
Hyperresonance
Pneumothorax
Tension pneumothorax
Hyporesonance (hemothorax)

7. “DEADLY DOZEN” Threats to life from chest injury

9. Opening pneumothorax - Sucking Chest Wound
• Defect in chest > 3cm
• Not to be fully closed
• Closed on three sides – acts as one way
valve
• Controlled chest drain must
• Formal debridment and closure.

10. Tension pneumothorax – oneway valve
CLINICAL DIAGNOSIS – NO NEED FOR RADIOLOGICAL DEMONSTRATIONS
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Clinical features
tacypnoea/dyspnoea
distended neck veins
hyperresonance
absent breath sounds

11. Contd..
Immediate decompression – needle 2nd IC space midclavicular line
Definitive Rx
Chest tube drain – 5th intercostal space

12. Pericardial tamponade
Penetrating injury near heart + Shock – R/O Tamponade
Pericardial sac – non distensible
BECK’S TRIAD
increased CVP
fall in BP
muffled heart sounds
CXR – widened heart shadow
ECHO
Central venous line – increased CVP
Sternotomoy / thoracotomy – repair of heart

13. Hemothorax
Most common in blunt injury
Intercostal vessel & internal mammary art
Clinical features
Shock with flat neck veins
Absent breath sounds
dull on percussion
Mediastinal shift – respiratory distress
ICD

14. Flail Chest
Segment of chest wall doesnot have bony
continuity with the rest of thoracic cage
3 0r more ribs # in 2 or more places
Clinical diagnosis
paradoxical chest wall movement
Rx
analgesia
O2
intrapleural local anesthetics
ventilator support
internal fixation

15. Thoracic aorta disruption – DIRE EMERGENCY
Sudden death in chest injury
Relatively fixed distal to ligamentum
arterisoum
Sudden impact – disrupt intima and media
Tunica adventia intact – pt may be stable
Interscapular pain
RF delay / assymetrical BP
CXR – widened mediastinum
CECT mediastinum / Transesophageal
ECHO
Rx
endovascular intra-aorticc stent
tear can be repaired surgically
dacron graftin

16. Tracheobronchial injury
• Severe subcutaneous empysema with respiratory compromise
• Hemoptysis
• Immediate chest drain
• Early intubation.
• Bronchoscopy is diagnostic
• Operative repair – definitvie RX

17. Oseophageal injuries
• Mostly from penetrating trauma
• HIGH INDEX OF SUSPICION
• C/F
• Odynophagia
• Mediastinal emphysema / mediastinitis
• Unexplained fever within 24 hours
• OGD – confirms diagnosis
• Operative repair and drainage
Mediastinal emphysema – evidence of aerodigestive tract injury until proved
otherwise

18. Blunt myocardial injury
• Most common
finding – ECG
abnormality
• ACUTE MI
• Hypotension
• 2 D ECHO
• Tranesophageal
ECHO
• Increased risk of
arrhythmia – first 24
hours
hence ICU observation necessary

19. Diaphragmatic Injuries
• Penetrating injuries to or below 5th IC space – R/O diaphramatic and
abdomen injury
• Dyspnoea / absent breath sounds
• Hollow abdomen/absent bowel sounds in abdomen
• No single standard investigation
• CXR with NG tube
• Contrast studies / CECT
• VATS / D- LAP – most accurate assesment
• Operative repair – Abdominal approach

20. Pulmonary contusion
• Most common cause for hypoxia
• Hemorrhage into lung parenchyma
• Hemoptysis + blood in ET tube = R/O Lung contusion
• Worsening hypoxemia
• CXR – delayed finidings
• CECT – Confirms
• Rx
• Nasal O2
• Analgesia
• Antibiotics
• Pulmonary toileting
• Ventilator support - PEEP.

21. Rib fractures
Most common finding in chest injury
1st and 2nd rib –
Violent injuries
Rule out vascular injuries
5th to 9th ribs most commonly affected
10th to 12th rib fracture – R/O abdomen injuries
Rx
adequate analgesia
O2
conservative management.
ROLE OF ICD IN RIB FRACTURE????

22. Operative treatment for chest injuries
• Initial tube thoracostomy - >1000ml (penetrating injury) or >1500ml
(blunt injury)
• >200ml/hr for 3 consecutive hours
• Caked hemothorax
• Great vessel injury (endovascular option)
• Pericardial tamponade
• Cardiac herniation
• Massive air leak from the chest tube
• Open pneumothorax
• Esophageal perforation
• Tracheal or main stem bronchial injury diagnosed by endoscopy or
imaging

23. Emergency room thoracotomy – life threatening bleeding
Indications
Internal cardiac massage
Control of hemorrhage – heart / lung or other sites
Control of massive air leak
Hemodynamically unstable patient as a last resort – usually unsuccessful
Left anterolateral thoracotomy
Usually futile :
CPR >10 minutes
blunt trauma with no signs
of life at scene

24. Clamshell thoracotomy
• Bilateral anterolateral thoracotomy + transverse sternotomy = "clamshell"
incision
• The largest incision commonly used in thoracic surgery.