Presentation on chest trauma that includes 6 lethal and 6 hidden conditions

1. CHEST TRAUMA
AND ITS
MANAGEMENT
DR MUHAMMAD UMAIR
PGR CARDIOVASCULAR SURGERY

2. LEARNING OUTCOMES:
• Introduction to chest trauma.
• Classification of chest trauma into deadly dozen.
• Initial evaluation and Resuscitation of Injured patient.
• Investigation and management of deadly dozen.
• Emergency thoracotomy ….Introduction , indications and contraindications, approaches.

3. DEFINITION:
Injury to any part of chest as a result of energy transfer from an
inflicting source that could be blunt or penetrating.

4. INTRODUCTION:
• Chest trauma accounts for 25% of all severe injuries.
• In a further 25% it may be significant contributor to the subsequent death of the patient.
• Approximately 80% of the patients of chest trauma can be managed non operatively.
• The key to a good outcome is Early physiological resuscitation followed by a correct
diagnosis.

5. CLASSIFICATION:
IMMEDIATELY LIFE THREATENING
• Airway Obstruction
• Tension Pneumothorax
• Open Pneumothorax
• Massive Hemothorax
• Pericardial tamponade
• Flail Chest
POTENTIALLY LIFE THREATENING
• Aortic injuries
• Tracheobronchial Injuries
• Myocardial Contusion
• Diaphragmatic Rupture
• Esophageal Injuries
• Pulmonary contusion

6. INVESTIGATIONS:
• Chest Radiography
• Ultrasound/ extended Focused assessment with sonography for trauma (e FAST)
• Finger thoracostomy ( in physiologically grossly unstable patients where physical
examination is inconclusive and there is no time for radiological investigation).
• CT scan.

7. MANAGEMENT:
• Resuscitation of all injuries to the chest should follow the latest advanced trauma life support(ATLS) principles.
• c : Catastrophic hemorrhage
• A: Airway
• B: Breathing
• C: Circulation
• D: Disability ( NEUROLOGY)
• E: Environment and Exposure
Routine investigation in the emergency department of chest injury is based on clinical examination supplemented
by appropriate imaging.

8. IMMEDIATE LIFE THREATENING

9. AIRWAY OBSTRUCTION:
• Clear the airway by suctioning of secretions or blood.
• Chin lift
• Jaw thrust
• Insertion of oropharyngeal airway
• Endotracheal intubation

10. TENSION PNEUMOTHORAX:
• Most common causes are penetrating chest trauma.
• Develops when a lung or chest wall injury is such that it allows air to enter in the pleural space but not out of it ( a one way valve).
• As a result air accumulates and compresses the lung resulting:
• SHIFTING OF MEDIASTINUM
• COMPRESSION OF CONTRALATERAL LUNG
• CLINICAL FEATURES:
• Sharp and stabbing chest pain ,dyspnea, distended neck veins, hypotension, diminished or absent breath sounds on affected side,
tracheal deviation to contralateral side.
• Hyper-resonant percussion and absent breath sounds.
• Diagnosis is clinically before CXR obtained.

11. INVESTIGATIONS:
Tension pneumothorax is a clinical
diagnosis;
Chest X-Ray can confirm it.

12. TREATMENT:
• Immediate needle decompression.
• Definitive treatment is chest intubation in the triangle of safety.

13. INTERCOSTAL CHEST DRAIN:
• Intercostal chest drain is placed in triangle of safety which has following boundaries.
• Boundaries of Triangle of safety:
• Anteriorly: lateral border of pectoralis major
• Posteriorly: anterior border of latissimus dorsi
• Inferiorly: 5th
intercostal space at the level of nipple

15. OPEN PNEUMOTHORAX: (SUCKING CHEST
WOUND)
• More common in penetrating injuries than blunt thoracic injuries.
• It is due to large open defect in chest (>3cm), leading to equilibration between intrathoracic and
atmospheric pressure.
• CLINICAL FEATURES:
• Tachypnea, decreased respiratory movements on affected site
• Central trachea.
• Absent breath sounds on affected side.
• Hyper-resonant percussion.

16. OPEN PNEUMOTHORAX: (SUCKING CHEST
WOUND)
• TREATMENT:
• Closing the defect with a sterile occlusive plastic dressing
taped on three side to act as a flutter type valve
• Chest intubation remote from injury site.

17. PERICARDIAL TAMPONADE:
• Most commonly caused by penetrating chest injuries.
• Accumulation of small amount of blood (50ml) in non distensible pericardial sac causing
compression of heart and obstruction of venous return and decreased filling of cardiac
chambers during diastole.
• Clinical features:
• Increased venous pressure, decreased arterial pressure
with tachycardia and muffled heart sounds. (BECK’STRIAD)

18. PERICARDIAL TAMPONADE:
• Investigations:
• e FAST ( most expeditious and reliable diagnostic tool)
• Chest X ray ( shows enlarged heart shadow)

19. TREATMENT:
• Pericardiocentesis
• Correct immediate treatment of tamponade is operative either via a subxiphoid window
on by open surgery ( sternotomy or left anterolateral thoracotomy).
• Pericardiocentesis has no role in treatment of tamponade secondary to myocardial injury

20. MASSIVE HEMOTHORAX:
• Most common source of massive hemothorax in blunt trauma is bleeding from torn
intercostal vessels or from internal mammary artery secondary to rib fractures.
• In penetrating injuries bleeding from variety of viscera may be involved.
• Clinical features:
• Hemorrhagic shock, flat neck veins, unilateral absence of breath sounds and dullness to
percussion.

21. INVESTIGATIONS:
• Chest X-Ray .

22. MASSIVE HEMOTHORAX:
• TREATMENT:
• Correction of hypovolemic shock.
• Insertion of chest tube.
• Urgent Thoracotomy:
 If initial blood loss more than 1500ml.
 200ml/hour over 3-4 hours.

24. FLAIL CHEST:
• Most commonly caused by blunt trauma.
• 3 or more consecutive ribs fracture in two or more locations.
• May also produce underlying pulmonary contusion.
• Diagnosed clinically in a patient who are not ventilated well and
with the help of paradoxical movement of segment.
• CT scan ( gold standard investigations).

25. FLAIL CHEST:
• TREATMENT:
• Oxygen administration.
• Adequate analgesia
• Physiotherapy
• Ventilation ( for patients developing respiratory failure despite analgesia and oxygen)
• Surgery (internal fixation) in patients with severe injury or pulmonary contusion.

26. POTENTIALLY LIFE THREATENING

27. • Traumatic aortic rupture is a common cause of sudden death after a vehicle collision or fall
from a great height.
The most common site for tearing in traumatic aortic rupture is proximal descending
aorta near where the left subclavian artery branches off from the aorta distal to the
ligamentum arteriosum.
• Clinical features:
• No specific clinical features but it should be suspected in patients with asymmetry of upper
and lower extremity blood pressure, widened pulse pressure and chest wall contusion.
THORACIC AORTIC DISRUPTION

28. THORACIC AORTIC DISRUPTION
• INVESTIGATIONS:
• Erect chest X-Ray (widened mediastinum)
• CT scan (confirmatory test)
• TREATMENT:
• Initial management consist of control of systolic pressure to less than 120mmHg.
• Thereafter endovascular intra-aortic stent can be placed or tear can be repaired by direct
repair or excision or grafting using a Dacron graft by thoracic and vascular surgeons.

29. TRACHEOBRONCHIAL INJURIES
INVESTIGATION:
• Bronchoscopy is diagnostic.
• TREATMENT:
• Treatment involves intubation of the unaffected bronchus followed by operative repair.

30. MYOCARDIAL CONTUSION
Most common cause is blunt injury.
• CLINICAL FEATURES:
• Hypotension,Tachycardia, Dysrhythmias and ECG changes, SOB, light headedness.
• INVESTIGATIONS:
• ECG
• Transthoracic echocardiography (show wall motion abnormalities)
• Transesophageal echocardiography.

31. MYOCARDIAL CONTUSION
TREATMENT:
• Conservative management if hemodynamically stable.
• Inotropic support if blood pressure falling down.
• Close monitoring because of risk of cardiac arrythmias.
• Rarely require surgical intervention.

32. DIAPHRAGMATIC INJURIES
• Any penetrating injury below the fifth intercostal space should raise suspicion of diaphragmatic
penetration and therefore, injury to abdominal contents.
• The diaphragmatic rupture is usually large with herniation of abdominal contents into the chest.
• INVESTIGATIONS:
• Chest radiography after placement of NG tube may be helpful ( may show the stomach herniation
into the chest).
• CT Scan with contrast.
• Video assisted thoracoscopy or laparoscopy ( most accurate evaluation)

33. DIAPHRAGMATIC INJURIES
• TREATMENT:
• Operative repair is recommended in all cases.
• All penetrating diaphragmatic injury must be repaired via the abdomen- not the chest- to
rule out penetrating hollow viscus injury.

34. ESOPHAGEAL INJURY
• Most esophageal injuries result from penetrating trauma.
• Esophagus has no serosal covering and any perforation results in direct drainage into mediastinum.
• The patient may present with odynophagia, subcutaneous or mediastinal emphysema, pleural
effusion, air in peri-esophageal space and unexplained fever.
• Mediastinal and deep cervical emphysema are evidence of an aerodigestive injury until proven
otherwise.

35. ESOPHAGEAL RUPTURE:
• INVESTIGATIONS:
• CT scan with oral contrast
• Esophagoscopy with esophagogram (detect 90% of esophageal injuries)
• TREATMENT:
• Suspension of all oral intakes.
• IV antibiotics and fluids for resuscitation.
• Operative repair of any defect and drainage.

36. PULMONARY CONTUSION
• Pulmonary contusion occur more frequently following blunt trauma and is usually
associated with a flail segment or fractured ribs.
• This is the major cause of hypoxemia after blunt trauma.
• Hemoptysis or blood in endotracheal tube is a sign of pulmonary contusion.

37. INVESTIGATIONS:
• Chest radiography
• CT scan with contrast ( confirmatory)

38. PULMONARY CONTUSION
• TREATMENT:
• In mild contusion, the treatment is oxygen administration, pulmonary toilet and adequate
analgesia.
• In more severe cases, mechanical ventilation is necessary.

39. TRACHEOBRONCHIAL INJURIES
• Almost 80% of injuries in blunt trauma causes death at site or transportation to hospital.
• Severe subcutaneous emphysema with respiratory compromise can suggest
tracheobronchial disruption.
• CLINICAL FEATURES:
• Respiratory distress
• A chest drain placed on the affected side will reveal a large air leak and the collapsed lung may fail
to re-expand

40. EMERGENCY THORACOTOMY

41. EMERGENCY THORACOTOMY
• GOALS OF EDT:
• Internal cardiac massage in cardio-vascularly ‘Full’ patient. ( NO ROLE FOR INTERNAL
MASSAGE IN THE EMPTY PATIENT).
• Control of hemorrhage from injury to heart or lung.
• Control of intra-thoracic hemorrhage from other sources.
• Control of massive air leak.
• Clamping of the thoracic aorta to preserve blood supply to heart and brain.

42. EMERGENCY THORACOTOMY
• Emergency thoracotomy should be reserved for those patients with penetrating injuries in whom signs of
life are still present.
• INDICATIONS:
• Salvageable post injury cardiac arrest:
• Patient sustaining witnessed penetrating trauma to the torso with less than 15 minutes of prehospital CPR.
• Patient sustaining witnessed blunt trauma with less than 10 minutes of prehospital CPR.
• Patient sustaining witnessed penetrating trauma to the neck or extremities with less than 5 minutes of pre
hospital CPR.

43. EMERGENCY THORACOTOMY
• Persistent severe post injury hypotension (SBP < 60mmHg) due to
• Cardiac tamponade
• Hemorrhage ( intrathoracic, intraabdominal, extremity, cervical)
• Air embolism
• 1500ml of blood after passing chest tube ( massive hemothorax)
• 200ml of blood/hour for 3-4 hour (massive hemothorax)

44. CONTRAINDICATIONS
• Penetrating trauma: CPR > 15 minutes and no signs of life.
• Blunt Trauma: CPR > 10 minutes and no signs of life
• Non traumatic cardiac arrest
• Penetrating trauma without cardiac activity
• Severe head and multi system injuries
• Improperly trained team.
• Insufficient equipment
• Old age > 55 years

45. APPROACHES OFTHORACOTOMY
• Left anterolateral thoracotomy
• Left lung and left hilum
• Thoracic aorta
• Origin of left subclavian artery
• Left side of heart
• Lower esophagus

46. APPROACHES OFTHORACOTOMY
• Right anterolateralThoracotomy
• Right lung and hilum
• Azygos vein
• Superior vena cava
• Infracardiac inferior vena cava
• Upper esophagus
• Thoracic aorta

47. APPROACHES OFTHORACOTOMY:
• Median sternotomy:
• Anterior aspect of heart
• Ascending aorta and arch of aorta
• Pulmonary arteries
• Carina of trachea

49. SURVIVAL RATES FOR THORACOTOMY IN PATIENTS
WITH PENETRATING TRAUMA
• Blood pressure despite
resuscitation:
• >60 mmHg
• >40mmHg
• <40mmHg
• Survival
• 60%
• 30%
• 3%

50. THANK YOU