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1. CHEST TRAUMA
)THORACIC TRAUMA(
PREPARED BY DR. ALI BARAT.

2. Ventilation
is the body’s ability to move air in
and out of the chest and lung tissue.

3. Respiration
is the exchange of gases in the alveoli of the
lung tissue.

4. The chest (thoracic cage)
extends from the lower end of the neck to the
diaphragm.

5. Your X-ray showed a broken rib, but
we fixed it with Photoshop.

6. Landmarks for the posterior
approach

8. Patient positioning for the posterior
thoracentesis approach. Note that the
patient should be sitting forward over a
support. The location of needle placement
is best determined by using ultrasound. A
typical puncture point is shown in this
illustration.
thoracentesis
Posterior approach is most common
 Identify the mid-scapular line and mark the site one to two rib spaces below the
superior portion of the effusion Intercostal neurovascular bundle runs along the inferior
portion of the rib. The needle should be inserted superiorly .
 Hemidiaphragm changes level with respiration. A thoracentesis should not be
performed below the eighth intercostal space, given the risk for splenic or hepatic injury.

9.  INTRODUCTION
 Anatomy  Definition  Epidemiology
 Mechanism of injury
 General management
 Discussion of selected
pathologies & specific
management.
 pathophysiology

10. CHEST WALL: Sternum
Ribs
Costal cartilage
Vertebral column
Intercostal
muscles and vessels
Anatomy
of
the Chest
includes

11. THORAX
includes the primary organs of the respiratory &
cardiovascular systems. It has three major spaces.
Mediastinum
Right &
left pulmonary cavities.
pleura
The thorax is lined by the pleural membrane
consisting of two layers:
Visceral: covers the visceral organ.
Parietal: lines chest wall, the upper surface of
the diaphragm, sides of the pericardium and
mediastinum.
Pleural space - contains serous fluid with in & it
lubricates & permits ease of expansion.
It is also a potential space for :
1-pneumothorax
2-hydrothorax
3-hemothorax

12. Muscles of respiration
Sternocleidomastoid
Intercostal muscles
Diaphragm
Abdominal muscle

13. Central space in the chest
Boundaries:
Anteriorly: sternum
Posteriorly: vertebral
column
Superiorly: thoracic inlet
Inferiorly: diaphragm
Mediastinum
 It is divided in to 2
compartments
 Superior & Inferior
 It contains :
 the thymus gland
 lymph nodes,
 ascending aorta, and great
veins.
 pericardium, heart,
 trachea, hilar
structures of the lung
 the sympathetic
chains
 intercostal nerves
 esophagus and
descending thoracic
aorta.

14. 3
Introduction to chest injury
 is any form of physical insult
to thoracic region of our body.
It could be due to:
• Blunt or
• Penetrating type of
trauma.

15.  25% of all trauma death
 2nd leading cause of death
 Major thoracic traumas are associated
with multi-system injuries in 70% of
cases.
3
Epidemiology
Introduction to chest injury
O Most thoracic injuries (90% of blunt
and 70% to 85% of penetrating) can be
managed without surgery (non operatively):

16. A. Blunt Trauma –
due to blunt force (blast, blow, crush)
to chest such as :
1.Road traffic accidents
2.Falls from a height
3.Direct blow(e.g: rib fracture)
4.Deceleration injury
Rib fracture is the most common sign of blunt thoracic trauma
Fracture of scapula, sternum, or first rib suggests massive force of injury
Pediatric Thorax: More cartilage = Absorbs force.

17. B. Penetrating Trauma
Low Energy
 Arrows, knives, handguns
 Injury caused by direct contact and
cavitations
High Energy
 Military, hunting rifles & high powered
hand guns
 Extensive injury due to high pressure
cavitations
Shotgun: I njury severity based upon the distanc e
between the vic tim and shotgun & c al iber of shot S hotgun

18.  Chest wall injuries: * Simple Rib fracture
(Flail chest).
Types of Chest injury preview
 Injuries with in the plural space
 Pneumothorax
 Tension pneumothorax
 Haemothorax
 Sucking chest wound
 Injury to the lung parenchyma & tracheobronchial tree
Lung contusion
Injury to the cardiovascular system
Rupture of great vessels
Cardiac tamponed
Diaphragmatic injuries, Oesophageal injuries

19. pathophysiology
→ Hypoventilation
→ Hypotension
→ Ventilation perfusion mismatch

20. Injuries Associated with Penetrating Thoracic Trauma
• Closed pneumothorax
• Open pneumothorax
(including sucking
chest wound)
• Tension pneumothorax
• Pneumomediastinum
• Hemothorax
• Hemopneumothorax
• Laceration of vascular
structures
• Tracheobronchial tree
lacerations
• Esophageal
lacerations
• Penetrating cardiac
injuries
• Pericardial tamponed
• Spinal cord injuries
• Diaphragm trauma
• Intra-abdominal
penetration with
associated organ
injury

21. Initial management (first aid
measures)(general management):
1
2 Specific (Real) management (Definite
therapy).
CHEST TRAUMA
a. ABC: (Resuscitation)
Airway, Breathing, Circulation
b. Primary survey:
Identify & treat immediately life threatening
Injuries.
c. Emergency thoracotomy.

22. 1
CHEST TRAUMA
I. Initial management (first aid
measures)(general
management):
a). ABCDE: (Resuscitation)
Airway, Breathing, Circulation
A:airway: Clear and maintain patent airway
Removal of any FB, blood clots, aspiration of
fluids and secretions.
Chin left and jaw thrust.
Forward traction of the tongue.
In unconscious patient may need
endotracheal
intubation or tracheostomy.
(why air way patency is very important?)

23. Chest trauma ABCDE: (Resuscitation)
B: breathing
Check if the lung is expanded or not.
Inspection of the chest for movement.
Inspect for equality in both sides.
Examine for any abnormality (flail
segment, wounds, lost segment, sucking
wound etc..).
Mouth to mouth or, Ambu bag
breathing
C: Circulation
Restore volume and maintain BP
Pulse and BP.
1 or 2 wide bore cannula.
Blood grouping and cross matching.
Compression of any site of bleeding.
Restore volume in major bleeding or
hypotension (fluids or blood).

24. Chest trauma ABCDE: (Resuscitation)
D:Disabilities
Splinting and fixation of any suspected fracture
specially the spine and long bones.
To avoid injury to the neurovascular structures,
E: exposure
Complete exposure of the injured patient:
1. Medicolegal aspect.
2. facilitate rapid and detailed examination.

25. Chest injury
Tension pneumothorax
Pericardial tamponed
Open pneumothorax
Massive hemothorax
Flail chest
Immediately life threatening
Aortic injuries
Tracheobronchial injuries
Myocardial contusion
Rupture of diaphragm
Esophageal injuries
Pulmonary contusion
Potentially life threatening

26. Rib fractures
Most common thoracic injury which characterized
by Localised pain, tenderness.
Upper ribs (mainly three pairs), clavicle , sternal or
scapula fracture indicate sever trauma and may be
associated with spinal injury or vascular damage .
With lower rib fractures, abdominal visceral injury,
 such as liver, spleen or kidney, may occur.
Sternal fracture
Fracture of the left first rib. This injury
is associated with an increased incidence of
neurovascular injury, in the subclavian vein.
Mgt:

effective analgesia ,

intercostal nerve block &muscle relaxant

27. Open Pneumothorax
 Opening in chest cavity that allows air to enter pleural cavity.
 A common complication of chest trauma (15–40%).
Causes the lung to collapse due to increased pressure in pleural cavity
 Can be life threatening
Simple pneumothorax: the edge of
the right lung is clearly seen
(arrows) devoid of peripheral lung
markings. No mediastinal shift
occurs.
Signs and symptoms
 Dyspnea
 Sudden sharp pain
 Subcutaneous Emphysema
 Decreased lung sounds on affected side
Rx chest tube
insertion

28. Flail chest
A condition of multiple rib fractures produce a mobile fragment which
moves paradoxically with respiration.
 Usually traumatic with two or more ribs fractured in two or more
places..
Always consider underlying lung injury (pulmonary contusion).
Underlying lung contusion are likely to contribute to the patient’s
hypoxia.
The main Clinical features are:
Dyspnoea, Tachycardia, hypoxia ,Cyanosis and Hypotension
Mgt: emergency
 stabilize the segment with sand bags
 traction with towel clip
 ventilation
careful fluid management to prevent fluid overload
 vigorous pulmonary toilet to prevent atelectasis and
pneumonia,
and adequate analgesia

29. Flail chest
Use Trauma
bandage and
Triangular
Bandages to splint
ribs
Surgical
technique for
the stabilization
of the anterior
flail chest with
crossed
Kirschner's
wires

30. Haemothorax
 Occurs when pleural space fills with blood
 Usually occurs due to lacerated blood vessel
in thorax
 As blood increases, it puts pressure on heart
and other vessels in chest cavity
 General increased opacification of the
hemithorax is seen on a supine film
The opacification
of the left
hemithorax is du to
a hemothorax.
 source of bleeding
 Intercostal vessels
 Internal mammary
vessels
 pulmonary vessels
Definitive treatment: Chest tube insertion
Indicated when there is air or fluid in the pleural
cavity
Should be inserted on the ‘safe triangle’
• anterior to the mid-axillary line;
• above the level of the nipple;
• below and lateral to the pectoralis major muscle

31. Tension pneumothorax
 develops when a ‘one-way valve’ air leak occurs either from the
lung or through the chest wall.
 Air is forced into the thoracic cavity without any
means of escape, completely collapsing the affected lung.
 The air is under tension or pressure.
 The mediastinum is displaced to the opposite side, decreasing
 venous return and compressing the opposite lung causing hypotension
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

32. Management of tension pneumothorax
No time for radiography
Immediate decompression by rapid insertion of a large-
bore needle into the
2nd intercostal space in the mid-clavicular line of the
affected hemithorax.
This is immediately followed by insertion of a chest tube
through the 5th intercostal space in the anterior axillary line.

33. CHEST TUBE
Patient performing incentive spirometry

34. CHEST TUBE
Eye of chest tube in subcutaneous
tissues with subcutaneous emphysema.
Mispositioned tube over the diaphragm
(arrow).

35. CHEST TUBE

36. CHEST TUBE
Important
Landmarks
How to insert an intercostal
tube?

37. CHEST TUBE
Underwater Seal
• It is an effective one
way valve allowing
air and fluid to go out
of the pleural cavity.
• All attachments
should be secure and
leak free.
• The intercostal tube
should be clamped if
the bottle needs to
be disconnected.
• The bottle must be
kept below the level
of the thorax. Under water seal:
@Below the level of the chest.
@The tubes should be clamped be
disconnection.

38. CHEST TUBE
Chest Tube Sizes Compared to Average
Intercostal Space (Mid-Axillary 5th Space
Chest Tube Placement

39. CHEST TUBE

40. Indications for Chest Tube Removal
Clinical Improvement
* Patient will no longer be short of breath
* Bilateral breath sounds heard
* Symmetrical rise of the chest on inspiration
*percussion note is normal
 when the drainage is <50 ml in 24 hour
 No more blood or pus is coming out
 No bubbling or fluctuation in the water-seal chamber

41. Complications of chest tube
 Bleeding
 Aspiration
 Damage to diaphragm
 Infection
 Subcutaneous emphysema
CI of chest tube insertion
 Refractory coagulopathy
 Diaphragmatic herina
 Hepatic hydrothorax
 Adhesion in the pleural space
Sucking chest wound[open
pneumothorax]
Caused by penetrating injuries that makes a
hole in the chest cavity which is greater 3
cm in diameter

42. Pulmonary contusion
Pulmonary contusion is an injury to the lung
parenchyma leading to edema & blood
collection in the alveolar space.
 This leads to loss of normal lung structure
and function.
Frequently manifests itself as Hypoxemia
Mostly it is self limiting
causes
Blunt trauma ( most common )
Penetrating trauma
Hemoptysis and excessive
tracheobronchial secretion give clue
to diagnosis
Normally, oxygen and
carbon dioxide diffuse
across the capillary
and alveolar
membranes and the
interstitial space (top).
Fluid impairs this
diffusion, resulting in
less oxygenated
blood (bottom).

43. Pulmonary contusion
Dx: dyspnea -
Hemoptysis
Chest pain & cough
• vital sign deranged
chest tenderness
CXR: non lobular patchy consolidation
Mx:
fluid restriction, supplemental oxygen,
vigorous chest physiotherapy, adequate
analgesia
Most common complications are

44. Cardiac tamponade
 It is dangerous situation in which
there is build up of fluid around the
heart within in pericardiac sac
causing compression of the heart.
 Normal pericardial fluid 15-20ml.
 In acute cases >100 cc of blood can
lead to cardiac tamponade
 In chronic cases pericardium can
accommodate up to 2 liters of fluid
with out tamponade effect

45. Cardiac tamponade
 All patients with penetrating injury
anywhere near the heart plus shock
must be considered to have cardiac
injury until proven otherwise
 Clinical presentation
 Beck’s triad
Dilated neck veins
Muffled heart sounds
Hypotension
 Treatment
Initially pericardiocentesis under ECG
monitoring plus rapid volume resuscitation to
increase preload
definitive sternotomy or left thoracotomy

46. Cardiac tamponade
Subxiphoid
Insertion: 1 cm inferior to the left xiphocostal
angle, 30 degrees with the patient’s chest
Direction: Towards left mid-clavicle. If
unsuccessful, retract the spinal needle and
redirect 10 degrees towards the patient’s right

47. Cardiac tamponade
Parasternal
Insertion: Fifth intercostal space at the left
parasternal border no more than 1 cm lateral,
cephalad to the inferior rib and perpendicular to the
patient’s chest
Direction: Posterio

48. Cardiac tamponade
Apical
Insertion: Fifth, sixth, or seventh left intercostal space
approximately 6 cm from the parasternal border,
cephalad to the inferior rib
Direction: Patient’s right shoulder
Position the ultrasound
machine and yourself
Local anesthesia and
equipment
Ultrasound-guided
needle insertion

49. Rupture diaphragm:
A tear in the Diaphragm that allows
the abdominal organs enter the chest cavity
O A tear in the Diaphragm that allows the
abdominal organs enter the chest cavity
O More common on Left side (90%) due to
liver helps protect the right side of
diaphragm
O Associated with multiplies injury
patients
O Common and usually missed especially
in penetrating injuries

50. Aortic rupture:
Usually blunt trauma involving Chest;
especially RTAs or fall from a height ~80-90%
die within minutes
clinical suspicion, CXR, aortography and
contrast CT are done
An aortic rupture should be suspected from
the mechanism of injury.
 Chest or inter-scapular pain will be present
Supine trauma chest radiograph showing
widened mediastinum with deviation of the
trachea to the right, depression of the left main
bronchus, left apical pleural capping and
increased density of the left hemithorax
consistent with hemothorax. Combination of
findings is highly suspicious for traumatic aortic
rupture

51. Indications of Thoracotomy in Chest trauma
7. Massive lung laceration (hemothorax,
massive air leak).
8. Traumatic diaphragmatic hernia.
9. Traumatic injury of the diaphragm.
10. Sternum (displaced fracture, lost
segment).
11. Chest wall (lost segment >10 cm
posteriorly and 5 cm anteriorly).
12. Others (thoracoabdominal injuries,
mediastinal structure injuries).
A). Emergency (immediate, early)
thoracotomy:
1. Massive hemothorax (>1500 cc).
2. Continuous bleeding (>300 cc/h. for > 3 hs)
3. Massive pneumothorax with lung collapse for >
7
days.
4. Cardiac arrest (open cardiac massage).
5. Cardiac tamponade.
6. Tracheobronchial injury (rupture trachea or
bronchus).

52. Indications of Thoracotomy in Chest trauma
NO signs of life in the field or
hospital.
Asystole and no pericardial
tamponade.
CPR>15 minutes.
Massive NON survivable injures.
NO thoracic or trauma surgeon within
45 minutes.
B). Late thoracotomy:
1. Neglected diaphragmatic hernia.
2. Pyopneumothorax.
3. Empyema
4. Clotted hemothorax.
5. Organized hemothorax (frozen chest).
6. Retained FB.
7. Traumatic cardiac valves injuries (MVR).
8. Traumatic septal defects (ASD, VSD)
9. Traumatic aortic aneurysm.
Contraindications of ERT:
Signs of life
• Spontaneous breathing.
Palpable carotid pulse.
Measurable BP.
Electric cardiac activity.
Pupillary light response.
Spontaneous extremity movements

53. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

54. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

55. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

56. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

57. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

58. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

59. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

60. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

61. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

62. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

63. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

64. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

65. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

66. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

67. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

68. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

69. Radiographic projections of the chest
PA )patient with pericardial
effusion
Lateral ) patient with air filled mass

70. Routine Radiographic projections of the
chest

71. Routine Radiographic projections of the
chest

72. Routine Radiographic projections of the
chest
Marked
contusions
GSW: Hemothorax, PTX

73. Routine Radiographic projections of the
chest

74. Routine Radiographic projections of the
chest
. Chest radiography showing a knife penetrating
the left chest wall and pneumothorax. The yellow
arrows indicate the collapsed left lung.

75. Routine Radiographic projections of the
chest
Chest CT showing penetration of the lower left lobe that reached
the left dorsal chest wall. The yellow arrows show the knife secured
with a towel or tape. The black arrows show the knife penetrating to
the dorsal muscle layer of the 9th intercostal space. The red arrows
show that there is no massive pleural effusion.
A knife was stuck in Sauer's danger zone on the patient’s chest,
and three other cuts were found. The yellow square indicates
Sauer’s danger zone. The yellow arrows indicate three cuts in the
intrathoracic mediastinal direction.

76. PLEURAL EFFUSION:
Definition:
It is an abnormal collection of
fluid in the pleural space
resulting from excess fluid
production or decreased
absorption.
Types:
• Hydrothorax: accumulation of serous fluid in
pleura
• Haemothorax: accumulation of blood in pleura.
• Pyothorax (Empyema thoracis): accumulation of
pus in pleura.
• Chylothorax: accumulation of chyle in pleura.

77. PLEURAL EFFUSION :
Etiology of hydrothorax:
The normal pleural space
contains fluid, representing
the balance between (1)
hydrostatic and oncotic
forces - plasma proteins - in
the visceral and parietal
pleural vessels and (2)
extensive lymphatic
drainage. Pleural effusions
result from disruption of this
balance. (3) Inflammatory
process of the capillary wall
results in increased
exudation.
Types of Hydrothorax:
Pleural effusions are generally classified as transudates or
exudates, based on the mechanism of fluid formation and
pleural fluid chemistry.
1. Transudates (an imbalance in oncotic and hydrostatic
pressures, low in proteins, usually systemic)
• Congestive heart failure. *Hepatic failure.
• Renal failure. *Hypoalbuminemia.
2. Exudates (the result of inflammation of the pleura or
decreased lymphatic drainage. High in proteins,
usually local causes)
• Infections (bacterial, tuberculous, fungal, parasitic,
viral).
• Malignancy (1ary tumour as mesothelioma, 2aries
from lung cancer, metastases, lymphoma…).
• Collagen disease (rheumatoid Lupus,..) .
• Pulmonary embolus.
• Pseudochylothorax (chronic condition with elevated
cholesterol in pleural fluid)
• Abdominal disease (pancreatitis, subphrenic
abscess,…) .

78. PLEURAL EFFUSION :
Clinical Picture:
• Small effusion may be
asymptomatic.
• Large effusion may be associated
with dyspnea, dry cough, chest pain
(more with exudative effusion,
pleuritic chest pain indicates
inflammation of the parietal pleura)
and low cardiac output syndrome if
under tension.
Investigations:
1. Laboratory:
CBC, ESR,…
2. CXR :
1. Blunting of the
costophrenic angle is
an early radiologic sign.
It already indicates
accumulation of more
than 400 ml of fluid.
2. A lateral decubitus film
confirms the presence
of free-flowing (vs.
loculated) pleural fluid.
Hydropneumothorax

79. PLEURAL EFFUSION :
• Chemical Examination:
– Total protein. Exudate (>3g/dl), transudate (<3g/dl). The ratio of pleural protein/serum protein is <0.5 in
transudate and >0.5 in exudate.
– LDH. Ratio of pleural LDH/serum LDH >0.6 suggests an exudate.
– Glucose. Low (<60mg/dl) suggests malignancy, tuberculosis, parapneumonic effusion or rheumatoid effusion.
– PH. Parapneumonic effusion with low pH (<7.0) suggests progression to empyema.
– Amylase. Elevated in pancreatitis, esophageal perforation, and malignant effusion.
– Triglycerides. High level (>110mg/dl) are diagnostic of chylothorax.
– Cholesterol: High in pseudochylothorax.
– Pleural complement, rheumatoid factor, antinuclear antibody are elevated in collagen vascular diseases.
– Tumor markers. (Alpha fetoprotein and Carcinoembryonic antigen)
Light’s criteria:
• To differentiate between transudate
and exudate, if one criterion is positive
it means exudative effusion:
• 1. Pleural protein > 0.5 serum protein
• 2. Pleural LDH > 0.6 serum LDH
• 3. Pleural LDH > 2/3 upper normal limit
of serum LDH
Treatment:
• Transudates and some exudates: treatment of underlying
cause.
• Medical treatment:
Symptomatic treatment: anti-tussives, analgesics
Diuretics and protein supplementation
• Drainage with thoracocentesis or intercostal tube
(thoracostomy) connected to an underwater seal for
moderate and massive effusions.
Therapeutic thoracentesis: no more than 1 L to 1.5 L of fluid
should be removed in one setting to avoid re-expansion
pulmonary edema and post-thoracentesis shock. The
maneuver can be repeated.
• Malignant pleural effusion:
1. pleurodesis,
2. surgery,
3. home management with indwelling pleural catheter.

80. Empyema Thoracis:
Definitions:
 Thoracic empyema is accumulation of infected
fluid or pus in the pleural cavity.
 It may be localized or involve the entire
pleural space.
Etiology:
• Contamination from contiguous
sources:
– Lung: Pneumonia (the most common
cause) & Lung abscess,
– Mediastinitis & Mediastinal abscess
(esophageal perforation).
• Direct inoculation: (Post traumatic):
– Penetrating chest injuries.
– Iatrogenic as complication of
thoracocentesis & postoperative as post
resection bronchopleural fistula.
• Transdiaphragmatic spread from
subphrenic abscess.
• Hematogenous spread from distant
sites.
Pathogenesis
The commonest isolated organisms
are:
• Aerobic:
– Gram-positive: Streptococcus,
staphylococcus.
– Gram-negative: Coliforms, proteus,
H.influenzae.
• Anerobic: Bacteroids.

81. PLEURAL EFFUSION :
Patholog
y
The evolution of parapneumonic effusion into
empyema involves 3 stages:
• Exudative: Thin pleural fluid occurs in response
to pleural inflammation. Thin fibrin is deposited
over pleural surfaces. If the pleural space is
drained, the lung will re-expand.
• Fibrinopurulent: Bacterial invasion of the pleural
fluid, influx of polymorphs, and the fluid
becomes turbid and purulent. Heavy fibrin
deposition prevents lung re-expansion &
produces loculations.
• Organization: Pus is very thick. Ingrowth of
fibroblasts into fibrin sheet coating the visceral
and parital pleura with collagen (fibrous tissue)
formation. The lung is trapped in thick fibrous
peel "pleural peel" causing entrapment of the
lung.
Time-scale and overlapping of stages of thoracic empyema
Complications of untreated empyema:
• Pulmonary: fibrosis and chest wall deformities.
• Spontaneous drainage of pus through chest wall (empyema necessitatis) or through bronchial tree (bronchopleural fistula).
• Local spread of infection to pericardium or mediastinum and rare to subdiaphragmatic area.
• General complications of chronic sepsis: clubbing of the fingers and pulmonary osteoarthropathy, general toxemia and cachexia,
amyloidosis, septicemia and septic embolization. Distant infection (osteomyelitis). Septic shock and Multi-organ failure.

82. Clinical Picture:
Clinical Stages of Empyema Thoracis
• Acute empyema stage:
Within the first 2 weeks of the onset.
• Subacute empyema:
Empyema after 2 weeks till becoming chronic
empyema.
• Chronic empyema stage:
Failure of complete lung expansion (entrapment
of lung with the formation of the thick peel and
loculations) after proper drainage of pus (well-
functioning chest tube). It is not a matter of time.
Generally, after 2 weeks.

83. Empyema
:
Presentation
• Common symptoms of bacterial
pneumonia with parapneumonic
effusion include a cough, expectoration,
pleuritic chest pain, and
difficulty breathing.
• Fever, tachypnea, and tachycardia
• Pleural effusion (dullness to
percussion decreased tactile fremitus
and
decreased or absent breath sounds)
• Adjacent pneumonia (rales or crackles
and/or bronchial breath sounds)
Investigations
• Plain chest x-ray
• Chest ultrasound:
• Chest computed tomography
(CT)
• Thoracentesis
Management
• Antibiotic Therapy
• Chest Tube Drainage
• Fibrinolytic Agents
• Thoracoscopy (VATS)
• Decortication
• Rib Resection and Open Drainage
of Pleural Space

84. Empyema
:
Complications
O Residual Pleural Thickening
O Extensive Pleural Fibrosis
O Bronchopleural Fistula Formation
O Empyema Necessitans
Portable chest radiograph of a five-year-old girl with
co-infection with pandemic (H1N1) 2009 virus
and Streptococcus pneumoniae, showing multiple
right pneumatoceles (bracket), opacification in the
right middle lobe (black arrow) and depression of the
right hemidiaphragm (white arrow).

85. 1.In patient with pneumothorax and shock, the first action should
be:
a- immediate X ray chest.
b- oxygen inhalation
c- insertion of chest intercostals tube/ or drain
d- putting the patient on ventilator
e- tracheostomy tube

86. 13. 25 years old man sustained stab wound injury to the right chest.
He admitted to Trauma Center with pain at the site of stab
wound. On examination there was restricted movement of the
chest of the same site. Chest X-ray shows collapse lungs on the
same side with obliteration costophrenic angel. The most likely
diagnosis is:
a.Pneumothorax
b.Hemopneumothorax
c.Tension pneumothorax
d.Pulmonary contusion
e.Cardiac tamponade

87. 20. Which of the following statements about empyema is true:
a. Empyema is a collection of pus within pleural cavity
b. Empyema is a collection of pus in the lung parenchyma
c All cases need lobectomy
d. All cases need pneumectomy

88. 19. Thoracotomy is indicated in all the following EXCEPT:
a. Penetrating chest injuries
b Rapidly accumulating hemothorax
c. massive air leak
d. Pulmonary contusion

89. 14. The next step in management of this patient:
a.Immediate thoracotomy at ER
b.The insertion of thoracostomy tube at 5 th intercostals space in mid-
axillary line
c.Tracheal intubation with mechanical ventilation
d.Insertion of thoracostomy tube at the 2 nd intercostal space at mid-
clavicular line
e.Pericardial paracenteses.