This document discusses various types of chest injuries including pneumothorax, haemothorax, flail chest, cardiac tamponade, and tension pneumothorax. It describes the causes, symptoms, diagnosis, and treatment options for each condition. For pneumothorax, it outlines treatment depending on size, including catheter drainage or chest tube insertion. For haemothorax, tension pneumothorax, and cardiac tamponade, immediate decompression or drainage is critical along with treatment for shock. Surgical interventions like VATS or open procedures are described for management of persistent air leaks or failures of non-surgical treatment.

1. INJURIES OF CHEST
DR.SHAIK EZDA JANI
GENERAL SURGERY PG 1

2. PNEUMOTHORAX
• INTRODUCTION
• Pneumothorax = presence of air outside the lung,
within the pleural space
• TWO TYPES
1. SPONTANEOUS PNEUMOTHORAX
2. TENSION PNEUMOTHORAX

3. PNEUMOTHORAX: CAUSES

4. 1.PRIMARY SPONTANEOUS
PNEUMOTHORAX
• usually tall and thin young men
• Due to leak from blebs, vesicles or bullae
• Most common seen at upper lobe of lung

5. 2.SECONDARY SPONTANEOUS
PNEUMOTHORAX
• Occurs when visceral peritoneum leaks
• Due to underlying lung diseases
• Seen in older patients

6. DIAGNOSIS:
• Chest X-ray:
• CT Chest:
• Occasionally
• Assess cause of spontaneous pneumothorax
• presence of other occult lung disease

7. TREATMENT:
• depends on size and symptoms
• Smaller pneumothorax may resolve spontaneously
• Progression in the size : intervention with drainage
• Initial spontaneous pneumothorax:
• small bore catheter drainage
• or chest tube and drainage with resolution of the air space and
cessation of air leak
• Persistent air leak (>5 days) or failure of the lung to expand fully
suggests additional intervention

8. INDICATIONS: SURGICAL
INTERVENTION
● Second ipsilateral pneumothorax
● First contralateral pneumothorax
● Bilateral spontaneous pneumothorax
● Pneumothorax fails to settle despite chest drainage
● Spontaneous haemothorax: professions at risk (e.g. pilots, divers)
● Pregnancy

10. CHEST DRAIN: INSERTING AND
MANAGING

11. INSERTION:
1. TRIANGLE OF SAFETY

12. • Penetration of the skin,
muscle and pleura
• Blunt dissection of the
parietal pleura;
• suture placement

13. • gauging the distance of
insertion
• digital examination
along the tract into the
pleural space
• withdrawal of
central trochar
and positioning of
drain

14. • Underwater seal chest drain bottle.

15. SURGICAL MANAGEMENT
• Can be performed by :
• video-assisted thoracoscopic surgery (VATS) or
• open procedure (Thoracostomy)
• Pleurectomy and pleurodesis

16. Objectives:
• deal with any leaks from
the lung
• search for and obliterate
any blebs and bullae
• make the visceral pleura
adherent to the parietal
pleura

17. • Pleural adhesion is achieved in one of three ways:
PLEURECTOMY
PLEURAL ABRASION
CHEMICAL PLEURODESIS

18. TENSION PNEUMOTHORAX
• Develops due to one way valve air leak
• Mediastinum displace to opposite side
• Compressing the affected lung
• Decreased venous return
• Mc cause penetrating chest trauma

19. Clinical presentation
• Tachypnea
• Dyspnea
• Distended neck veins
• Tracheal deviation
• Hyper resonance and decreased breath sounds

20. TREATMENT
• IMMEDIATE DECOMPRESSION
• With large wide bore canula
• Followed by insertion of chest tube in safety triangle

21. FLAIL CHEST

22. INTRODUCTION
• Results from blunt trauma associated
with multiple rib fractures
• Defined as three or more ribs fractured
in two or more places.
• blunt force typically also produces an
underlying pulmonary contusion

23. MECHANISM

24. DIAGNOSIS
• made clinically in patients who are not ventilated,
• not by radiography
• Confirmation: paradoxical motion of a chest wall segment

25. • Voluntary splinting of the chest
wall due to:
• Pain
• Mechanically impaired chest wall
movement
• Lung contusion
HYPOXIA

26. MANAGEMENT:
• Traditionally, mechanical ventilation was
used to ‘internally splint’
• Disadvantage:
• intensive care unit (ICU) resources
• ventilation-dependent morbidity

27. • Currently:
• oxygen administration
• adequate analgesia (including opiates)
• Physiotherapy
• If chest tube is in place: topical intrapleural local analgesia
• Ventilation (respiratory failure )
• Surgery :
• stabilise the fail segment using internal fxation of the ribs
• patients with
• isolated or severe chest injury
• pulmonary contusion.

28. HAEMOTHORAX
• BLUNT INJURY(m/c)
• torn intercostal vessels
• internal mammary artery
secondary to fractures of
the ribs
• PENETRATING INJURY
• Viscera: both thoracic and
abdominal
• blood leaking through a
hole in the diaphragm
from the positive pressure
abdomen into the
negative pressure thorax

29. PRESENTATION : HAEMOTHORAX
• haemorrhagic shock
• fat neck veins
• unilateral absence of breath sounds
• dullness to percussion

30. MANAGEMENT:
• INITIAL TREATMENT:
• correcting the hypovolaemic shock
• insertion of an intercostal drain
• Intubation
• Indication for urgent thoracotomy
• Initial drainage > 1500 mL of blood
• ongoing haemorrhage > 200 mL/h over 3–4 hours

31. • NOTE: There is no role for clamping a chest tube to tamponade a massive
haemothorax.
• IMPORTANT POINTS:
• if the lung does not reinfLate -> the drain should be placed on low-pressure
(5 cmH2O) suction
• Check for clot occlusion of chest tube
• Second drain is sometimes necessary
• Role of chest radiograph or eFAST
• physiotherapy and active mobilisation

32. CARDIAC TAMPONADE

33. PERICARDIAL TAMPONADE
• INTRODUCTION:
• m/c due to penetrating trauma
• All patients with penetrating injury anywhere
near the heart + shock must be considered =
cardiac injury until proven otherwise.

34. MECHANISM: CARDIAC TAMPONADE
• Accumulation of small amount(50ml) blood
in non distensible pericardial sac
• compression of the heart ;
• obstruction of the venous return,
• decreased filling of the cardiac chambers
during diastole

35. PRESENTATION
• central venous pressure elevation,
• a decline in arterial pressure
• tachycardia
• mufed heart sound
• deteriorating cyanosis
• agitation
• earliest manifestation is an acute drop in mixed
venous oxygen saturation

36. DIAGNOSIS
• eFAST
• fuid in the pericardial sac
• Most reliable
• chest radiography
• looking for an enlarged heart shadow

37. MANAGEMENT:
• NOTE: Pericardiocentesis has no role in the management of cardiac
tamponade secondary to penetrating myocardial injury
• Immediate treatment:
• Operative:
• subxiphoid window or
• by open surgery (sternotomy or left anterolateral thoracotomy)
• with evacuation of the haematoma and repair of the myocardium

39. THANK YOU