This document provides information on key topics in the management of chest trauma: - Tension pneumothorax is a medical emergency diagnosed clinically and treated with needle or tube thoracostomy without delay. - Hemothorax over 1.5L or drainage over 200mL/hr requires tube thoracostomy or thoracotomy. Cardiac tamponade is diagnosed clinically and with ultrasound. - Pulmonary contusions are managed with oxygenation, fluids restriction, and analgesia. Blunt cardiac injuries may cause hypotension or arrhythmias.

1. Dr. Mohamed El Sayed
Lecturer of Anesthesia and intensive care
ALS provider –ACLS provider –ATLS provider

3. The primary survey: The secondary survey:
- airway obstruction
- Tracheo-bronchial tree
injury
- tension pneumothorax
- open pneumothorax
- massive hemothorax
- cardiac tamponade
- Simple pneumothorax
- hemothorax
- flail chest
- pulmonary contusion,
-blunt cardiac injury –
- traumatic aortic disruption
- traumatic diaphragmatic
injury
- blunt esophageal rupture.
3. Others subcutaneous emphysema, thoracic crush injuries, and
sternal, rib, and clavicular fractures

4. Tracheobronchial Tree Injury
Injury to the trachea or a major bronchus is
 an unusual but potentially fatal condition.
 The majority of tracheo-bronchial tree injuries
occur within 1 inch (2.54 cm) of the carina.
These injuries can be severe.
 Majority of patients die at the scene

5.  a “one-way valve” air leak occurs from the
lung or through the chest wall).
 Air is forced into the pleural space with no
means of escape, eventually collapsing the
affected lung.
 The mediastinum is displaced to the opposite
side, decreasing venous return and
compressing the opposite lung.
 Shock.

6. Tension pneumothorax
is a clinical diagnosis
reflecting air under
pressure in the
affected pleural
space.
Do not delay treatment
to obtain radiologic
confirmation.

7.  Patients who are mechanically ventilated manifest
hemodynamic collapse.
 Tension pneumothorax is characterized by some or
all of the following signs and symptoms:
 Chest pain + Air hunger
 Tachypnea + Respiratory distress
 Tachycardia + Hypotension
 Tracheal deviation away from the side of the injury
 Unilateral absence of breath sounds
 Elevated hemithorax without respiratory movement
 • Neck vein distention
 • Cyanosis (late manifestation)

9.  Recent evidence supports placing the
large, over-the-needle catheter at the
fifth inter-space, slightly anterior to
the mid-axillary line.
 Successful needle decompression
converts tension pneumothorax to a
simple pneumothorax.
 Tube thoracostomy is mandatory after
needle or finger decompression of the
chest

11. ** Open Pneumothorax
 Large injuries to the chest wall that remain
open can result in an open pneumothorax, also
known as a sucking chest wound .
 Equilibration between intrathoracic pressure
and atmospheric pressure is immediate.
 Open pneumothorax is commonly found and
treated at the scene by pre-hospital personnel.
** Massive hemothorax
 Accumulation of blood in pleura
 One of hidden places of bleeding
 Resuscitation and replacement
 Thoracotomy and repair

14. ** Cardiac tamponade
 The classic clinical triad of
◦ Muffled heart sounds
◦ Hypotension
◦ Distended veins
 Focused assessment with sonography for
trauma (FAST) is a rapid and accurate
method of imaging the heart and
pericardium that can effectively identify
cardiac tamponade.
 Treatment subxiphoid pericardiocentesis

16.  . Simple pneumothorax
 • Hemothorax
 • Flail chest
 • Pulmonary contusion
 • Blunt cardiac injury
 • Traumatic aortic disruption
 • Traumatic diaphragmatic injury
 • Blunt esophageal rupture

17.  lung to collapse. A ventilation-perfusion
 Any pneumothorax is best treated with a
chest tube placed in the fifth intercostal
space, just anterior to the midaxillary line

18.  Pleural effusion in which blood (<1500
mL) accumulates in the pleural cavity
 Decision to operate on a patient with a
hemothorax,
◦ the patient’s physiologic status and the
volume of blood drainage
◦ Greater than 1500 mL of blood obtained
immediately through the chest tube
◦ Drainage of more than 200 mL/hr for 2 to 4 h
◦ if blood transfusion is required

19.  A flail chest occurs when a segment of the chest
wall does not have bony continuity with the rest of
the thoracic cage
 Two or more adjacent ribs fractured in two or
more places.
 A pulmonary contusion = bruise of the lung,
caused by thoracic trauma.
 Pulmonary contusion can occur without rib
fractures or flail chest, particularly in young
patients without completely ossified ribs.
 Children have far more compliant chest walls than
adults and may suffer contusions and other
internal chest injury without overlying fractures.

21.  Abnormal respiratory motion and palpation of
crepitus from rib or cartilage fractures
 Patients with significant hypoxia (i.e., PaO2 <
60 mm Hg [8.6 kPa] or SaO2 < 90%) on room
air may require intubation and ventilation
within the first hour after injury.
 Associated medical conditions, such as chronic
requiring early intubation and mechanical
ventilation
Management 
1. Ensuring adequate oxygenation
2. Fluids restriction
3. Providing analgesia to improve ventilation

22.  Blunt cardiac injury can result in myocardial
muscle contusion, cardiac chamber rupture,
coronary artery dissection and/or thrombosis,
and valvular disruption.
 Clinically significant sequelae are hypotension,
dysrhythmias, and/or wall-motion abnormality
on two-dimensional echocardiograph
 The presence of cardiac troponins in
diagnosing blunt cardiac injury is inconclusive.
 Diagnosed by conduction abnormalities

23.  Traumatic aortic rupture is a common cause
of sudden death.
 Blood may escape into the mediastinum, but
one characteristic shared by all survivors is
that they have a contained hematoma
 Persistent or recurrent hypotension

26.  Chest trauma one of leading causes of death
 Tension pneumothorax is a clinical diagnosis
 Needle or finger or tube thoracostomy insertion
5th intercostal space
 Hemothorax one of hidden places for bleeding
 Cardiac tamponade = clinical + FAST
 Flial chest = oxygenation +fluid restriction +
analgesia
 Donot forget aortic root rupture and
giaphragmatic rupture.

27. 1. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency
department thoracotomy: review of published data from the
past 25 years. J Am Coll Surg 2000;190(3):288–298.
2. Stafford RE, Linn J, Washington L. Incidence and management
of occult hemothoraces. Am J Surg 2006;192(6):722–726.
3. Karmy-Jones R, Jurkovich GJ, Nathens AB, et al. Timing of
urgent thoracotomy for hemorrhage after trauma: a
multicenter study. Archives of Surgery 2001;136(5):513–518.
4. Simon B, Cushman J, Barraco R, et al. Pain management in
blunt thoracic trauma: an EAST Practice Management
Guidelines Workgroup. J Trauma 2005;59:1256–1267.
5. Wilkerson RG, Stone MB. Sensitivity of bedside ultrasound and
supine anteroposterior chest radiographs for the identification
of pneumothorax after blunt trauma. [Review] [24 refs] Acad
Emerg Med 2010;17(1):11–17.
6. Inaba K, Lustenberger T, Recinos G, et al. Does size matter? A
prospective analysis of 28-32 versus 36-40 French chest tube
size in trauma. J Trauma 2012;72(2):422–427.

29. Thank you