chest trauma -simplified approach

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.

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29. Thank you