Chest trauma can cause significant morbidity and mortality if not managed promptly and effectively. The document discusses the pathophysiology of chest trauma from both blunt and penetrating mechanisms. It emphasizes the importance of the primary survey approach, including assessing the airway, breathing, and circulation (ABCs). For patients who are unstable, interventions like intubation, chest tube insertion, and fluid resuscitation may be required during the initial assessment to stabilize their condition.

1. Chest Trauma
By
Dr. Dixit Prajapati (MS)
Dr. Neet Chotai (MS)

2. Introduction
 Thoracic injuries are directly
responsible for 25% of all trauma
deaths and are a major contributory
factor to mortality in a further 25%.
 Although many of these deaths occur
almost immediately, there is a
significant group of patients that may
be salvaged with early effective
management.

3.  The majority (approximately 90%) of
all patients who sustain thoracic
trauma can be managed
conservatively, with no more than a
chest drain, monitoring and
analgesia.
 Few patients require surgery, and an
emergency department thoracotomy
is indicated in only a very small
minority.

4.  A reproducible and safe approach to
the diagnosis and management of
chest injury is taught by the ATLS
course of the American College of
Surgeons.

5. Anatomy of thoracic cavity
• 12 pair of ribs with intercostal muscles.
• The lungs occupy the majority of the
thoracic volume.
• Mediastinum - heart and great
vessels.
• Diaphragm

8. PATHOPHYSIOLOGY OF
CHEST TRAUMA

9. Blunt Trauma- Blunt force to chest. E.g.
automobile crashes and falls.

11. Penetrating Trauma- Projectile that enters chest
causing small or large hole. E.g. gun shot and
stabbing.

14.  Anatomical Injuries
◦ Thoracic Cage (Skeletal)
◦ Cardiovascular
◦ Pleural and Pulmonary
◦ Mediastinal
◦ Diaphragmatic
◦ Esophageal
◦ Penetrating Cardiac

15.  The main consequences of chest
trauma occur as a result of its
combined effects on respiratory and
haemodynamic function.
 The commonest manifestation of
thoracic trauma is hypoxia

16.  Mechanism of injury is important in so
far as blunt and penetrating injuries
have different pathophysiologies and
clinical courses.
 Most blunt injuries are managed non-
operatively or with simple
interventions such as intubation and
ventilation and chest tube insertion.

17.  Diagnosis of blunt injuries may be
more difficult and require additional
investigations such as CT scanning
(when the patient is STABLE).
 In contrast, penetrating injuries are
more likely to require operation, and
complex investigations are required
infrequently.

18. • Impairments in ventilatory efficiency
 Chest movement compromise due to
pain
air in pleural space
asymmetrical movement
 Bleeding in pleural space
 Ineffective diaphragm contraction

19. ◦ Impairments in gas exchange
 Atelectasis
 Pulmonary contusion
 Respiratory tract disruption

20. Causes of hypoxia in chest
trauma
 Haemorrhage;
 Lung collapse and compression;
 Ventilatory or cardiac failure;
 Pulmonary contusion;
 Changes in intrathoracic pressure;
and
 Mediastinal displacement.

21.  Profound hypovolaemia in chest
trauma due to
Great vessel damage,
Pulmonary hilar injury
Cardiac or pericardial
laceration without tamponade.
Hypovolaemia produces a low cardiac
output state, which further contributes
to the pathophysiological
consequences of chest injury.

22.  Hypovolaemia produces a low cardiac
output state, which further contributes
to the pathophysiological
consequences of chest injury.
 Pulmonary contusion is one of the
main factors responsible for the
increased morbidity and mortality
associated with chest trauma.

23.  It is a progressive condition,
Alveolar haemorrhage and oedema
Interstitial fluid accumulation
Decreased alveolar membrane
diffusion.

24.  These changes produce
 Relative hypoxaemia,
 Increased pulmonary vascular
resistance,
 Decreased pulmonary vascular flow
 Reduced lung compliance.

25.  Importantly, there is a Ventilation-
perfusion mismatch' (alveoli are
perfused, but are unavailable for gas
exchange because they are full of
blood).
 This contributes significantly to the
hypoxaemia, especially in the early
stages following trauma.

26.  Later, hypoxia-induced pulmonary
vasoconstriction will divert the blood
away from the non-ventilated alveoli
 A loss of mechanical function of the
chest wall will also result in hypoxia

27.  If the chest wall is sufficiently
disrupted, the patient may be unable
spontaneously to generate sufficient
movement of air to allow adequate
gas transfer.

28.  Cardiac output may be directly
reduced by
 Decreased myocardial contractility (e.g.
myocardial contusion),
 Cardiac disruption (e.g. a tear in a cardiac valve),
 Reduced venous filling (e.g. in cardiac
tamponade),
 With changes in intrathoracic pressure (tension
pneumothorax).

30. ASSESSMENT
 On arrival in the emergency
department, decisions and action
need to be taken without delay.
 Important information may be obtained
from the ambulance service relating to
the patient's history and mechanism of
injury.

31. The sequence of questions as follow
 Mechanism of injury
 Injuries found and suspected
 Signs (respiratory rate, SpO2, pulse,
blood pressure)
 Treatment given pre-hospital.

32.  In every case, the system of a primary
survey with simultaneous resuscitation
is followed.
 In the stable patient, once this has
been completed, a secondary survey
can be performed.

33.  Certain wounds or bruising patterns
highlight the likelihood of underlying
injury
 for example a seat-belt mark on the
chest wall may arouse suspicion of
fractured ribs, lung contusion, or
solid organ injury in the abdomen,

34.  Penetrating wound medial to the
nipple or the scapula suggests
possible damage to the heart (with
potential cardiac tamponade), the
great vessels, or the hilar
structures.
 However, major intrathoracic injuries
may occur without obvious external
damage

35.  Additionally, some injuries point to
possible associated more serious
pathology
 for example, fractures of the first
and second ribs are associated
with major vessel injury.

36.  The Advanced Trauma Life Support
(ATLS) course of the American
College of Surgeons Committee on
Trauma was developed in the late
1970s,
 based on the premise that appropriate
and timely care can significantly
improve the outcome for the injured
patient.

37.  ATLS provides a structured approach
to the trauma patient with standard
algorithms of care
 It emphasizes the “golden hour”
concept that timely, prioritized
interventions are necessary to prevent
death and disability.

38.  The initial management of seriously
injured patients consists of phases
that include
 Primary survey/concurrent
Resuscitation,
 Secondary survey/diagnostic
evaluation,
 Tertiary survey.

39.  The first step in patient management is
performing the primary survey, the goal
of which is to identify and treat
conditions that constitute an
immediate threat to life.
 The ATLS course refers to the primary
survey as assessment of the “ABCs”
(Airway with cervical spine protection,
Breathing, and Circulation).

40.  Although the concepts within the
primary survey are presented in a
sequential fashion, in reality they are
pursued simultaneously in coordinated
team resuscitation.
 Life-threatening injuries must be
identified and treated before being
distracted by the secondary survey.

41. AIRWAY
 It is necessary to recognize and
address major injuries affecting the
airway during the primary survey.
 Airway patency and air exchange
should be assessed by listening for air
movement at the patient’s nose,
mouth, and lung fields; inspecting the
oropharynx for foreign-body
obstruction.

42.  Laryngeal injury can accompany major
thoracic trauma.
 Patients who have an abnormal
voice, abnormal breathing sounds,
tachypnea, or altered mental status
require further airway evaluation

43.  Endotracheal intubation is indicated in
Patients with apnea
Inability to protect the airway due to
altered mental status
Impending airway compromise due to
inhalation injury, hematoma, facial
bleeding, soft tissue swelling, or
aspiration;
Inability to maintain oxygenation.

44.  Altered mental status is the most
common indication for intubation.
 Options for endotracheal intubation
include nasotracheal, orotracheal, or
operative routes.

45.  Patients in whom attempts at intubation
have failed or who are precluded from
intubation due to extensive facial injuries
require operative establishment
(cricothyroidotmy/tracheostomy) of an
airway.
 In patients under the age of 11,
cricothyroidotomy is relatively
contraindicated due to the risk of
subglottic stenosis, and tracheostomy
should be performed.

46.  Emergent tracheostomy is indicated in
patients with laryngotracheal
separation or laryngeal fractures, in
whom cricothyroidotomy may cause
further damage or result in complete
loss

47. BREATHING
 Before examining the chest, the neck
should be carefully examined for
wounds,
bleeding,
tracheal deviation,
laryngeal crepitus,
jugular vein engorgement

48.  If a cervical collar is already in place, it
should ideally be removed temporarily
to allow examination, Bt
 Do not forget to examine the neck

49.  The chest must be completely
exposed so that respiratory movement
and quality of ventilation can be
assessed.
 The mechanics of breathing can be
disrupted by major airway obstruction,
haemothorax or pneumothorax, pain
or pulmonary contusion.

50.  Impending hypoxia is sometimes
indicated by subtle changes in the
breathing pattern, which may become
shallow and rapid.
 Visual inspection and palpation of the
chest wall may reveal
deformity,
contusion,
abrasion,
penetrating injury,

51. paradoxical breathing,
tenderness,
crepitus.
 All are markers suggestive of
underlying injury.

52. CIRCULATION
 The pulse should be assessed for
quality, rate and regularity.
 The peripheral circulation is assessed
by skin colour, temperature and
capillary return.
 Venous distension in the neck may not
always be present in a patient with
cardiac tamponade who has
hypovolaemia.

53. Circulation maintained by
 IV fluids (crystalloids,PCV )
 External control of any visible
hemorrhage should be achieved
promptly while circulating volume is
restored.
 Manual compression of open wounds
with ongoing bleeding should be done
with a single 4 × 4 gauze and a gloved
hand.

54.  During the circulation section of the
primary survey, two life-threatening
injuries must be identified promptly:
(a) massive hemothorax, (b) cardiac
tamponade.
 Two critical tools used to differentiate
these in trauma patient are chest
radiograph and focused abdominal
sonography for trauma (FAST)

55.  A massive hemothorax is defined as
>1500 mL of blood or, in the pediatric
population, >25% of the patient’s
blood volume in the pleural space
 Although it may be estimated on
chest radiograph, tube thoracostomy
is the only reliable means to quantify
the amount of hemothorax.

56.  After blunt trauma, a major
hemothorax usually is due to
Multiple rib fractures with severed
intercostal arteries
Lacerated lung parenchyma

57.  Cardiac tamponade occurs most
commonly after penetrating thoracic
wounds, although occasionally blunt
rupture of the heart, particularly the
atrial appendage, is seen.
 Acutely, <100 mL of pericardial blood
may cause pericardial tamponade.

58.  The classic Beck’s triad—
dilated neck veins,
muffled heart tones, and a
decline in arterial pressure
 is usually not appreciated in the
trauma bay because of the noisy
environment and associated
hypovolemia.

59. DISABILITY
 The hypoxic patient will initially be
confused. Primary head injury will also
cause an altered mental state, which
will be compounded by hypoxia or
hypercarbia.

60. Immediately life-threatening injuries to be
identified during the primary survey
 Airway
Airway obstruction
Airway injury
 Breathing
Tension pneumothorax
Open pneumothorax
Flail chest

61.  Circulation
Hemorrhagic shock
Massive hemothorax
Cardiac tamponade
 Disability
spine injury

62. Secondary Survey
 Once the immediate threats to life
have been addressed, a thorough
history is obtained and the patient is
examined in a systematic fashion
 Adjuncts to the physical examination
include
vital sign and CVP monitoring,
ECG monitoring
nasogastric tube placement,

63. Foley catheter placement,
Xray chest
hemoglobin
USG chest.

64. Assessment Findings
◦ Mental Status (decreased)
◦ Pulse (absent, tachy or brady)
◦ BP (hypotension)
◦ Ventilatory rate & effort (tachy- or
bradypnea, labored, retractions)
◦ Skin (pallor, cyanosis, open injury,
ecchymosis)

65. ◦ Neck (tracheal position, subcutaneous
emphysema, JVD, open injury)
◦ Chest (contusions, tenderness,
asymmetry, absent or decreased lung
sounds, abnormal percussion, open injury,
impaled object, crepitus, hemoptysis)
◦ Heart Sounds (muffled)
◦ Upper abdomen (contusion, open injury)

66. Red flag signs of chest injury
 Hemoptysis.
 Chest wall contusion.
 Flail chest.
 Open wounds.
 Jugular vein distention (JVD).
 Subcutaneous empysema.
 Tracheal deviation.

67.  Lung sounds:
◦ Absent or decreased
 Unilateral
 Bilateral
◦ Bowel sounds in chest
 Percussion.
◦ Hyperresonance
 Pneumothorax
 Tension pneumothorax
◦ Hyporesonance (hemothorax)

68. DEADLY DOZEN Threats to life from chest
injury
 Immediately life threatening – primary
survey
◦ Airway obstruction
◦ Tension pneumothorax
◦ Pericardial tamponade
◦ Open pneumothorax
◦ Massive hemothorax
◦ Flail chest

69.  Potentially life threatening –
secondary survey
◦ Aortic injuries
◦ Tracheobronchial injuries
◦ Myocardial contusion
◦ Rupture of diaphragm
◦ Oesophageal injury
◦ Pulmonary contusion

70. Evaluation
 Most thoracic injuries can be identified
with a physical examination and plain
chest radiography.
 Physical examination will reveal
superficial injuries, including chest wall
defects and penetrating wounds.
 Chest radiography is performed on all
significantly injured patients at risk for
thoracic injuries.

71.  The chest radiograph easily identifies
the presence of a pneumothorax or
hemothorax, as well as rib and sternal
fractures.
 The appearance of the mediastinum
may suggest a thoracic aortic injury.
 An ultrasound of the pericardium is a
component of the FAST examination,
which may reveal pericardial blood.

72.  In recent years, thoracic CT
angiography has emerged as a
valuable tool in the evaluation of blunt
thoracic trauma.
 CT provides visualization of the chest
wall and hemithoraces, allowing
determination of rib fractures,
pneumothoraces and hemothoraces,
and pulmonary contusion.

73.  Chest CT angiography is able to
identify transection of the aortic wall,
as well as lower grade injuries that
involve only the aortic intima.