Chest Trauma and It's Management

1. CHEST TRAUMA AND IT’S
MANAGEMENT
Tajdit Rahman Tanim
Thoracic Surgery
NIDCH

2. Introduction
• Chest trauma is often sudden and
dramatic
• Accounts for 25% of all trauma deaths
• 2/3 of deaths occur after reaching hospital
• Second leading cause of trauma deaths
after head injury (in USA)
• RTA is common etiology 65-70 %
• Abdominal injuries are common with chest
trauma.

3. Epidemiology
• The fact that it has become possible in recent
decades for millions of people to travel at high speed
had led to a phenomenal increase in blunt injury to
the chest - a most lethal type of injury.

4. Types of Chest injury
• Blunt thoracic injuries
 Forces distributed over large
area
• Penetrating thoracic injuries
 Forces distributed over small
area
 Organs injured usually those
that lie along path of
penetrating object

5. CAUSES OF CHEST INJURIES
BLUNT
TRAUMA
• Motor vehicle
accidents
• Auto vs.
pedestrian
• Falls
• Blast injuries
PENETRATI
NG TRAUMA
• Gunshot
wounds
• Stab wounds
• Shrapnel
wounds

6. Pathophysiology in Chest Injury
Flail chest
Contusion
Pneumothorax
Haemothorax
Heart & vessel
Associated injury
Decreased
alveolar
ventilation
Shock
Rt to Lt Shunting
Decreased CO
Hypoxia
Hypotension
Respiratory Acidosis
Metabolic Acidosis
Death

7. Initial assessment and
management
• Primary survey by ATLS guideline
• Resuscitation of vital functions
• Detailed secondary survey
• Definitive care

8. The first step is to make a rough estimate of
the status of the circulatory and respiratory
systems. This provides the first diagnostic clues and
often determines which therapeutic action is to be
taken. Specific questions are then posed pertaining
to individual injuries or their consequences.
Assessment of patient with
Thoracic injury

9. • The evaluation of thoracic injuries is only
one aspect of the total assessment of
severely injured patients.
• Both diagnosis and therapy go hand in
hand.
• The basic principle of elective surgery -
“First investigate and make the diagnosis,
then treat the illness” - is a dangerous
illusion.
Assessment of patient with
Thoracic injury

10. Immediately life-
threatening; diagnosis
and therapy before
taking other steps
TEN QUESTIONS to be asked in the initial
assessment of severe blunt thoracic injuries
1. Hypovolemia?
2. Respiratory insufficiency?
3. Tension pneumothorax?
4. Cardiac tamponade?

11. 1. Multiple rib fractures? (Paradoxical respiration?)
2. Pneumothorax ? (subcutaneous emphysema?
mediastinal emphysema?)
3. Hemothorax?
4. Diaphragmatic rupture?
5. Aortic rupture?
6. Cardiac contusion?
TEN QUESTIONS to be asked in the initial
assessment of severe blunt thoracic injuries

12. Monitoring and evaluating the
patient with Thoracic trauma
• Radiograph of the thorax
(Chest wall i.e. ribs, sternum,
vertebral, clavicles).
• Mediastinum (wide or normal)
shifted or not.
• Lung parenchyma (Contusion).
• The heart (cardiac tamponade).
• Diaphragm.
• Pneumothorax, hemothorax.



ECG
CVP
Arterial blood
gases.
Urine output.
Lab. Investigations.
Others.




13. • The treatment of polytraumatized patient must follow
a certain protocol which includes.
• Adequate oxygenation.
• Fluid replacement.
• Surgical intervention.
• Treatment of septic complications.
• Adequate caloric and substrate supplementation.
• Prevention of stress bleeding.
• Finally, be alert of possible complication (CNS,
ARDS, hepatic, renal, coagulation disorders,
sepsis.
Management of patients with
Thoracic Trauma

14. Deadly Dozen
• Immediate Life Threatening injuries (Lethal Six)
• Potential Life Threatening injuries( Hidden Six)

15. Immediate Life Threatening injuries
(Lethal Six)
Fatal if they are not recognized and treated immediately:
Airway Obstruction
Tension pneumothorax
Open pneumothorax
Massive hemothorax
Flail chest
Cardiac tamponade
“sucking chest wound”

16. Potential Life Threatening injuries
( Hidden Six)
Primary or secondary survey may reveal one of six
potentially life-threatening thoracic injuries
• Cardiac contusion
• Aortic disruption
• Diaphragmatic rupture
• Oesophageal injury
• Pulmonary contusion
• Tracheo-bronchial injuries

17. Airway obstruction
– Control of the airway is foremost in trauma resuscitation.
– Protect the cervical spine as the airway is being managed
Causes
The tongue is the most common cause
Dentures, avulsed teeth, tissue, secretions, and blood
Bilateral mandibular fracture
Expanding neck hematomas
Laryngeal trauma
Tracheal tear or transection

18. Sign and Symptoms
Stridor, hoarseness
of voice
subcutaneous emphysema,
altered mental status,
accessory muscle working
apnea, and cyanosis (sign of pre-terminal hypoxemia).
if any suspicion of airway obstruction or inability to
exchange air adequately mandates early intubation

19. Management
Intubate using a controlled rapid sequence when in
doubt of obstruction
Provide inline cervical spine immobilization during
intubation.
Early intubate in cases of neck hematoma or possible
airway edema
Emergency cricothyroidotomy should perform if
endotracheal intubation fails.

20. Tension Pneumothorax
Air enters pleural space and becomes trapped leads to
pressure increase
Increased pressure which collapses lung and shifts
mediastinum to unaffected side
Increased dyspnoea and compressed heart and great vessels
leads to decreased cardiac output.
Leads to Cardiogenic Shock

21. Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Tension Pneumothorax

22. Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

23. Tension Pneumothorax
Heart is being
compressed
The trachea is
pushed to
the opposite side

24. Tension Pneumothorax
Signs & Symptoms
Dyspnoea
Tachypnoea
Anxiety
Diminished breath sounds
Hypotension
Tachycardia
JVD
Narrowing pulse pressure
Tracheal Deviation
– Late Sign
Shock

25. Inferior vena cava

26. Treatment
Needle Thoracostomy ( 12 or 14 gauge IV catheter in 2nd ICS )
Tube Thoracostomy

27. Open Pneumothorax
(Sucking Chest Wound)
Open chest wall injury
Stab wounds usually self-sealing
Extensive damage
Air passes through opening into
the pleural space and remains
outside of lung
Large open defect in chest wall
(>3 cm diameter) with
equilibration between
intrathoracic and atmospheric
pressure

28. MECHANISM
Opening of chest wall exceeds two third of the
diameter of the trachea
with each inspiratory cycle air is drawn through
the defect rather than through the trachea
Accumulation of air in hemithorax rather than in the
lung
Leading to profound hypoventilation on the affected
side and hypoxia
If there is valvular effect increasing air
accumulation in the pleural cavity results in a
tension pneumothorax

29. Open Pneumothorax

30. Open Pneumothorax
Inhale

31. Open Pneumothorax
Exhale

32. Open Pneumothorax
Inhale

33. Open Pneumothorax
Exhale

34. Open Pneumothorax
Inhale

35. Open Pnuemothorax
Inhale

37. Signs & Symptoms
Gurgling sound during respiration
Bubbling wound
Dyspnea
Tachypnea
Diminished breath sound

38. MANAGEMENT
Promptly closing of the defect with a sterile
occlusive plastic dressing (e.g Opsite ) taped
on three sides to act as a flutter type valve.
Tube thoracostomy on the affected side remote
from the injury
Do not close a sucking chest wound until a
drain is in place

40. Haemothorax
Haemothorax following a blunt or penetrating
wound to the chest can be caused by bleeding
from any structure in the thorax: the intercostal
arteries, the lung, the great vessels or heart.

41. Hemothorax

42. Hemothorax

43. Hemothorax

44. Hemothorax
May put pressure on the heart

45. Lots of blood vessels
Where does the blood come
from.

46. Massive Hemothorax
Blood in the pleural space
Each side of the chest can
hold 2500-3000ml of
blood
Possible Sources
– Intercostal vessels
– Internal mammary
artery
– Pulmonary vessels
– Lung parenchyma
Can lead to tension
pneumothorax

47. Clinical Feature
• Initial findings include anxity,dyspnea,
tachypnea,tachycardia
• Diminish breath sound and dullness to
percussion are found over the affected
hemithorax
• Massive hemothorax can produce
significant hemodynamic instability
secondary to hemorrhagic shock

49. Diagnosis
By physical
examination and
CXR

51. Indication of Thoracaotomy
• Persistent shock
• Suspect or proven cardiac injury
• Massive hemothorax(>1500ml on chest tube
insertion)
• Persistent hemothorax(>500ml/hr initial hour of
drainage or >200ml/hr for several hours)
• Retained hemothorax

52. PERICARDIAL TAMPONADE
All patient with penetrating injury
anywhere near the heart plus shock
must be considered to have a cardiac
injury until proven otherwise.
• Collection of blood between heart and
pericardium
• Source of blood can be coronary arteries or
myocardium.
• Pericardium may hold up to 200-300ml of
blood before S&S develop
• Most commonly due to penetrating trauma

54. Cardiac Tamponade
Diagnosis- eFAST
Signs & Symptoms
Tachycardia
Paradoxical pulse
JVD
Narrowing pulse
pressures
Muffled heart sounds
S&S of shock
Beck’s Triad
MHS
JVD
Hypotension

55. MANAGEMENT
 According to ATLS protocol
 Insertion of a CV line to check raising CVP
 Needle pericardiocentesis under ECG control
(temporary measure)
 Ideal management is emergency left antero-
lateral thoracotomy to relieve the tamponade.

56. Three or more ribs
fractured in two or
more places

57. Flail Chest
• Blunt Force
• The blunt force typically also produces an
underlying pulmonary contusion.
• Dx is made clinically in pts who are not
ventilated, not radiography.
• Paradoxical respiration.

58. Flailed Chest

61. Treatment
-Directed towards
Protected underling lung
Maintain ventilation
Prevent pneumonia
-Analgesia is the main treatment
PCA and NSAID
Epidural is the best option ( elderly )
-Intubations and mechanical ventilation is rarely indicated –
-Operative Fixation by wires or plates was indicated in
Patient going for thoracotomy
Fixed thoracic impaction
Failure to wean from ventilator

62. Myocardial Contusion
• Cardiac arrhythmias following blunt chest
trauma
• Angina-like pain unresponsive to
nitroglycerin
• Precordial discomfort independent of
respiratory movement
• Pericardial friction rub (late)
 Treatment of complication

63. Traumatic Aortic Dissection/Rupture
• Retrosternal or interscapular pain
• Pain in lower back or one leg
• Respiratory distress
• Asymmetrical arm BPs
• Upper extremity hypertension with
• Decreased femoral pulses, OR
• Absent femoral pulses
• Dysphagia

64. -Widening of mediastinum
-Loss of aortic contour
-Tracheal shift to right
-Nasogastric tube shift
-Left sided haemothorax

65. MANAGEMENT
1. Control of systolic blood pressure (
less than 100 mm of Hg)
2. Placing of an endo vascular intra
aortic stent
3. Surgical repair / Aortic resection
with grafting-
surgical removal of some
portion of diseased aorta is called
aortic resection. A polyester
graft(Dacron) is used to replace
the diseased aortic tissue.

66. Esophageal injury
• Results from penetrating trauma; blunt injury is rare
Patient can present with odynophagia,
subcutaneous or mediastinal emphysema,
pleural effusion, air in the retro-oesophageal space an
unexplained fever within 24 hours of injury
• Combination of oesophagogram and oesophagoscopy confirm
diagnosis
• CT can be done
• Treatment is operative repair and drainage
• Mid-oesophageal injury => Right thoracotomy
• Distal oesophageal injury => Left thoracotomy

67. Diaphragmatic Rupture
• A tear in the Diaphragm that allows the abdominal
organs enter the chest cavity
• Any penetrating injury to or below 5th intercostal
space can cause diaphragmatic penetration &
abdominal injury
• Blunt injury to the diaphragm is usually caused by a
compressive force applied to the pelvis & abdomen.
• More common on Left side due to liver helps protect
the right side of diaphragm
• Associated with multiple injury patients

68. Diaphragm Rupture

69. S/S of Diaphragmatic Rupture
• Abdominal Pain
• Shortness of Air
• Decreased Breath Sounds on side of rupture
• Bowel Sounds heard in chest cavity

70. Diagnosis
• Chest radiography after placement of a
nasogastric tube, Contrast studies of the
upper or lower gastrointestinal tract, CT
scan & diagnostic peritoneal lavage.
• Most accurate evaluation is by video-assisted
thoracoscopy (VATS) or laparoscopy.

71. Treatment of Diaphragmatic Rupture
 Operative Repair.
Penetrating diaphragmatic injury must be
repaired via the abdomen and not the chest,
to rule out penetrating hollow viscus injury.
Laproscopy can be done.

72. Pulmonary Contusion
 Crushing and bruising of the lung parenchyma.
 Sudden blow or blunt injury to the chest => compression
of thoracic cavity and lung followed by an equally sudden
decompression. Concussive and compressive force is
most important cause.
 The natural progression of pulmonary contusion is
worsening hypoxemia for the first 24 to 48 hours.
 X-ray findings not significant initially.
 CT with contrast is confirmatory.

73. Contusion of left upper & lower lobe with
aspirated blood around

74. S/S of Pul. Contusion
• Hemoptysis
• Dyspnea
• Cough
• Chest wall abrasion
• Echymosis.

75. Tx. Of Pul. contusion
• Oxygen administration
• Pul. Toilet
• Mechanical ventilation => in severe case

76. Tracheo-bronchial Injuries
• Blunt and penetrating trauma
• Presented as hoarseness, SCE.
• Dyspnea , Pneumothorax , hemoptysis ,
Mediastinal shift
• Intercostal retractions, Respiratory distress ,
Stridor.
• Chest drain will reveal a large air leak and the
collapsed lung may fail to re-expand.
• Diagnosis => Bronchoscopy

77. Managment
• Priority is to stabilize AIRWAY.
• Intubation of the unaffected bronchus and
operative repair.

78. THORACOTOMY & TUBE
THORACOSTOMY

79. INDICATIONS FOR THORACOTOMY
• Post-traumatic cardiovascular collapse
• Pericardial tamponade
• Vascular injury to the thoracic outlet
• Control of Hge from lung injury
• Massive Air leak
• Proved tracheobronchial injury
• Internal cardiac massage

80. Types
• Emergency / Resuscitative Thoracotomy
For bleeding control
• Planned Thoracotomy
For repair of specific injury

81. Approaches
• Median Sternotomy
• Anterolateral & Posterolateral
Approach
131

82. Median Sternotomy
• Anterior aspect of the heart
• Anterior mediastinum
• Ascending and arch of aorta
• Pul. Arteries
• Trachea.. Carina

83. Lt A/L Thoracotomy
• Lt lung and hilum
• Thoracic Aorta
• Origin of Lt Sub clavian artery
• Lt side of the heart
• Lower esophagus

84. Rt A/L Thoracotomy
• Rt lung and hilum
• Azygous vein
• SVC
• IVC
• Upper esophagus
• Thoracic trachea
134

85. Tube Thoracostomy

86. Triangle Of Safety

87. Indications
• Pneumothorax
• Malignant pleural effusion
• Empyema and complicated parapneumonic
pleural effusion
• Traumatic haemopneumothorax
• Postoperative—for example, thoracotomy,
oesophagectomy, cardiac surgery.

88. Contra- Indications
• Aďsolute…. NO
• Relatives are
Bleeding Diathesis
Anti-coagulation
Adhesions
Loculations
Pulmonary bullae
69

89. Complications of tube thoracostomy
• Hemorrhage
• Infection
• Trauma to the Liver, spleen, Diaphragm,
Aorta, Heart.
• Minor complications like,
Subcut hematoma, Cough, dyspnea,
• Improper placement

90. Take home message
• Chest Injuries are common and life
threatening
• Early identification and prompt action
needed
• Follow ATLS protocol
• Airway maintenance is essential
• Aggressive treatment may be needed

92. THANKS A LOT