Any injury to the chest wall and surrounding structures

1. CHEST TRAUMA
Presented by; Namisi Nathanael Paul
Supervisor; Dr. Fiston

2. Outline
• Introduction
• Brief Anatomy
• Types of chest trauma
• Pathophysiology
• Classification
• Clinical Approach
• Investigations
• Complications

3. Introduction
• Definition
• Chest trauma, also known as thoracic trauma, refers to any injury to the
chest wall, lungs, or surrounding structures, including the ribs, sternum,
trachea, bronchi, and major blood vessels.
• Epidemiology
• Chest trauma comprises 20-25% of all traumas worldwide and constitutes
the 3rd
most common cause of death after abdominal injury and head
injury in polytrauma patients.
• RTA is the most common cause.
• Hemorrhage is the most common cause of death.

4. Brief Anatomy
• Consists of left and right pleural cavity as well as the mediastinum.
• Mediastinum is further divided into;
• Superior mediastinum
• Thymus, trachea, oesophagus etc
• Inferior mediastinum
• Anterior- Loose connective tissue
• Middle- pericardium, heart, origin of great vessels, carina, phrenic
nerves
• Posterior – Thoracic aorta and it’s branches, azygous venous
system, oesophagus, sympathetic trunk
• Bony structure
• Clavicle, sternum, 12ribs, 12thoracic spines, scapula.

5. Types of Chest Trauma
1. Blunt chest trauma (closed chest injury)
• E.g RTA, Fall, Crush injury
• Associated with multiple injuries.g head, limb, abdomen
• Mechanism of chest injury
1. Body acceleration and deceleration e.g RTA
2. Body compression (force >the strength of skeleton) e.g crush injury and fall
2. Penetrating chest injury (open chest injury)
• Mostly by assault
• Associated with chest wall damage, open pneumothorax and organ injury
• Mechanism of injury
• Penetrating wounds e.g assaults from stabbings, gunshots etc

6. Pathophysiology

7. Classification
1. Immediate Life Threatening Injuries (Lethal 6)
• Fatal if not recognized and treated immediately
1. Airway obstruction
2. Tension pneumothorax
3. Open pneumothorax “sucking chest wound”
4. Massive hemothorax
5. Flail chest
6. Cardiac tamponade

8. Classification contn
2. Potential Life threatening injuries (Hidden 6)
• Primary or secondary survey may reveal any one of them;
1. Cardiac contusion
2. Aortic disruption
3. Diaphragmatic rupture
4. Esophageal injury
5. Pulmonary contusion
6. Tracheo-bronchial injuries

9. Clinical Approach
• Fractures of ribs, sternum and clavicle are most common injuries to
chest wall and rarely life threatening
• The primary survey of ATLS is vital in evaluating the 6 conditions that
result from Immediate Life threatening injuries.
• Secondary survey is started only after assessment of hemodynamics
stability and stabilization of airway, breathing and circulation

10. Clinical Approach contn.
1. HISTORY
• What was the mechanism of injury?
• If a motor vehicle collision, what details can be obtained by
paramedic/attendant
• Patient’s complaints
• Localization of pain
• Difficulty breathing
• Coughing blood
• AMPLE( Allergies, Medications, Past medical hx, Last meal, Events
leading to presentation)

11. 2. PHYSICAL EXAM
• General examination (secondary survey)
• Monitor the vital signs( pulse rate, SPO2, BP etc. Look for
Jugular Vein distension, LOC.
• Physical examination is interrupted if life saving procedure
such as airway or chest tube placement is required.
• Inspection (Look)
• Position; observe patient’s position nothing signs of distress.
• Breathing pattern; assess respiratory rate, rhythm and effort
• Chest wall; deformities, swelling, bruising
• Tracheal deviation; pneumothorax or hemothorax

12. Contn.
• Palpation
• Chest wall; assess for tenderness, crepitus
• Ribcage; check for rib fractures
• Sternal fracture; assess for tenderness
• Percussion
• Chestwall; assess for dullness or hyper-resonance which indicates
hemothorax or pneumothorax
• Auscultation
• Breath sounds; note any areas of decreased or absent breath sounds
• Heart sounds; for any abnormalities in heart sounds.

13. Investigations
• Labs
• ABG analysis
• Imaging
• Chest X-ray
• CT scan
• Echocardiography
• Angiography
• Bronchoscopy

14. Closed pneumothorax
• Accumulation of air in the pleural space without an apparent antecedent
event
• Caused by rupture of small blebs
• Blunt trauma is the main cause. Maybe spontaneous and self correcting
• Clinical features;
• Pleuritic chest pain
• Dyspnoea
• Tachypnea
• Decreased breath sounds on affected side
• Hyper resonance

15. • Diagnosis
• Diagnosis is made by Chest X-ray provided hemodynamics
are stable
• Treatment
• ABCs (primary survey)
• Administer oxygen
• Insert chest tube with connection suction to remove air
• Semi- fowlers position
• Administer antibiotics
• Constant monitoring (Vitals, LOC, SPO2, Respiratory rate
etc)

16. X-ray of closed pneumothorax

17. Open pneumothorax
• The chest wall is compromised and pleural cavity exposed to
atmosphere. Since the negative intrathoracic pressure is lost,
all dynamic lung mechanics are affected
• Intrathoracic pressure rises and shifts mediastinal
components to the opposite side and causes cardiovascular
decompensation.
• Clinical features;
• Respiratory distress due to lung collapse
• Obvious chest wall defect on inspection
• Reduced or absent breath sounds on auscultation

18. • Diagnosis
• On Physical examination and Chest X-ray
• Treatment
• ABC’s (primary survey)
• 3 way occlusive dressing to prevent inflow of air with
inhalation to prevent rise of intrathoracic pressures in
the affected hemithorax
• A chest tube is then placed. After stabilization, most
patients undergo operation for definitive chest wall
closure.

19. Tension pneumothorax
• Ongoing air leak allows continued ingress of air into the
pleural space without egress. This accumulation of air
compresses the lung and mediastinal structures.
• Clinical features;
• Early findings ;Anxiety, dyspnoea, tachypnea, tachycardia
• Diminished breath sounds and hyper-resonance on
affected side
• Tracheal deviation from affected side
• Jugular Vein distension

20. Simple illustration

21. • Diagnosis
• Physical examination
• Treatment
• Immediate needle decompression
• Chest tube placement

22. X-ray of left sided tension pneumothorax with
mediastinal shift

23. Hemothorax
• Bleeding from any structure in the thorax; the intercostal
arteries, the lung, great vessels or heart
• Clinical features
• Initially; anxiety, dyspnoea, tachypnea, tachycardia
• Diminished breath sounds
• Dullness on percussion over affected side
• Massive hemothorax can cause significant hemodynamic
instability 2° to hemorrhagic shock.

24. • Diagnosis
• Physical examination and Chest X-ray
• Treatment
• Chest tube placed when decreased breath sounds
• Findings of 1500mL of blood initially or >200 mL/hr for 2
to 4hours indicates a thoracotomy to control bleeding.

25. Chest X-ray of hematoma

26. Flail chest
• Involves 3 or more consecutive rib fractures in two or more
locations. Occurs when segment of chest wall does not have
bony continuity with the rest of the thoracic cage.
• Pulmonary contusion is most commonly associated.
• Clinical features
• Respiratory distress(most common), dyspne, pain,
tachycardia, tachypnea
• Labored respirations
• Decreased breath sounds on affected side
• Flail segment moves in opposite motion of the remainder
of hemithorax

27. • Diagnosis
• Physical examination and Chest X-ray (On coughing, flail
chest moves in while flail segment moves out)
• CT in identification of early pulmonary contusion
• Treatment
• Pain control, pulmonary toilet and supplemental oxygen
are the primary therapies for pulmonary contusion
• If severe, Endotracheal intubation and positive pressure
mechanical ventilation
• Reducing fluid intake
• Prepare for operative stabilization of chest wall

28. Cardiac tamponade
• Pericardium normally contains 20 to 50mL of fluid. Rapid
accumulation of as little as 150mL after trauma can produce
cardiac tamponade and hypotension.
• Intrapericardial blood may originate from; chamber rupture,
especially the right due to anterior orientation, coronary
artery laceration.
• Rapid accumulation of blood causes impaired distension of
pericardium which causes pressure in pericardial sac to rise.
• When pressure exceeds that of right atrium, RA filling is
impaired and RA preload reduced.

29. Illustration of Cardiac tamponade

30. Clinical features
• Beck’s triad
• Muffled heart sounds
• Arterial hypotension
• Venous hypertension (distended neck vein)
• Narrowing of pulse and pulsus paradoxus
• Dyspnoea, tachycardia, tachypnea

31. • Diagnosis
• Physical examination
• FAST scan may show pericardial fluid
• Ultrasonogram
• Treatment
• Pericardiocentesis in blunt trauma
• In penetrating trauma, Immediate operative exploration and repair of source
of bleeding.
• Fluid resuscitation to maintain preload and cardiac output during
transport to OR.

32. Complications
• Aspirations
• Atelectasis
• Infections
• Pneumonia
• Respiratory failure.