Chest Trauma

2. INTRODUCTION
• Thoracic injury is a contributing factor in as many as 75% of all trauma-related deaths.
• Unfortunately, a large proportion of these patients die before reaching the hospital.
• Among those reaching the trauma bay, the prompt diagnosis and management of injuries
to the heart, lungs, great vessels, and other mediastinal structures is essential for patient
survival.

3. Anatomy of Chest Wall
• Thoracic Inlet
Connects thoracic cavity to the root of the Neck.

6. Epidimiology
 A third of RTA’s have significant chest trauma
 Approx. 80% is blunt chest trauma
 20 - 25% overall mortality
 Majority of the deaths are preventable
 < 10% of BCT require surgical intervention as opposed to 15 - 30% in PCT

7. TRAUMA EVALUATION
• Every hemodynamically stable patient with suspicion for thoracic trauma should undergo plain chest
radiography following the ATLS primary survey.
• Based on the results of the initial chest x-ray, as well as the overall stability of the patient, further
workup and management can be directed.
• Computed tomography (CT) should be based on patient stability and the mechanism of
injury.
• The Focused Assessment with Sonography for Trauma (FAST) examination is another valuable tool
in the workup of patients with chest trauma.
• Ultrasound examination is being increasingly utilized in the emergency setting.

8. “TREAT LIFE
THREATENING
INJURIES AS THEY
ARE IDENTIFIED”

9. IMMEDIATE LIFE THREATENING THORACIC INJURIES
 Tension pneumothorax
 Massive hemothorax
 Open pneumothorax
 Cardiac disruption/tamponade
 Tracheal disruption
 Contained Aortic transection
transection

11. I. PENETRATING THORACIC INJURIES
• As many as 40% of all penetrating injuries involve the thorax.
• These occur most frequently from gunshot wounds and stabbings.
• Although less common than blunt thoracic trauma, penetrating trauma to the chest is
more lethal, with 15% to 30% of all penetrating injuries to the chest requiring thoracotomy.

12. A. Chest Wall Injuries
• Low-velocity injuries, such as those suffered from a stab to the chest, may result in
intercostal artery laceration, pulmonary laceration, and/or fracture of a single rib.
• High-velocity penetrating trauma (i.e., a gunshot wound to the chest) may result in more
significant chest wall injury, such as soft tissue loss, multiple rib fractures, and severe
damage to the pulmonary parenchyma.

14. 1. Open pneumothorax
• An open pneumothorax (“sucking chest wound”) may develop following significant chest
wall trauma when a soft tissue defect ≥2/3 the circumference of the trachea is present.
• In this condition, air is preferentially drawn into the pleural space through the chest wall
when negative intrathoracic pressure is generated during inspiration.
• Initial management includes supplemental oxygen or intubation if oxygenation or
ventilation is inadequate and thoracostomy tube placement at a site remote from the
wound.

15. • Definitive treatment requires operative closure.
• If operative repair is not an immediate option, an occlusive dressing taped on three sides
provides a temporizing flap valve effect, in which air escapes from the pleural space
during expiration but does not enter during inspiration.

17. B. Lung Injuries
• Injury to the lungs occurs in 65% to 90% of all penetrating trauma to the chest, resulting in
pulmonary laceration, pneumothorax, hemothorax, and/or pulmonary contusion.
• Concomitant injury to other intrathoracic structures may also occur.

18. a. Tension pneumothorax
• Tension physiology must be suspected in the unstable patient with chest trauma.
• Following pulmonary laceration, a progressive accumulation of air in the pleural cavity
may pressurize the space such that the mediastinum deviates to the contralateral
hemithorax, thereby obstructing venous return to the heart.
• Although easily recognizable on chest x-ray, tension pneumothorax is a clinical diagnosis.
• Without rapid diagnosis and treatment, these early signs are followed by obstructive
shock and subsequent traumatic arrest, usually with pulseless electrical activity.
• As such, chest trauma accompanied by the triad of absent breath sounds, tachycardia,
and hypotension refractory to fluid resuscitation merit immediate decompression.
•

20. • In the field, this may be accomplished with a large-bore angio catheter inserted in the
second intercostal space at the midclavicular line.
• Subsequent ipsilateral tube thoracostomy provides definitive decompression and directs
further
management

23. 2. Pulmonary contusion.
• When the lung parenchyma absorbs force from a penetrating injury, alveolar hemorrhage and tissue
edema may occur, resulting in a pulmonary contusion.
• Respiratory complications typically peak 24 hours post injury and frequently cause difficulty with
oxygenation and ventilation, at times requiring mechanical ventilation.
• Providers must anticipate worsening respiratory function after diagnosing a pulmonary contusion
and closely monitor the patient until the condition improves.

24. C. Heart and Great Vessels
• Major injuries to the heart and great vessels occur in approximately 4% of patients with penetrating
chest injuries and are associated with a high mortality rate.
• These injuries are rarely encountered as part of a trauma activation, as over 80% of these patients
expire in the field.
• Overall, gunshot wounds to the heart are more universally fatal, with an overall mortality of greater
than 90%.
• In contrast, stab wounds to the heart are said to carry an overall 67% mortality

25. 1. Pathophysiology of cardiac trauma.
• Penetrating cardiac injury is associated with anterior chest trauma between the midclavicular
lines, though it may occur outside of these anatomical landmarks.
• The right ventricle is the most commonly injured chamber due to its anterior position in the
chest cavity, followed by the left ventricle.
• Atrial injuries are both less common and less severe, though they contribute to a higher
overall mortality when involved in a multichamber injury.
• Penetrating cardiac injuries can cause obstructive or hemorrhagic shock.
• Due to the poor compliance of the pericardium, a sudden accumulation of as little as 50 mL of
blood may cause tamponade physiology.
• Beck’s triad is the classic presentation of acute pericardial tamponade, consisting of
hypotension, diminished heart sounds, and distended neck veins.

27. 2. Diagnosis.
• In the hemodynamically stable patient with suspicion for an occult penetrating cardiac injury,
transesophageal echocardiography is the diagnostic modality of choice.
• However, many of these injuries can be more readily identified with transthoracic echocardiography.
• The presence of pericardial fluid on echocardiography warrants emergent operative exploration.
• Another diagnostic and potentially therapeutic modality is emergent subxiphoid pericardial
exploration.
• The diaphragm is exposed via a subxiphoid approach and incised longitudinally to expose the
pericardium.
• A 1-cm longitudinal pericardial incision is then made under direct vision.
• The presence of straw-colored fluid within the pericardium constitutes a negative examination.
• Blood within the pericardium mandates prompt exploration for definitive repair.

28. 3. Treatment.
• In hemodynamically unstable patients with suspected penetrating injury to the mediastinum, the preferred
operative approach is via median sternotomy, which provides access to the proximal aorta, superior vena cava,
right subclavian, innominate and carotid arteries, and heart.
• If injury to the left subclavian artery is identified or suspected, a supraclavicular extension (“trapdoor”) of the
median sternotomy is often required.
• Atrial and ventricular cardiac wounds are repaired using monofilament sutures (cardiorrhaphy).
• Wounds adjacent to major branches of the coronary circulation require horizontal mattress sutures placed
beneath the artery.
• Distal coronary artery branches may be ligated.
• Patients in extremis may require resuscitative thoracotomy.

33. D. Diaphragm
• Injuries to the diaphragm may be difficult to diagnose.
• Up to 31% of patients may demonstrate no abdominal tenderness and 40% may have normal chest
radiographs.
• Among all asymptomatic patients with penetrating chest injuries, the risk of occult diaphragm injury
is reported to be 7%.
• When left unrepaired, diaphragmatic injury is associated with a high risk of bowel herniation.

35. • Penetrating diaphragmatic injuries are usually discovered on operative exploration of the
chest and abdomen
• Chest Radiograph may demonstrate the presence of abdominal viscera which may need
operative exploration
• In patient who have no need of laparotomy video assisted thoracoscopy or cautious
laparoscopy conducted to avoid tension pneumothorax
• Closure is performed with a single layer of non absorbable suture incorporating large full
thickness bites of healthy diagrammatic tissue.
• A peripheral detachment of the diaphragm from the wall of the torso can be repaired by
reinserting the injured tissue one or two interspace superior.

36. E. Aerodigestive System
• Injury to the tracheobronchial tree and the esophagus are more common in the setting of
penetrating than blunt trauma.
• Given the close proximity of these structures, penetrating wounds involving the tracheobronchial
tree are associated with concurrent esophageal and major vascular injuries in approximately 30% of
cases.
• Patients with an airway injury may present with hypoxia, inability to ventilate, hemoptysis, and/or
subcutaneous emphysema.
• Chest x-ray can reveal disruption of the tracheobronchial tree, subcutaneous emphysema,
pneumomediastinum, or air and fluid in the pleural space.

37. 1. If a tracheobronchial injury is suspected, control of the unstable airway is first priority.
• If possible, intubation should be done over a flexible bronchoscope
• Once the airway is stabilized, the tracheobronchial tree should be evaluated for injury via
bronchoscopy.
• The operative approach is dictated by the location of the injury.
• Upper tracheal injuries require a median sternotomy.

38. • Distal tracheal or right bronchial injuries are repaired via a right thoracotomy.
• Left bronchial injuries mandate a left thoracotomy.
• Many penetrating injuries can be debrided and repaired primarily.
• Tracheal defects involving up to two rings can usually be approximated after adequate
mobilization.
• Transections resulting from blunt injuries usually require debridement of the
tracheobronchial segment with anastomosis.

39. 2. Traumatic esophageal injury is associated with a very high mortality rate and requires
prompt attention
• Esophagoscopy is the diagnostic modality of choice
• Esophagography using oral contrast is often used in hemodynamically stable patients with
suspected esophageal injury.
• As in the case of tracheobronchial injuries, the operative approach for esophageal
injuries is determined by the level of injury.

40. • A right thoracotomy provides excellent exposure for most thoracic esophageal injuries
• A left thoracotomy is recommended for distal esophageal injuries.
• In the unstable patient injury exclusion and esophageal diversion may be necessary;
primary
repair, however, should be undertaken whenever possible.
• Primary repair is done using an absorbable synthetic suture and can be buttresses with a
vascularized flap (i.e., pleural or pericardial) or fundoplication in the case of distal injuries.
• Drain placement and gastric decompression are highly recommended.
• Esophageal resection is avoided at all cost, as this is associated with a high rate of
morbidity and mortality.

41. II. BLUNT THORACIC INJURIES
• Blunt thoracic injury directly accounts for 20% to 25% of deaths resulting from trauma
• Over 70% of these injuries are the result of motor vehicle collisions (MVCs).
• Blunt thoracic injuries are identified in 40% to 50% of all unrestrained drivers following MVC
• Patients who present following a blunt trauma injury should promptly undergo ATLS with specific
focus on the ABCs.
• Chest x-ray is the first diagnostic tool used to evaluate the injured thorax in the trauma bay and
serves to direct management

42. A.Chest Wall Injuries
• The chest wall is injured in 70% of blunt trauma to the chest, ranging from a soft tissue
contusion to severe injuries that limit ventilation.
• Rib fractures are among the most common chest wall injuries and may cause acute
respiratory failure, particularly in the elderly.
• Flail chest is one particularly severe injury that occurs when a portion of the rib cage fractures
under extreme force and becomes detached from adjacent ribs; this requires fracture of at
least three adjacent ribs in at least two places, which may be seen as paradoxical movement
of the affected portion of chest wall during inspiration.

44. • Underlying pulmonary contusion is extremely common in patients with flail chest and
contributes to respiratory failure.
• Occasionally, operative repair of the flail segment is required to liberate patients from
supplemental oxygen or mechanical ventilation.

45. • Open reduction and internal fixation of rib fractures is being increasingly used following
significant chest wall trauma.
• Other bony structures of the thoracic cage that may be injured following blunt trauma
include the sternum, clavicles, and scapulae, all of which may require surgical repair.
• Occasionally, a chest wall hematoma may develop can usually be managed
conservatively, though these may occasionally warrant decompression and/or
angioembolization.

46. B. Lung Injuries.
• As in penetrating injuries to the chest, pneumothorax and/or hemothorax may be
seen following blunt thoracic trauma.
• In this setting, hemopneumothorax is usually secondary to broken ribs.
• Rarely, acutely increased intrathoracic pressure can lead to bleb rupture and
pneumothorax in patients with pre-existing emphysematous disease.
• The treatment for hemopneumothorax caused by blunt trauma is the same as
that caused by penetrating trauma, with similar late complications as well.

47. C. Blunt Cardiac Injury (BCI)
• The heart is injured in roughly 7% of blunt thoracic trauma.
• BCI accounts for up to 20% of deaths from MVC.
• Clinician to be concerned for BCI include mid anterior chest pain or tenderness, sternal fracture, a
mechanism of major blunt force directly to the chest, and ongoing signs or symptoms of cardiac
pathology.

48. 1. Diagnosis.
The right side of the heart (right ventricle and atrium) is injured more frequently in blunt
trauma.
• Following routine chest x-ray, the first diagnostic test that should be performed to evaluate
a patient for BCI is an electrocardiogram (EKG).
• New arrhythmia, bundle branch block, ST changes, and even unexplained tachycardia
should prompt further investigation with continued cardiac monitoring and
echocardiography.
• The Eastern Association for the Surgery of Trauma (EAST) guidelines now recommend
that
troponin I be measured routinely for all patients with a suspected BCI

49. 2. Classification.
• The American Association for the Surgery of Trauma
(AAST) grades cardiac injuries I to VI with grade VI injuries being the most severe.
• Myocardial contusion is the most common category of injury, commonly resulting in
echocardiography changes and/or elevation in cardiac enzymes.
• Pericardial injury may occur as well as a result of a sudden high energy impact to the
chest or an increase in intraabdominal pressure.
• Rupture of the pericardium can result in cardiac evisceration and torsion of the great
vessels, causing life-threatening obstructive shock.

50. • Valvular injuries (most commonly the aortic and mitral) are rare, but may lead to
cardiogenic shock or acute pulmonary edema.
• Survivors will present to the ED in obstructive shock from cardiac tamponade or
hypovolemic shock.

55. • Rx-Arrythmias resolve spontaneously in most case and need no medical treatment.
• Cardiogenic shock require treatment with inotropic support and right ventricular afterload
reduction.
• Some patient who demonstrate structural abnormalities on echocardiography may require urgent
operation to repair cardiac injuries, such as valvular failure.

56. D. Blunt Traumatic Aortic Injury (BTAI)
• Blunt injury to the aorta is the second most common cause of traumatic death, with the
majority of patients dying before even reaching the hospital.
• Among those that reach the hospital alive, 50% will die within the following 24 hours.
• While many of these injuries can be definitively treated in a delayed fashion, a rapid
diagnosis of those that warrant immediate intervention is required to ensure patient
survival.

57. 1. Diagnosis.
• BTAI occurs in the setting of severe acceleration/deceleration forces.
• Widened mediastinum on chest x-ray, bright red blood return from the thoracostomy tube, or
hemodynamic instability should raise suspicion for aortic injury.
• CT angiography should be done, when concern for a BTAI exists; this study carries a nearly 100%
sensitivity for diagnosing BTAI.
• The area of injury is most commonly at the level of the left subclavian artery takeoff, where the
aorta is fixed at the ligamentum arteriosum.

58. 2. Treatment
• Immediate repair was traditionally considered the gold standard in order to maintain distal
perfusion and decrease the risk of rupture.
• However, studies over the last two decades have shown that delayed repair of BTAI with
strict blood pressure control results in decreased mortality and paraplegia.
• It is thought that patients who survive long enough to make it to the trauma bay are likely
suffering from a partial-thickness tear which can be temporized by preventing
hypertension and overresuscitation.
• Endovascular repair using a stent graft is the treatment of choice.

59. III. PROCEDURES
• A. VATS is a minimally invasive method of operating within the thoracic cavity.
Indications.
• Any patient with a retained hemothorax or pneumothorax after a well-placed thoracostomy tube is likely to
benefit from VATS.
• Other indications include persistent air leak, posttraumatic emphysema, intrapulmonary abscess, foreign
body removal, or diagnostic purposes.
• Evidence suggests that VATS is most beneficial when done in the first 3 to 7 days.
• It should be noted that any patient with active bleeding, hemodynamic instability, or massive bleeding
(>1,500 mL of blood immediately or 200 mL/hr for 2 to 3 hours) after placing a thoracostomy tube should
receive an urgent thoracotomy in the operating room rather than VATS.

61. 2. Technique.
• The surgical technique is similar to laparoscopic surgery of the abdomen.
• One or more port sites are created in the chest wall, preferably using a previously established
thoracostomy tube track, and operations in the thoracic cavity are conducted with the aid of a
camera.
• The thoracic cavity should be thoroughly inspected for the presence of injuries missed on prior
imaging.
• Upon completion of the operation, a thoracostomy tube is placed under thoracoscopic guidance to
optimize postoperative drainage of the pleural place.

62. 3. Complications.
• Injury to the thoracic organs, namely the lung, can occur during VATS, resulting in additional
bleeding or postoperative air leak.

63. B. Resuscitative Thoracotomy.
• Resuscitative thoracotomy is performed in a final attempt to salvage a certain subset of patients
presenting in extremis to the emergency department.
• The goals are to control intrathoracic hemorrhage, relieve cardiac tamponade, cross-clamp the
thoracic aorta, and restore cardiac output.
• AIM-To open the pericardium to relieve cardiac tamponade,to perform internal cardiac
massage,to cross clamp the distal thoracic aorta and to manage intrathoracic bleeding.

65. 1. Indications.
The current indication includes any patient with penetrating chest trauma and hemodynamic
deterioration (systolic blood pressure <60 mm Hg) or cardiopulmonary arrest occurring within the
emergency department or shortly before arrival.
• In addition, it can be used to gain access to the descending aorta for cross-clamp in certain cases
of penetrating abdominal trauma fulfilling the same criteria.

67. 2. Technique.
• Resuscitative thoracotomy is performed via a left anterolateral thoracotomy in the fifth or sixth
intercostal space.
• The skin, subcutaneous tissues, and intercostal muscles are sharply divided.
• A Finochietto retractor is placed to spread the ribs and aid in exposure.
• First, the pericardium is identified and incised vertically and anterior to the phrenic nerve.
• Any clot or debris is removed from around the heart.
• The heart is then inspected for injury, and if identified, repaired as previously described.
• After cardiorrhaphy, air is evacuated from the heart by needle aspiration and the adequacy of
cardiac filling is assessed to determine intravascular volume status.

68. • In the absence of associated pulmonary vascular or great-vessel injury,
vigorous volume resuscitation is undertaken.
• If peripheral vascular access is insufficient, direct infusion into the right atrium can be
performed.
• During volume resuscitation, open cardiac massage can be employed to provide
adequate circulation.
• In severely hypovolemic patients, the descending thoracic aorta may be exposed
and cross-clamped to maintain coronary and cerebral perfusion.
• The aorta should also be clamped if any intra-abdominal hemorrhage is
suspected.
• After a successful resuscitation the patient should be transported to the operating room
for definitive repair and wound closure.

69. 3. Complications.
• Complications of resuscitative thoracotomy are many including
• Lung laceration
• Transection of the phrenic nerve while performing pericardiotomy.
• Injury to the coronary vessels during cardiorrhaphy.
• Esophageal trauma while clamping the descending thoracic aorta.
Given that this procedure is most commonly performed in a patient population at high risk of carrying
blood-borne disease, the risk to the trauma team is not insubstantial and must be considered.

70. CONCLUSION
• Injury to the chest and its contents represents a significant portion of traumatic injuries
and deaths.
• Attention to mechanism of injury and a high index of suspicion for life-threatening thoracic
injuries is crucial when caring for the traumatically injured patient.
• While the majority of thoracic trauma can be managed expectantly or with a thoracostomy
tube, certain injuries are immediately life-threatening and require an early, accurate
diagnosis and intervention.

71. • THANK YOU