thoracic injury during trauma is one of most important life threaten that maybe occurred. so all of medical practitioner must learn and must do some primary survey

1. Penetrating Chest Trauma

2. Anatomy of the Chest

3. Specific organ chest injury
• Great Vessels Injury
• Heart Injury
• Trachea and Bronchi Injury
• Lung Parenchyma Injury
• Esophagus Injury
• Chest Wall and Diaphragm Injury

4. History of the Procedure
• One of the earliest writings of
thoracic injury was noted in the
Edwin Smith Surgical Papyrus,
written in 3000 BCE. Galen
reported attempts to treat
gladiators with chest injuries
with open packing.
• Hill performed the first
cardiorrhaphy in the United
States in 1902 and initiated the
modern treatment of the
wounded heart.

6. Problem
• Any penetrating wound below the nipples (front) and the
inferior scapular angles (dorsum) should be considered an
entry point for a course that may have carried into the
abdominal cavity

7. • Low-velocity injuries include
impalement (eg, knife
wounds), which disrupts only
the structures penetrated.
• Medium-velocity injuries
include bullet wounds
characterized by much less
primary tissue destruction than
wounds caused by high-
velocity forces.
• High-velocity injuries include
bullet wounds caused by rifles
and wounds resulting from
military weapons.
Mechanism of injury
The mechanism of injury may be categorized as:

8. • The initial management of seriously injured patients consists
of performing the primary survey (the “ABCs”—Airway with cervical spine
protection, Breathing, and Circulation);
• the goals of the primary survey are to identify and treat conditions that
constitute an immediate threat to life.
• For penetrating thoracic trauma, physical examination, plain
posteroanterior and lateral chest radiographs with metallic markings of
wounds, pericardial ultrasound, and CVP measurement will identify the
majority of injuries.
• Bronchoscopy should be performed to evaluate the trachea in patients
with a persistent air leak from the chest tube or mediastinal air.

9. • As with neck injuries, hemodynamically stable patients with
transmediastinal gunshot wounds should undergo CT scanning to
determine the path of the bullet.
• CT scanning identifies the vascular or visceral structures at risk for injury
and directs angiography or endoscopy as appropriate.
• Therefore, CTA should be performed based on injury proximity to
intrathoracic vasculature.

10. • The most common injuries from penetrating thoracic
trauma are hemothorax and pneumothorax.
• The majority of pulmonary parenchymal injuries are
suspected based upon identification of a pneumothorax.
• the vast majority is managed by tube thoracostomy.

11. • Pneumothorax
• The alveoli can rupture, causing a
pneumothorax
• In traumatic pneumothorax, chest
tube drainage is recommended,
even for small collection of air.
• When large air leak is present or
reexpansion of the lung is
incomplete, a tracheobronchial
injury should be suspected and
prompt flexible bronchoscopy
performed

12. • Very large pneumothoraxes produce tension by shifting the
mediastinal structures toward the contralateral side.
• In these situations, the anatomic distortion combined with the
increase in intrathoracic pressure decreases cardiac output.
• If untreated, this can cause cardiac arrest.
• Immediate release of a tension pneumothorax may be
accomplished by placing a needle into pleural space to allow
pressure in the pleura to equilibrate with the outside air.

13. • Tension pneumothorax should be suspected in any patient with chest wall
trauma receiving general anesthesia who suddenly develops deterioration
associated with a markedly increased requirement o inspiratory ventilator
pressure.

14. • Hemothorax
Sources of intrathoracic bleeding include:
- Intercostal vessels
- Internal mammary arteries
- Pulmonary parenchyma
- Major pulmonary vessels
- Cardiac and great vessels injuries
Intrathoracic bleeding recognized in the emergency
department requires a closed-tube thoracostomy.
Massive hemorrhage defines the need for exploration.
The generally accepted criteria are:
- initial drainage of 1,500 mL at the time of chest tube placement
- continued drainage of 250 mL/hr for next 4 hours.

15. • Residual hemothorax must be evacuated as soon as the patient is
stable to reduce the risk for empyema or prevent the formation of a
fibrous peel(resulting in lung entrapment).
• It is not emergency situation if bleeding has stopped. However,
thoracoscopic drainage is the best perfomed within 1 to 3 days after injury
to reduce the risk for empyema or lung entrapment.

17. • Peripheral lacerations with persistent bleeding can be managed
with stapled wedge resection using a stapler.
• central injuries, the current treatment is pulmonary tractotomy, which
permits selective ligation of individual bronchioles and bleeders, prevents
the development of an intraparenchymal hematoma or air embolism, and
reduces the need for formal lobar resection.
• The injury track is thus filleted open, which allows direct access to the
bleeding vessels and leaking bronchi. The majority of injuries are
definitively managed with selective ligation, and the defect is left open.

18. • Less than 1% of all injured patients sustain intrathoracic tracheobronchial
injuries and penetrating injuries may occur throughout the
tracheobronchial system.
• For patients with a massive air leak requiring emergent exploration, initial
control of the injury to provide effective ventilation is obtained by passing
an endotracheal tube either beyond the injury or into the contralateral
mainstem bronchus.
• For patients with a massive air leak requiring emergent exploration, initial
control of the injury to provide effective ventilation is obtained by passing
an endotracheal tube either beyond the injury or into the contralateral
mainstem bronchus.

19. • Principles of repair are devitalized tissue is
debrided, and primary end-to-end
anastomosis with 3-0 PDS suture is
performed.
• Suture lines should be encircled with
vascularized tissue, either pericardium,
intercostal muscle, or pleura.
• Expectant management is employed for
bronchial injuries that are less than one-
third the circumference of the airway and
have no evidence of a persistent major air
leak
• In patients with peripheral bronchial
injuries, indicated by persistent air leaks
from the chest tube and documented by
endoscopy, bronchoscopically directed
fibrin glue sealing may be useful.

20. • Traumatic cardiac penetration is highly lethal, with case fatality rates of
70-80%.
• Ventricular injuries are more common than atrial injuries, and the right
side is involved more often than the left side.
• The Beck triad (ie, high venous pressure, low arterial pressure, muffled
heart sounds) is documented in only 10-30% of patients who have proven
tamponade.
• Pericardiocentesis can be both diagnostic and therapeutic. This procedure
is reserved for patients with significant hemodynamic compromise
without another likely etiology.
• Echocardiography is a rapid, noninvasive, and accurate test for pericardial
fluid.

21. • The management algorithm is based on the patient's hemodynamic
status, with patients who are in extremis or who are profoundly unstable
benefiting from emergency thoracotomy with ongoing aggressive
resuscitation.
• Stable patients with cardiac wounds may be diagnosed using a subxiphoid
pericardial window.

22. • Over 90% of thoracic great vessel injuries are due to penetrating trauma.
• Simple lacerations of the ascending or transverse aortic arch can be
repaired with lateral aortorrhaphy.
• Repair of posterior injuries, or those requiring interposition grafting of the
arch, require full cardiopulmonary bypass, and repair of complex injuries
may require circulatory arrest.

23. • Innominate artery injuries are repaired using the bypass exclusion
technique, which avoids the need for cardiopulmonary bypass.
• Bypass grafting from the proximal aorta to the distal innominate with a
prosthetic tube graft is performed before the postinjury hematoma is
entered. The PTFE graft is anastomosed end to side from the proximal
undamaged aorta and anastomosed end-to-end to the innominate artery.
• The origin of the innominate is then oversewn at its base to exclude the
pseudoaneurysm or other injury

25. • Subclavian artery injuries can be repaired using lateral arteriorrhaphy or
PTFE graft interposition; due to its multiple branches and tethering of the
artery, end-to-end anastomosis is not advocated if there is a significant
segmental loss.

27. • Descending thoracic aortic injuries may require urgent if not emergent
intervention. However, operative intervention for intracranial or intra-
abdominal hemorrhage or unstable pelvic fractures takes precedence.
• To prevent aortic rupture, pharmacologic therapy with a selective β1
antagonist, esmolol, should be instituted in the trauma bay, with a target
SBP of <100 mm Hg and heart rate of <100/min.
• Endovascular stenting is now the mainstay of treatment, but open
operative reconstruction is warranted, or necessary, in select patients.
• Open repair of the descending aorta is accomplished using partial left
heart bypass.
• In most patients a short PTFE graft (usually 18 mm in diameter) is placed
using a running 3-0 polypropylene suture.

28. • Esophageal injuries often occur
with tracheobronchial injuries,
particularly in cases of penetrating
trauma.
• Operative options are based on
the extent and location of
esophageal injury.
• With sufficient mobilization, a
primary single-layer end-to-end
anastomosis may be performed
after appropriate debridement.

29. • Perforations at the gastroesophageal junction may be treated with repair
and Nissan fundoplication or, for destructive injuries, segmental resection
and gastric pull-up.
• With large destructive injuries or delayed presentation of injuries,
esophageal exclusion with wide drainage, diverting loop esophagostomy,
and placement of a gastrostomy tube should be considered.
As with cervical repairs, if there are
two suture lines in close
approximation (trachea or bronchi
and esophagus) interposition of a
vascularized pedicle is warranted to
prevent fistula formation.

30. • Open Wounds of the Chest Wall
• These injuries, also known as
“sucking chest wounds”, are the
result of full-thickness loss of
portion of the chest wall.
• The injury presents as a life-
threatening emergency.
• The loss of negative intrathoracic
pressure results in an open
pneumothorax leading to collapse
of ipsilateral lung.

31. • A temporary dressing should be applied to have wound at
the scene of accident in an attempt to improve ventilation.
The “three-way dreaaing” involves placing a plastic sheet
taped shut on three sides, leaving the fourth one(at least a
few inches) unsealed, thus creating a one-way valve
dressing.

32. • In the emergency department, a chest tube is placed to reexpand the lung
and the wound is covered with an impermeable dressing..
• Most open wounds require operative debridment with removal of
devitalized tissue and foreign bodies.
• Closure of the wounds may be accomplish by mobilizing the surrounding
tissues.
• However, large defects may require rotational or free musculocutaneous
flaps.

33. • Injured intercostal arteries
• Persistent hemorrhage from a chest
tube after blunt trauma most often is
due to injured intercostal arteries;
• for unusual persistent bleeding,
thoracotomy with direct ligation or
angioembolization may be required to
arrest hemorrhage.

34. • Diaphragmatic Injuries
• Penetrating diaphragmatic injuries are variable in size and location
depending on the agent of injury.
• Penetrating injuries also have high rates of associated injuries, especially
to intra-abdominal viscera, but including a hemothorax or pneumothorax,
as well. Specific intra-abdominal organs typically injured with penetrating
diaphragmatic injury include the upper abdominal organs.
• In general, acute injuries are approached with laparoscopy or laparotomy
because of associated injuries and chronic injuries are approached with
thoracoscopy because of dense adhesions that arise between the
abdominal contents and the lung.

35. • Most injuries require repair with heavy, nonabsorbable sutures

36. • some large tears may require mesh closure

38. • Only a low percentage of trauma patients require an emergency
thoracotomy(EDT)
• Indication for EDT :
– Acute pericardial tamponade unresponsive to cardiac
massage.
– Exsanguinating intrathoracic hemorrhage.
– Need for internal cardiac massage