The document discusses various types of thoracic injuries that can result from blunt or penetrating trauma. It describes thoracic aortic disruption, which is a common cause of sudden death after major accidents. Tracheobronchial injuries and blunt myocardial injuries are also addressed. Diagnosis involves imaging like CT scans. Treatment depends on the specific injury but may include endovascular stents, surgery to repair damage, and intensive monitoring. The document provides details on managing various thoracic injuries as well as potential complications.

1. THORACIC AORTIC DISRUPTION
• It is the m/c cause of sudden death after an automobile collision
or fall from great height.
• Clinical features: gross asymmetric systolic blood pressure, wide
pulse pressure and chest wall contusion.
• Chest x rays shows : widening of mediastium.
• Confirmatory diagnosis by CT scan of the mediastium or
Transeosophageal echocardiograohy in unstable patients.
• Initial treatment: control of systolic arterial blood pressure
(<120mmHg)
• Then endovascular intra aortic stent, direct repair, excision and
grafting using a Dacron graft.

3. TRACHEOBRONCHIAL INJURIES
• Severe subcutaneous emphysema
with respiratory compromise can
suggest tracheobronchial disruption.
• Chest drain will reveal a large air leak
and the collapsed lung may fail to
re-expand.
• Bronchoscopy is diagnostic.
• Treatment involves intubation
followed by operative repair.
• Referral to a trauma centre is advised.

4. BLUNT MYOCARDIAL INJURY
• It should be suspected in any patient sustaining blunt trauma
who develops early ECG abnormalities.
• Two dimentional echocardiography may show wall motion
abnormalities.
• Transoesophageal echocardiogram may also be helpful.
• These patients are at high risk of developing sudden
dysarrythmias and should be closely monitored.

5. DIAPHRAGMATIC INJURIES
• Any penetrating injury below the 5th intercostal space.
• Blunt injury to the diaphragm is usually caused by a compressive
force.
• Diaphragmatic rupture is usually large, with herniation of the
abdominal contents into the chest.
• Due to thorax is at negative pressure and abdomen is at positive
pressure.
• Most diaphragmatic injuries are silent and the presenting features
are those of injury to the surrounding organs.

6. • Chest radiography after placement of
a nasogastric tube may be helpful (as
this may show the stomach herniation
into the chest)
• The most accurate evaluation is by
VATS (video assisted thoracoscopy) or
Laparoscopy.
• Operarive repair is recommended in all
cases.
• All penetrating diaphragmatic injury
must be repaired via the abdomen and
not the chest, to rule out penetrating
hollow viscus injury.

7. OESOPHAGEAL INJURIES
• Most oesophageal injuries resulting from penetrating trauma.
• Clinical features: odynophagia, subcutaneous or mediastinal
emphysema, pleural effusion, air in the perioesophageal space.
• Mediastinal and deep cervical emphysema are evidence of an
aerodigestive injury until proven otherwise.
• Oesophagogram in the decubitus position and oesophagoscopy
confirms the diagnosis.
• Treatment is operative repair of any defect and drainage.

9. PULMONARY CONTUSION
• This is most frequently following blunt trauma.
• Usually associated with a flail segment or fracture ribs.
• This is a major cause of hypoxaemia after blunt trauma.
• Following gunshot wounds, there is an area of contusion from the shock
wave of the bullet.
• The natural progression of pulmonary contusion is worsening
hypoxaemia for the first 24-48hrs.
• Haemoptysis or blood in the endotracheal tube is a sign of pulmonary
contusion.
• Contrast CT scanning can be confirmatory.
• In mild contusion treatment is oxygen administration, pulmonary toilet
and adequate analgesia.

11. INVESTIGATIONS
• Chest X-ray shows haemothorax, pneumothorax, fracture ribs.
• eFAST – extended focused assessment with sonar for trauma: looking for cardiac
tamponade or free blood and air in the hemithorax on each side, and assessment for
blood in the abdominal cavity, in the paracolic gutters, subdiaphramatic spaces and
pelvis.
• CT chest
• Hb%, PCV to assess blood loss.
• Blood grouping and cross matching.
• Blood gas analysis, i.e. PO2 and PCO2.
• U/S abdomen to look for associated abdominal injuries.

12. TREATMENT
INITIAL FIRST AID:
• Airway: Prevention of aspiration, intubation, tracheostomy.
• Breathing: ICD placement, supportive measures.
• Circulation: Fluid therapy, CVP line, blood transfusion.
• Look for disability.
• Expose the patient properly for proper breathing and assisting.
• Examine the patient thoroughly.
• Evaluate the patient for associated injuries like of head, abdomen,
fracture limbs, spine.

13. PRINCIPLES OF MANAGEMENT OF CHEST
INJURIES:
• Pulmonary physiotherapy.
• Aspiration of secretions—trachea, nasotracheal, oral, pharyngeal.
• Pain relief—oral narcotics, intercostal nerve block, epidural
anaesthesia.
• Respiratory supports—encourage coughing, chest percussion, deep
inspiration efforts, humidification, mobilisation.
• ICD placement for haemo/pneumothorax.
• Management of shock.
• Focused abdominal sonography on trauma (FAST).
• Surgery when indicated—thoracotomy and proceed.

14. INDICATIONS FOR THORACOTOMY
• Haemothorax more than 1500 ml found when ICD is placed or
hourly collection in ICD is 200-300 ml
• ICD placed shows persistent drainage of blood.
• Diaphragmatic injury
• When associated with liver and spleen injuries
• Bronchus and major vessel injuries.
• Haemopericardium.
• Oesophageal and thoracic duct injuries.

15. COMPLICATIONS:
• Infections—empyema, lung abscess, pneumonia, septicaemia.
• Respiratory failure.
• Traumatic asphyxia.
• Traumatic shock lung.
• Disseminated intravascular coagulation (DIC).
• ARDS (Acute Respiratory Distress Syndrome).

16. • Thank you