1) Chest injuries account for 20-25% of all trauma deaths and are a leading cause of death worldwide. Life-threatening conditions include tension pneumothorax, open pneumothorax, massive hemothorax, flail chest, and cardiac tamponade. 2) Tension pneumothorax requires immediate needle decompression without waiting for imaging if suspected clinically. Open pneumothorax is managed with an occlusive dressing. 3) Flail chest involves fractures of 3 or more ribs in two places, leading to paradoxical chest wall movement and impaired ventilation. Massive hemothorax involves over 1.5L of blood drained by chest tube or more than 200cc/hour

1. RESUSCITATION
& THORACIC
TRAUMA
PRESENTERS: DR UMAR & DR MARYAM
SUPERVISOR: DR FAIZUL

2. OUTLINE
• INTRODUCTION
•LIFE THREATENING THORACIC INJURY
•COMMON CONDITION OF THORACIC INJURY
• TAKE HOME MESSAGES

3. INTRODUCTION
• Trauma causes 100,000 deaths and more than 9 million disability
injury annually in worldwide (6th
leading cause of death).
• Chest injuries are responsible for 20-25% of all trauma death.
• The World Health Ranking 2011 has ranked Malaysia at number 20
with the most deaths caused by road accidents.
• An average of 18 people were killed on Malaysian roads daily.
* Malaysian Institute of Road Safety (MIROS)

4. CLASIFICATION
•Anatomy
• Lungs, pleura and ribs
• Cardiac injury
• Trachea , oesophagus & major vessels
• Diaphragm
•Mechanism of injury
• Blunt
• Penetrating
• Shearing / acceleration-decelaration injury
•Cause / Aetiology
• MVA / trauma
• Fall from height
• Gunshot / sharp or blunt object

5. LIFETHREATENING
CONDITION

6. TENSION
PNEUMOTHORAX

7. TENSION PNEUMOTHORAX
Develops when air leak occurs
from the lung or through chest
wall.
Air is forced into thoracic
cavity without means of
escape
Creating a “one-way valve”.
Affected lung collapsed
Displaced mediastinum to
opposite site
Decrease venous return
Compressing the opposite
lung

8. TENSION PNEUMOTHORAX
SIGNS AND SYMPTOMS

9. TENSION PNEUMOTHORAX
RADIOGRAPHIC FINDINGS
Mediastinal
shift to the
right
TENSION
PNEUMOTHORAX
Tension pneumothorax is a clinical diagnosis.
Treatment should not be delayed to wait for radiologic confirmation.

10. TENSION PNEUMOTHORAX
Management
1. Initial Management: needle thoracostomy
- convert the injury to simple pneumothorax.
2. Definitive management: chest tube insertion
3. Supportive management:
- Analgesia
- Ventilatory support
- CXR monitoring
- Chest phyisotherapy

11. NEEDLE THORACOSTOMY

12. OPEN
PNEUMOTHORAX

13. OPEN PNEUMOTHORAX:
Pathophysiology
• Known as “sucking
chest wound.”
• Air allowed to enter
pleural space from the
outside.
• Ineffective ventilation
because air goes in and
out from the chest
wound, rather than
from trachea.
• Leading to hypoxia and
hypercarbia.

14. Open Pneumothorax
Clinical Findings
•A defect in the chest wall
with air coming in & out
•A sucking sound on
inhalation
•Tachycardia & tachypnea
•Respiratory distress
•Subcutaneous
emphysema
•Decreased breath sounds
on the affected side

15. OPEN PNEUMOTHORAX
MANAGEMENT
1. Initial management:
• 3 sided sterile occlusive
dressing
•Treat concurrent shock
2. Definitive management
•Chest tube insertion

16. 3-sided occlusive dressing

17. FLAIL CHEST
& PULMONARY
CONTUSION

18. FLAIL CHEST
• Described as the
paradoxical movement
of a segment of chest
wall caused by
fractures of 3 or more
ribs in 2 or more
placed.

19. FLAIL CHEST
Severe hypoxia resulting from:
•The underlying lung injury  disturbance of ventilation & perfusion
•Restricted chest wall movement associated with pain  impaired ventilation

20. FLAIL CHEST
Clinical findings
INSPECTION
-Chest wall contusion
-Paradoxical chest wall
movement
-Respiratory distress
Palpation
-Crepitation of rib

21. FLAIL CHEST
Investigation
•CXR : multiple
ribs fracture
•ABG: respiratory
failure with
hypoxia

22. FLAIL CHEST
Management
1. Initial management:
- adequate ventilation
fluid resuscitation
In absence of systemic hypotension, fluid
resuscitation should be carefully controlled to
prevent overhydration.

23. FLAIL CHEST
Management
2. Definitive management
Positive-pressure ventilation may be needed.
•Reverses the mechanism of paradoxical chest wall
movement
•Restores the tidal volume
Adequate analgesic
•Reduces the pain of chest wall movement
Assess for the development of a pneumothorax
•May need chest tube insertion

24. MASSIVE
HEMOTHORAX

25. MASSIVE HEMOTHORAX
Defined as presence of
>1.5 liter
of blood drained from
the pleural space upon
chest tube insertion
or >200cc/hour in first
4 hours.

26. MASSIVE HEMOTHORAX
Clinical Findings

27. MASSIVE HEMOTHORAX
Management
Large caliber IV lines
Crystalloid infusion
Blood transfusion
Chest tube insertion
Consider for thoracotomy

28. MASSIVE HEMOTHORAX
Chest tube insertion

29. MASSIVE HEMOTHORAX
10 days after chest tube insertionOn admission

30. CARDIAC
TAMPONADE

31. CARDIAC TAMPONADE
•Suspect if injury within
the “box”.
•May need prompt
involvement of
cardiothoracic team

32. CARDIAC TAMPONADE
Pathophysiology
•A blunt or penetrating trauma may cause tears
in the myocardial walls, allowing blood to leak
from the heart.
If 150 to 200 mL of blood enters the pericardial
space acutely, pericardial tamponade can develops

33. CARDIAC TAMPONADE

34. CARDIAC TAMPONADE

35. CARDIAC TAMPONADE

36. Cardiac Tamponade
Management
•Airway and ventilation
•Circulation—IV fluid challenge
•Pericardiocentesis
•Prompt involvement of cardiothoracic team.
•Do not take out the penetrating object

37. CARDIAC TAMPONADE
Pericardocentesis

38. OTHER CHEST INJURIES
1. RIB FRACTURE
2. SIMPLE PNEUMOTHORAX
3. HEMOTHORAX
4. PULMONARY CONTUSION
5. TRACHEOBRONCHIAL TREE INJURIES
6. CARDIAC CONTUSION
7. TRAUMATIC MAJOR VESSEL DISRUPTION
8. DIAPHRAGMATIC INJURIES

40. *Hemorrhage should be excluded in all patients who are in shock after major trauma
†Neck vein distention may be absent in patients with hypovolemic shock.

41. GENERAL MANAGEMENT
•Primary & secondary survey
•Serial clinical assessment & SPO2 monitoring
•Adequate analgesia (pain control CPG)
•Oxygen therapy tailored to oxygenation status
•Chest tube insertion
•Intensive & vigorous chest physiotherapy, deep
breathing exercise & incentive spirometry
•Mucolytic & nebulizer
•Early referral to appropriate team (i.e. anaest, CTC)
•± Assisted ventilation or intubation
•± Thoracotomy / thorachoscopy and proceed

42. TAKE HOME MESSAGES
1. Life threatening condition in thoracic injury are
• Tension pneumothorax
• Open pneumothorax
• Massive hemothorax
• Flail chest
• Cardiac temponade.
2. Tension pneumothorax required emergent needle
thoracotomy without waiting for CXR if highly suspected
clinically
3. Do not remove the object causing the penetrating thoracic
injury
4. Open pneumothorax is managed with flutter-valve dressing or
three sided dressing

43. TAKE HOME MESSAGES
5. Flail chest is defined as segmental fractures in 2 or more
places of 3 or more consecutive ribs.
6. Massive hemothorax happen when
• more than 1.5 liters blood drained upon chest tube insertion
• Or more than 200cc/hour in 4 hours
5. All symptomatic traumatic pneumo/hemothorax require chest
tube insertion
6. Cardiac tamponade is recognized by presence of Beck’s Triad
which are
• Muffled heart sound
• Hypotension
• Distended neck veins

44. TAKE HOME MESSAGES
9. Key management in thoracic injury include
• Identifying the life threatening condition
• Resuscitation and oxygen therapy
• Chest tube insertion
• Adequate pain control and aggressive chest physiotherapy
• Ventilation and early associate team referral

45. REFERENCES
• ATLS for Doctors, 8th
Edition
• Bailey & Love Short Practice of Surgery, 25th
Editions
• Emergency Medicine Clinics of North America
- Volume 30, Issue 2 (May 2012)
• SRB’s Manual of Surgery 4th
edition