Thoracic injuries can cause serious complications by compromising the airway, ventilation, and circulation. Key threats include tension pneumothorax, massive hemothorax, and cardiac tamponade. Proper assessment is important to identify these life-threatening injuries through primary and secondary surveys using inspection, auscultation, palpation, and adjuncts like ultrasound. Early interventions such as needle decompression, chest tube insertion, and surgery can help manage injuries and prevent further deterioration.

1. Thoracic Injuries
Moderator: Dr. Shamila Ali

2. Intro
• Thoracic trauma - TRAUMA
• Treated by intervention (needle/finger/tube)
• Serious complications:-
- Hypoxia
- Hypercarbia
- Acidosis

3. Anatomy
Source: https://www.anatomynote.com/

4. Pathophysiology
• Causes:
- Compromise of airway patency
- Ventilation mechanic failure
- Circulatory failure

5. Airway and Ventilation
• Direct tissue damage
- Tracheobronchial disruption and lung
contusion
• Altered Ventilation mechanics of breathing
- Hemo/pneumothorax, flail chest
-> rapid intrapleural pressure ->obstructive
shock
-> if leaks to mediastinum causes
pneumomediastinum.
-> if subcutaneous tissue -> s/c emphysema

6. Circulation (Shock)
• Bleeding
-> hemothorax – intrathoracic vessel/parenchymal
injury -> hypovolemic shock
• Pump failure ( myocardial injury)
-> cardiac contussion
• Obstructive Shock ( decreased venous return)
-> tension pneumo and cardiac tamponade
-> intrathoracic/intra-pericardial pressure
-> venous return and ventricular distolic filling
Obstructive SHOCK

7. Assestment
• PRIMARY SURVEY (ATOM TC- in your head)
A-B-C
A - Airway & C – Spine control
Look - Inspection
Listen - Hearing
Feel - palpation
- Rigid cervical collar / head immobilizer

8. B – Breathing
- Proper exposure of neck and chest
Inspection
-> RR, breathing depth and pattern, chest wall
movements( paradoxical )
-> external injuries
-> usage of accessory muscles

9. Palpation
-> trachea central? Deviation ? (tension)
-> rib fractures
-> s/c emphysema
Percussion
->dullness(hemo-T)/hyperresonance (pneumo–T)

10. Auscultation
-> breathing sound – equal ?
Chest spring – (cause further harm)
Single hand palpation

11. Early intervention – as required
• High concentration O2
• BVM ventilation , SPo2 monitoring
• Secure airway
• Finger thoraco/needle thoraco
• 3-sided occlusive dressing
• Chest tube

12. Circulation and haemorrhage control
-> massive hemothorax/cardiac tamponade
Assest:-
-> external source
-> pulse – volume, rate, regularity, paradox.
-> CRT, Skin colour, temperature of skin,
-> jugular vein
-> BP and PR

13. Management
Stop the bleeder – direct pressure
IV ascess – Large bore (2) , safe O/GXM
Warm Crystalloid/blood product
Massive hemothorax- chest tube
Cardiac tamponade – pericardiocentesis
* Surg Team early involvement

14. Adjuncts
• ECG
• ABG
• Spo2 monitoring
• ETCo2 monitoring
• E-FAST – Lung point/ Sliding Sign/Pericardial
Fluid
• X-ray – Chest – What to look for?
(loss of lung marking, intrapleural fluid, widening
mediastinum, rib fracture, s/c emphysema, ETT
placement, shift of midline)

15. 2ndary Survey
• Reexamine head to toe – look for missed
injuries – esp on chest region.
• Intervention as required
• Adjuncts
-> Ct Scans?angiography
Bronchoscopy

16. ATOM - TC
• AIRWAY OBSTRUCTION
• TENSION PNEUMOTHORAX
• OPEN PNEUMOTHORAX
• MASSIVE HEMOTHORAX
• TRACHEOBRONCHIAL TREE INJURY
• CARDIAC TAMPONADE

17. AIRWAY OBSTRUCTION
• Mechanism:-
-> laryngeal injury
-> Post. Dislocation of clavicular head
-> Penetrating Trauma to Neck
-> Edema/Blood/Vomitus/floppy tongue

18. • L: ICS, supraclavicular & Accesory muscle retraction /
FB in oropharynx
• L: Stridor, Air movement over nose, mouth and lung
field
• F: crepitus over Ant. Neck, Deformity in
sternoclavicular joint region
• Remove the obstruction - finger sweep,
jaw thrust, Suction, OPA,LMA, ETT
- Reduction of Post. Dislocation of head of clavicle by
shoulder extension

19. Tension Pneumothoraax
Definition:
Immediate life threatening condition from a
‘1 way valve air leak’ occurring from either lung
or the chest wall.

20. Pathophysio

21. • 1 way valve air leak
• Air is trapped within pleural cavity
• Compressing the lungs
• Causes displacement of mediastinum
• Leads to raised intrapleural/intrathoracic
pressure, kinking of great vessels
• Reduction of venous return , reduced CO,
-> Obstructive shock

23. Diagnosis
• Always CLINICAL !!!
- Distended neck veins
- Asymmetrical chest
wall movmnts
- Cyanosis (late)
- Unilateral
absence/reduced
breathing sound
- Trachea shift
- Hyperresonance
- Hypotension
- Tachycardia
- Crepitus
- E-FAST: -ve sliding sign ,
+ve barcode sign,
absence lung pulse

24. Treatment
• Principle : decompression – converting tension
pneumoT to simple pneumoT
1) Needle thoracocentesis
- 2nd Ics, midclav line VS Safety Triangle( 5th ICS ,
ant to mid axillary line)
2) Finger Thoracostomy
- Safety Triangle
- Mandatory chest tube
3) Chest Tube with under water seal

25. Open Pneumothorax
• Definition: large open chest wall defect
creating a direct communication btwn pleural
space and atmosphere, resulting in collapse of
the lungs.
• If opening is 2/3 size of trachea
crossectionally, then air will flow thru the
chest wall defect. (Sucking chest wound)

26. Pathophysio

27. Diagnosis
• Open chest wound
• Respi distress
• Nisy air movement over chest wall
• Decreased breathing sound of affected side
• Hyper resonance
• Crepitus, tenderness

28. Treatment
• 3 way secure occlusive dressing ( temporary)
-> Disable air entry toward pleural space during
inspiration.
• Chest tube and seal the opening – dressing –
seal 4 ways or repair surgically.

29. Massive Hemothorax
Defination:
1) Rapid accumulation of > 1.5 L of blood
(initially) or more than 1/3 of patients total
Blood volume in the thoracic intra pleural space
chest cavity.
2) Continuous blood loss of 200 ml/hr for 2-4 hrs

31. Pathophysio
• Penetrating
injury
• Blunt injury
• Injury to
intercostal
vessel, internal
mammary
artery
• Thoracic spine
fractures

32. Diagnosis
• Bruises/laceration/contusion to chest wall
• Distended neck vein – early
-> displacement of mediastinum due to massive hemothorax
• Collapsed Neck vein
-> severe hypovolemia – shock
• Reduced chest wall expansion
• Respi distress
• Decreased Spo2
• Decreased breathing sound
• Dullness
• Tachycardia, Hypotension, Shock
• EFAST: collection in lungs, +ve spine sign, -ve curtain sign

33. Treatment
Principle: Hemostatic resus and Thoracic decompression
• Activate MTP
• GXM – emergency cross match / Safe O/Tranexamic acid
• Chest Tube
• Get Primary( Surg) Team involved Early
• Indication for urgent thoracotomy
-> > 1.5L of blood drain in chest tube
-> continuous bleeding of 200 ml/ hr for 2-4 hrs
-> penetrating injury to region of mediastinal box, possibility
of cardiac, major vessel and hilar structural injury.

34. Tracheobronchial Tree injury
Definition: Injury to trachea of major bronchus
- Within 1 inches from carina
- High mortality rate. Mostly don’t make it.

35. Pathophysio
• Blunt trauma
-> Potential shearing injuries occurring at
junction where fixed structure meets relative
mobile segment. ( Point of attachment )
- Areas near the cricoid cartilage and carina are
fixed to the thyroid cartilage and
the pericardium.

36. 2) Blast injury - causes severe injury at air fluid
interface – alveoli
3) Penetrating Trauma
- Direct laceration, tear or transfer of kinetic
injury with cavitation

37. When to suspect?
• Hemoptysis
• Respi distress
• S/c Emphysema over neck
• Tension pneumothorax
• Persistent pneumothorax despite on chest tube
• Continuous chest tube bubbling and multiple
chest tube required
Diagnostic -> Bronchoscopy

38. Treatment
• Definitive airway needed.
- > get Surgical and ENT / Anest team early
- > Fiberoptic intubation to intubate unaffected
bronchus
- Surgery

39. Cardiac tamponade
Definition: accumulation of fluid within the
pericardial sac -> increased intrapericardial
pressure -> reduced venous return due to
compromise of Right Ventricular Diastolic and
inflow function -> Reduced CO. ( Obstructive
Shock)
- 150 mls can cause cardiac tamponade

40. Mechanism
• Penetrating injury
• Blunt Injury

41. Diagnosis
• Beck Triad : Muffled Heart sound,
hypotension, Distended JV
• PEA
• Adjunct: E-FAST: echo for accurate diagnosis
-> collection over pericardium
-> collapsed RV during diastolic
-> distended IVC

42. Treatment
Pericardiocentesis
- To relieve the tamponade
Approaches
1) Subxiphoid ( Blind)
The needle insertion site is between the
xiphisternum and left costal margin. Once
beneath the cartilage cage, lower the needle to
a 15-to-30-degree angle, with the abdominal
wall directed towards the left shoulder.

43. Parasternal
Insertion site is in the fifth left intercostal space
close to the sternal margin. Advance the needle
perpendicular to the skin (at the level of the cardiac
notch of the left lung). Avoid the internal mammary
artery.
Apical
Needle insertion site is 1-2 cm lateral to the apex
beat within the fifth, sixth or seventh intercostal
space. Advance the needle over the superior border
of the rib to avoid intercostal nerves and vessels.

44. • Emergency Thoracotomy or sternotomy in OT

45. Flail Chest & pulmonary contusion
Definition: 3 or more adjacent rib fracture in at
least 2 or more places.
This causes ribs being separated and paradoxical
movements during inspiration.
-> flail segment moves inwards and during exp,
moves outwards.

46. Pulmonary contusion is the bruising of the lung
causing accumulation of blood/fluids – leading
to inadequate oxygenation, ventilation and V/Q
mismatch.
-> commonly associated with rib fracture

51. Diagnosis
Paradoxical movement of flail segment
Inadequate respiratory effort – due to pain
Tenderness and crepitation on palpation
Adjunct: CXR – rib fracture, lung contusion,
hemo/pneumothorax

52. Management
• Analgesia : Iv morphine, PCA/regional block
• Oxygenation Supplement
• Ventilation – Non invasive / Intubation
• w/o hypoxia, co2 retention, reduced breathing
effort

53. Esophageal injury
Def: Injury to the Esophagus
-> Mechanism
1) Penerating – common
2) Blunt – rare
- Forceful expulsion of gastric content into
esophagus – produced linear tear and leaking
into mediastinum. – causing mediastinitis

55. Diagnosis
• Pain and shock that is out of porportion to
other obvious injuries
• Presence of left pneumo/hemothorax without
clear evidence of rib fracture – drainage may
have gastric content.
• Pneumomediastinum
• S/c Emphysema

56. Management
• Drainage of the effected pulmonary
intrapleural space
• Opearative Repair - Surg

57. Traumatic Diaphragmatic Injury (TDR)
• More common to the left side
• Suspected when Bowel shadow seen in
thoracic cavity on CXR
Mechanism
-> Blunt – may produce large tears
-> Penetrating – Small perforation that maybe
Asymtomatic

58. Adjuncts:-
1) CXR:
Subpulmonic effusion
Loculated Hemopneuthorax
Elevated diaphragm
Acute gastric dilatation
NGT visualised in thoracic cavity
2) CT scan
3) Upper GI contrast Study

61. Definitive treatment is surgery.
Complications:
Pulmonary compromise
Strangulation or entrapment of peritoneal
contents

62. • Why Finger thoracocentesis prefered than
needle thoracocentesis?
- The latter is a blind procedure
- Success rate influenced by chest wall thickness
- Risk of iatrogenic injuries – pneumothorax or
injury to lung tissue in cases of wrongly
diagnose of clinical tension pneumothorax.

63. Finger and tUbe thoracostomy
• Indication:-
-> rapid thoracic decompression in tension
pneumothorax
-> Actual/near traumatic cardiac arrest
-> shocked state with no apparent cause in
trauma patient

64. Safety Triange
• Ant border: Lateral
boerfer of
pectoralis major
muscle
• Lateral brder: Mid
axillary Line
• Inferiror border: 5th
ICS

65. Steps
1. Indication for finger thoraco
2. Locate the safety triangle
3. Clean the area with povidone / chlorhexidine
4. Local Analgesia
5. On Sterile gloves
6. Scaplel no 10/11, make a 4cm incision thru
the skin to the superior border of inferior
ribs.

67. 7. Use blunt forceps and dissect thru the muscles
and tissue – non stabbing manner
8. Feel the gift – a gush of air/blood/fluids
9. Remove blunt forceps and insert finger in the
tract and confirm the intrapleural space by
palpation and sweep.
10. Convert to Chest tube , use clamp and guide the
tip of chest tube into the tract , advance to desired
depth and connect to under water seal.
11. Secure the tube with sutures and apply sterile
dressing
12. Post procedure cxr and reassest patient.

68. ENDD………