The document discusses various chest conditions including chest trauma, pneumothorax, haemothorax, flail chest, and pericardial tamponade. It describes the classification, clinical features, and management of these conditions. Specifically, it covers tension pneumothorax diagnosis and the need for immediate decompression. It also outlines procedures for inserting and managing chest drains.

1. The THORAX
Common conditions in
Surgical ward
Dr. Nabarun Biswas
(FCPS Surgery)
Registrar
Mymensingh Medical College
Hospital

2. Chest Trauma

3. that threat to life from
chest injury
• Immediately life
threatening (primary
survey)
– Airway obstruction
– Tension pneumothorax
– Pericardial tamponade
– Open pneumothorax
– Flail chest
– Massive haemothorax
Potentially life threatening
(2ndary survey)
Trachio-bronchial injury
Aortic injury
Pulmonary contusion
Oesophageal injury
Myocardial contusion
Diaphragmatic rupture

4. Pneumothorax
Definition
Air accumulation in the pleural space
with secondary lung collapse
• Sources
– Visceral pleura
– Ruptured esophagus
– Chest wall defect
– Gas-forming organisms

5. Classification of Pneumothorax (according to
cause)
• Spontaneous
Primary
Secondary
– COPD
– Infection
– Neoplasm
– Miscellaneous
• Traumatic
– Blunt
– Penetrating
•Iatrogenic
– Inadvertent
– Diagnostic
– Therapeutic

6. Types (communication between airway and
pleural space)
1. Open Pneumothorax
2. Closed Pneumothorax
3. Tension Pneumothorax

7. Tension Pneumothorax
Def: Tension pneumothorax develops
when a “One – way valve” air leak
occurs either from the lung or
through the chest wall.
• Air is sucked into thoracic cavity
without any means of escape,
completely collapsing then
compressing the affected lung

8. Tension Pneumothorax
• Patho-physiology
–Mediastinum displaced to opposite site
–Affected lung is collapsed
–Diaphragm is flattened
–⇩venous return
–Compressing opposite lung
–Trachea shifted to opposite side

9. Tension Pneumothorax
Causes:
–Penetrating chest trauma
–Blunt chest trauma with lung
parenchymal injury
–Iatrogenic lung puncture
–Mechanical PPV

10. Tension Pneumothorax
Clinical feature:
Panicky
Tachypnoea
Dyspnoea
Distended neck vein
Tracheal deviation
Hyper resonance
Absent breath sound

11. Tension Pneumothorax
Tension
pneumothorax is a
clinical diagnosis
and treatment should
never be delayed by
waiting for
radiology

12. Management:
Immediate decompression , initially by rapid insertion of a
large-bore needle into second intercostal space in the mid
clavicular line of affected site
Then insertion of a chest tube through the angle of safety.

13. Open pneumothorax/ sucking chest wound
• It develops due to a large open defect
in the chest (>3cm), leading to
equilibration between intrathoracic and
atmospheric pressure.

14. Open pneumothorax/ sucking chest wound
• Air accumulates in
pleural cavity rather
than lung 
hypoventilation 
hypoxia

15. Open pneumothorax
Clinical Feature:
H/O penetrating injury & open chest wound
Severe chest pain
Restless
Tachycardia
Hypotension
Dyspnoea

16. Management
• Initially :
3 sided flatter type sterile plastic dressing
• Definitive:
Chest drain tube is inserted remote from injury site.

17. Haemothorax
• Blood in the pleural cavity
• Cause: common cause is blunt chest injury
• Source: common source is internal mammary
artery
• C/F: - haemorrhagic shock
- flat neck vein
- absent breath sound
- dull on percussion

18. Management
• Correction of hypovolaemic shock
• Intercostal drain
• Blood should be remove completely to prevent
future complication like: empyema, fibrothorax.
• Indication for urgent thoracotomy:
- initial drainage of > 1500 ml of blood
- ongoing haemorrhage > 200ml /hr over
3-4 hour

19. Flail Chest
• It is defined as 3 or more ribs fractured in 2 or more places.
• Results from blunt trauma associated with multiple rib #
• Types:
1. Lateral flail
2. Central flail

20. Flail Chest

21. Flail Chest
• Effect:
1.Impairment of chest wall movement
2. Pain
3. lung contusion
• Complication:
– Hypoxia
– Pneumothorax
– haemothorax

22. Flail Chest
• Clinical feature:
– H/O trauma
– Respiratory distress
– Severe chest pain
– Tachycardia
– Hypotension
–Paradoxical movement of chest
wall

23. Flail Chest
• Management: (According to ATLS)
– Oxygen administration
– Adequate analgesic (including Opiates)
– Physiotherapy
– Ventilation – if respiratory failure
– Severe chest injury/ lung contusion - Surgery

24. Stove in chest
When fracture of multiple ribs causes
indentation of a segment of chest wall
without showing any paradoxical
movement is known as STOVE in
Chest

25. Pericardial Tamponade
• Def: Accumulation of a relatively small amount of blood into
the non-distensible pericardial sac which can produce
physiological obstruction of the heart is called pericardial
tamponade.
• Distended neck vein in a shocked patient is a differentiating
point from Pneumothorax

26. Pericardial Tamponade
• All patients with penetrating injury anywhere
near the heart plus shock must be considered
to have a cardiac injury until proven
otherwise.
• Classical presentation:
– venous pressure elevation,
– decline in arterial pressure
– tachycardia, and
– muffled heart sounds

27. Pericardial Tamponade
• Cardiac ultrasound is diagnostic
• Needle pericardiocentesis + rapid volume
resuscitation to increase preload can buy
enough time to move the patient to the
operating room, but complication is high
• The correct immediate treatment of
tamponade is operative (sternotomy or left
thoracotomy)

28. Pleural Diseases

29. Spontaneous pneumothorax
1. Primary spontaneous pneumothorax
2. Secondary spontaneous pneumothorax

30. Primary Spontaneous
Pneumothorax:
• It occurs due to leaks from small blebs,
vesicles or bullae which may become
pedunculated.
• Occurs in young people (mid teen to
late twenties). 75% are male who are tall
& runs in families.
: at the apex of the upper lobe or on
the upper border of the lower or middle
lobes

31. Secondary Spontaneous Pneumothorax
It occurs when visceral pleura leaks as a part of an underlying
disease that involves pleura. Such as:
- Tuberculosis
- Degenerating or cavitating lung
disease
- Necrotizing tumor
- Emphysema
Occurs in older patients

32. Presenting complains:
 Sudden onset of sharp pleuritic chest pain
 Breathlessness
On examination:
Inspection: - Tachypnoea
- Reduced chest wall movement
Palpation:
- Reduced expulsion of lung
Percussion:
-Resonant or hyper-resonant
Auscultation:
-Absent breath sound

33. Indications for surgical
intervention for pneumothorax
• Second ipsilateral pneumothorax
• First contralateral pneumothorax
• Bilateral spontaneous pneumothorax
• Spontaneous haemothorax
• Professions at risk (e.g. pilots, divers)
• Pregnancy

35. Inserting and Managing a Chest Drain
• Underwater seal chest drain is central to the management of
chest disease
• Site:
– anterior to the mid- axillary line;
– above the level of the nipple;
– below and lateral to the pectoralis major muscle.
Fifth space.

36. Chest Drain Inserting Technique

37. Chest Drain Inserting Technique
1. Aseptic precaution
2. Local anaesthesia
3. Skin incision
4. Muscle dissection & creation of oblique tunnel
5. Direction: hemo + pneumo  apex
effusion + empyema  below

38. Chest Drain Inserting Technique

39. Chest Drain Inserting Technique
6. Drain passed through upper
border of lower rib
7. Drain fixed
8. Vertical mattress suture for
future wound closer
9. Connection to under water seal
device
10.Check CXR

40. Chest Drain Inserting Technique

41. Management of chest drain
• Don’t apply suction
• Don’t clamp the drain as it may be forgotten
• Care to be taken the level of the device not to
be above the level of the chest
• A bubbling drain should (almost) never be
clamped
• Remove the drain when it no longer has a
function

42. Removal of the chest drain
• Radio graph is essential before & after removal
• Drain is removed when objective is over and ceased
functioning
• For pneumothorax: no air bubbling, pleural layers are
apposed
• Haemothorax, pyothorax & for pleural effusion : no
collection for 24 hours.

43. Definitive management of pneumothorax
Surgery
 Pleurectomy and
 Pleurodesis
• Performed by
–VATS
–Open thoracotomy

44. Objectives of surgery
• to deal with any leaks from the lung;
• to search for and obliterate any blebs and bullae
(Bullectomy);
• to make the visceral pleura adherent to the parietal pleura so
that any subsequent leaks are contained and the lung cannot
completely collapse