Thoracic trauma can result from blunt or penetrating injuries and often involves rib fractures, pneumothorax, hemothorax, or injuries to the heart or lungs. Assessment focuses on life-threatening injuries like tension pneumothorax, massive hemothorax, or pericardial tamponade. Management priorities are airway control, oxygen therapy, needle decompression for tension pneumothorax, chest tube insertion for pneumothorax or hemothorax, and rapid transport to a trauma center.

1. Thoracic Trauma
Prepared by : PS
Created by groups: 09DCEM2- 2018
 University of Health Sciences(UHS)

2. .Objectif
After learning you will be know about:
• Anatomy and physiopathology of thoracic
• Identify Common Mechanisms for Thoracic Trauma
• How to examination, assessment and treatment patients with
thoracic trauma

3. Introduction
• 25% of motor vehicle crash deaths are related to thoracic trauma
• Approximately 16,000 deaths annually in US
• Second only to brain and spinal cord injuries as the leading cause of
traumatic death
• Motor vehicle crashes and interpersonal violence are the two main
causes of thoracic trauma
• Most thoracic traumas will also involve the abdominal cavity

4. Thoracic Trauma Anatomical Injuries Thoracic
Cage (Skeletal)
• Cardiovascular
• Pleural and Pulmonary
• Mediastinal
• Diaphragmatic
• Esophageal
• Penetrating Cardiac

5. Mechanism of Thoracic Trauma
• Acceleration and Deceleration forces
• First and second rib fractures can severely injure the pulmonary and cardiac
tissues underneath
• Falls
• Crush Injuries
• Violence
• Motor Vehicle Crashes

6. Pathophysiology of Thoracic Trauma
Blunt Trauma
Results from kinetic energy forces
Subdivision Mechanisms
Blast
-Pressure wave causes tissue disruption
-Tear blood vessels & disrupt alveolar tissue
-Disruption of tracheobronchial tree
-Traumatic diaphragm rupture
Crush (Compression)
-Body is compressed between an object and a hard surface
-Direct injury of chest wall and internal structures
Deceleration
-Body in motion strikes a fixed object
-Blunt trauma to chest wall
-Internal structures
Age Factors
-Pediatric Thorax: More cartilage = Absorbs forces
-Geriatric Thorax: Calcification & osteoporosis = More fractures

7. Pathophysiology of Thoracic Trauma
Penetrating Trauma
Low Energy
-Arrows, knives, handguns
-Injury caused by direct contact and cavitation
High Energy
-Military, hunting rifles & high powered hand guns
-Extensive injury due to high pressure cavitation
-Missile or Shotgun

8. Assessment General of Thoracic Injuries
Initial exam directed toward life-threatening: Assessment finding:
Injuries -Mental status(decreased)
-Open pneumothorax -Pulse (absent, tachy or brady)
-Flail chest -Blood pressure
-Tension pneumothorax -Ventilatory rate & effort(tachy-or bradypnea)
-Massive hemothorax -Skin(pallor, cyanosis, open injurie, ecchy-)
-Cardiac tamponade -Neck( TC, JVD, open injury…)
Conditions -Chest(contusion, tenderness, asymmetry,
-Apnea absent or decreased lung sounds, impale
-Respiratory distress chest, OI, AP, Crepitus)
-Heart sounds(muffled, distant, RM).

9. Ribs Fracture
• Most common chest wall injury from direct trauma
• More common in adults than children
• Especially common in elderly
• Ribs form rings
-Possibility of break in two places
• Most commonly 5th - 9th ribs
-Poor protection
• Fractures of 1st and 2nd second require high force
-Frequently have injury to aorta or bronchi
-Occur in 90% of patients with tracheo-bronchial rupture
-May injure subclavian artery/vein
-May result in pneumothorax
• 30% will die

10. Ribs Fracture
• Fractures of 10 to 12th ribs can cause damage to underlying
abdominal solid organs:
• Liver
• Spleen
• Kidneys

11. Ribs Fracture
Assessment Findings
• Localized pain, tenderness
• Increases on palpation or when patient:
• Coughs
• Moves
• Breathes deeply
• “Splinted” Respirations
• Instability in chest wall, Crepitus
• Deformity and discoloration
• Associated pneumothorax or hemothorax

12. Ribs Fracture
Management
• High concentration O2
• Positive pressure ventilation as needed
• Splint using pillow or swathes
• Encourage patient to breath deeply
-Helps prevent atelectasis
• Non-circumferential splinting
• Monitor elderly and COPD patients closely
-Broken ribs can cause decompensation
-Patients will fail to breathe deeply and cough, resulting in poor clearance of
secretions
• Usually Non-Emergent to Transport

13. Flail Chest
Two or more adjacent ribs fractured in two or more places producing a
free floating segment of the chest wall.
Usually secondary to blunt trauma
• Most commonly in MVC
• Also results from
-falls from heights
-industrial accidents
-assault
-birth trauma
More common in older patients
Mortality rates 20-40% due to associated injuries

14. Flail Chest
Consequences of flail chest
Contusion of lung
-decreased lung compliance
-intra alveolar-capillary hemorrhage
Decreased ventilation
-Hypercapnea
-Hypoxia
• Pain, decreased chest expansion
-leading decreased ventilation

15. Flail Chest
Assessment Findings
-Chest wall contusion
-Respiratory distress
-Pleuritic chest pain
-Splinting of affected side
-Crepitus
-Tachypnea, Tachycardia
-Paradoxical movement (possible)

16. Flail Chest
Management
• Suspect spinal injuries
• Establish airway
• High concentration oxygen
• Assist ventilation with BVM
-Treat hypoxia from underlying contusion
-Promote full lung expansion
• Mechanically stabilize chest wall
• IV of LR/NS
-Avoid rapid replacement in hemodynamically stable patient
-Contused lung cannot handle fluid load
• Consider need for advanced airway placement

17. Simple Pneumothorax
Pathophysiology
• Air enters pleural space causing partial lung collapse
-small tears self-seal
-larger tears may progress
• Usually well-tolerated in the young & healthy
• Severe compromise can occur in the elderly or patients with
pulmonary disease
• Degree of distress depends on amount and speed of collapse

18. Simple Pneumothorax
Assessment Findings
• Tachypnea, Tachycardia
• Difficulty breathing or respiratory distress
• Pleuritic pain
-may be referred to shoulder or arm on affected side
• Decreased or absent breath sounds
-patients with multiple ribs fractures may splint injured side by
not breathing deeply

19. Simple Pneumothorax
Management
• Establish airway
• High concentration O2 with Non-rebreather mask(NRM)
• Assist with Bag Valve Mask(BVM)
• IV of LR/NS
• Monitor for progression
• Request Advanced Cardiovascular Life Support (ACLS) responsible
• Usually Non-emergent transport

20. Open Pneumothorax
•Hole in chest wall that allows air to enter pleural space.
•The larger the hole, the more likely air will enter there than through
the trachea.
•If the trauma patient does not ventilate well with an open airway,
look for a hole
-May be subtle
-Abrasion with deep punctures

21. Open Pneumothorax
Pathophysiology
• Result of penetrating trauma
• Profound hypoventilation may occur
• Allows communication between pleural space and atmosphere
• Patients development of negative intrapleural pressure
• Results in uni- or bilateral lung collapse
• inability to ventilate affected lung
• Pressure may increase within pleural space
• Leading to hypoxia and hypercarbia

22. Open Pneumothorax
Assessment Findings
• Opening in the chest wall
• Sucking sound on inhalation
• Tachycardia
• Tachypnea
• Respiratory distress
• Subcutaneous Emphysema
• Decreased lung sounds on affected side

23. Open Pneumothorax
Management
-Cover chest opening with occlusive dressing
-High concentration O2
-Assist with positive pressure ventilations prn
-Monitor for progression to tension pneumothorax
-IV with LR/NS
-Emergent Transport
-Trauma Center…

24. Tension Pneumothorax
• Incidence
-Penetrating Trauma
-Blunt Trauma
• Morbidity/Mortality
-Severe hypoventilation
-Immediate life-threat if not managed early

25. Tension Pneumothorax
Pathophysiology
• Air enters pleural space,
but cannot leave(one-way
valve)
-Air is trapped in pleural
space
• Pressure collapses lung on
affected side
• Mediastinal shift to
contralateral side
Reduction in cardiac
output
-Increased intrathoracic
pressure
-deformed vena cava
reducing preload

26. Tension Pneumothorax
Assessment Findings : Most Likely
Severe dyspnea  extreme resp distress
Restlessness, anxiety, agitation
Decreased/absent breath sounds
Hyperresonance to percussion
Cyanosis (late)

27. Tension Pneumothorax
• Management
• Recognize early
• Establish airway
• High concentration O2
• Positive pressure ventilations BVM
• Consider need for advanced airway placement
-immediate perform needle to decompression
• IV of LR/NS
Trauma Center preferred.

28. Hemothorax
Pathophysiology
• Blood in the pleural space
• Most common result of major trauma to the chest wall
• Present in 70 - 80% of penetrating and major non-penetrating trauma cases
• Associated with pneumothorax
• Rib fractures are frequent cause
• Life-threatening often requiring chest tube and/or surgery
• If assoc. with great vessel or cardiac injury
-50% die immediately
-25% live five to ten minutes
-25% may live 30 minutes or longer
• Blood loss results in
-Hypovolemia
-Decreased ventilation of affected lung
• Accumulated blood can eventually produce a tension hemothorax
• Shifting the mediastinum producing

29. Hemothorax
• Assessment Findings
• Tachypnea or respiratory distress
• Shock
• Rapid, weak pulse
• Hypotension
• Restlessness, anxiety
• Cool, pale, clammy skin
• Chest pain
• Decreased lung sounds
• Dullness on percussion.

30. Diaphragmatic Rupture
• Usually due to blunt trauma but may occur with penetrating trauma
• Usually life-threatening
• Likely to be associated with other severe injuries

31. Diaphragmatic Rupture
Pathophysiology
• Compression to abdomen resulting in increased intra-abdominal
pressure
-abdominal contents rupture through diaphragm into chest
-bowel obstruction and strangulation
-restriction of lung expansion
-mediastinal shift
• 90% occur on left side due to protection of right side by liver

32. Diaphragmatic Rupture
• Assessment Findings
• Decreased breath sounds
-Usually unilateral
-Dullness to percussion
• Dyspnea or Respiratory Distress
• Scaphoid Abdomen (hollow appearance)
• Usually difficult to hear bowel sounds

33. Diaphragmatic Rupture
Management
• Establish airway
• Assist ventilations with high concentration O2
• IV of LR
• Request ACLS Response
• Surgery
• Avoid
-Trendelenburg position

34. Pericardial Tamponade
• Incidence
-Usually associated with penetrating trauma
-Rare in blunt trauma
-Occurs in < 2% of chest trauma
-GSW wounds have higher mortality than stab wounds
-Lower mortality rate if isolated tamponade

35. Pericardial Tamponade
Pathophysiology
-Space normally filled with 30-50 ml of straw-colored fluid
-lubrication
-lymphatic discharge
-immunologic protection for the heart
-Rapid accumulation of blood in the inelastic pericardium
-Heart is compressed decreasing blood entering heart
.Decreased diastolic expansion and filling
.Hindered venous return (preload)

36. -Myocardial perfusion decreased due to
.pressure effects on walls of heart
.decreased diastolic pressures
-Ischemic dysfunction may result in
injury
-Removal of as little as 20 ml of blood
may drastically improve cardiac output

37. Pericardial Tamponade
Signs and Symptoms
-Beck’s Triad
.Hypotension
.Increased jugular venous pressure
.Diminished heart sounds
-Radial pulse becomes weak or disappears when patient inhales
-Increased intrathoracic pressure on inhalation causes blood to be
trapped in lungs temporarily

38. Pericardial Tamponade
Management
-Augment venous return
-Raise patient’s leg (if possible)
-Rapid IV fluid infusion
-Pericardiocentesis
-If urgent, thoracotomy in OR can be effective
Note: Pericardiocentesis should be considered only if expertise not
available and patient is dying

39. Conclusion
• 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