This document summarizes various types of thoracic trauma. It discusses chest injuries such as rib fractures, flail chest, pneumothorax, hemothorax, and cardiac injuries including myocardial contusion and cardiac tamponade. It provides details on signs, symptoms, and management of each condition. Thoracic trauma can range from minor rib fractures to life-threatening injuries like aortic rupture or cardiac tamponade and requires prompt evaluation and treatment.

1. Thoracic Trauma
Dr Shankar Hippargi
A & E Consultant
MMHRC
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2. Chest Trauma
 Second leading cause of deaths due to
trauma
 About 20% of all trauma deaths
 About 80% of thoracic traumas do not
need surgery
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3. Chest Trauma
 Initial examination directed towards
identification and treatment of:
• Tension pneumothorax
• Cardiac tamponade
• Open pneumothorax
• Flail chest
• Massive hemothorax
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4. Rib Fracture
 Most common chest injury
 More common in adults than children
 Especially common in elderly
 Ribs form rings- Consider possibility of
break at two places
 30% - 40% rib #s missed on CXR
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5. Rib Fracture
 Most commonly 5th to 9th ribs
 Poorly protected
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6. Rib Fracture
 Fractures of 1st, 2nd ribs require great force
 Frequently have injury to aorta, subclavian
artery / vein or bronchi
 Look for swelling in supraclavicular fossa
 Compare the radial pulses, urgent intervention
needed if unequal / absent
 30% of the patients will die
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7. Rib Fracture
 Fractures of 7th to 12th ribs can damage
underlying abdominal solid organs:
• Liver
• Spleen
• Kidneys
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8. Rib Fracture
 Management
• High concentration O2
• Adequate pain relief
• Encourage patient to breath deeply
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9. Rib Fracture
Management
• Monitor elderly and COPD patients carefully
o Broken ribs can cause decompensation.
o Patients will fail to breath deeply and cough,
resulting in poor clearance of secretions.
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10. Flail Chest
 Three or more adjacent ribs broken at
two or more places
 Produces free-floating chest wall
segment (Flail segment)
 Secondary to blunt trauma
 More common in older patients
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11. 11

12. Paradoxical respiration
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13. Flail Chest
 Signs and Symptoms
• Paradoxical movement
oMay NOT be present initially due to
intercostal muscle spasms
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14. Flail Chest
 Consequences
• The major complication is respiratory failure
due to the underlying lung contusion
• Increased work of breathing (exhaustion)
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15. Flail Chest
 Management
• Establish airway, breathing & circulation
• Suspect spinal injuries
• Stabilize chest wall
• Pain relief
• IV fluids
Consider early intubation and ventilation
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16. 16

17. Simple Pneumothorax
 Air in pleural space
 Partial or complete lung collapse
occurs
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18. Simple Pneumothorax
Causes
• Chest wall penetration
• Fractured rib lacerating lung
• May occur spontaneously following:
o Exertion
o Coughing
o Air Travel
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19. Simple pneumothorax
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20. Simple Pneumothorax
 Signs and Symptoms
• Pain on inhalation
• Difficulty breathing
• Tachypnea
• Decreased or absent breath sounds
• Hyper resonant to percussion
Severity of symptoms depends on size of
pneumothorax, speed of lung collapse,
and patient’s health status
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21. Simple Pneumothorax
 Management
• Establish ABC
• Suspect spinal injury based on mechanism
• High concentration O2 with NRB
• Assist decreased or rapid respirations with
BVM
• Monitor for tension pneumothorax
• ICD depending on patient’s condition & amount
of air in pleural cavity
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22. Intercostal drainage
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23. Open Pneumothorax
 Hole in chest wall
 Allows air to enter pleural space
 Larger hole = Greater chance of air
entering through it
 Frothy blood at wound site
“Sucking Chest Wound”
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24. 24

25. 25

26. Open Pneumothorax
 Management
• Close hole with 3 way occlusive dressing
• High concentration O2
• Assist ventilations
• Watch for tension pneumothorax
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27. 27

28. Sealing all the 4 sides may cause
tension pneumothorax if an ICD is not in
place 28

29. Tension Pneumothorax
 One-way valve forms in lung or
chest
wall
 Air enters pleural space; cannot
leave
 Air is trapped in pleural space
 Pressure rises
 Pressure collapses lung
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30. Tension Pneumothorax
 Trapped air pushes heart, lungs
away from injured side
 Venacava become kinked
 Blood cannot return to heart
 Cardiac output falls
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32. 32

33. 33

34. Tension Pneumothorax
Signs and Symptoms
• Extreme dyspnea
• Restlessness, anxiety, agitation
• Absent breath sounds
• Hyper resonance to percussion
• Cyanosis
• Subcutaneous emphysema
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35. Tension Pneumothorax
Signs and Symptoms
• Rapid, weak pulse
• Decreased BP
• Tracheal shifts away from injured side
• Jugular vein distension
Early dyspnea/hypoxia - Late shock
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36. Tension Pneumothorax
Management
• Secure airway
• High concentration O2 with NRB
• Needle decompression (temporary measure)
• Pain relief
• ICD (definitive treatment)
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37. Needle decompression
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38. Subcutaneous emphysema
 Can be due to rib fracture, injury to lungs
or airway
 Can extend to neck, face, abdomen, and
upper limbs
 May require ICD if source is in lungs.
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40. Hemothorax
 Blood in pleura space
 Most common result of major chest wall
trauma
 Present in 70 to 80% of penetrating,
major non-penetrating chest trauma
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42. Hemothorax
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43. Hemothorax
 Signs and Symptoms
• Rapid, weak pulse
• Dyspnea
• Cool, clammy skin
• Restlessness, anxiety
• Hypotension
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44. Hemothorax
 Signs and Symptoms
• Decreased breath sounds
• Dullness to percussion
• Ventilatory failure
Shock precedes respiratory
failure
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45. Hemothorax
 Management
• Secure airway
• Assist breathing with high
concentration O 2
• Aggressive fluid resuscitation
• Transfuse blood as soon as possible
• ICD insertion
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46. Indications for thoracotomy
 Thoracotomy is indicated if there is
>1500ml blood loss or <1500 ml with
continuous loss > 200ml/hr
 Penetrating anterior wound medial to
nipple line or posterior wound medial to
scapula may need thoracotomy due to
damage to great vessels, hilar structures
or heart
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47. Traumatic Asphyxia
 Blunt force to chest causes
• Increased intrathoracic pressure
• Backward flow of blood out of heart into
vessels of upper chest, neck, head
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48. Traumatic Asphyxia
 Signs and Symptoms
• Possible sternal fracture or central flail
chest
• Shock
• Purplish-red discoloration of:
o Head
o Neck
o Shoulders
• Protruding eyes
• Swollen, cyanotic lips
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49. Traumatic Asphyxia
Name given because
patients look like they had
been strangled or hanged
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50. Traumatic Asphyxia
 Management
• Airway with C-spine control
• Assist ventilations with high
concentration O 2
• IV fluids
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51. Do not forget the underlying
structures
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52. Cardiovascular Trauma
Any patient with significant
blunt or penetrating trauma to
chest has heart / great vessel
injury until proven otherwise.
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53. Myocardial Contusion
 Bruise of heart muscle
 Most common blunt cardiac injury
 Usually due to steering wheel
impact
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54. Myocardial Contusion
 Behaves like acute MI
• May produce arrhythmias
• May cause cardiogenic shock,
hypotension
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55. Myocardial Contusion
 Signs and Symptoms
• Cardiac arrhythmias after blunt chest
trauma
• Angina-like pain unresponsive to
nitroglycerin
• Chest pain independent of respiratory
movement
Suspect in all blunt chest trauma
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56. Myocardial Contusion
 Management
• High concentration O 2
• Cardiac monitoring
• Consider ACLS intercept
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57. Cardiac Tamponade
 Rapid accumulation of blood / air in
space between heart & pericardium
 Heart compressed
 Blood entering heart decreases
 Cardiac output falls
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58. Cardiac Tamponade
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59. Cardiac Tamponade
 Signs and Symptoms
• Hypotension unresponsive to treatment
• Increased central venous pressure
(distended neck/arm veins in presence of
decreased arterial BP)
• Muffled heart sounds
Beck’s Triad
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60. Cardiac Tamponade
 Signs and Symptoms
• Narrowing pulse pressure
• Pulsus paradoxicus
• Radial pulse becomes weak or disappears
when patient inhales
• ECG shows low amplitude complexes
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61. Cardiac Tamponade
 Management
• Secure airway
• High concentration O2
• IV fluids
• Definitive treatment is pericardiocentesis
followed by surgery
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62. Penetrating injury
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63. Penetrating chest injuries
 Never try to remove penetrating foreign
objects from the wound.
 May cause severe uncontrollable
bleeding, tension pneumothorax, cardiac
tamponade and sudden death.
 Maintain ABCs in ED
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64. Treatment
 Should be shifted to OT immediately and
object removed under direct vision in a
controlled environment.
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65. Other thoracic injuries
 Aortic rupture
 Esophageal rupture
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66. Aortic rupture
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67. Associated Abdominal Trauma
 Diaphragm forms dome that extends up
into rib cage - Diaphragmatic rupture
 Trauma to chest below 4th rib indicates
abdominal injury until proven otherwise
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68. Diaphragmatic rupture
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69. Questions ? ? ?
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