The document discusses various types of thoracic trauma injuries that can occur. It covers immediately life-threatening injuries like tension pneumothorax, massive haemothorax, and pericardial tamponade that require urgent treatment to control bleeding and decompress the chest. It also discusses potentially life-threatening injuries such as aortic injuries, flail chest, pulmonary contusion, and diaphragmatic injuries that may require procedures like chest drain insertion or surgery if complications occur.

1. THORACIC
TRAUMA
D R . S U N I L K . S . G A U R
S E N I O R R E S I D E N T

2. A.T.L.S.
A DVA N C E D T R A U M A L I F E S U P P O RT

3. INTRODUCTION
• a training program for medical providers in the management of acute trauma
cases
• developed by the American College of Surgeons
• goal is to teach a simplified and standardized approach to trauma patients
• premise of the ATLS program is to treat the greatest threat to life first
• no need of a definitive diagnosis and a detailed history
• with the most time-critical interventions performed early – best utilization of
“golden hour” which lies between life and death after a traumatic event

4. ATLSPROTOCOL
• Scene safety
• Primary survey
– identify and manage the most immediately life-threatening pathologies first
• Resuscitation
• Secondary survey
– detailed head to toe examination

5. PRIMARY SURVEY
• ‘c’ : Exsanguinating external haemorrhage
• A :Airway & cervical spine control
• B : Breathing and ventilation
• C : Circulation and haemorrhage control
• D : Disability (neurological evaluation)
• E : Exposure (assess for other injuries) + environmental control

6. C: EXSANGUINATING EXTERNAL
HAEMORRHAGE
• Controlled immediately by the application of packs and pressure directly onto the bleeding
wound and artery.
• Haemostatic dressings that contain agents that augment local coagulation are now available.
• In case of failure to control bleeding on a limb, application of a tourniquet proximal to the
wound.
• The time at which the tourniquet is applied must be recorded.
• Requires urgent surgical control of the bleeding in order to re-perfuse the limb.

7. A: AIRWAY CONTROL
• General measures
– Suctioning secretions or blood
– Clearing any foreign bodies, dentures
etc.
– Chin lift
– Jaw thrust
• No head tilt to be done in trauma
patients – Why?

8. A: AIRWAY CONTROL (CONTD.)
• Advanced measures
– Oropharyngeal airway devices
– Endotracheal intubation
– Cricothyroidotomy
– Tracheostomy

9. A: CERVICAL
SPINE CONTROL
• Immobilize the patient
• Avoid hyperextension of
neck
• Apply cervical collar
• Can be stabilized manually
by assistant during airway
management

10. B : BREATHING AND VENTILATION
• Expose the chest & assess RR & respiration type.
• Give O2 inhalation
• Check chest wall, lungs & diaphragm by inspection, palpation, percussion & auscultation
• Pulse oximeter
• Look for conditions that impair ventilation
– Tension pneumothorax
– Massive haemothorax
– Flail chest
– Rib fractures
– Open pneumothorax
– Pulmonary contusion

11. THORACIC
TRAUMA

12. INTRODUCTION
• Thoracic injury accounts for 25% of all injuries.
• In a further 25%, it may be a significant contributor to the subsequent death of
the patient.
• In most of these patients, the cause of death is haemorrhage.
• About 80% of patients with chest injury can be managed non-operatively.
• The key is early physiological resuscitation followed by diagnosis.

13. CLINICAL INDICATORS OF BLEEDING
• Physiological
– Increasing respiratory rate
– Increasing pulse rate
– Falling blood pressure
– Rising serum lactate
• Anatomical
– Visible bleeding
– Injury in close proximity to major vessels
– Penetrating injury with a retained weapon

14. INVESTIGATIONS
• Ultrasound – eFAST
– extended Focused Assessment with Sonar forTrauma is becoming the most common investigation.
– The technique uses sonographic assessment in the chest, looking for
• cardiac tamponade
• free blood/air in the hemithorax on each side
– Also assessment for blood in the abdominal cavity, in the paracolic gutters, subdiaphragmatic spaces
and pelvis.
• Underwater chest drain
– In the physiologically grossly unstable patient in respiratory distress, there is no time for radiological
investigations
– Insertion of an underwater chest drainage tube can be a diagnostic procedure as well as a
therapeutic one.

15. INVESTIGATIONS (CONTD.)
• Chest radiograph
– In those cases where the patient is haemodynamically unstable but with acceptable oxygenation, an
anteroposterior (AP) supine chest radiograph is usually the simplest initial investigation,
– Will provide good information regarding
• tracheal deviation
• injury to the lung parenchyma
• mediastinal pathology
• injury to skeletal elements causing pneumothorax, haemothorax or lung contusion.
– The presence of thoracic skeletal injury should alert the clinician to the possibility of adjacent
thoracic or abdominal visceral injury.

16. INVESTIGATIONS (CONTD.)
• Computed tomography scan
– Only indicated in stable patients.
– CT scan with contrast allows for three-dimensional reconstruction of the chest and
abdomen, as well as of the bony skeleton.
– It has become the principal and most reliable examination for major injury in thoracic
trauma.
– Has replaced angiography as the diagnostic modality of choice for the assessment of the
thoracic aorta and mediastinal vessels.

17. ‘DEADLY DOZEN’
IMMEDIATELY LIFE
THREATENING
1. Airway obstruction
2. Tension pneumothorax
3. Pericardial tamponade
4. Open pneumothorax
5. Massive haemothorax
6. Flail chest
POTENTIALLY LIFE
THREATENING
7. Aortic injuries
8. Tracheo-bronchial injuries
9. Myocardial contusion
10. Rupture of diaphragm
11. Oesophageal injuries
12. Pulmonary contusion

18. IMMEDIATELY
LIFE-THREATENING
INJURIES

19. AIRWAY OBSTRUCTION
• Early preventable trauma deaths are often due to lack of or delay in airway control.
• Causes:
– Dentures, teeth, secretions and blood
– Bilateral mandibular fracture,
– Expanding neck haematomas producing deviation of the pharynx and mechanical compression of the
trachea
– Laryngeal trauma such as thyroid or cricoid fractures
– Tracheal injury

20. AIRWAY OBSTRUCTION (CONTD.)
• Management
– Early intubation is very important,
particularly in cases of neck haematoma
or possible airway oedema.
– Airway distortion can be insidious and
progressive and can make delayed
intubation more difficult if not impossible.
– Tracheostomy if required

21. TENSION PNEUMOTHORAX
• Develops when a ‘one-way valve’ air leak
occurs either from the lung or through
the chest wall.
• Collapsing the affected lung.
• Mediastinum displaced to the opposite
side.
• Decreased venous return.
• Compression of the opposite lung.

22. TENSION PNEUMOTHORAX (CONTD.)
• Causes:
– penetrating chest trauma
– blunt chest trauma with parenchymal lung injury
– iatrogenic lung punctures (e.g. due to subclavian central venepuncture) and
– mechanical positive pressure ventilation
• Clinical presentation:
– Dramatic
– The patient is increasingly restless with tachypnoea, dyspnoea and distended neck veins
– Clinical examination may reveal tracheal deviation, hyper-resonance and decreased or absent breath
sounds over the affected hemithorax
– Is a clinical diagnosis and treatment should never be delayed by waiting for radiological confirmation

23. TENSION PNEUMOTHORAX (CONTD.)
• Treatment:
– Needle thoracostomy
• immediate decompression
• by rapid insertion of a large-bore
cannula into the second intercostal
space in the mid-clavicular line of the
affected side.
– Followed by tube thoracostomy
(inter-costal drain)
• insertion of a chest tube through the
fifth intercostal space in the anterior
axillary line.

24. TENSION PNEUMOTHORAX (X-RAY)

25. PERICARDIAL
TAMPONADE
• Accumulation of a relatively small amount of blood into
the non-distensible pericardial sac.
• Compression of the heart and obstruction of the venous
return, leading to decreased filling of the cardiac
chambers during diastole.
• M/C cause penetrating trauma
• All patients with penetrating injury anywhere near the
heart plus shock must be considered to have cardiac
injury until proven otherwise

26. PERICARDIAL
TAMPONADE (CONTD.)
• Clinical presentation
– Classically, Beck’s triad
• decline in arterial pressure
• central venous pressure elevation
• muffled heart sounds
– However, in cases in which major bleeding from other
sites has taken place, the neck veins may be flat.
• Needs to be differentiated from a tension
pneumothorax in the shocked patient with
distended neck veins.

27. PERICARDIAL
TAMPONADE (CONTD.)
• Investigations:
– eFAST
• showing fluid in the pericardial sac.
• This is the most expeditious and reliable diagnostic tool.
– Chest radiograph
• shows an enlarged heart shadow.

28. PERICARDIAL TAMPONADE (CONTD.)
• Treatment
– Operative repair –The correct immediate treatment
• left antero-lateral thoracotomy – preferred
• clamshell thoracotomy (if both hemithorax also to be explored)
• sternotomy
• subxiphoid window
– in the operating theatre if time allows
– otherwise in the emergency room – Emergency Department Thoracotomy

29. PERICARDIAL TAMPONADE (CONTD.)

30. PERICARDIAL
TAMPONADE (CONTD.)
• Treatment (contd.)
– Needle pericardiocentesis
• always under ECG control
• only as a desperate temporary measure in a
transport situation
• high potential for iatrogenic injury to the heart
• “dry tap” does not rule out tamponade

31. OPEN
PNEUMOTHORAX
• aka,‘sucking chest wound’
• due to a large open defect in
the chest (>3 cm)
• negative intra-pleural
pressure is lost

32. OPEN PNEUMOTHORAX (CONTD.)
• Treatment:
– 3-way occlusive dressing
– initial management consists of
promptly closing the defect with a
sterile occlusive plastic dressing,
taped on three sides to act as a
flutter-type valve
– a chest tube is inserted as soon as
possible in a site away from the
injury site.
– definitive management includes
proper cleaning and suturing of
wound

33. MASSIVE
HAEMOTHORAX
• collection of blood in pleural cavity
• causes:
– in blunt injury
• m/c is continuing bleeding from torn
intercostal vessels or
• occasionally from the internal mammary
artery secondary to fractures of the ribs
– in penetrating injury a variety of viscera, both
• thoracic and
• abdominal (with blood leaking through a hole
in the diaphragm from the positive pressure
abdomen into the negative pressure thorax)

34. MASSIVE
HAEMOTHORAX (CONTD.)
• Clinical presentation:
• haemorrhagic shock
• flat neck veins
• unilateral absence of
breath sounds
• dullness to percussion
• dyspnoea and cyanosis –
late.

35. MASSIVE HAEMOTHORAX (CONTD.)

36. MASSIVE HAEMOTHORAX (CONTD.)
• Treatment:
– intercostal drain
– correcting the hypovolemic shock
– urgent thoracotomy
• >1500 mL of blood drained
• ongoing haemorrhage >200 mL/h
over 3–4 hours
– clamping a chest drain to tamponade
a massive haemothorax is not helpful

37. FLAIL CHEST
• three or more ribs fractured in
two or more places
• leads to paradoxical motion of a
chest wall segment
• on inspiration, the loose segment is
displaced inwards and therefore
less air moves into the lungs
• on expiration, the segment moves
outwards

38. FLAIL CHEST (CONTD.)
• diagnosis is made clinically in
patients who are not ventilated,
not by radiography
• observe for paradoxical motion
of a chest wall segment
• high risk of developing a
pneumothorax or haemothorax
• CT scan, with contrast to display the
vascular structures and a 3-D reconstruction
of the chest wall, is the gold standard for
diagnosis of this condition – but rarely
indicated for only this

39. FLAIL CHEST (CONTD.)
• Treatment:
– oxygen administration
– powerful analgesia (including opiates)
– physiotherapy
– if ICD in situ, topical intrapleural local analgesia introduced via the tube
– ventilation is reserved for cases developing respiratory failure despite
adequate analgesia and oxygen
• Traditionally, mechanical ventilation (IPPV) was used to ‘internally splint’ the chest, but had a
price in terms of ICU resources and ventilation-associated morbidity – not recommended now

40. FLAIL CHEST (CONTD.)
• Treatment (contd.):
– surgery to stabilize the flail segment using internal fixation of the ribs may
be useful in a selected group of patients with isolated or severe chest
injury and pulmonary contusion
– strapping of chest wall by adhesive bandages is not recommended now.

41. POTENTIALLY
LIFE-THREATENING
INJURIES

42. THORACIC AORTIC
DISRUPTION
• common cause of sudden death after an automobile
collision or fall from a great height
• fixed distal to the ligamentum arteriosum, shear forces
from a sudden impact disrupt the intima and media
• if the adventitia is intact, the patient may remain
haemodynamically stable
• salvage is frequently possible if aortic rupture is identified
and treated early

43. THORACIC AORTIC
DISRUPTION (CONTD.)
• Clinical features:
– should be suspected in patients with
• gross asymmetry in systolic blood
pressure (between the two upper limbs,
or between upper and lower limbs)
• widened pulse pressure (SBP – DBP)
• chest wall contusion
• sudden deceleration

44. THORACIC AORTIC
DISRUPTION
(CONTD.)
• Investigations:
– erect chest radiography
most commonly shows a
widened mediastinum
– confirmed by a CT scan of
the mediastinum
– transoesophageal
echocardiography, in
unstable patients who
cannot be moved to the
scanner

45. THORACIC AORTIC DISRUPTION
(CONTD.)
• Treatment:
– initially, control of the systolic arterial
blood pressure <120 mmHg
– an endovascular intra-aortic stent can
be placed
– operatively repaired by
• direct repair
• excision and grafting using a Dacron
graft.

46. TRACHEOBRONCHIAL
INJURIES
• severe subcutaneous emphysema with
respiratory compromise
• chest drain placed on the affected side
will reveal a large air leak
• the collapsed lung may fail to re-
expand

47. TRACHEOBRONCHIAL
INJURIES (CONTD.)

48. TRACHEOBRONCHIAL INJURIES
(CONTD.)
• bronchoscopy is diagnostic
• treatment:
– ICD insertion for
pneumothorax
– intubation of the unaffected
bronchus
– operative repair

49. MYOCARDIAL CONTUSION
• should be suspected in any patient sustaining blunt trauma who
develops early ECG abnormalities
• 2-D echocardiography may show wall motion abnormalities
• no role of enzyme estimations in diagnosis
• are at risk of developing sudden dysrhythmias and should be closely
monitored

50. PULMONARY CONTUSION
• very common injury and the major cause of hypoxaemia after blunt
trauma
• causes:
– more frequently following blunt trauma, usually associated with a flail segment or
fractured ribs
– following gunshot wounds, there is an area of contusion from the shock wave of
the bullet
• clinical features:
– worsening hypoxaemia for the first 24–48 hours
– haemoptysis or blood in the endotracheal tube

51. PULMONARY CONTUSION (CONTD.)
• investigations:
– chest radiographic findings may be typically
delayed
– contrast CT scanning is confirmatory
• treatment:
– In mild contusion
• oxygen administration
• pulmonary toilet
• adequate analgesia
– In more severe cases
• mechanical ventilation is necessary
• normovolaemia is critical for adequate
tissue perfusion

52. DIAPHRAGMATIC INJURIES
• any penetrating injury below the 5th ICS should raise suspicion of diaphragmatic and
visceral injury
• blunt injury to the diaphragm is usually caused by a compressive force applied to the
pelvis and abdomen, rupture is usually large, with herniation of the abdominal
contents into the chest
• diagnosis can easily be missed in the acute phase, and may only be discovered at
operation, or through the presentation of complications
• most diaphragmatic injuries are silent and the presenting features are those of injury
to the surrounding organs

53. DIAPHRAGMATIC
INJURIES (CONTD.)
• thorax is at negative pressure and the
abdomen is at positive pressure
• breach of the diaphragm leads to
herniation of abdominal contents into
the chest
• may present much later, and
strangulation of any of the contents
can occur – with a high mortality rate

54. DIAPHRAGMATIC INJURIES (CONTD.)
• Presentation:
– most are silent, presenting features of injury to the surrounding organs
• Investigations:
– no single standard investigation
– chest radiography after placement of a NG tube may be helpful
– contrast studies, CT scan, ultrasound and diagnostic peritoneal lavage all
lack positive or negative predictive value
– most accurate evaluation is by
• video-assisted thoracoscopy (VATS) or
• laparoscopy – allows repair and additional evaluation of the abdominal organs

55. DIAPHRAGMATIC INJURIES (CONTD.)
• Treatment:
– operative repair is
recommended in all cases
– must be repaired via the
abdomen and not the chest, to
rule out penetrating hollow
viscus injury

56. DIAPHRAGMATIC
INJURIES (CONTD.)

57. OESOPHAGEAL INJURY
• most from penetrating trauma
• blunt injury is rare
• Presentation:
– a high index of suspicion is required
– odynophagia (pain on swallowing)
– subcutaneous or mediastinal emphysema
– air in the peri-oesophageal space
– pleural effusion
– unexplained fever
• Mediastinal and deep cervical emphysema are evidence of an
aerodigestive injury until proven otherwise.

58. OESOPHAGEAL INJURY (CONTD.)
• A combination of following confirm the
diagnosis in the great majority of cases
– oesophagogram in the decubitus position
and
– oesophagoscopy
• The treatment is operative repair of any
defect and drainage
• The mortality rate rises exponentially if
treatment is delayed

59. SURGERIES IN
THORACIC
TRAUMA

60. EMERGENCY THORACIC SURGERY
• timely surgical intervention can be the key step in saving an injured
patient’s life
• could be:
– Emergency Department Thoracotomy (EDT)
• urgently done bedside in the emergency room
– Planned emergency thoracotomy
• takes place in the more controlled environment of the operating theatre
• clinical decision as to whether a patient requires ED surgery can be
complex
• far better to perform a thoracotomy in the operating room, with good
light and assistance and the potential for bypass, than it is to attempt
heroic emergency surgery in the resuscitation area

61. EMERGENCY DEPARTMENT
THORACOTOMY (EDT)
• reserved for those patients suffering penetrating injury in whom signs of life
are still present
• EDT is considered futile if:
– CPR in the absence of endotracheal intubation >5 min
– CPR with endotracheal intubation >10 min
– when there have been no signs of life at the scene

62. EMERGENCY DEPARTMENT
THORACOTOMY (CONTD.)
• Aim:
– internal cardiac massage
– control of ongoing severe haemorrhage
– control of massive air leak
– clamping of the thoracic aorta
• to preserve the blood supply to the heart and brain, and cutting off the arterial supply distally,
in a moribund patient with a major distal penetrating injury

63. HOME WORK
• Please watch following two videos on before next slides, as it will be
easier to understand them:-
1. ChestTube ATLS
– https://youtu.be/qR3VcueqBgc
2. The fundamentals of Chest Tube Physiology
– https://youtu.be/1CYAYNJNias

64. TUBE THORACOSTOMY - INTRODUCTION
• aka
– inter-costal drain (ICD)
– chest tube
– tube thoracocentesis
• inserted to provide outlet of
air/fluid from pleural cavity
• always placed in Under
Water-Seal Drainage

65. INTRODUCTION (CONTD.)

66. INDICATIONS
IN TRAUMA
• Pneumothorax
– Simple
– Tension
– Open
• Haemo-pneumothorax
• Haemothorax
• Diaphragm injury
NON-TRAUMA
• Spontaneous pneumothorax
• Subcutaneous emphysema
• Pleural effusion “with respiratory
distress”
• “Recurrent” pleural effusion
• Empyema thoracis
• Chylothorax
WITH OTHER
• With any thoracic
surgery
• Diaphragmatic hernia
repair

67. ANATOMICAL PLACEMENT
• in the 5th intercostal space slightly
anterior to the mid axillary line
• Zone of safety
– recommended by BritishThoracic
Society
– is a region bordered by
• the lateral border of pectoralis major
• a horizontal line inferior to the axilla
• the anterior border of latissimus
dorsi
• a horizontal line superior to the
nipple

68. ANATOMICAL
PLACEMENT (CONTD.)
• inserted just at the upper border of the rib
• Directed
– Medially
– Posteriorly
– Apically – if air
– Downward – if fluid/blood
• Size – Measured in French gauge (Fr)
– Adult – 28-40 Fr
– Children – 16-28 Fr
– Infants – 12-20 Fr

69. MATERIALS REQUIRED
INSTRUMENTS
• Sponge-holding forceps
• BP handle (knife)
• Curved artery forceps – 2
• Needle holder
• Toothed forceps
• Drape sheets (sterile)
CONSUMABLES
• Sterile gloves
• Sterile gauges
• Povidone-iodine solution
• Disposable syringe
• Inj. Lignocaine with adrenaline
• Surgical blade (to fix on BP handle)
• ICD tube
• Under water-seal drain bottle/bag
• Sterile water/saline
• Non-absorbable suture

70. PRE-PROCEDURE PREPARATION
• Obtain informed consent from patient/guardian
• Explain the procedure to the patient in detail
• Establish intra-venous access
• Patient to be placed on oxygen inhalation and continuous Pulse oximetry and ECG monitoring
• Confirm the side on which ICD to be placed by History, Clinical examination and X-ray/CT
• Position the patient
– 45 degree recumbent
– with ipsilateral hand above the head
• Identify anatomical landmarks
• Charge the drain bag/bottle with sterile water

71. PROCEDURE
1. Part painting and draping
– Paint the area of insertion with Povidone-iodine solution (or any other antiseptic) using sponge-
holding forceps
– Cover rest of the surrounding area with sterile drape sheets
2. Anaesthesia
– Local anaesthesia
– Lignocaine with adrenaline infiltrated at the site of insertion, first in skin then deeper, till pleura

72. PROCEDURE (CONTD.)
3. Steps
– a 1-2 cm transverse incision is given on the skin using BP knife
– blunt dissection is done in the subcutaneous and muscle plane using curved
artery forceps and finger
– intercostal muscles also dissected similarly just at the upper border of rib
– confirmed that pleura is reached by inserting finger (will feel as soft
smooth structure)
– if needed further local anaesthetic can be given directly in the pleura
– using the tip of artery forceps in a controlled manner under finger
guidance, pleura is punctured; a gush of air/blood/fluid will confirm this

73. PROCEDURE (CONTD.)
3. Steps (contd.)
– opening is kept occluded with finger
– the external end of ICD tube is
clamped with one artery forceps
– the internal end is grasped in other
artery forceps and inserted via the
incision
– tube is guided medially, posteriorly
and apically/downward as needed

74. PROCEDURE (CONTD.)
3. Steps (contd.)
– external end is connected with
UWSD bag/bottle and unclamped
– evacuation of fluid/bubbles via the
tube and movement of column of fluid
with breathing confirms correct
placement
– the tube is now fixed with non-
absorbable suture using needle holder
and toothed forceps
– dressing is done
– post-procedure x-ray is taken to
confirm position and lung re-
expansion

75. POST-PROCEDURE MONITORING
• continuous oxygen saturation monitoring
• periodic chest examination to look for bilateral movement and air-entry
• periodic examination of ICD to look for:
– output – amount and character (blood, serous, pus, etc.)
– column movement
– persistent air leak
• periodic dressing and examination of drain site for infection and displacement of tube

76. COMPLICATIONS
IMMEDIATE
• bleeding (due to injury of the intercoastal
artery)
• injury of the lung
• diaphragmatic injury and intra-peritoneal
placement
• liver/spleen injury
• subcutaneous emphysema
• injury to the intercostal nerves
DELAYED
• occluded tube – M/C
• leaks
• inadequate drainage
• persistent collection of air/fluid – may
need second tube
• pulmonary edema secondary to lung re-
expansion
• infection (specially pneumonia)

77. THANK
YOU