This document discusses various types of thoracic trauma, including injuries to the chest wall, lungs, heart and great vessels. It describes evaluation and management of specific injuries such as rib fractures, flail chest, pneumothorax and hemothorax. Treatment options include chest tube insertion, ventilation support, epidural analgesia, thoracotomy and thoracoscopy. Complications like pulmonary contusion, hematoma and acute respiratory distress syndrome are also covered. The document provides detailed clinical guidance for treating thoracic trauma injuries.

2. THORACIC TRAUMA
MOHAMMAD VAZIRI
Thoracic Surgeon
Iran University of Medical Sciences
Member of
European Society of Thoracic Surgeons
New York Academy of Sciences
European Society of Medical Oncology
International Association for Study of Lung CA

3. Thoracic Trauma
1-Chest wall
2-Pleura
3-Lung
4-Diaphragm
5-Esophagus
6-Heart
7-Barotrauma and Inhalation Injuries
8-Foreign body
9-Acute Respiratory Distress Syndrome

4. Blunt and Penetrating Injuries of the
Chest Wall, Pleura, and Lungs
INCIDENCE
In persons younger than 40 years of age, traumatic injury is
the most common cause of death.
Thoracic injuries are responsible for about one fourth of
this mortality.
In the military trauma experience, chest injuries are lethal
before the patient receives any sort of medical treatment
facility

5. EVALUATION AND MANAGEMENT
The assessment and treatment prioritization schema
recommended by the Advanced Trauma Life Support
Course of the American College of Surgeons should be
followed for all patients.
The primary survey of all patients considers Airway,
Breathing, and Circulation as the most important features
to be stabilized immediately.

6. EVALUATION AND MANAGEMENT
Identification of symptoms of airway obstruction
Protection against any further injury due to cervical spine
manipulation.
Neck veins are examined for either distention or collapse
Evaluation of the chest wall : rib fractures - flail chest-
crepitus - hyper resonance – dullness - hematoma
Auscultation of breath sounds

7. EVALUATION AND MANAGEMENT
Imaging (after the patient has been stabilized)
Chest radiographies are the most frequently used
modality, followed closely by computed
tomography (CT).

8. INJURIES SUSTAINED AS THE RESULT OF THORACIC
TRAUMA
Traumatic Asphyxia
Results from severe blunt injury >>>
facial and upper chest petechiae - subconjunctival hemorrhages,
cervical cyanosis, neurologic symptoms. Temporary impairment or
loss of vision
Thoracoabdominal compression after deep inspiration against a closed
glottis, which results in venous hypertension in the valveless
cervicofacial venous system.
Treatment is primarily supportive; concurrent injuries should be
excluded.

11. Mediastinal and Subcutaneous Emphysema
Injuries to the tracheobronchial tree, esophagus, and lungs can all lead
to mediastinal emphysema.
Air may dissect back along the bronchi and vessels into the
mediastinum. If the leak is large, air migrates into the subcutaneous
space of the neck, from where it can extend to the face and torso
down to the inguinal ligament and occasionally to the external
genitalia.
Tracheobronchial injury should be suspected when a large amount of
mediastinal air is present.
Decompression incisions in the skin are not indicated.

15. Rib Fractures
In 35% to 40% of thoracic trauma victims >>> the most
common thoracic injury.
The diagnosis is based primarily on clinical findings:
Posttraumatic pleuritic chest pain localized by Palpation
Chest radiographs are largely used to identify associated
intra thoracic injuries.

17. Fractures of One or Two Ribs Unilaterally
Management : identifying any associated injuries and
controlling the chest wall pain that, if left untreated,
leads to splinting of the chest with resultant hypo
ventilation , atelectasis, pneumonia, and respiratory
failure.

18. Rib Fracture Management
Early mobilization, deep inspiratory efforts, and frequent
coughing
Pulmonary physiotherapy,nasotracheal suctioning, and
prompt bronchoscopy should be instituted in patients
unable to clear secretions.
Younger patients with a single rib fracture >>oral
narcotics. those with multiple fractures often require
parenteral narcotics.
The older patient even with less than three fractured ribs, is
best managed with patient-controlled intravenous
analgesia

19. Rib Fracture Management
Alternative methods for controlling pain :
Intercostal nerve blocks, Intrapleural catheter analgesia
Transcutaneous electric nerve stimulation.
Each of these modalities has disadvantages:
First, intercostal nerve blocks require repeated
administration >>> risk for pneumothorax.

20. Rib Fracture Management
Alternative methods for controlling pain - Disadvantages
Second, intrapleural regional analgesia :
Catheter placement carries the risk for pneumothorax –
less effective than epidural analgesia.
Third, transcutaneous electric nerve stimulation :
this method should be limited to controlling pain in a
chronic setting.

21. Use of Epidural Analgesia
results in a lower morbidity and mortality than
the use of parenteral narcotics, particularly in
elderly patients.

22. Fractures of the First and Second Ribs
Indicate the possible existence of additional intrathoracic
injury
Aortography is not needed unless other signs of injury to
the thoracic aorta or great vessels are present
Concomitant injuries to the head (2.3%), abdomen
(33 %), and other structures within the thorax 64%) are
often found in these patients.

24. Multiple or Bilateral Rib Fractures
The prognosis for rib fractures is related to the number of
ribs injured, the patient's age, and the patient's underlying
pulmonary status
Continuous administration of epidural analgesia is
universally useful in patients with severe chest wall
injuries
The mortality rate from isolated rib fractures in the elderly
patients may be as high as 10% to 20%.
Rib fractures in children >> Mortality rate of 5%.

27. Flail Chest
Instability of the chest wall from unilateral or bilateral
multiple rib fractures or from disruptions of the costo
chondral junctions, has been estimated to occur in 5% of
patients with thoracic trauma
The force needed to create a flail chest depends on the
compliance of the ribs; elderly persons may
suffer an unstable chest wall after low-energy impact.
Whereas flail chest occurs in less than 1% of children after
severe thoracic trauma.

28. Flail Chest
Paradoxic chest wall motion leads to a reduction in vital capacity and
along with associated pulmonary contusion, may lead to the
development of adult respiratory distress syndrome (ARDS).
Early documentation of respiratory compromise by frequent
monitoring of respiratory rate, oxygen saturation and arterial blood
gases is crucial.
Objective information obtained from arterial blood gas
determinations is the guide to therapy.

34. Flail Chest - Management
Observation and aggressive Pain management
Endotracheal intubation and ventilator assistance for
patients :
whose respiratory rate is more than 30 breaths per minute,
whose PO2 is less than 60 mm Hg,
or whose Pco2 is more than 45 mm H are indicated.

35. Flail Chest - Management
Patients are given aggressive Pulmonary physiotherapy :
Encouraged to cough deeply – suctioning -
humidification of air - chest percussion - postural
drainage.
Bronchoscopy is used to remove retained secretions and to
expand areas of collapsed lung.
Surgical fixation is a viable option in the management of a
flail chest in an appropriately selected trauma victim.

36. Flail Chest
Mortality rate:11% to 16%.
Associated injuries such as underlying pulmonary
contusion contribute significantly to this mortality rate.
Flail chest injuries may have long-term consequences :
Impaired pulmonary function
Dyspnea - Persistent Pain
Abnormal Spirometry - Abnormal Treadmill Tests
In 50%-70%

37. Sternal Fractures
Occur in about 4% of patients involved in major
motor vehicle crashes.
Older patients and front-seat vehicle occupants are at
greatest risk.
The fracture is typically transverse and is located in the
upper and midportions of the body of the sternum.
Diagnosis can be made on physical examination : localized
tenderness, swelling, and deformity.
Radiographic confirmation of these fractures requires a
lateral view

38. Sternal Fractures
Sternal fractures are frequently associated with other
significant intrathoracic injuries.
Myocardial injury should be considered in the
hemodynamically unstable patient with evidence of anterior
chest wall injury.

39. Sternal Fractures - management
Pain control and appropriate pulmonary hygiene.
Patients with isolated, stable sternal fractures who have normal
radiographic findings and electrocardiograms may be treated as
outpatients.
When the sternal fracture is severely displaced, open reduction
through a midline incision with internal fixation using cross wires
is indicated.
In the rare patient with a flail sternum that is due to disruption of the
costochondral junctions, internal or external fixation has been
advocated to minimize the need for positive-pressure ventilation.

41. Scapular and Clavicular Fractures
Fractures of the scapula are uncommon (they are due
to a severe force of impact)
This results in an 80% to 90% incidence of associated
injuries and 10% mortality rate.
High incidence of concurrent brachial plexus injuries.
Treatment consists of shoulder immobilization with
subsequent early range-of-motion exercises.

42. Clavicular fractures
Are common and often the only injury.
Do not compromise ventilation
Treatment = immobilization of the shoulder with a sling
and analgesia
Only rarely operative repair is necessary for the
management of a severely displaced fracture.
Damage to the underlying subclavian vessels or the
brachial plexus is rare.

52. Open Wounds of the Chest Wall:
Air can freely flow in and out of the pleural space.
The "sucking chest wounds" present as life-threatening
emergencies.
Such wounds are often associated with other devastating
intrathoracic injuries.
Open pneumothorax leads to collapse of the lung
Cover the defect and place a chest tube

53. Minor Penetrating Wounds of the Thorax
Many stab wounds and low-velocity gunshot wounds of the
chest (80% to 85%) result in only minor injury to the
chest wall, pleura, or lung.
Pneumothorax and hemothorax are the major complications
in this group of patients.

54. Pneumothorax
Simple Pneumothorax
Chest tube drainage of posttraumatic
pneumothoraces is recommended, even for small
collections of air, especially in patients who
require positive-pressure ventilation.
When a large air leak is present or reexpansion of
the lung is difficult, a tracheo-bronchial injury
should be suspected, and bronchoscopy should be
performed.

55. Tension Pneumothorax
Severe respiratory distress, distended neck veins, a deviated
trachea, and absent breath sounds on the affected side
Placing a needle into the pleural space to allow pressure in
the pleura to equilibrate with the outside air.
This relieves the compression of the underlying lung as well
as the distortion of vital mediastinal structures( superior
and inferior vena cavae)

56. Tension Pneumothorax
After the pressure has been equilibrated, a chest tube can
then be inserted into the thoracic cavity.
Tension pneumothorax should be suspected in any patient
with chest wall trauma receiving general anesthesia when
sudden cardiopulmonary deterioration is associated
with a marked increase in the required inspiratory
ventilatory pressures.

57. .

62. Is it necessary to insert Chest tubes in patients with
rib fractures and no pneumothorax, to prevent the
possible occurrence of an intraoperative Tension
pneumothorax?
This is not necessary but careful monitoring is
necessary, and one should have a low threshold
for inserting a tube thoracostomy

63. Hemothorax
Requires the use of a large tube thoracostomy.
Bedside ultrasound may be used in the initial evaluation of
the blunt trauma victim to detect traumatic pleural
effusions.
On the initial radiographs obtained with the patient in the
supine position, the detection of a small hemothorax may
be difficult

64. Hemothorax should be evacuated to prevent the
formation of a fibrous peel and to reduce the risk
of empyema.
Video-assisted thoracic surgery (VATS) techniques
to evacuate large retained clotted hemothoraces is
best performed 1 to 3 days after injury to reduce
the rebleeding from the injured lung.

65. Indications for Thoracoscopy in Thoracic Trauma
Persistent minor hemorrhage
Retained hemothorax
Empyema
Chylothorax
Retained foreign bodies
Treatment of persistent air leak

67. Sources for intrathoracic bleeding include :
Intercostal vessels, pulmonary parenchymal injuries, major
pulmonary vessel and injury to the heart or great vessels.
Most pulmonary parenchymal injuries can be managed with
a tube thoracostomy simply by evacuating the
hemothorax and allowing the lung to re-expand.

68. In patients with large chest wall injuries in whom the
bleeding may be diffuse and difficult to localize, ligation
of the intercostal vessels near their origins may be a life-
saving maneuver.
If bleeding from intercostal vessels occurs at the level of the
intervertebral foramen, control may require laminectomy
Packing of the foramen should be avoided because it may
place patients at risk for spinal cord injury and
subsequent paraplegia.

69. Pulmonary Contusion
Consists of hemorrhage into the alveolar and interstitial
spaces
In adults, they are typically associated with other
injuries and have an overall mortality rate of 22% to 30%,
Large contusions lead to hypoxia and the need for
mechanical ventilation.
The increased use of CT scan in in the evaluation of acute
chest trauma has improved the diagnosis.

70. Pulmonary Contusion
Pulmonary contusion should be suspected in any patient
with major chest wall injury
Most clinically significant contusions appear
on the initial chest radiographs and may be difficult to
differentiate from aspirations.

71. Pulmonary contusion versus Aspiration
The first post-trauma chest radiograph of patients suffering from
aspiration may be normal, with the development of an infiltrate
occurring during the next several hours.
Infiltrates that are due to aspiration may be confined by anatomic
pulmonary segments, those associated with pulmonary contusions
outline the area of impact
Aspiration is associated with copious secretions that may contain
particulate matter, whereas contusions may be associated with
bloody secretions.

74. Treatment of patients with pulmonary contusions
Ventilator support, as needed, based on clinical and
laboratory findings.
Associated injuries to the chest wall, pleura, and lungs
should be identified and treated.
Fluid administration should be adequate to resuscitate shock
Oxygen delivery and consumption should be made optimal.

75. Pulmonary Hematoma
May be difficult to differentiate from pulmonary contusion.
24 to 48 hours after injury, a hematoma typically develops
into a discrete mass with distinct margins.
CT scans can be helpful in distinguishing between
contusion and hematoma.
In most cases, the hematoma itself does not interfere with
gas exchange and with time is resorbed
Only rarely hematomas become secondarily
infected and present as an abscess requiring drainage

77. ACUTE INJURIES REQUIRING URGENT
THORACOTOMY
About 85% of the chest trauma victims who arrive
alive at a trauma center can be managed without a
thoracotomy.
The remaining 15% require urgent thoracotomy

78.  Acute Indications for Thoracotomy
Acute deterioration and hemodynamic instability
(blood pressure< 80mm Hg)
Initial chest tube output of 1500mL of blood
(20mL/kg)
Continued bleeding of >200 m/h
Traumatic thoracotomy
Massive air leak
Documented tracheal or bronchial injury
Suspected air embolism

79. Contraindications to Thoracoscopic Surgery in Thoracic Trauma
Hemodynamic instability
Signs of hypovolemic shock
Cardiac arrhythmia
Suspected injuries to the heart or great vessels
Widened mediastinum
Suspicion of major injuries to the trachea or bronchus
Substantial hemorrhage

80. Contraindications to Thoracoscopic Surgery in
Thoracic Trauma
Inability to tolerate one-lung ventilation
Previous injury or surgery
Severe pulmonary contusion
Intercurrent lung disease
Bilateral lung injury
Other emergency conditions requiring major operative
procedures to stabilize the patient
Celiotomy
Craniotomy

81. ED Thoracotomy
At times, an immediate thoracotomy must be done in the
emergency room in an attempt to save the patient's life
This is often successful in patients with penetrating trauma
but rarely so in patients with blunt trauma.
The main maneuvers are control (occlusion) of the hilum of
the injured lung and open cardiac massage as needed
The incision of choice is an antero-lateral thoracotomy

82. Air Embolism
When endo-bronchial pressure exceeds 60 mm Hg in
patients with injured (open) bronchiolar and pulmonary
venules, the gas (air) will readily pass into the pulmonary
venous system and will be transported to the left
ventricle.
As the gas is pumped out into the systemic circulatory
system, air embolism to the coronary arteries, ascending
aorta, and cerebral circulation will occur.

83. In a conscious person, air embolism may lead to abrupt
cardiovascular collapse, seizures, or sudden death.
Treatment consists of:
(a) Occlusion of the hilar structures of the injured lung
(b) Placement of the patient in the Trendelenburg position
(c) Aspiration of air from the apex of the left ventricle and
aorta
(d) Open cardiac massage
(e) Maintenance of adequate blood pressure.

84. Treatment of Air Embolism
1 mL of 1:1000 epinephrine be injected intravenously or placed down
the endotracheal tube to provide an adrenergic effect that is
thought to drive air out of the microcirculation.
With aggressive treatment, 55% of Patients with air embolism from
penetrating trauma and 20% of patients with air embolism from
blunt trauma could be salvaged.

85. Indications for Late Post Traumatic Thoracotomy
Chronic, clotted hemothorax
Chylothorax unresponsive to conservative therapy
Traumatic arterio-venous fistula
Empyema
Missed Tracheo-bronchial injury
Traumatic Tracheo-esophageal fistula

86. Tracheobronchial Injuries
Blunt and penetrating injuries of the cervical portion of
the trachea are more common than intrathoracic portion
of the trachea or of the major bronchi.
Peripheral bronchial injuries are not uncommon with
penetrating thoracic injuries and at times are associated
with major hemoptysis or air embolism.

87. Blunt Intrathoracic Tracheal and Major Bronchial
Injuries
The mechanisms are due to
(a) Rupture of the membranous portion of the trachea as the result of a
rapid increase in intraluminal pressure within the structure caused
by sudden thoracic compression in a patient with a closed glottis.
(b) Disruption at a point of fixation (i.e., the carina) due to the
shearing force as seen with rapid deceleration.
(c) Laceration or complete avulsion as the result of lateral traction on
the lung caused by crushing chest injuries.
80% of blunt traumatic tracheobronchiaJ tears occur within 2.5 cm of
the tracheal carina.

88. Blunt Intrathoracic Tracheal and Major Bronchial Injuries
Incidence
Injury to the trachea or major bronchi was found in 0.03%
in an autopsy study of 1,178 trauma deaths.
In 2,455 patients with chest injuries over a 10-year period
>> an incidence of 0.16%

89. Blunt Intrathoracic Tracheal and Major Bronchial Injuries
Diagnosis
Most of the patients with a tracheobronchial tear present
with a pneumothorax
Subcutaneous emphysema is common as is airway distress.
With the initiation of closed-tube drainage, the air loss
continues to be excessive in amount.
This should alert the clinician to carry out an emergent
bronchoscopic examination.

90. Blunt Intrathoracic Tracheal and Major Bronchial Injuries
Diagnosis
Rarely the "fallen lung sign" (collapse of the lung toward
the lateral chest wall), is detected in CXR
Infrequently, hemothorax or hemoptysis is seen, and either
is indicative of associated vascular injury.
At times the injury may be missed owing to initial
expansion of the lung and discontinuation of the air leak
>> Subsequent atelectasis >> stenosis of the distal
bronchial lumen >> distal intermittent or persistent
infection with associated secondary parenchymal damage

94. Blunt Intrathoracic Tracheal and Major Bronchial Injuries
When complete disruption occurs, it most often results in
total obstruction of the proximal and distal ends of the
divided bronchus.
Excellent ventilatory function can be expected when
bronchial continuity is reestablished within
a few weeks up to 6 months after the injury

95. Treatment
Operative repair should be done as soon as feasible after
the injury
A standard posterolateral thoracotomy is used
A right sided approach is used for repair of the trachea and
the right bronchial tree and when an injury of the
proximal left main stem bronchus is well above the
takeoff of the left upper lobe bronchus and no vascular
injury is suspected.
Other injuries of the left bronchial tree are approached from
the left side.

96. Blunt Intrathoracic Tracheal and Major Bronchial Injuries
Treatment
Anastomosis of a comletely divided bronchus is done
with interrupted sutures of No. 0-3 or 0-4 Vicryl.
The suture line is routinely covered with adjacent tissues or
a pedicled intercostal muscle flap, making sure all
periosteal tissue has been removed because ossification
from retained periosteum can result in late stenosis of the
area

97. Intubation Injuries of the Trachea
Laceration of the membranous wall of the trachea
during intubation
Less than one fourth of these lacerations are recognized
intraoperatively, and most are identified only 1 to 5
hours after the injury had occurred >>> dyspnea,
subcutaneous emphysema, or hemoptysis.

98. Intubation Injuries of the Trachea
Treatment
Membranous tears less than 2 cm in length are managed
conservatively with antibiotic administration and supportive care
The longer tears, especially those that extended into a main
bronchus, are repaired through a right thoracotomy.
Tears confined to trachea can be repaired using a transcervical
transtracheal approach with closure of the membranous laceration
With No. 4-0 polydioxanone continuous suture and the transverse
anterior tracheal incision with interrupted No. 3-0 sutures of the
same material.

99. Primary traumatic bronchial stenosis
Is rare and is the result of a missed bronchial tear or
avulsion .
With the exception of malignant strictures, most stenotic
lesions of the trachea or bronchi are Iatrogenic (i.e.
endotracheal tube dependence, sleeve resections, and
initial repairs of bronchial traumatic injuries).
Postintubation injuries of the trachea are as a rule the most
common.

100. The principal management of such stenotic lesions is
dilation and the placement of a bronchial or tracheal
stent.
Bronchial stents may be rigid silicone stents or flexible
or self-expanding wire stents
Initial endobronchial dilation is essential in the stenting
process.

101. Types of Bronchial Stents
Rigid
Straight-flanged silicone stent (Hood Laboratories)
Dumon endobronchial stent (Bryan Corporation,
Expandable and self-expanding stents (wire stents)
Ultraflex stent (nitinol) (Boston Scientific Corp.,
Gianturco Rosch tandem stent (Wilson Cook Inc.,
Wallstent stent (Boston Scientific)
Microinvasive stent (Boston Scientific)
Palmaz stent (stainless steel) (Cordis/Johnson & Johnson)
Strecker stent (tantalum) (Boston Scientific)
Hybrid stents
Covered expanding prostheses

102. Lung Herniation after Blunt Trauma
Lung hernia was first reported by Roland (1499).
The classification is simple: congenital or acquired.
The acquired hernias are subclassified as spontaneous-
pathologic or traumatic (the latter being the more
common type).
Congenital hernias are most often found in the
supraclavicular space and infrequently at one of the
anterior costochondral junctions or laterally in an
intercostal space owing to the lack of development of an
intercostal muscle.

103. Traumatic Lung Herniation
May occur after non traumatic penetrating injuries such as
surgical incision
Blunt trauma occurring during motor vehicle crashes to
patients with seatbelt >> Sternal fractures/or/
"seatbelt fractures" : another aspect of the "seatbelt
syndrome
The site of the rib fractures is most often along the
costochondrosternal junction

104. The lung herniation may be identified early, or its
identification may be delayed for months to years.
Symptoms are often minimal but the chest wall hernia is
accompanied by a localized soft bulge that changes its
shape paradoxically with the respiratory cycle.
The actual hernia may not vary much in size because of
incarceration of a portion of the lung within the hernial
sac.
The diagnosis may be made by standard radiographs or CT
examination

109. Lung Herniation
Repair of these hernias consists of reduction of the lung
back into the pleura space and closure of the defect with
a Prosthesis such as polytetrafluoroethylene mesh or a
Gore-Tex patch
At times, the chest wall opening may be closed by simple
suture approximation of the edges of the defect

110. Postsurgical lung hernias:
Harvesting of the left internal mammary artery
Minimally invasive direct coronary artery bypass grafting.
Post-thoracoscopic chest wall defect after a VATS
procedure.
Pleuroscopy and chest tube drainage of a localized
empyema.

111. Spontaneous Lung Herniation
Caused by coughing, sneezing, or abnormal body motion.
Occur in the anterior wall as a rule, on either side with
equal frequency and in older persons, and are seen
exclusively in men
Most of the men are smokers, and they present with
anterior chest wall pain and chest wall ecchymosis.
Radiographs reveal the fracture site, which is usually in
the lower rib cage (>93%).

112. FOREIGN BODY PULMONARY EMBOLUS
On rare occasion as the result of a gunshot wound of the
abdomen or of an extremity, a bullet or metal fragment
gains entrance into a major vein and is carried to the
right ventricle.
With changes in the position of the body, the object may
embolize into one of the pulmonary arteries
The foreign body should be removed, but this is not of
emergent priority.

113. FOREIGN BODY PULMONARY EMBOLUS
When the patient is placed in the appropriate lateral decubitus
position and the involved pulmonary artery explored, the foreign
body was no longer present in the exposed, uppermost pulmonary
artery.
The object had been dislodged by gravity and had fallen into the
pulmonary artery in the opposite dependent hemithorax.
To prevent such an untoward event, the patient must be operated on
in the supine position with the opposite hemithorax maintained at a
higher level than the hemithorax with the involved pulmonary
embolus.

114. FOREIGN BODY PULMONARY EMBOLUS
Once the patient is in the appropriate position a radiograph must be
obtained to determine whether the foreign body is still in the
pulmonary artery that is to be explored.
These foreign bodies can now be removed by intraluminal
manipulation by experienced invasive cardiologists or radiologists,
and an open operation is required only infrequently.
Small metallic foreign bodies located in the pulmonary parenchyma
generally need not be removed.