This document discusses various types of chest trauma, including penetrating and blunt injuries. It covers mechanisms of injury, specific injuries like rib fractures, pneumothorax, hemothorax, flail chest, and cardiac injuries. Management of life-threatening injuries like tension pneumothorax, pericardial tamponade, and tracheal disruptions are outlined. Imaging findings and treatments for many chest trauma injuries are also presented.

1. CHEST TRAUMA

2. Mechanism of Injury
Penetrating Trauma
– Low Energy
• Arrows, knives, handguns
• Injury caused by direct contact
– High Energy
• Military, hunting rifles & high powered hand guns
• Extensive injury due to high pressure

3. • Either:
– direct blow (e.g. rib fracture)
– deceleration injury
– compression injury
• Rib fracture is the most common sign of blunt thoracic
trauma
• Fracture of scapula, sternum, or first rib suggests
massive force of injury
• Age Factors
• Pediatric Thorax: More cartilage = Absorbs forces
• Geriatric Thorax: Calcification & osteoporosis = More fracture
Blunt injuries

4. Injuries Associated with
Cardio Thoracic Vascular Trauma
• Airway obstruction
• Closed pneumothorax
• Open pneumothorax
(sucking chest wound)
• Tension pneumothorax
• Pneumomediastinum
• Hemothorax (massive)
• Hemopneumothorax
• Rib fracture (flail chest)
• Tracheobronchial tree
lacerations (rupture)
• Esophageal lacerations
• Penetrating cardiac injuries
• Pericardial tamponade
• Spinal cord injuries
• Diaphragm trauma
• Intra-abdominal trauma
associated organ injury
• Laceration of vascular
structures (central &
peripheral)

6. Basic management concept
in traumatic patient
Is
ABCDE
Sub Department of Cardio Thoracic & Vascular Surgery
responsible in ABC

7. Airway obstruction
• Clinical finding
– Shortness of breath (dyspnea)
– Stridor
– Apnea
• Management
– Chin lift
– Jaw thrust
– Triple finger manuever
– Evacuate foreign body
– ET insertion
– Cricothyroidostomy
– Tracheostomy

8. Tension Pneumothorax
– Ventile phenomenon
– Build up of air under
pressure in the thorax.
– Excessive pressure
reduces effectiveness
of respiration
– Air is unable to escape
from inside the pleural
space
– Progression of Simple
(closed) or Open
Pneumothorax

9. CXR image

10. • Anx: Progressive shortness of breath
• PE :
– Respiratory distress
– Tracheal deviation (away)
– Absence of breath sound & percusion: hypersonor
– Jugular Vein Distend
– Hypotension
• Treatment :
– Needle thoracocentesis
– Consult : chest tube insertion
Tension Pneumothorax (simplify)

11. Needle thoracocentesis

12. OPEN (SUCKING) CHEST WOUND

13. SUCKING CHEST WOUND

14. SUCKING CHEST WOUND
• Upon exhaling, air in
the chest escapes
through the flutter-type
valve created by taping
3 sides only
• With inhaling, the patch
should suck against the
skin, preventing air
entry

15. – Restriction to cardiac filling caused by blood or
other fluid within the pericardium
– Occurs in <2% of all serious chest trauma
• However, very high mortality
– Results from tear in the coronary artery or
penetration of myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of
cardiac contractions
– Removing as little as 20 ml can provide relief
Pericardial Tamponade

16. • Dyspnea
• Possible cyanosis
• Beck’s Triad
– JVD
– Distant heart tones
– Hypotension or
narrowing pulse
pressure
• Weak, thready pulse
• Shock
Pericardial Tamponade (simplify)
• Kussmaul’s sign
– Decrease or absence of
JVD during inspiration
• Pulsus Paradoxus
– Drop in SBP >10 during
inspiration
– Due to increase in CO2
during inspiration
• Electrical Alterans
– P, QRS, & T amplitude
changes in every other
cardiac cycle
• PEA

17. CARDIAC TRAUMA

18. Pericardial or Cardiac tamponade

19. Cardiac Tamponade

20. Pericardial Tamponade (ilustrations)

21. Crucial 1° Survey Differential Dx:
Cardiac Tamponade vs. Tension
Pneumothorax
Clinical Sign Cardiac
Tamponade
Tension
Pneumothorax
Blood Pressure
Cardiac Tones
Breath Sounds
Neck Veins
Respirations
Treatment
Low (PEA) Low
Muffled Normal
Normal Absent - collapsed side
Distended (flat
in hypovolemia)
Flat
± Normal Tachypnea



Needle/drain
pericardium
Needle/tube chest

22. Hemothorax
• Hemothorax
– Accumulation of blood in the pleural space
– Serious hemorrhage may accumulate 1,500 mL of blood
• Mortality rate of 75%
• Each side of thorax may hold up to 3,000 mL
• MASSIVE (criteria)
– Blood loss in thorax causes a decrease in tidal volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax
• Hemopneumothorax

23. • Blunt or penetrating chest
trauma
• Shock
– Dyspnea
– Tachycardia
– Tachypnea
– Diaphoresis
– Hypotension  massive
• Dull to percussion over injured
side
• Treatment
Chest tube insertion & consult
Hemothorax (simplify)

24. Trauma.org
CXR Image

26. Flail chest
• Multiple rib fractures produce a mobile
fragment which moves paradoxically with
respiration
• Significant force required
• Usually diagnosed clinically
• Treatment
– ABC
– Analgesia
– Fixation : internal &/ external

27. PARADOXICAL RESPIRATIONS

28. Flail Chest - detail

29. Tracheobronchial Injury
– MOI
• Blunt trauma
• Penetrating trauma
– 50% of patients with injury die within 1 hr of injury
– Disruption can occur anywhere in tracheobronchial tree
– Signs & Symptoms
• Dyspnea
• Cyanosis
• Hemoptysis
• Massive subcutaneous emphysema
• Suspect/Evaluate for other closed chest trauma

31. Tracheal Disruption
Massive subcutaneous
emphysema in chest wall –
displaced trachea
Cervical, facial sub-
cutaneous emphysema
Hemoptysis
Blunt injuries almost always
within 1” carina

32. Blunt Thoracic Trauma:
Tracheobronchial Injury
• 2° Blunt injury
• Persistent
pneumothorax
• Huge air leak
• Rare injury 2-3% of
survivors MVA
• Definitive repairs
with pleural flap

33. Tracheal Disruption

34. Tracheal Disruption

35. • Blunt or penetrating trauma (extrinsic compression from
hematoma)
– Intra/extra thoracic location (supraglotic, glotic, subglotic
• Presentation
• Massive, sometimes uncontrollable air leak
– Stridor, acute respiratory distress, Δ voice
– Neck, upper chest subcutaneous emphysema – often
– massive and disfiguring
• Acutely manage with deep intubation (beyond injury), scope,
sometimes tracheostomy
Tracheal Disruption

36. – Restriction to cardiac filling caused by blood or
other fluid within the pericardium
– Occurs in <2% of all serious chest trauma
• However, very high mortality
– Results from tear in the coronary artery or
penetration of myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of
cardiac contractions
– Removing as little as 20 ml can provide relief
Pericardial Tamponade

37. • Dyspnea
• Possible cyanosis
• Beck’s Triad
– JVD
– Distant heart tones
– Hypotension or
narrowing pulse
pressure
• Weak, thready pulse
• Shock
Pericardial Tamponade (simplify)
• Kussmaul’s sign
– Decrease or absence of
JVD during inspiration
• Pulsus Paradoxus
– Drop in SBP >10 during
inspiration
– Due to increase in CO2
during inspiration
• Electrical Alterans
– P, QRS, & T amplitude
changes in every other
cardiac cycle
• PEA

38. Pericardial or Cardiac tamponade

39. Pericardial Tamponade (ilustrations)

40. Laceration of vascular structures
• General sign
– Shock Hypovolemia (co morbid cardiogenic)
– Penetrating trauma (mostly)
• Internal bleeding
– Thoracic  Chest XR
– Abdominal  FAST or CT
– Pelvicum  CXR
– Femur  expanding hematoma + XR
• External bleeding  thorough examination &
suturing

42. Coronary Artery Laceration

43. Laceration of vascular structures
• Internal bleeding  consult
• External bleeding

45. Blunt Cardiac Injuries

46. Blunt Thoracic Trauma: Cardiac
Contusions
• Blunt anterior chest trauma
• Acute injury pattern (anterior wall: ↑ST’s I, aVL, V2-V4, ↓II,III,
aVF), AF, BBB
• W/U & Rx acute myocardial infarction, inotropes
• Watch for & treat PVC’s aggressively (K+,temp)
• Cardiac echo to assess wall motion, valves

47. Other thoracic cases
• Empyema
• Pleural effusion
• Chylothorax
• Cancer
– Lung
– Mediastinal

48. Empyema & pleural effusion
• Fluid in pleural cavity
– Empyema  infection material
– Pleural effusion  non infection
– Chylothorax  lymphatic fluid

49. Thoracic Tumor cases
Clinical finding: dull area not change by positions

50. Immediate Life Threatening Thoracic
Injuries: Aortic Disruption
• Most common at ligamentum
arteriosum but can be
multiple (pendulum effect)
• ~⅓ fatal on site due to free
rupture (uncontained)
• Hypotension, exsanguination
• MVA, falls from height

51. Contained Injuries to the Aorta
Widened mediastinum (53%
sensitivity, 59% specificity and
83% negative predictive value)
Obliteration of aortic knob
Rightward deviation of trachea
(compare NG tube to trachea)
Depression of left main stem
bronchus
Pleural/apical cap
Left hemothorax (can be bilateral)
Fractures of 1st and/or 2nd ribs

52. Contained Injuries to the Aorta

53. Contained Injuries to the Aorta
• Not a source of multiple hypotensive episodes in
survivors - look for other injuries
• Salvageable tear when hematoma contained
• ~⅓ die per 24 hours without treatment
• Widened mediastinum very unreliable sign on
portable x-ray
• TEE, helical contrast CT scan, MRI, aortogram
• Consider percutaneous stent placement
• Address after life threatening injuries stabilized

54. Summary
• Life ending thoracic injuries are common
• Survival depends on proper and immediate
diagnosis and appropriate management
• ED thoracotomy can save lives but expected
survivorship is <10%
• Don’t forget ABC’s of trauma and damage
control principles