seminar presentation during residency in MS (General Surgery)

1. Chest Trauma
By
Dr. Dixit Prajapati (MS)
Dr. Neet Chotai (MS)

2. Introduction
 Thoracic injuries are directly
responsible for 25% of all trauma
deaths and are a major contributory
factor to mortality in a further 25%.
 Although many of these deaths occur
almost immediately, there is a
significant group of patients that may
be salvaged with early effective
management.

3.  The majority (approximately 90%) of
all patients who sustain thoracic
trauma can be managed
conservatively, with no more than a
chest drain, monitoring and
analgesia.
 Few patients require surgery, and an
emergency department thoracotomy
is indicated in only a very small
minority.

4.  A reproducible and safe approach to
the diagnosis and management of
chest injury is taught by the ATLS
course of the American College of
Surgeons.

5. Anatomy of thoracic cavity
• 12 pair of ribs with intercostal muscles.
• The lungs occupy the majority of the
thoracic volume.
• Mediastinum - heart and great
vessels.
• Diaphragm

8. PATHOPHYSIOLOGY OF
CHEST TRAUMA

9. Blunt Trauma- Blunt force to chest. E.g.
automobile crashes and falls.

11. Penetrating Trauma- Projectile that enters chest
causing small or large hole. E.g. gun shot and
stabbing.

14.  Anatomical Injuries
◦ Thoracic Cage (Skeletal)
◦ Cardiovascular
◦ Pleural and Pulmonary
◦ Mediastinal
◦ Diaphragmatic
◦ Esophageal
◦ Penetrating Cardiac

15.  The main consequences of chest
trauma occur as a result of its
combined effects on respiratory and
haemodynamic function.
 The commonest manifestation of
thoracic trauma is hypoxia

16.  Mechanism of injury is important in so
far as blunt and penetrating injuries
have different pathophysiologies and
clinical courses.
 Most blunt injuries are managed non-
operatively or with simple
interventions such as intubation and
ventilation and chest tube insertion.

17.  Diagnosis of blunt injuries may be
more difficult and require additional
investigations such as CT scanning
(when the patient is STABLE).
 In contrast, penetrating injuries are
more likely to require operation, and
complex investigations are required
infrequently.

18. • Impairments in ventilatory efficiency
 Chest movement compromise due to
pain
air in pleural space
asymmetrical movement
 Bleeding in pleural space
 Ineffective diaphragm contraction

19. ◦ Impairments in gas exchange
 Atelectasis
 Pulmonary contusion
 Respiratory tract disruption

20. Causes of hypoxia in chest
trauma
 Haemorrhage;
 Lung collapse and compression;
 Ventilatory or cardiac failure;
 Pulmonary contusion;
 Changes in intrathoracic pressure;
and
 Mediastinal displacement.

21.  Profound hypovolaemia in chest
trauma due to
Great vessel damage,
Pulmonary hilar injury
Cardiac or pericardial
laceration without tamponade.
Hypovolaemia produces a low cardiac
output state, which further contributes
to the pathophysiological
consequences of chest injury.

22.  Hypovolaemia produces a low cardiac
output state, which further contributes
to the pathophysiological
consequences of chest injury.
 Pulmonary contusion is one of the
main factors responsible for the
increased morbidity and mortality
associated with chest trauma.

23.  It is a progressive condition,
Alveolar haemorrhage and oedema
Interstitial fluid accumulation
Decreased alveolar membrane
diffusion.

24.  These changes produce
 Relative hypoxaemia,
 Increased pulmonary vascular
resistance,
 Decreased pulmonary vascular flow
 Reduced lung compliance.

25.  Importantly, there is a Ventilation-
perfusion mismatch' (alveoli are
perfused, but are unavailable for gas
exchange because they are full of
blood).
 This contributes significantly to the
hypoxaemia, especially in the early
stages following trauma.

26.  Later, hypoxia-induced pulmonary
vasoconstriction will divert the blood
away from the non-ventilated alveoli
 A loss of mechanical function of the
chest wall will also result in hypoxia

27.  If the chest wall is sufficiently
disrupted, the patient may be unable
spontaneously to generate sufficient
movement of air to allow adequate
gas transfer.

28.  Cardiac output may be directly
reduced by
 Decreased myocardial contractility (e.g.
myocardial contusion),
 Cardiac disruption (e.g. a tear in a cardiac valve),
 Reduced venous filling (e.g. in cardiac
tamponade),
 With changes in intrathoracic pressure (tension
pneumothorax).

30. ASSESSMENT
 On arrival in the emergency
department, decisions and action
need to be taken without delay.
 Important information may be obtained
from the ambulance service relating to
the patient's history and mechanism of
injury.

31. The sequence of questions as follow
 Mechanism of injury
 Injuries found and suspected
 Signs (respiratory rate, SpO2, pulse,
blood pressure)
 Treatment given pre-hospital.

32.  In every case, the system of a primary
survey with simultaneous resuscitation
is followed.
 In the stable patient, once this has
been completed, a secondary survey
can be performed.

33.  Certain wounds or bruising patterns
highlight the likelihood of underlying
injury
 for example a seat-belt mark on the
chest wall may arouse suspicion of
fractured ribs, lung contusion, or
solid organ injury in the abdomen,

34.  Penetrating wound medial to the
nipple or the scapula suggests
possible damage to the heart (with
potential cardiac tamponade), the
great vessels, or the hilar
structures.
 However, major intrathoracic injuries
may occur without obvious external
damage

35.  Additionally, some injuries point to
possible associated more serious
pathology
 for example, fractures of the first
and second ribs are associated
with major vessel injury.

36.  The Advanced Trauma Life Support
(ATLS) course of the American
College of Surgeons Committee on
Trauma was developed in the late
1970s,
 based on the premise that appropriate
and timely care can significantly
improve the outcome for the injured
patient.

37.  ATLS provides a structured approach
to the trauma patient with standard
algorithms of care
 It emphasizes the “golden hour”
concept that timely, prioritized
interventions are necessary to prevent
death and disability.

38.  The initial management of seriously
injured patients consists of phases
that include
 Primary survey/concurrent
Resuscitation,
 Secondary survey/diagnostic
evaluation,
 Tertiary survey.

39.  The first step in patient management is
performing the primary survey, the goal
of which is to identify and treat
conditions that constitute an
immediate threat to life.
 The ATLS course refers to the primary
survey as assessment of the “ABCs”
(Airway with cervical spine protection,
Breathing, and Circulation).

40.  Although the concepts within the
primary survey are presented in a
sequential fashion, in reality they are
pursued simultaneously in coordinated
team resuscitation.
 Life-threatening injuries must be
identified and treated before being
distracted by the secondary survey.

41. AIRWAY
 It is necessary to recognize and
address major injuries affecting the
airway during the primary survey.
 Airway patency and air exchange
should be assessed by listening for air
movement at the patient’s nose,
mouth, and lung fields; inspecting the
oropharynx for foreign-body
obstruction.

42.  Laryngeal injury can accompany major
thoracic trauma.
 Patients who have an abnormal
voice, abnormal breathing sounds,
tachypnea, or altered mental status
require further airway evaluation

43.  Endotracheal intubation is indicated in
Patients with apnea
Inability to protect the airway due to
altered mental status
Impending airway compromise due to
inhalation injury, hematoma, facial
bleeding, soft tissue swelling, or
aspiration;
Inability to maintain oxygenation.

44.  Altered mental status is the most
common indication for intubation.
 Options for endotracheal intubation
include nasotracheal, orotracheal, or
operative routes.

45.  Patients in whom attempts at intubation
have failed or who are precluded from
intubation due to extensive facial injuries
require operative establishment
(cricothyroidotmy/tracheostomy) of an
airway.
 In patients under the age of 11,
cricothyroidotomy is relatively
contraindicated due to the risk of
subglottic stenosis, and tracheostomy
should be performed.

46.  Emergent tracheostomy is indicated in
patients with laryngotracheal
separation or laryngeal fractures, in
whom cricothyroidotomy may cause
further damage or result in complete
loss

47. BREATHING
 Before examining the chest, the neck
should be carefully examined for
wounds,
bleeding,
tracheal deviation,
laryngeal crepitus,
jugular vein engorgement

48.  If a cervical collar is already in place, it
should ideally be removed temporarily
to allow examination, Bt
 Do not forget to examine the neck

49.  The chest must be completely
exposed so that respiratory movement
and quality of ventilation can be
assessed.
 The mechanics of breathing can be
disrupted by major airway obstruction,
haemothorax or pneumothorax, pain
or pulmonary contusion.

50.  Impending hypoxia is sometimes
indicated by subtle changes in the
breathing pattern, which may become
shallow and rapid.
 Visual inspection and palpation of the
chest wall may reveal
deformity,
contusion,
abrasion,
penetrating injury,

51. paradoxical breathing,
tenderness,
crepitus.
 All are markers suggestive of
underlying injury.

52. CIRCULATION
 The pulse should be assessed for
quality, rate and regularity.
 The peripheral circulation is assessed
by skin colour, temperature and
capillary return.
 Venous distension in the neck may not
always be present in a patient with
cardiac tamponade who has
hypovolaemia.

53. Circulation maintained by
 IV fluids (crystalloids,PCV )
 External control of any visible
hemorrhage should be achieved
promptly while circulating volume is
restored.
 Manual compression of open wounds
with ongoing bleeding should be done
with a single 4 × 4 gauze and a gloved
hand.

54.  During the circulation section of the
primary survey, two life-threatening
injuries must be identified promptly:
(a) massive hemothorax, (b) cardiac
tamponade.
 Two critical tools used to differentiate
these in trauma patient are chest
radiograph and focused abdominal
sonography for trauma (FAST)

55.  A massive hemothorax is defined as
>1500 mL of blood or, in the pediatric
population, >25% of the patient’s
blood volume in the pleural space
 Although it may be estimated on
chest radiograph, tube thoracostomy
is the only reliable means to quantify
the amount of hemothorax.

56.  After blunt trauma, a major
hemothorax usually is due to
Multiple rib fractures with severed
intercostal arteries
Lacerated lung parenchyma

57.  Cardiac tamponade occurs most
commonly after penetrating thoracic
wounds, although occasionally blunt
rupture of the heart, particularly the
atrial appendage, is seen.
 Acutely, <100 mL of pericardial blood
may cause pericardial tamponade.

58.  The classic Beck’s triad—
dilated neck veins,
muffled heart tones, and a
decline in arterial pressure
 is usually not appreciated in the
trauma bay because of the noisy
environment and associated
hypovolemia.

59. DISABILITY
 The hypoxic patient will initially be
confused. Primary head injury will also
cause an altered mental state, which
will be compounded by hypoxia or
hypercarbia.

60. Immediately life-threatening injuries to be
identified during the primary survey
 Airway
Airway obstruction
Airway injury
 Breathing
Tension pneumothorax
Open pneumothorax
Flail chest

61.  Circulation
Hemorrhagic shock
Massive hemothorax
Cardiac tamponade
 Disability
spine injury

62. Secondary Survey
 Once the immediate threats to life
have been addressed, a thorough
history is obtained and the patient is
examined in a systematic fashion
 Adjuncts to the physical examination
include
vital sign and CVP monitoring,
ECG monitoring
nasogastric tube placement,

63. Foley catheter placement,
Xray chest
hemoglobin
USG chest.

64. Assessment Findings
◦ Mental Status (decreased)
◦ Pulse (absent, tachy or brady)
◦ BP (hypotension)
◦ Ventilatory rate & effort (tachy- or
bradypnea, labored, retractions)
◦ Skin (pallor, cyanosis, open injury,
ecchymosis)

65. ◦ Neck (tracheal position, subcutaneous
emphysema, JVD, open injury)
◦ Chest (contusions, tenderness,
asymmetry, absent or decreased lung
sounds, abnormal percussion, open injury,
impaled object, crepitus, hemoptysis)
◦ Heart Sounds (muffled)
◦ Upper abdomen (contusion, open injury)

66. Red flag signs of chest injury
 Hemoptysis.
 Chest wall contusion.
 Flail chest.
 Open wounds.
 Jugular vein distention (JVD).
 Subcutaneous empysema.
 Tracheal deviation.

67.  Lung sounds:
◦ Absent or decreased
 Unilateral
 Bilateral
◦ Bowel sounds in chest
 Percussion.
◦ Hyperresonance
 Pneumothorax
 Tension pneumothorax
◦ Hyporesonance (hemothorax)

68. DEADLY DOZEN Threats to life from chest
injury
 Immediately life threatening – primary
survey
◦ Airway obstruction
◦ Tension pneumothorax
◦ Pericardial tamponade
◦ Open pneumothorax
◦ Massive hemothorax
◦ Flail chest

69.  Potentially life threatening –
secondary survey
◦ Aortic injuries
◦ Tracheobronchial injuries
◦ Myocardial contusion
◦ Rupture of diaphragm
◦ Oesophageal injury
◦ Pulmonary contusion

70. Evaluation
 Most thoracic injuries can be identified
with a physical examination and plain
chest radiography.
 Physical examination will reveal
superficial injuries, including chest wall
defects and penetrating wounds.
 Chest radiography is performed on all
significantly injured patients at risk for
thoracic injuries.

71.  The chest radiograph easily identifies
the presence of a pneumothorax or
hemothorax, as well as rib and sternal
fractures.
 The appearance of the mediastinum
may suggest a thoracic aortic injury.
 An ultrasound of the pericardium is a
component of the FAST examination,
which may reveal pericardial blood.

72.  In recent years, thoracic CT
angiography has emerged as a
valuable tool in the evaluation of blunt
thoracic trauma.
 CT provides visualization of the chest
wall and hemithoraces, allowing
determination of rib fractures,
pneumothoraces and hemothoraces,
and pulmonary contusion.

73.  Chest CT angiography is able to
identify transection of the aortic wall,
as well as lower grade injuries that
involve only the aortic intima.