1. Chest Trauma

2. Chest Trauma - BLUNT

3. Chest Trauma - PENETRATING

4. Chest Trauma - INCIDENCE
Sudden and dramatic
Directly => 20 – 25% (1 in every 4)
trauma deaths
Contribute to 25-50% of the remaining
deaths
=> 16,000 deaths per year in USA

5. Chest Trauma - CARE Improved pre-hospital & peri-operative care
=> More pts getting to ER alive
Many die after coming to hospital
Deaths possibly preventable
=> by prompt Dx and Tx

6. Chest Trauma - HISTORY 3000 BC – treating gladiators chest injuries
De Vacca => removal of arrowhead from chest wall
1814 -Larrey reported injuries to subclavian vessels
Hill performed first cardiorrhaphy in US
Blalock first American to successfully repair an aortic injury

7. BOUNDARIES of Chest Superiorly => clavicles Inferiorly
=> diaphragm
Laterally
=> rib cage

8. BOUNDARIES of Chest Anteriorly => sternum Posteriorly
=> vertebral bodies & ribs

9. STRUCTURES Injured Any organ in chest potentially susceptible
especially to penetrating trauma

10. CONTENTS - Thoracic cavity
- Chest wall and ribs
- Lungs and pleura
- Great and thoracic vessels
- Heart and mediastinal structures
- Diaphragm

11. CONTENTS - Thoracic cavity
Esophagus
Thoracic duct
Tracheobronchial system

12. OTHER ORGANS at risk Thoraco-abdominal injury
any wound below nipples in front and
inferior scapula angles dorsally
may result in intra abdominal injury

13. OTHER ORGANS at risk Peritoneal viscera Liver Spleen Stomach
Colon & small intest.
Biliary system
Retro-peritoneum
kidneys

14. RESULTING INJURIES Rib fractures Sternal fractures
Open or Closed Pneumothorax
- unilateral / bilateral
Hemothorax
Hemopneumothorax

15. RESULTING INJURIES Pneumo-mediastinum Pulmonary contusion
Myocardial contusion
Diaphragmatic rupture

16. RESULTING INJURIES
Subcutaneous emphysema

17. CLINICAL CONSEQUENCIES
RELATED TO :
Mechanism of injury
Location of injury
Associated injuries
Co-morbidities

18. Mechanism of Injury BLUNT Mostly managed non-operatively
Simple intubation & ventilation or
chest tube placement

19. Mechanism of Injury
PENETRATING
Low energy
Medium energy
High energy

20. Penetrating (Low energy)
Impalements
Knife wounds
=> disrupts only structures penetrated

21. Penetrating (Medium energy)
Bullet wounds from most handguns
=> primary tissue damage
< than higher velocity forces

22. Penetrating (High energy)
From rifles and military weapons
+ Shotguns (low velocity)
Transfers kinetic energy to tissues
=> cavitation
=> high velocity.
Amount of tissue damage proportional to amount of energy exchanged between the penetrating object and the body part.

23. Pathophysiology
Quite serious

24. 1. HYPOXIA / HYPO-VENTILATION
Primary acute killer of trauma patients
inadequate delivery of O2
to tissues

25. Signs of HYPOXIA Increased RR Change in breathing pattern (shallow)
Anxious behavior
Poor air movement
Diaphoresis
Dilated pupils
Cyanosis – (late sign)

26. 2. Hypovolemia
Inadequate intravascular volume
=> BLOOD LOSS

27. 3. Ventilation / Perfusion Mismatch
Contusion
Hematoma
Alveolar collapse

28. 4. CHANGES IN INTRATHORACIC PRESSURE RELATIONSHIPS
- Tension pneumothorax
- Open pneumothorax

29. 5. METABOLIC ACIDOSIS
Hypo perfusion of tissues (shock)

30. MANAGEMENT - Chest Trauma
ABCs
PRIMARY SURVEY
Most important feature of chest injury evaluation
=> Aim to identify & treat immediately life threatening conditions

31. MANAGEMENT - Chest Trauma
EARLY INTERVENTIONS geared towards
identifying / correcting / preventing problems
Tension pneumothorax
Massive hemothorax
Open pneumothorax
Cardiac tamponade
Flail chest

32. MANAGEMENT - Chest Trauma
Resuscitation of vital functions
REMEMBER :
- Most life threatening injuries txd by
- Airway control
- Chest tube

33. MANAGEMENT - Chest Trauma - Detailed Secondary Survey
Influenced by:
Mechanism of injury
High level of suspicion
May show:
Simple pneumothorax
Hemothorax
Pulmonary contusion
Myocardial contusion
Blunt aortic injury
Rib fractures
Diaphragmatic rupture

34. MANAGEMENT - Chest Trauma
Definitive care
Usually operative

35. MANAGEMENT - Chest Trauma
Adjuncts
CXR
=> basis for initiating other investigations
ALL wounds to thoracic cavity bounded back & front by
Neck & umbilicus for stabs
Neck & pelvis for GSW
MUST HAVE CXR
=> UPRIGHT if possible

36. Adjuncts - FAST Focused Abdominal Sonography for Trauma (FAST)
- All hemodynamically unstable blunt trauma pts

37. Adjuncts - Cat Scan - (CT angio)
Becoming a primary diagnostic tool
fast (spiral)
allow for reconstruction etc

38. SPECIFIC CHEST INJURIES
Chest Wall
Rib fractures
Most common sign of blunt chest injury
Fx scapula, first rib, sternum suggest massive force of injury
1st & 2nd rib fx associated with serious other injuries
Upper ones => suspect vascular injury

39. Rib Fractures

40. Rib fractures Signs and Symptoms - Tenderness - Crepitus - Deformity
- Localized pain
- Tenderness
- Crepitus

41. Rib Fractures Treatment Analgesia (PCA) Pulmonary toilet
Observe for possible pneumothorax

42. Flail Chest Segment of chest wall that does not have
continuity with rest of thoracic
cage
Usually 2 fractures per rib in at least 2 ribs
Segment does not contribute to lung expansion
Disrupts normal pulmonary mechanics
Accompanied by pulmonary contusion in 50% of patients with flail chest

43. Flail Chest - Pathophysiology
A major problem is the injury to
the underlying lung
=> Pulmonary Contusion

44. Flail Chest – Signs & Symptoms
Dyspnea
Chest pain
Paradoxical chest wall movement
Poor air movement
Crepitus
Hypoxia
Cyanosis

45. Flail Chest - Treatment
Pain control
Humidified O2
Close observation for respiratory
decompensation
Aggressive pulmonary & physical
therapy

46. Flail Chest - Treatment
Selective intubation and ventilation:
significant other injuries
respiratory rate > 35
paO2 < 80
paCO2 > 66
Other treatments:
tight fluid resuscitation

47. Flail Chest - Treatment
Operative fixation not usually required (historical)

48. Lung Injuries Pneumothorax or Hemothorax
most treated with simple tube thoracostomy

49. Pneumothorax Less than 1-2 cm may be observed in otherwise healthy pts if stable on f/u CXR 6-8 hrs after

50. Open Pneumothorax Open sucking chest wound
if opening 2/3 of diameter of trachea air will come through wound (preferentially)
allows free passage of air into and out pleural cavity
=> effective ventilation impaired
=> hypoxia & hypercarbia

51. Open Pneumothorax Signs & Symptoms Penetrating chest wound
Decreased breath sounds
Sucking sounds on inspiration

52. Open Pneumothorax Treatment : 3 sided occlusive dressing
Observe for tension pneumothorax
Operative

53. Tension Pneumothorax
One way valve allows air leak from lung or chest wall
=> air forced into chest cavity
without escape

54. Tension Pneumothorax
Collapses ipsilateral lung

55. Tension Pneumothorax
Displaces mediastinum to opposite side

56. Tension Pneumothorax
Compresses opposite lung

57. Tension Pneumothorax
Decreases venous return

58. Tension Pneumothorax Signs & Symptoms air hunger chest pain
respiratory distress
tachycardia
hypotension
tracheal deviation
absent breath sounds
hyper-resonant percussion
JVD

59. Tension Pneumothorax - Treatment
Immediate decompression
large bore needle
2nd intercostal space
midclavicular line
chest tube as definitive tx
NOTE – may mimic a collapsed lung on the other side
- i.e. trachea deviates towards the collapsed lung
- however, one resonant (empty), other tympanic (full)

60. Pulmonary Contusion Largest # of pts are those with blunt trauma
Most common chest injury in children
Usually develops over 24 hours
Can occur with or without laceration of parenchyma

61. Pulmonary Contusion
Results from:
Leakage of blood and fluid into interstitial spaces of lung
- Significant inflammatory reaction to blood components in the lung

62. Pulmonary Contusion - Pathophysiology
Loss of normal lung structure & function leads to
- poor gas exchange
- increased pulmonary vascular resistance
- decreased lung compliance

63. Pulmonary Contusion - Complications
Atelectasis
Pneumonia
ARDS
Respiratory failure

64. Pulmonary Contusion - Diagnosis
Parenchymal infiltrate seen in CXR adjacent to injured chest wall

65. Pulmonary Contusion - Diagnosis
No real clinical findings especially initially
dyspnea
chest wall contusions / abrasions
increased RR
may have crackles

66. Pulmonary Contusion - Diagnosis
Lung gets stiffer causing dyspnea and increased RR
Blood gases worsen 2-3 days as edema increases
CXR changes may lag hrs behind
May underestimate the true extent
CT - very sensitive – can allow quantifying

67. Pulmonary Contusion - Treatment
MOSTLY supportive - usually resolve in days
- O2 + observation in milder cases
- Pain control to allow:
- adequate ventilation and better management of secretions
- Fluid restriction
- Intubation + mechanical ventilation
if respiratory distress present

68. Pulmonary Contusion Indications for intubation Respiratory distress
Co-morbidities esp. lung disease
Other injuries
– intra-abdominal

69. Myocardial contusion Physical bruising of the cardiac muscle
Usually associated with fractures of the sternum
Any severe anterior chest injury

70. Myocardial contusion Difficult to dx => HIGH LEVEL OF SUSPICION
ALL pts with pattern of injury must have an EKG

71. Myocardial contusion - Diagnosis
Ectopy
ST elevation
Tachycardia
Friction rub
Enzymes may be normal

72. Myocardial contusion - Treatment
Monitor in ICU & treat dysrhythmias
Serial enzymes
Analgesia

73. Massive Hemothorax Pleural cavity hold 3 liters blood
200cc – 1L in chest cavity seen on CXR
90% from internal mammary or intercostals
10% from pulmonary vessels

74. Massive Hemothorax - Treatment
Decompression
Chest tube (most need just that)
Bleeding may stop when lung re-expands

75. Aortic Rupture / Great Vessel Injuries
Abrupt deceleration or compression injury
Sudden motion of heart / great vessels within thorax
Great vessel injury may occur in 0.3 => 10% penetrating trauma
Often rapidly fatal
Only 10% survive to hospital
Only 20% survive > 1 hour
90% who reach hospital will die
EARLY DX and aggressive tx best chance

76. Aortic Rupture - Signs and Symptoms
Hypovolemic shock
Chest wall ecchymosis
Marked difference in BP b/l arms
Fx 1st, 2nd, 3rd ribs especially on left

77. Aortic Rupture - Diagnosis
Consider mechanism of injury
widened mediastinum on CXR
40% normalizes with sitting up

78. Aortic Rupture - Diagnosis
Mediastinum > 8cm wide
Blurring of aortic knob

79. Aortic Rupture - Diagnosis
Deviation of NGT to right

80. Aortic Rupture - Diagnosis
CT with contrast then angiogram if abnormal

81. Aortic Rupture - Treatment
Contained injury
=> BP control
Operative repair

82. Cardiac Injury Highly lethal : fatality rates - 70 => 80%
Mostly ventricular
right > left

83. Cardiac Tamponade => Blood in pericardial sac
Occurs most frequently with penetrating injuries

84. Cardiac Tamponade - Signs and Symptoms
Shock
JVD
Dyspnea
PEA
Beck’s triad = minority of pts
- Distended neck veins
- Muffled heart sounds
- Hypotension

85. Cardiac Tamponade - Treatment
Volume resuscitation
Pericardiocentesis
Surgery
- Pericardial window
- sternotomy
- thoracotomy

86. Diaphragmatic Rupture
Traumatic herniation of abdominal contents into the chest

87. Diaphragmatic Rupture
Mostly on left side

88. Diaphragmatic Rupture
Liver “protective” on right side

89. Diaphragmatic Rupture
Frequent in thoracoabdominal trauma
15% stab wounds
46% GSW
15% greater than 2cm long
May be no immediate herniation of abdominal contents

90. Diaphragmatic Rupture - Signs and symptoms
No distinctive signs / symptoms seen
High index of suspicion needed especially with mechanism of injury
dyspnea
cyanosis
shoulder pain
bowel sounds in lower chest

91. Diaphragmatic Rupture - Treatment
Up to 13% acute injuries missed initially
85% presenting in 3 years as
- obstruction or with
- decreased cardio / pulmonary reserve
Goal of treatment:
- Maintain adequate oxygenation => intubate
- NG decompression of stomach

92. Diaphragmatic Rupture - Surgery

93. Esophageal Injuries Most due to penetrating trauma Diagnosis Treatment
- Difficult
- If delayed => rapid sepsis & high mortality
- Requires aggressive investigation
- Radiography
- Endoscopy
- Thoracoscopy
Treatment
- Thoracotomy, etc.

94. Thoracic Duct Injuries
Accompany thoracic vessel injuries
Noted much later i.e. not in acute phase
Huge morbidity due to severe nutritional depletion Mn
=> initially aggressive and nonoperative
= hyperalimentation => TPN
and if not sealed in 5-7 days
surgical intervention

95. Emergency Thoracotomies
“ACUTE” THORACOTOMY
Cardiac tamponade (relieved)
Vascular injury to thoracic outlet
Massive air leak
Endoscopic/radiographic evidence of tracheal or bronchial injury
Esophageal injury
Chest tube output
immediate evacuation of 1500ml blood
or > 250cc/ hour
TREND MORE IMPORTANT than initial output

96. “ER” THORACOTOMY – survival rates < 8%

97. “ER” THORACOTOMY - To do or NOT to do…
Type of CARDIAC
ACTIVITY
asystole
bradycardia
tachycardia

98. “ER” THORACOTOMY - To do or NOT to do…
Type of VITAL SIGNS
electrical cardiac activity (PEA)
palpable pulse
recordable blood pressure

99. “ER” THORACOTOMY - To do or NOT to do…
LOCATION of LOSS
of vital signs
street
in transit ambulance/helicopter
unloading area
hallway
resuscitation area

100. “ER” THORACOTOMY - Unlikely to benefit if ...
BLUNT injury with arrest
Arriving without pulse/BP
Penetrating injury with arrest
Better chance
High likelihood of
isolated / correctable intra-thoracic injury (?GSW?)
still EXTREMELY RARE

101. “ER” THORACOTOMY - Bottom line
ER THORACOTOMY if presence of MEASUREABLE
pulse
blood pressure
organized cardiac activity
(or just lost IN trauma bay)
MUST consider also
age
co-morbidities (ie infectious diseases)
AVOID if arrest
occurs OUTSIDE OF RESUSCITATION AREA or
due to BLUNT trauma.

102. “ER” THORACOTOMY - Consider . . .
Be mindful that circulatory arrest
=> cerebral hypoxia
=> permanent neurologic deficits
=> non-functional survivor
occurs in 10 => 15% of survivors

103. Chest tube insertion Most common intervention
Relatively simple procedure
Definitively manage > 85% of chest trauma : penetrating or blunt
Has significant complication rate 2-19%
May be minor but
May require operative intervention and
Can result in death

104. Chest tube insertion - Indications
Drain contents of
pleural space
air
blood
chyle
gastric contents
Prevent development of pleural collection i.e. after thoracotomy
Prevent tension pneumothorax in ventilated pt with rib fractures

105. Chest tube insertion - Indications
Absolute indications
pneumothorax
hemothorax
traumatic arrest - (b/l)
Relative indications
rib fractures and positive pressure ventilation
profound hypoxia/hypotension with penetrating chest injury

106. Placement may be diagnostic or therapeutic
Bright red blood
suggest arterial injury = possible thoracotomy
Intestinal contents
esophageal, stomach, diaphragm
intestinal injury
Large air leak
- bronchial disruption
Technique = important to avoid complications

107. Chest tube insertion - Insertion Site
mid or anterior axillary line behind pectoralis major
above 5th rib since on expiration diaphragm rises that high
count down from sternomanubrial joint (2nd rib)

108. Chest tube insertion - Analgesia
Painful especially in muscular pts
Morpine IV or Ketamine 20mg in adult
10-20 ml local analgesia
along line of incision
perpendicularly thru all layers of chest wall to rib below space
up into pleural cavity after aspirating air

109. Chest tube insertion - Procedure
Prep and drape
Incise along upper border of the rib below the intercostal space to be used
Track is to be directed over top of lower rib so as to avoid intercostal vessels lying below each rib
should be big enough to fit finger
Use curved clamp to develop tract by blunt dissection only – use to spread the muscle fibers, develop tract with fingers
On reaching rib, clamp angled upward just above the rib and dissection continued till pleural space entered

110. Chest tube insertion - Procedure
Finger inserted into pleural space and area palpated
32-36 F tube attached to clamp and inserted along track into the pleural cavity

111. Chest tube insertion - Procedure
Connect tube to
underwater seal
and suture in place
Examine chest to
check effect
CXR to check
placement and
position

112. POSITION - Dependent on direction of tract
Blunt chest trauma pts lying flat
place drain anteriorly
prevents blockage of tube and development of tension pneumothorax
Penetrating
Posteriorly & basally directed drain
Last hole should be INSIDE the CHEST CAVITY
If too far in could cause severe intractable pain when up against mediastinum

113. Chest tube insertion - Underwater Seal
Allows air to ESCAPE but NOT RE-ENTER chest cavity
Negative pressure dependent upon level of water
Pleurovac must always be below level of patient
Persistent bubbling = air leak from lung

114. Chest tube insertion - Underwater Seal
May be connected to suction (water level 20cm H2O)
Aid lung re-expansion especially if there is an air leak
CHEST TUBES SHOULD NEVER BE CLAMPED =
TENSION PNEUMOTHORAX

115. Chest Tube Removal When? When no air leak No more fluid draining How?
Occlude hole while pulling tube
Remove at end of expiration or at peak of inspiration
Avoids air being drawn into cavity
Remove rapidly and close wound quickly

116. Chest tube insertion - Complications
“there is no organ in the thoracic or abdominal cavity that has not been pierced by a chest drain”
mainly historical since drains used to be inserted with
- a steel trocar
- excessive force

117. Chest tube insertion - Acute complications
Hemothorax – usually laceration of intercostals vessel, may require thoracotomy
Lung laceration especially when adhesions present
Diaphragm / abdominal cavity penetration - placed too low
Stomach colon injury - diaphragmatic hernia not recognized
Tube placed
subcutaneously – not in
pleural cavity
Tube placed too far = pain
Tube falls out = not secured properly

118. Chest tube insertion - Late complications
blocked tube
= clot, lung
retained hemothorax
empyema
pneumothorax after removal
= poor technique

119. Chest Trauma - Conclusion
Chest trauma is
COMMON
SERIOUS
AIM in TREATMENT
to provide oxygen to vital organs
Be alert to changes in clinical condition
Managed MOST of the time with a CHEST TUBE

120. CHEST TRAUMA
END