1. By : Dr Gholamreza Masoumi Assistant Professor of Emergency medicine Iran University Of Medical Sciences

2. ThoracicTrauma

3. EPIDEMIOLOGY
Thoracic injury directly causes 20% to 25% of deaths resulting from trauma. Accounting for more than 16,000 deaths annually in the United States.

4. Immediate deaths are often due to a rupture of the myocardial wall or the thoracic aorta.

5. Early deaths(within the first 30 minutes to 3 hours) resulting from thoracic trauma are often preventable. Causes of these early deaths include tension pneumothorax, cardiac tamponade, airway obstruction, and continued uncontrolled hemorrhage.

6. Because these problems are often reversible, it is vital that emergency physicians be thoroughly familiar with the pathophysiology, symptoms, and treatment.

7. Chest Anatomy

8. Primary Survey Airway obstruction Open pneumothorax Flail chest
Tension pneumothorax
Massive hemothorax
Cardiac tamponade

9. Secondary Survey
Myocardial contusion Traumatic aortic rupture Tracheal or bronchial tree injury Diaphragmatic tears Esophageal injury Pulmonary contusion

10. Airway obstruction Always assume cervical spine injury
Secondary hypoxia
Common cause of preventable death
Foreign body, tongue, aspiration
Always assume cervical spine injury

11. Signs Of Obstruction Snoring or gurgling Stridor Agitation (hypoxia)
Use of accessory muscles
Cyanosis

12. Airway Management
Clear mouth Chin lift/jaw thrust Airway Intubation Cervical spine care

13. Open pneumothorax
“Sucking chest wound” Air enters pleural space Ventilation impaired Hypoxia results

14. PNEUMOTHORAX Erect AP/PA view best Visceral pleural line
No vessels or markings
Variable degree of lung collapse
No shift

15. Open pneumothorax
Close chest wall defect

16. Flail chest
Flail chest results when three or more adjacent ribs are fractured at two points, allowing a freely moving segment of the chest wall to move in paradoxical motion.

17. Flail chest paradoxical motion of the chest wall
outward with expiration
inward with inspiration

18. Management
Oxygen should be administered in the field, cardiac and oximetry monitors should be applied if available, and the patient should be observed for signs of an associated injury, such as tension pneumothorax.

19. Management
The cornerstones of therapy include aggressive pulmonary physiotherapy, effective analgesia, selective use of endotracheal intubation and mechanical ventilation, and close observation for respiratory compromise.

20. Stabilization of the flail segment, by positioning the patient with the injured side down or placing a sandbag on the affected segments, has been abandoned. These interventions actually inhibit expansion of the chest and increase atelectasis of the injured lung.

21. Tension Pneumothorax
Treat before X-ray
Should be a clinical diagnosis

22. Tension Pneumothorax Signs
Respiratory distress Tachycardia Hypotension Distended neck veins Resonant percussion note Tracheal deviation ↓ Air entry

23. Tension Pneumothorax Management
Immediate decompression
Large bore needle
Second intercostal space
Mid clavicular line
Formal chest
drain must follow

24. The second intercostal space, midclavicular line is
preferred for needle aspiration or catheter insertion.
B, The fourth or fifth intercostal space,midaxillary line, lateral to the pectoralis muscle and breast tissue, is the preferred site for a chesttube, regardless of pathology.

25. Massive hemothorax Anxiety and confusion Neck veins
Flat: hypovolemia
Distended: mediastinal compression
Breath sounds decreased
Hypotympany if percussed
Shock

26. Cardiac tamponade Beck’s triad Paradoxical pulse Breath sounds equal
Hypotension
Neck veins distended
Heart sounds muffled
Paradoxical pulse
Breath sounds equal

27. Neck veins distended

29. To measure pulsus paradoxus, the patient breathes normally while lying at a 45° angle. The blood pressure cuff is inflated well above systolic pressure and slowly deflated. When the pulse is first heard only during expiration, this is the upper value. The cuff is deflated until the pulse is heard during both inspiration and expiration, and this is the lower value. The difference in the two values is the amount of pulsus paradoxus. A difference of more than 12 mm Hg is abnormal.

30. Ultrasound: Apical view of a large pericardial effusion in early ventricular diastole; marked right atrial collapse is seen

31. Myocardial contusion Most common cardiac injury
Blunt anterior chest injury
Same as myocardial infarction
Chest pain
Dysrhythmias
Cardiogenic shock (rare)
Treat as cardiac tamponade

32. Traumatic aortic rupture
Most common cause of immediate death
Motor-vehicle collisions or falls from heights
90% die immediately
Scene Size-up and history extremely important
No obvious sign of chest trauma
Hypertension in upper extremities and hypotension in lower extremities (rare)

33. Tracheal or bronchial tree injury
Subcutaneous emphysema
Chest, face, neck
Ensure adequate airway
Cuffed ET tube past site of injury
Monitor for:
Pneumothorax
Hemothorax

34. Diaphragmatic tear Severe blow to abdomen
Herniation of abdominal organs
More common on left
Breath sounds diminished
Bowel sounds auscultated in chest (rare)
Abdomen appears scaphoid

35. Esophageal injury Penetrating trauma Difficult to assess in field
If unrecognized, may be lethal

36. The most reliable symptom of an esophageal injury is pleuritic pain localized along the course of the esophagus that is exacerbated by swallowing or neck flexion. Pain may be located in the epigastrium, substernal area, .or back

37. 1. Mediastinal air with or without subcutaneous emphysema 2
1. Mediastinal air with or without subcutaneous emphysema 2. Left-sided pleural effusion 3. Pneumothorax 4. Widened mediastinum

38. Pulmonary contusion
Common from blunt trauma Hours to develop Marked hypoxemia

39. Traumatic Asphyxia Severe compression Ruptures capillaries
Cyanosis above crush
Swelling of head, neck
Swollen tongue, lips
Conjunctival hemorrhage

40. Diagnostic Strategies
Chest wall and pulmonary injuries are most common. These patients should undergo CT of the chest to identify any potentially serious intrathoracic injuries.

41. Although the appearance of these patients can be quite dramatic, the condition itself is usually benign and self-limiting.

42. CHEST WALL INJURY

43. Rib Fracture
Epidemiology
Simple rib fractures are the most common form of significant chest injury, The importance of this injury is not the fracture itself, but the associated potential complications, particularly pneumothorax or hemothorax , pulmonary
.contusion

44. The(4-9) fourth through ninth ribs are most commonly involved
The(4-9) fourth through ninth ribs are most commonly involved. Ribs 1 to 3 are relatively protected, and ribs 9 to 12 are more mobile at the anterior end; this confers the “high” and “low” ribs' relative resistance to fracture.

45. Fractures of ribs one to three may indicate severe intrathoracic injury. Fractures of the 9th, 10th, or 11th ribs suggest an associated intra-abdominal injury.

46. displaced rib fractures
Elderly patients with displaced rib fractures may be at higher risk for delayed and profound intercostal artery bleeding, and serial hemoglobin measurements should be done during observation of these patients.

47. displaced rib fractures
In penetrating chest trauma, patients with displaced rib fractures should be observed for the occurrence of delayed pneumothorax with a repeat chest x-ray at 3 hours.

48. Sternal Fracture
Restrained passengers are more likely than unrestrained passengers to sustain a sternal fracture.

49. isolated sternal fractures are relatively benign patients with sternal fracture should be screened for myocardial contusion with .(ECG) and serum troponin level

50. Summary Chest injuries common Often life-threatening
Require prompt recognition
Require prompt intervention
Airway and oxygenation always priority