1. CDR JOHN P WEI, USN MC MD 4th Medical Battallion, 4th MLG BSRF-12
CHEST TRAUMA
CDR JOHN P WEI, USN MC MD
4th Medical Battallion, 4th MLG
BSRF-12

2. CHEST TRAUMA Blunt versus penetrating trauma
Injury dependent on mechanism
Motor vehicle accident
Fall from height
Physical assault
Explosive blast
Gunshot wound
Stab wound

3. CHEST TRAUMA Blunt force injuries from assault or fall from height
Bony fractures
Lung injuries
Cardiac contusion

4. CHEST TRAUMA
Acceleration : Deceleration Injuries

5. CHEST TRAUMA
Penetrating injuries:
Gunshot wounds
Stabbing wounds

6. CHEST TRAUMA
Improved field diagnosis and treatment of life threatening conditions
Rapid evacuation to higher level of care
High risk of death despite acute intervention
Need for prompt diagnosis and treatment

7. CHEST TRAUMA Chest wall and ribs Lungs and pleura
Great and thoracic vessels
Heart and mediastinal structures
Diaphragm

8. CHEST TRAUMA Common Injuries Rib fractures Sternal fractures
Open or Closed Pneumothorax
- unilateral / bilateral
Hemothorax
Hemopneumothorax

9. CHEST TRAUMA Clinical consequences associated with:
Mechanism of injury
Location of injury
Associated injuries
Co-morbidities

10. CHEST TRAUMA Blunt injuries managed non-operatively
Management of airway / oxygenation
Analgesia
Intubation and ventilator support if needed
Chest tubes if needed for pneumothorax or hemothorax

11. CHEST TRAUMA PENETRATING INJURIES Trajectory across chest
Mechanism due to knife or gunshot
Type of bullet

12. CHEST TRAUMA INITIAL MANAGEMENT Airway, Breathing, Circulation
PRIMARY SURVEY
Identify & treat immediately life threatening conditions

13. CHEST TRAUMA
Early intervention directed toward diagnosing and treating:
Tension pneumothorax
Massive hemothorax
Open pneumothorax
Cardiac tamponade
Flail chest

14. CHEST TRAUMA RADIOLOGIC TESTS Chest X-ray, usually portable
Abdominal KUB and FAST Ultrasound Exam
CAT scan, and CT Angiogram if needed

15. CHEST TRAUMA Rib Fractures Physical Diagnosis: Deformity
Localized pain
Crepitus
Treatment:
Analgesia (PCA)
Pulmonary toilet
Observe for pneumothorax

16. CHEST TRAUMA 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

17. CHEST TRAUMA Flail Chest Diagnosis: Paradoxical chest wall movement
Poor air movement
Hypoxia
Therapy:
Pain control
Pulmonary & physical therapy
Intubation and ventilator support if needed
Fluid restriction if possible

18. CHEST TRAUMA Pneumothorax or Hemothorax
most treated with simple tube thoracostomy

19. CHEST TRAUMA Decompression of Tension Pneumothorax large bore needle
2nd intercostal space
midclavicular line
Chest tube as definitive treatment

20. PULMONARY CONTUSION Common with blunt trauma
May be associated with laceration of lung parenchyma
Leakage of blood and fluid into interstitial spaces of lung
Significant inflammatory reaction to blood components in the lung

21. PULMONARY CONTUSION
Parenchymal infiltrate seen on CXR adjacent to injured chest wall

22. PULMONARY CONTUSION Indications for intubation Respiratory distress
Hypoxia
Other injuries which compromise respiratory effort, such as abdominal or neurologic

23. MYOCARDIAL CONTUSION Physical bruising of the cardiac muscle
Associated with fractures of the sternum
Any severe anterior chest injury

24. MYOCARDIAL CONTUSION DIAGNOSIS: Ectopy ST elevation Tachycardia
Friction rub
CPK enzymes, Troponin
Monitor in ICU & treat dysrhythmias
Serial enzymes
Analgesia

25. MASSIVE HEMOTHORAX From blunt or penetrating injuries
200cc – 1L in chest cavity seen on CXR
Treat with chest tube, if immediate drainage is 1500 cc or if 250 cc/hr for 4 hours, then immediate thoracotomy
Bleeding may be from ribs, lung, blood vessels

26. AORTIC RUPTURE Abrupt deceleration or compression injury
Sudden motion of heart / great vessels in chest
Great vessel injury may occur in 0.3 => 10% penetrating trauma
Often rapidly fatal
10% survive to hospital
20% survive > 1 hour
90% who reach hospital will die
Early diagnosis and treatment

27. AORTIC RUPTURE
mechanism of injury
widened mediastinum on CXR

28. AORTIC RUPTURE CT with contrast angiogram
Contained injury treat with BP control
Operative repair

29. CARDIAC INJURY AND TAMPONADE
Fatality rates > 80%
Mostly ventricular, right > left
Blood in pericardial sac causes tamponade
Occurs with penetrating injuries

30. DIAPHRAGM RUPTURE Associated with blunt trauma or blast injury
Can be due to stab wounds

31. DIAPHRAGM RUPTURE
Surgical repair to replace herniated contents back into abdomen
Close muscular diaphragm to restore pulmonary function
Chest tube to treat pneumothorax

32. ESOPHAGEAL INJURY Most due to penetrating trauma
Difficult to diagnosis
If delayed or missed, rapid sepsis & high mortality
Radiography
Endoscopy
Thoracoscopy
Treatment: surgical repair via thoracotomy

33. EMERGENCY THORACOTOMY
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

34. ER THORACOTOMY
survival rates < 8%

35. ER THORACOTOMY BLUNT injury with arrest Arriving without pulse/BP
Penetrating injury with arrest
High likelihood of isolated / correctable intra-thoracic injury
ER THORACOTOMY in presence of :
pulse
blood pressure
organized cardiac activity

36. CHEST TUBE INSERTION Insertion Site
mid or anterior axillary line behind pectoralis major
above 5th rib avoid diaphragm

37. CHEST TUBE INSERTION
Connect tube to underwater seal and suture in place
Examine chest to check effect
CXR to check placement and position

38. SUMMARY
Chest trauma may be due to blunt, penetrating or combination of causes
Organs at risk include bony, hollow, as well as cardiovascular structures
Immediate life threatening conditions need to be treated
Maintenance of airway, oxygenation, and control of hemorrhage are important goals