1. Chest Trauma 19thApril 2013 Kenyatta National Hospital
Dr. Josiah Ruturi
Thoracic and Cardiovascular Surgeon .

2. Approximately 150,000 people die each year in the United States as a result of trauma.
25% of the deaths can be directly related to thoracic injury.
Almost all patients with thoracic trauma are treated conservatively with a successful outcome.
urgent operative treatment was required in only:
- 0.5% of blunt thoracic injuries.
- 2.8% of penetrating thoracic injuries .

3. OBJECTIIVES
Identify and initiate treatment of life-threatening thoracic injuries
Primary survey
Secondary survey
Procedures
Special considerations

6. Immediate Life-Threatening Injuries
Airway obstruction
Tension Pneumothorax
Open Pneumothorax
Massive Hemothorax
Flail Chest
Cardiac Tamponade

7. Potentially Life-Threatening Injuries:
Pulmonary Contusion
Myocardial Contusion
Aortic Disruption
Traumatic Diaphragmatic Rupture
Tracheobronchial Disruption
Esophageal Disruption

8. An unstable hemodynamic state :
1. Traumatic cardiac arrest or near arrest and
an Emergency department thoracotomy.
2. Cardiac tamponade
3. Persistent ATLS class III shock despite fluid
resuscitation
(blood loss 1500–2000 mL, pulse rate > 120,
blood pressure decreased)
4. Chest Tube output > 1500 mL of blood on insertion
5. Chest Tube output > 500 mL/hour for the initial hour
6. Massive hemothorax after chest tube drainage

9. Primary Survey Airway: patency, retractions, obstruction
Breathing: exposure, rate, pattern, cyanosis
Circulation: *Pulses, color, *neck veins, monitor for arrythmias
*hypovolemic patients might not exhibit

11. Initial Management
Airway - with cervical spine control - tracheobronchial tree disruption
Breathing - tension/open pneumothorax, flail chest, lung contusion
Circulation - cardiac tamponade, hemothorax, cardiac contusion, aortic disruption

12. Specific signs and symptoms Pneumothorax
Tension Pneumothorax
Hypotension, tracheal deviation, distended neck veins
Pneumothorax
No signs, tachypnea, tachycardia, decreased breath sounds, hyperresonance, SQ emphysema
Pneumomediastinum
Hamman’s sign, SQ emphysema

13. Subcutaneous Emphysema
Airway, Lung or Blast injury
esophageal injury: Boerhaave’s
Adjacent penetrating wound
Progression to tension pneumothorax

14. Pneumothorax

15. Pneumothorax -Treatment
<15% -very small spontaneous can be given 100% O2 in ED and observed
<25% - simple pneumothorax can be aspirated through a small catheter
Larger pneumothoraces/ underlying lung dz –tube thoracostomy
Pneumonediastinum – conservative

16. Tension Pneumothorax “one-way valve”: air enters, can’t exit
displacement of mediastinum/trachea
decreases venous return, displaces opposite lung
Causes: spontaneous pneumothorax, blunt chest trauma, penetrating trauma

17. Tension Pneumothorax

18. Pleural margin; partial lung collapse
Tension Pneumothorax
A: Air under tension in left thorax A
Pleural margin; partial lung collapse B
B: Collapsed right lung
Left
Right

19. B: pressure of tension pneumothorax pushing midline structures (heart, mediastinum) into patient’s left thoracic cavity
A: air, under tension, in thoracic cavity A B
Heart B
Right
Left

20. Tension Pneumothorax Clinical manifestations in patient with
Spontaneous breathing
Respiratory distress
Florid face
Tracheal deviation
Distended neck veins
Tachycardia
Hypotension

21. Needle Thoracentesis
Indication: Rapidly deterioration with tension pneumothorax.
Equipment
Povidone-iodine solution
14-gauge catheter-over-needle device
Technique
Cleanse overlying skin
Insert needle at 2nd or 3rd intercostal space, midclavicular line, over top of rib
Leave catheter in pleural space open to air

22. Sucking Chest Wound AKA communicating pneumothorax
Large defects: if opening > 2/3 trachea, air will pass preferentially.
Cover immediately with cleanest occlusive dressing
3 sides vs 4 sides

23. Massive Hemothorax >1500 cc blood Mechanism:
Penetrating injury of systemic or hilar vessels, especially wounds medial to nipples, scapulas.
Blunt trauma
Loss of Breath sounds, dullness to percussion

24. Flail Chest No bony continuity with rest of cage
Multiple rib fractures, paradoxical movement
Hypoxia from injury to underlying lung
30% missed in first 6 hours

25. Flail chest is a marker for significant injuries
Retrospective analysis, 92 pat, L-1 center.
46% had pulmonary contusion
70% had pneumo or hemothorax
Great vessel, tracheobronchial injuries had no associated.
27% developed ARDS
69% required mechanical ventilation
33% mortality
Ciraulo DL et al. J Am Coll Surg 1994;178(5):466. (Penn)

26. Traumatic Aortic Injury
Retrosternal/intrascapular pain
Dyspnea, hoarseness, dysphagia, HTN
Pseudocoarctation syndrome
Hypotension
Harsh systolic murmur (AI)
50% without external findings

31. Cardiac Tamponade Penetrating injuries most common Beck’s Triad
Kussmaul’s sign (rise in CVP with inspiration)
Mimic: tension pneumo on left side
EKG: electrical alternans (rare)

32. Management of Tamponade:
Cautious fluid management
Pericardiocentesis: cc may immediately improve hemodynamics
Open thoracotomy and inspection

33. Pericardiocentesis Indications Immediate threat to life
Severe hemodynamic impairment
Fall in systolic blood pressure >30 mm Hg

34. Pericardiocentesis Technique
Patient in supine position, upper torso elevated
ECG limb leads attached to patient
Use echocardiography guided procedure (rarely: ECG-guided, V lead)
Subxiphoid approach
Continuous aspiration

36. Pulmonary Contusion Determinants of outcome ISS > 25
Initial GCS < 7
Transfusion > 3 U blood
pO2/FiO2 < 300
Not correlated to shock or IV fluid administration
Extent of contusion seen on initial chest X-ray
not predictive of mortality or intubation.
Johnson JA et al. J Trauma 1986; 26(8):695.

37. Diaphragmatic Rupture
Blunt trauma: large tears
Penetrating: small tears, subtle
More commonly diagnosed on the left

38. Tracheobronchial Tree
Larynx
Hoarseness
Subcutaneous emphysema
Palpable Fracture
Crepitus
Trachea:
Noisy breathing
Penetrating injuries: esoph, carotid artery, jugular vein trauma

39. Scapular and Rib Fractures
Splinting impairs ventilation
Majority – optimise pain mx
Scapula, often indicate major injury to the head, neck, spinal cord, lungs and great vessels: mortality > 50%
pain, tenderness, crepitus

40. Sternal Fractures Mortality 25-45% Underlying injuries to myocardium
Flail segment

45. Penetrating Cardiac Injury
Ventricles: will self seal more commonly
RV>LV>RA>LA
56-66% overall survival
87% survival in OR thoracotomy
Positive predictors: VS on admission, short transport, SW

46. penetrating cardiac injury
A combination of:
- unstable patient: aggressive operative intervention
- stable patient: ultrasound evaluation
provided an overall survival of 40% in the patients with known cardiac injury.
The diagnosis of a traumatic pericardial effusion can be made by the visualization of an echolucent region between the heart and pericardium,
right ventricular diastolic collapse will confirm tamponade.
ultrasound imaging appears to be with an accuracy, sensitivity, and specificity that exceeds 95%

47. Classification of Mediastinal Injuries
M1= base of the neck into mediastinum or
pleura
M2= one pleural cavity and mediastinal
violation
(central hematoma, visceral or spinal
cord injury,metallic fragments in the
mediastinum)
M3 = parasternal injury within the nipple line
or < 4 cm from the sternum
M4 = two pleural cavities and mediastinal
traverse.

48. M4 - All of the mediastinal traverse injuries were caused
by gunshot wounds
- this trajectory had the highest rate of instability and
subsequent operative intervention.
- the highest observed mortality rate (60%),
M1 - Injuries from a cephalad direction were predominately stab
wounds.
- were responsible for the second highest incidence of instability
and subsequent operative intervention.
The presence of a gunshot wound, was associated
with significant risk of both instability and death.

50. Penetrating Chest Trauma
Low chest SW: 15% intraperitoneal, 15% require operative intervention (diaphragm)

51. Pediatric Chest Trauma
Compliance = internal injury
Mobility = tension pneumos, flail chest
Bronchial and diaphragmatic injuries
Infrequent injuries to great vessels

58. Summary Thoracic trauma is common in multiply injured patients
Life- threatening problems may be temporarily relieved by simple measures
Injury recognition important
High index of suspicion for occult injuries