1. Chest injuries
Supervised by:
Dr. Waseem Hajjar

2. INTRODUCTION The chest contains vital organs.
Damage to vital organs threatens life.
Most common consequence is hypoxia.
Chest injuries result in a significant number of deaths each year.
One in every 4 cases of trauma death caused by chest injury.

3. *Chest injuries can be divided into: Immediate life threatening injuries Potentially life threatening injuries

4. Immediate life threatening injuries
Injuries that can cause death in a matter of minutes and, therefore, must be identified and treated during the initial evaluation and resuscitation.

5. Airway obstruction
Tension pneumothorax
Open pneumothorax
Massive heamothorax
Cardiac tamponad
Flial chest

6. Potentially life threatening injuries
Injuries that, left untreated, would likely result in death but that usually allow several hours to establish a definitive diagnosis and institute appropriate treatment

7. Traumatic aortic rupture.
Myocardial contusion.
Tracheal bronchial injury.
Rupture diaphragm.
Esophageal trauma.
Pulmonary contusion.

8. Mechanism of injury : 1) Blunt chest trauma 2) Penetrating trauma
Most common cause of serious chest injuries.
Post RTA, falls, direct blows, and crushing injuries.
Many injuries are not immediately apparent in physical exam.
2) Penetrating trauma
Immediate result can be severe bleeding or impaired breathing.
Any chest wound can involve underlying organ injury.
No matter how superficial it looks.
Injuries to the heart, lungs, and great vessels can quickly lead to shock and cardiac arrest.
3) Iatrogenic

9. Signs and symptoms: Assessment:
Most common symptoms: pain and difficulty breathing.
Signs are obvious injury to the chest wall ( looking at both the front and back of the chest).
Note any subcutaneous emphysema, or air present under the skin
Assessment:
Follow all steps in the assessment of the trauma patient:
Primary survey( A. Airway B. Breathing C. Circulation).
Resuscitation.
Detailed secondary survey (CXR , ABG ,ECG , CT Chest , Aortogram).

10. Management Ensure patient has adequate oxygenation and perfusion
Provide high-flow oxygen, ventilating when necessary
Halt any obvious bleeding
Support circulation when needed
Rapidly transport patient to definitive care

11. Rib fracture
Simple rib fractures are the most common injury sustained following blunt chest trauma
More common in adults than children.
The most common mechanism of injury for rib fractures in elderly persons is a fall from height or from standing. In adults, motor vehicle accident (MVA) is the most common mechanism.

12. Ribs four through nine (4-9) are the most commonly injured.
Ribs commonly fracture at the point of impact or at the posterior angle (structurally their weakest area(.
Ribs four through nine (4-9) are the most commonly injured.
Dr slides its written that ribs 5-9 are the most commonly injured

14. Signs and Symptoms: Pain when breathing or with movement
Patient often presents with guarding and shallow breathing
Chest wall instability
Deformity, discoloration
Local swelling and tenderness may be the only sing of broken rib

15. Complication s of rib fracture:
Chronic chest pain
Lung contusion
Pneumo or hemothorax
Injury to aorta or bronci
Flail chest
Fracture of the 8th to 12th ribs can damage underlying abdominal solid organs:
liver, spleen or kidneyes

16. Management:
Move the patient carefully to prevent the bone ends from puncturing the lung.
Administer O2.
Allow patient to self-splint by assuming the most comfortable position possible.
Encourage patient to limit movement.
Analgesia like Morphine, PCA, Epidural.
Evaluation: hx, px and tests (CBC, CXR and MRI)

17. FLAIL CHEST
Blunt chest trauma, causing extensive anterior and posterior rib fractures or sternocostal disconnection, results in paradoxical chest wall movement

19. Management:
Adequate pain control
Quickly stabilize flial segment by placing gloved hand over injured area
After manual stabilization, place folded universal dressing over segment and tape securely.
Fixation (external, internal)
Chest tube as required
Mechanical ventilation may be required in severe cases.

20. Paradoxical chest movement

21. Post Traumatic Pneumothorax
Types:
Opened pneumothorax.
Close pneumothorax.

22. Open Pneumothorax
An injury in which an open wound in the chest wall has exposed the pleura space to the atmosphere.
The open wound allows air movement through the defect during spontaneous respiration, causing ineffective alveolar ventilation.

24. Signs: difficulty breathing Cyanosis
Diminished breath sounds on the affected side

25. Management:
Cover open chest wounds with occlusive dressing and inserting a thoracostomy tube
Gloved hand is an effective temporary occlusive dressing
High flow oxygen
Transport with unaffected side slightly elevated
Later closure of the wound may be necessary

26. Tension Pneumothorax
Potentially life-threatening condition that must be treated immediately.
Can occur in blunt or penetrating chest trauma.

28. Right sided pneumothorax
Right sided pneumothorax. An arrow indicatingthe edge of the collapsing lung

30. What Happen in Tension Pneumothorax
One-way valve forms in lung or chest wall
Air enters pleural space; cannot leave
Air is trapped in pleural space
Pressure rises
Pressure collapses lung
Shifting of the mediastinum to the contralateral side, which compreses the vena cava and obstructs venous return to the heart.

31. Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation
Decreased breath sounds
Hyperresonance to percussion
Cyanosis
Subcutaneous emphysema
Rapid, weak pulse
Decreased BP
Tracheal shift away from injured side
Jugular vein distension
Early dyspnea/hypoxia - Late shock

32. Management:
The thorax must be decompressed with a needle, which is replaced by an intercostal tube with underwater seal and suction.

33. Hemothorax Sign & symptoms :
Blood in the pleural space .
Most common result of major chest wall trauma
Present in 70 to 80 % of penetrating and major non penetrating trauma .
Sign & symptoms :
Signs of Shock , Frothy Bloody sputum , collapsed neck veins ,cool, clammy skin, chills and restlessness
Source of bleeding :
intercostal vessels, internal mammary vessels , lung parenchyma, bronchial arteries, major pulmonary vessels ,heart and great vessels

35. Management ABC’s : secure airway , assist the breathing with high o2 .
Rapid transport .
A hemothorax is managed by removing the source of bleeding and by draining the blood.
*Indications for urgent thoracotomy
Chest drainage >1250 ml
or >1000 ml with hypotension
or >200 ml per hour for 3 hours

36. Chest tube indicated to drain the contents of the pleural space , usually air or blood ,but may include other contents .

39. Relative indication Absolute indications
Contra-indication:
Refractory 
coagulopathy .
lack of cooperation by the patient
diaphragmatic hernia
Relative indication
Rib fracture & positive.
pressure ventilation.
Profound hypoxia/ hypotension and penetrating injury.
Profound hypoxia / hypotension and unilateral hemothorax.
Absolute
indications
Pneumothorax (tension , open or closed )
Hemothorax .
Bilateral traumatic arrest

40. Pulmonary contusion
Bleeding into the lung itself is a pulmonary contusion
The excess fluid interferes with gas exchange , potentially leading to inadequate oxygen levels (hypoxia) .
occurs in 25–35% of all blunt chest trauma .
About 70% of cases result from motor vehicle collision .

41. Sign & symptoms: Diagnosis :
Soft crackles may be heard over injury site
Chest pain, point tenderness, and localized swelling over area of impact
Diagnosis :
X-ray
CT is a more sensitive test for pulmonary contusion

42. A CT scan showing a pulmonary contusion (red arrow) accompanied by a rib fracture
(blue arrow)

43. Management : Supply high-flow supplemental oxygen . analgesics.
Support ventilation as needed with
Mechanical ventilation (in the patient with worsening pulmonary insufficiency).

44. Cadiac inuries 1 )Pericardial tamponade :
 Emergency condition in which fluid accumulates in the pericardium (the sac in which the heart is enclosed).
Usually result from a penetrating chest trauma with laceration to the heart itself .
Blood filling the pericardial sac compresses the heart, witch prevents the heart's ventricles from filling properly. This in turn leads to a low stroke volume
The end result is ineffective pumping of blood , shock , and often death.

45. Sign & symptoms: Management :
The classical cardiac tamponade presents three signs known as Beck's triad. (Hypotension , jugular-venous distension , and muffled heart sounds )  .
other signs , like pulses paradoxux and ECG changes as well as general signs & symptoms of shock .
Management :
ABC’s With High Flow oxygen .
Treat S/S of shock .
Notify Hospital and ALS Unit as soon as possible
Pericardiocentesis :Using aseptic technique, Insert at least 3” needle at the angle of the Xiphoid Cartilage at the 7th rib.

46. 2 ) Myocardial contusion :
Common site: Rt ventricle
Considered in trauma patients with blunt chest injury and unexplained hypotension or ECG abnormalities
Diagnosis :
clinical eg: fractured sternum
ECG: (arrhythmia, ST elevation).
CPK-MB
Echocardiography

47. Management : ABC + high flow o2, ventilation support as needed
Cardiac monitor
Antiarrhythmic drugs.
Inotropic support.
request ALS backup .

48. Blood vessel injuries Aortic injury (Traumatic aortic rupture) :
The aorta is torn or ruptured as the result of trauma.
It s frequently fatal due to the profuse bleeding 
Occurs when the body suddenly decelerates but the organs continue to move.
Common sites: The most common site of injury is the aortic isthmus ,
Symptoms-signs: sever chest or back pain, weak or absent femoral pulses, unequal arm BPs .

49. Diagnosis
After a clinical evaluation, most patients are best evaluated wit CXR followed by Chest CT or Angiography.
however CXR demonistrat a classical finding

50. widened mediastinum. blurred aortic knob.
Aortopulmonary window opacification.
First or second rib #.
NG tube deviation.
Depressed Lt mainstem bronchus.
Pleural apical capping.
Widened paratracheal stripe.

51. Management
ABC’s
Surgical repair, usually with cardiopulmonary bypass technique

52. Diaphragmatic Rupture
Common site: Lt hemidiaphragm
Symptoms-signs: dyspnea, orthopnea, chest pain, bowel sounds in the chest

53. Diagnosis
CXR: NG tube or bowel in the chest, gastric distention with ipsilateral lung collapse.
Management
surgical repair

54. THANK YOU