CHEST TRAUMA

HOWARD FRIEDLAND DO FACOEP

NICOLE MAGUIRE DO

OBJECTIVES
Anatomical Review of Chest
I Approach to Chest Trauma
I Identifying and Treating Immediately Life
Threatening Conditions.
I Identifying and Treating Potentially Life
Threatening Conditions.
I Diagnostic Studies and Chest Trauma
I

INCIDENCE OF CHEST TRAUMA

I Trauma is the # 1 cause of death in ages 1-

55.
I Chest trauma causes 1 in 4 deaths in
America.
I Less than 10% of Blunt Chest Trauma
requires surgery, where as 15-30% of
Penetrating Chest Trauma requires an
open thoracotomy.

CAUSES OF
BLUNT TRAUMA VS CHEST TRAUMA
I

MVA = 70-80%

FALLS

Act of violence - IE.

bat to chest etc.

Blast Injuries

Low Velocity impalements, knife

wound.
I Medium Velocity bullets from most
hand guns and air
powered pellet guns.
I High Velocity - rifles
and military weapons.
I

THORACIC CAVITY
Superior Border of Thorax - Thoracic Inlet which
holds the major blood supply to and venous
drainage from the neck.
I Superior-lateral Border of Thorax - Thoracic
Outlet, Brachial Plexus, Axillary Vein, Brachial
Artery.
I Inferior Border - hemidiaphragm - holds the
diaphragmatic hiatus = Aorta, Esophagus, Vagal
Nerve, Thoracic Duct and Vena Cava.
I

ANATOMY REVIEW CONTINUED

I Within Chest Wall - Muscles, Ribs,

Sternum,Clavicle, Scapulae.
I Parietal Pleura - inner lining of chest wall.
I Visceral Pleura - invests major organs.
I Pleura Space - potential space between the
two with a small amount of fluid in it.

RESPIRATORY SYSEM
IN 2 LINES OR LESS

I Lungs - Right has 3 lobes, Left has 2 lobes.

I Trachea splits into R and L mainstem

bronchi then divides into lobar bronchi.

Incase you forgot about the heart

I Heart is contained within pericardium.
I Blood flow:

blood is received from the superior and

inferior vena cava ~RA~RV via tricuspid
valve ~ lungs via pulmonic valve ~ LA ~ LV
via mitral valve ~ thoracic aorta via aortic
valve.

Miscellaneous Organs
I Esophagus lies posterior to the trachea.
I To the right of it is the Aortic Arch.
I To

the left of it is the Descending Aorta.

I Thoracic Duct runs posterior and is

proximal to the spinal column, it enters the

Left Subclavian Vein in the neck.

Primary Survey (ATLS)

Physician must begin with ABCs Trauma for any
chest trauma patient:
I A - airway
I B - breathing
I C circulation
I T - thoracotomy
I D - disability - neuro check
I E - exposure - remove clothing, roll person.
I

AIRWAY
I Listen for airway movement at patients

nose and mouth.

I Access intercostal and supraclavicular
muscle retractions.
I Assess oropharynx for foreign body
obstruction, especially in an unconscious
patient.

BREATHING
I Expose patients chest.
I Observe, palpate and listen for respiratory

movement.
I Rate of breathing.
I Breathing pattern - shallow breaths are
ominous.
I Cyanosis - late sign of hypoxia.

Circulation
I Check pulse for quality, rate and regularity.
I Blood Pressure
I Asses and palpate skin for color and

temperature.
I Check neck veins for distention - indication
of cardiac tamponade that may be absent if
patient is hypovolemic.
I Cardiac Monitor - dysrythmia, PVC, PEA

Pulseless Electrical Activity

I
I
I
I
I
I

Hypovolemia
Hypoxia
H+ - Acidosis
Hemothorax
Hypothermia
Hyperkalemia

I
I
I

Tension Pneumothorax
Tamponade
Toxins
Beta Blockers
Digitalis
TCA
Ca++ Channel Blockers
Thrombus
Pulmonary Embolus
Myocardial Infarction

Thoracotomy
I Closed heart massage is ineffective in

patients in PEA with hypovolemia.

I Candidates for ED thoracotomy include
patients with exsanguinating, penetrating,
precordial injuries who arrive in PEA
and there is a SURGEON PRESENT.
I Thoracotomy is usually not effective in
patients with blunt thoracic injuries in PEA.

OPEN THORACOTOMY

THORACOTOMY
I Use of emergent resuscitative thoracotomy

has been reported to result in survival as

follows:
9-57% patients with penetrating
cardiac injury.
0-66% patients with non-cardiac
thoracic injury.
8%
overall survival rate.

SECONDARY SURVEY
I Head to foot exam, remember the back.
I If the patient is unstable a brief history is

applicable at this time =

I A - allergies
I M - medications
I P past medical history
I L last meal eaten
I E - events of trauma

SECONDARY SURVEY (cont)

If the patient is stabilized obtain a more in depth
history including:
I Time of injury.
I Mechanism of Injury - velocity and deceleration
for MVA.
I Complete Physical Exam - including evidence of
injuries to other systems.
I Preliminary tests - CXR, EKG, ABG.
I

IMMEDIATELY LIFE THREATENING

CHEST INJURIES
These conditions are evidenced in the primary
survey:
I Airway Obstruction and Traumatic Asphyxia
I Tension Pneumothorax
I Open Pneumothorax
I Massive Hemothorax
I Flail Chest
I Cardiac Tamponade
I

POTENITALLY LIFE THREATENING

CHEST INJURIES
I These conditions are evidenced in

secondary survey:
I Pulmonary Contusion
I Myocardial Contusion
I Aortic Disruption
I Traumatic Diaphragmatic Rupture
I Esophageal Rupture
I Blunt injuries to SVC and other major veins.

OTHER INJURIES EVIDENCED IN

CHEST TRAUMA
I Rib Fractures
I Clavicular Fractures
I Scapular Fractures
I Blunt injuries to Thoracic Duct.

AIRWAY OBSTRUCTION
I Evidenced in blunt trauma, especially MVA

and blast injuries.

I Will be seen in primary survey during
airway step.
I Readjust head to sniffing position.
If C-spine has been cleared.

I Attempt direct visualization and removal.

I May need fiberoptics for visualization.

Traumatic Asphyxia
I Result of thoracic injury due to strong

crushing injury.

I Signs and Symptoms:

cyanosis of head and neck, subconjuctival

hemorrhage, periorbital ecchymosis,
petechiae, edematous moon-like face,
epistaxis, hemotypmany, LOC, seizure.

TREATMENT OF
TRAUMATIC ASHPYXIA
I Maintain adequate airway.
I Elevate head of bed to 30 degrees to

decrease pressure to the head.

I ICU admission with serial neuro checks.
I Associated injuries of head and torso seen
with this type of injury often need surgery.
I No specific surgery for this condition.

TENSION PNEUMOTHORAX
I A one war air leak that collapses the

affected lung with mediastinal and

tracheal shift to the opposite side.

I Signs and Symptoms:

respiratory distress, tachycardia,

hypotension, tracheal deviation, unilateral
absent breath sounds, neck vein
distension, cyanosis.

TREATMENT OF
TENSION PNEUMOTHORAX
I Immediate Decompression with a 14

gauge needle into the second intercostal

space at midclavicular line of affected
side.

I Definitive treatment - insertion of a chest

tube into the fifth intercostal space

anterior to mid-axillary line.

Pneumothorax

S/P CHEST TUBE INSERTION

OPEN PNUEMOTHORAX
SUCKING CHEST WOUND
I A large defect of the chest wall causing

equilibration between the interthoracic

and atmospheric pressure.
I If the opening is 2/3 or more in diameter of
the trachea, air will prefer to pass through
the open chest wound.
I Signs and Symptoms:
a large open wound of the chest,
respiratory distress.

TREATMENT OF
OPEN PNEUMOTHORAX
I Promptly close the defect with a sterile

dressing taped on 3 sides creating a

flutter-type valve.
I Closure of all 4 sides of the dressing could
cause a tension pneumothorax if chest
tube is not in place.
I Definitive surgical closure of the defect is
required.

Massive Hemothorax
I Accumulation of more than 1500ml of

blood.

I Usually secondary to penetrating wound.

I Signs and Symptoms:

shock, absent breath sounds, dullness to

percussion on one side of the chest.

TREATMENT OF
MASSIVE HEMOTHORAX
I Manage with simultaneous restoration of

blood volume and decompression of chest

cavity.
I CHEST TUBE - 38 french or larger
I Prepare for auto-transfusion with massive
blood loss.
I Thoracotomy.

THORACOTOMY AND
MASSIVE HEMOTHORAX
I Thoracotomy is indicated if there is

>1500ml blood loss or <1500 ml with

continuous loss > 200ml/hr.
I Penetrating anterior wound medial to
nipple line or posterior wound medial to
scapula may need thoracotomy due to
damage to great vessels, hilar structures
or heart.
I Surgeon must be present!

FLAIL CHEST
I Secondary to multiple rib fractures.
I A segment of the chest wall does not have

bony continuity with the rest of the thoracic

cage.
I Major problem is from the injury to the
underlying lung.
I Paradoxical motion alone does not cause
hypoxia, it is the pain with restricted chest
wall movement and lung injury .

SIGNS AND SYMPTOMS OF

FLAIL CHEST
I Poor inspiratory effort.
I Asymmetrical movement of thorax.
I Crepitus of rib or cartilage fractures.

TREATMENT OF
FLAIL CHEST
I Fluids - be careful not to overload patient.
I Adequate ventilation - some patients may

require intubation.
I Humidified oxygen.
I Analgesics.
I Re-expansion of lung via CT if necessary for
pneumothorax.

CARDIAC TAMPONADE
I Usually a result of penetrating injuries.
I Only a small amount of blood in the

pericardial sac is needed to restrict

cardiac activity.

SIGNS AND SYMPTOMS OF

CARDIAC TAMPONADE
Becks Triad:
Muffled Heart Tones
Increased Venous Pressure distended
neck veins (absent with hypovolemia).
Decreased Arterial Pressure Hypotension
I Pulsus Paradoxus decreased pressure during
inspiration in excess of 10mmHg.
I Kussmauls Sign rise in venous pressure with
inspiration while breathing normal.
I

CARDIAC TAMPONADE
SECONDARY TO HEMOPERICARDIUM

TREATMENT OF
CARDIAC TAMPONADE
I Pericardiocentesis use a plastic

sheathed needle if available and enter via

subxyphoid route.
I All patients with a positive
pericardiocentesis secondary to trauma
will require an open thoracotomy.
I Open pericardiotomy may be required if
blood in pericardial sac is clotted.

POTENTIALLY LETHAL CHEST INJURIES

I These injuries are not obvious on initial

exam and require a high index of suspicion

to diagnose them.

I They are evaluated through the secondary

survey and are lethal if not detected and

treated promptly.

PULMONARY CONTUSION
Most common potentially lethal chest injury
I Sx Respiratory failure that occurs over time.
I Comorbidities COPD, renal failure, CHF all
predispose patients for early intubation.
I Treatment closely monitor, pulse oximetry, ABG,
EKG, intubation if necessary.
I Patients with significant hypoxia will need
intubation within the first hour after dx.
I

MYOCARDIAL CONTUSION
I

Patients complain of chest discomfort that may

be misinterpreted as pain secondary to chest
wall injury.

Diagnosis is made via abnormalities on EKG

without any other cause acute MI, multiple
PVCs, unexplained sinus tachycardia, a-fib,
Bundle branch block ST segment changes.

TREATMENT OF
MYOCARDIAL CONTUSION
I Patient is at high risk for sudden

dysrythmias.

I ICU admission with cardiac monitor and

close observation.

I Treat dysrythmias as per ACLS protocols.

TRAUMATIC AORTIC RUPTURE

I Common cause of death after MVA or fall

from a great height.

I Usually fatal at scene.
I Viable patients usually have a tear near
the ligamentum arteriosum and continuity
of the adventitia layer prevents immediate
death.
I Considered a contained hematoma.

SIGNS, SYMPTOMS, AND DIAGNOSTIC

FINDINGS OF AORTIC RUPTURE
Signs and Symptoms are usually absent.
I Pressure usually drops but responds to fluid
resuscitation.
I Radiology Signs widened mediastinum (most
significant finding), fracture of first and second
ribs, obliteration of the aortic knob, deviation of
the trachea to the right, presence of pleural cap,
elevation and R shift of R mainstem bronchus,
depression of the L mainstem bronchus, deviation
of the esophagus (seen via NGT placement).
I

TREATMENT OF
TRAUMATIC AORTIC RUPTURE
I Angiography should be performed liberally

if high index of suspicion of injury.

I Direct repair of the aorta or resection of the

injured area and grafting.

TRAUMATIC DIAPHRAGMATIC
RUPTURE
I

More commonly dx on L secondary to liver

obliterating defect on R.

Blunt Trauma large radial tears that lead to

herniation.

Penetrating Trauma small perforations that take

time even years to develop into hernias.

TRAUMATIC DIAPHRAGMATIC
RUPTURE
I If a laceration of the Left diaphragm is

suspected, place a NGT. If this appears in

the thoracic cavity on CXR need for contrast
study is eliminated.
I Right diaphragmatic rupture is rarely
diagnosed early suspect if there is an
elevated R. diaphragm on CXR.
I Treatment Direct Repair.

ESOPHAGEAL TRAUMA
I Usually due to penetrating trauma.
I Blunt injury causes a forceful expulsion of

gastric contents into mediastinum

mediastinitis and may be lethal if not
recognized.
I Delayed rupture into pleural space may
cause an empyema.

SIGNS AND SYMPTOMS OF

ESOPHAGEAL TRAUMA
I L. pneumothorax or hemothorax without rib

fracture.
I Severe blow to the sternum or epigastrum
with pain or shock out of proportion to
injury.
I Particulate matter in the chest tube after
blood clears.
I Presence of mediastinal air on CXR

TREATMENT OF ESOPHAGEAL TRAUMA

I Confirm with contrast study or

esophagoscopy.

I Wide drainage of the mediastinum and

pleural space.

I Direct Repair of injury.

DIAGNOSTIC STUDIES AND TRAUMA:

LABS
I To aid in confirmation of diagnosis and

monitor patient.
I CBC helps gauge blood loss.
I BMP patients requiring massive fluid
resuscitation should have electrolytes
monitored. Aids with acid-base disorders.
I Coagulation Profile for patients receiving
massive transfusions (look for DIC).

LABS
Type and Cross
I ABG allows you to evaluate ventilation,
oxygenation and acid-base status.
I Cardiac Enzymes correlate with patients EKG,
abnormalities in patients with blunt cardiac
injury (Myocardial contusion).
I Lactate Level measure of tissue perfusion.
Levels that clear quickly = better outcomes.
I

DIAGNOSTIC STUDIES AND TRAUMA:

IMAGING STUDIES
I CXR aids in confirmation of

pneumothorax, hemothorax, cardiac and

great vessel injuries. (Should not wait for
one to confirm clinical suspicion of tension
pneumothorax).
I CT Scan useful in more occult or
undetected injury. CT patients with
possible aortic injuries

IMAGING STUDIES
Aortogram gold standard in diagnosis of aortic
and great vessel injury. If CT is positive for aortic
injury, do aortogram to see exact location and
extent of injury.
I Thoracic US usually done in ED during
secondary survey. May visualize pericardium,
heart, thoracic cavity. Pericardial effusions,
tamponade, and hemothoraces are recognized
with sensitivity and specificity of 90%.
I

DIAGNOSTIC STUDIES AND TRAUMA:

EKG
I Aids in identification of new cardiac

abnormalities and underlying cardiac

problems.
I Important in patients with clinically
significant blunt cardiac injury.
I Most common EKG finding in patients with
myocardial contusion tachyarrhythmia,
first degree blocks, bundle branch blocks.

SUMMARY
Chest Trauma is common in multiple injured
patients and is often associated with life
threatening problems.
I Remember Primary Survey ABCT(rauma)
I Always treat first step of ABCs before proceeding
to the next, a change in vitals start from
beginning.
I Have high suspicion for potentially life
threatening condition in secondary survey.
I