Thoracic Trauma

Initial assessment and management:

ABCs
Airway
Asses airway patency and air exchange by listening at patients
nose and mouth, observe for intercostal/supraclavicular
retractions, assess oropharynx for any FB obstruction
Breathing
Expose patients chest and assess breathing. Assess respiratory
movement and quality of respiration by observing, palpating,
auscultating
Circulation
Assess pulse for quality and rate and regularity
Assess blood pressure
Observe and palpate skin for color and temperature
Check for neck vein distention
Attach cardiac monitor if present
Thoracic Injuries: Secondary Survery

Inspection:
Neck veins distended/collapsed
Chest wall flail chest ?

Palpation:
Crepitation SQ emphysema
Point tenderness rib fracture
Auscultation
Thoracic Injuries: Important Points

Location of penetrating wound noted

NEVER probe

If wound below the 5th rib

Evaluate abdomen

All critically injured patients

Do chest x-ray
 Immediate Life-
Threatening
Deadly Dozen
-12-
Potensial Life-
Threatening
 Obstruksi
Airway

Massive Tension
Haemo Pneumo
thorax thorax

Immediate
(Letal)

Open
Flail Chest Pneumo
thorax

Pericardial
Tamponad
Life threatening chest injuries:
Tension pneumothorax
Tension pneumothorax
Air forced into the thoracic cavity without any means of
escape completely collapsing affected lung
(parenchymal injury fails to seal)
Mediastinum and trachea displaced to the opposite side
compressing opposite lung
s/sx: respiratory distress, tachycardia, hypotension,
absent breath sounds, NVE
Tx: immediate decompression needle/ chest tube
insertion
X-ray:
Tension Pneumothorax
Tension Pneumothorax
Tension Pneumothoraks
Needle decompression for Tension
Pneumothorax
Chest Tube
Life threatening chest injuries: Open
Pneumothorax
Open pneumothorax (sucking chest wound)
Open large defects of the chest wall
If opening in the chest wall is 2/3 diameter of the
trachea, air passes thru the chest defect into the pleural
space with each respiratory effort
Mgt: close defect with occlusive dressing taped securely
on three sides chest tube
Open pneumothorax from chest wall
defect
Close up view of chest wall defect
open pneumothorax
Open Pneumothoraks
Open Pneumothoraks
Cardiac tamponade
Results from penetrating injuries to the heart
Becks triad
Neck vein engorgement (venous pressure elevation)
Hypotension
Muffled/distant heart sounds
Its absence does not rule out presence of tamponade
Suspect Cardiac injury
Penetrating injury: cardiac
tamponade
X-ray: Penetrating Cardiac Injury
Pericardial Tamponade
Flail chest
Segment of chest wall does not have bony
continuity with the rest of the thoracic cage
Associated with 2 point fracture involving 3 or more
consecutive/adjacent ribs
Associated with injury to the underlying lung
pulmonary contusion hypoxia
Mgt: intubation with assisted ventilation, O2
administration, careful fluid administration, provide
adequate analgesia
Flail Chest
X-ray: Flail chest
Flail Chest
Life threatening injuries: Massive
Hemothorax
Massive hemothorax
rapid accumulation of 1500 cc of blood in the chest
cavity
Penetrating injury to the systemic and hilar vessels,
blunt trauma
Initially managed with volume restoration and
decompression of chest cavity
Thoracotomy may be needed: initial drainage of > 1 liter
or with continuous bleeding from the chest tube (>100
cc/hr)
Massive Hemothorax
Massive Hemothoraks
1. Gatot/ / 36 Years Old
Admitted on Wednesday, May 5th 2017 at 11:30 WIB

ANAMNESIS
Shortness of breath with Pain on chest and abdomen after a trafic
accident
His motorcycle got hit by a car from behind. He fell with his chest and
abdomen got run over by the car.
( 1 hour before admission)

PRIMARY SURVEY
A. Clear, trachea in the middle
B. RR : 48 x/mnt, JVP: increased
C. BP : 90/60mmHg
PR : 130x/mnt
T : 36,2 C
VAS : 6
D E4M6V5 GCS 15, isochoric pupils
SECONDARY SURVEY
Head Region
I: Hematome (-)

Chest Region
I : Asimetric Right>left.
Bruise (+) at the right hemithorax
P : Emphysema subcutan at the level of ICS 5
P : Hipersonor on the right hemithorax
A : Vesicular decreased on right hemithorax
Abdominal region
I : Flat, bruise(+) upper right and lower quadrant
P : Defans muscular (+)
P : tympani
A : Bowel sound (+)
DRE
Blood (-)
B: right tension pneumothorax Needle thoracosintesis ->
Vital sign post Needle thoracosintesis
RR : 36x/minute
BP : 160/100mmHg
PR : 98x/minute
Post ches tube dextra
Inisial : 100cc
Undulation : (+)
Expiratory bubble : (+)
Air bubble : (+)

Vital sign:
RR : 30x/minute
BP : 100/60mmHg
PR : 110x/minute
RADIOLOGICAL FINDINGS
Chest X Ray AP
Fracture of rib 3,4,5,6,7 anterior
Pneumothorax sinistra et dextra
Chest tube dextra
RADIOLOGY FINDING
USG FAST
Free fluid (-)
RADIOLOGY FINDING
USG Abdomen dr H.M Yusri SpRad
No lession on solid abdominal organ
No free fluid intraabdominal
INTRA OPERATIF
Inisial : 50cc
Undulation : (+)
Expiratory bubble : (-)
Air bubble : (+)

Post chest tube sinistra

Vital sign
RR : 28x/minute
BP : 110/60mmHg
PR : 106x/minute
LABORATORY FINDING
Hb : 12,5gr/dl (12-16 gr/dl)
Ht : 41 vol % ( 40-48vol%)

DIAGNOSIS
Blunt trauma of the right thoracal region with right tension
pneumothorax + left hemopneumothorax + Fracture of rib 3,4,5,6,7
anterior
Blunt trauma of the abdominal region with no sign of peritonitis

MANAGEMENT
IVFD RL gtt XX/minute (Fluid maintanance 1800cc/24 hours)
Inj Ceftriaxone 1gr/12 hours IV
Inj Ketorolac 30mg/8 jam IV
Chest tube bilateral

Patient was treated in the ward

 Thoracic
Aortic
Disruption

Tracheo
Pulmonary
broncial
Contusion
injuries

Potensial
(Hiden)
Blunt
Oesophag
Byocardial
eal Injury
Injury

Diaphrag
ma
Injuries
Potentially lethal: pulmonary
contusion
Associated with or without flail chest
Result from blunt chest injury or gun shot wound
Respiratory failure develops over time; hemorrhage
into the alveolar and interstitial spaces
Diagnosed by xray radiodense area within the
lung parenchyma
Stable patients managed selectively
Unstable patients with significant hypoxia
intubated with assisted ventilation
X-ray: Pulmonary Contusion Left
Myocardial contusion
Difficult to diagnose
Symptoms nonspecific: chest discomfort
Dx: abnormalities in the EKG or 2D echo
Multiple PVC, unexplained sinus tachycardia, AF, bundle
branch block and ST segment changes
Mgt: expectant, patients admitted at the ICU for
observation and cardiac monitoring
Aortic rupture
Common cause of sudden death after an
automobile collision or fall from a significant height
For survivors, salvage possible if condition
identified and treated early
Tear near the ligamentum arteriosum of the aorta
intact adventitial layer prevents free rupture and
immediate death
Aortic rupture
Diagnosis is difficult; signs and symptoms are
absent; high index of suspicion based on history of
decelerating force and x-ray findings; angiography
is gold standard
X-ray findings:
Widened mediastinum (most consistent finding)
Fracture of the 1st and 2nd ribs
Obliteration of aortic knob
Tracheal deviation to the right
Depression of left main stem bronchus
Deviation of the esophagus (NGT) to the right
Traumatic diaphragmatic rupture
Commonly diagnosed on the left side
Blunt trauma large radial tears that may lead to
herniation
Penetrating trauma small lacerations that take
some time to develop into a diaphragmatic hernia
May be missed initially
Traumatic diaphragmatic rupture
Diagnosis
Chest xray/flouroscopy
Elevated left hemi-diaphragm
Blunted CP angle
Air fluid levels in the mid to lower chest area
NGT within the chest cavity
Ultrasound
Upper GI series
CT scan
Laparoscopy/thoracoscopy
Treatment: surgical
X-ray: diaphragmatic hernia Left (air
fluid level mid to lower lung field)
Upper GI series: Diaphragmatic
hernia
Arrow points to the edge of the
Diaphragmatic defect
Diaphragmatic Defect mobilized and
herniated organs reduced
Repaired Diaphragmatic hernia
Tracheobronchial tree injuries
Larynx
Hoarseness, subcutaneous emphysema, palpable
fracture crepitus
Severe distress intubate, tracheostomy
Trachea
SQ emphysema, dysphonia, hemoptysis, dyspnea
Bronchus
SQ emphysema,pneumomediastinum, air outlining a
bronchus, persistent air leak, unexpanded lung despite
tube
Esophageal injuries
Commonly a result of penetrating injury
Suspected:
Severe blow to the lower sternum or epigastrium and
patient is in pain or shock out of proportion to the
apparent injury
Particulate matter in the chest tube
Mediastinal air
Other manifestations of chest injuries
Subcutaneous emphysema
Simple pneumothorax
Hemothorax
Scapular and rib fractures
Subcutaneous emphysema
Results from injury to the airway or to the lung
parenchyma
No specific treatment if this is the sole finding
O2 administration in selected cases
Simple pneumothorax
Non expanding collection of air in the pleural space
Results from injury to the lung parenchyma with air
leakage, bronchial injury, chest wall injury
PE: dec breath sounds, hyperresonance
Dx: chest PA
Mgt: chest tube insertion and observation in some
selected cases
Simple pneumothorax
X-ray: simple pneumothorax (close up
view)
Hemothorax
Blood within the pleural cavity
Causes:
Lung parenchyma
Intercostal vessels
Pulmonary vessels
Dx: chest x-ray, chest ultrasound
90%, bleeding will stop and can be managed with
CTT, remaining 10% may need thoracotomy
X-ray: Hemothorax Left
Pneumohemothorax
Focus Assessment with Sonography
for Trauma (FAST)
FAST: Pericardial sub-xiphoid scan
FAST: Areas examined
Pericardium (subxiphoid)
Peri-hepatic and hepato-renal space (Right
midaxillary line, between 11th and 12th ribs)
Peri-splenic space (Left posterior axillary line
between the 9th and 10th ribs)
Pelvis (above symphysis pubis)
Rib and scapular fractures
Rib fractures: most common injury involving the
chest wall
Blunt trauma to the chest
s/sx: chest pain, point tenderness, crepitations over
involved rib
Fractures of the 1st, 2nd ribs and scapula may
indicate major injury to the head and neck, lungs
and great vessels
Rib fractures
Fractures of the lower ribs (10-12) possible
hepatosplenic injury
May be a serious problem in the elderly
Diagnosis: chest PA, chest bucky
Treatment:
pain control: oral analgesia, intercostal nerve block,
epidural analgesia
Chest tube if with associated pneumo/hemothorax
Close Tube Thoracostomy
Technique of Chest Tube Insertion
Technique of Chest Tube Insertion