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Thoracic Trauma
BY : dr. ADRIAN KHU,SpOT
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Objectives
 Indentify and treat injuries found during the
primary survey.
 Indentify and treat injuries found during the
secondary survey.
 Demonstrate the ability to perform life
saving chest management.
• Indications
• Contraindications
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Thoracic Trauma

 1 out of 4 deaths
 Blunt : < 10% require operation
 Penetrating : 15% - 30% require operation
 Majority : require simple procedures
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Initial Assessment/ Management

Primary Survey
 Identifies most life -threatening injuries

Resuscitation
 Airway control

 Ensure oxygenation/ventilation

 Needle / tube thoracostomy

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Initial Assessment/Management
Secondary Survey Definitive Care
 Identifies most  Airway control
potentially lethal  Ensure oxygenation
/ventilation
injuries
 Tube thoracostomy
 Physical exam/
 Hemodynamic
diagnostic tests
support
 Operation
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Life threatening Chest Trauma

Primary Survey
 Airway obstruction

 Tension pneumothorax

 Open pneumothorax

 Flail chest

 Massive hemothorax

 Cardiac tamponade
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Airway Obstruction
Laryngeal injury
 Rare occurrence

 Hoarseness

 Subcutaneous emphysema

 Treatment

• Intubation (caution)
• Tracheostomy (by surgeon)
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Breathing

Tension pneumothorax: Etiology

 Parenchymal and / or chest-wall injuries

 Air enters pleural space with no exit

 Positive pressure ventilation

• Collapse of affected lung

• ↓ Venous return
• ↓ Ventilation of opposite lung
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Breathing
Tension Pneumothorax : Signs / Symptoms
• Respiratory distress
• Distended neck veins
• Unilateral ↓in breath sounds
• Hyperresonance
• Cyanosis, late
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Breathing
Tension
Pneumothorax
 Immediate

decompression
 Clinical diagnosis,

not by x-ray
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Breathing
Open Pneumothorax
• Cover defect
• Chest tube
• Definitive operation
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Breathing
Flail chest
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Breathing
Flail Chest/pulmonary Contusion
 Reexpand lung

 Oxygen

 Judicious fluid management

 Intubation as indicated

 Analgesia
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Circulation
Massive Hemothorax
 ≥ 1500 ml blood loss

 Systemic / pulmonary vessel disruption

 Flat vs distended neck veins

 Shock with no breath sounds and /or

percussion dullness
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Circulation
Massive Hemothorax
 Rapid volume restoration

 Chest decompression and x-ray

 Autotransfusion

 Operative intervention
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Circulation
Cardiac Tamponade
• ↓Arterial pressure
• Distended neck veins
• Muffled heart sounds
• PEA
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Circulation
Cardiac Tamponade
 Patent airway

 IV therapy

 Pericardiocentesis

 Pericardiotomy
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Resuscitative Thoracotomy
• Qualified surgeon presnt on patient’s arrival
 Indications

• Penetrating thoracic injury

• Pulseless with electrical activity
 Contraindications

• Blunt injury
• Pulseless without electrical activity
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Potentially- Lethal Chest Trauma

Identified by :
 In –depth examination

 Upright chest x-ray, if possible

 ABGs

 Pulse oximetry

 ECG
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Potentially- Lethal Chest Trauma

 Simple pneumothorax
 Hemothorax
 Pulmonary contusion
 Tracheobronchial tree injury
 Blunt cardiac injury
 Traumatic aortic disruption
 Traumatic diagpramatic injury
 Mediastinal traversing wounds
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Secondary Survey
Pneumothorax
 Penetrating /blunt

trauma
 V / Q defect

 Hyperresonance

 ↓ Breath sounds

 Tube thoracostomy
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Secondary Survey
Hemothorax

 Chest – wall injury

 Lung /vessel
laceration
 Tube thoracostomy
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Secondary Survey
Pulmonary Contusion
 Most common

 Oxygenate , ventilate

 Selective intubation
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Secondary Survey
Tracheobronchial injury
 Frequently missed
 Treatment
injury
• Airway
 Blunt / penetrating

trauma ventilation
 Partial vs complete • Operation
 Diagnostic aid : Endoscopy
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Secondary Survey
Blunt Cardiac Injury
 Injury spectrum

 Abnormal ECG : Monitor changes

 Echocardiography

 Treat : Dysrhythmias, Q, complications

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Secondary Survey
Traumatic Aortic
Rupture
 Rapid acceleration/

deceleration
 Ligamentum

arteriosum
 Salvage : identify early

 Surgical consult
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Secondary Survey
Diaphragmatic Rupture
 Most diagnosed on left

 Blunt → large tears

 Penetrating → small

perforations
 Misinterpreted x –ray

 Contrast radiography

 Operation
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Mediastinal Traversing wounds

Hemodynamically Abnormal
 Exsanguinating thoracic hemorrhage

 Tension pneumothorax

 Pericardial tamponade

 Esophageal / tracheobronchial injury

 Spinal cord injury

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Mediastinal Traversing Wounds

Hemodynamically Abnormal
 Treatment
• Bilateral tube thoracostomies
• Emergent surgical consultation
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Mediastinal Traversing Wounds

Hemodynamically Normal
 Vascular : Angiography

 Tracheobronchial : Bronchoscopy

 Esophageal Esophagography,

esophagoscopy
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Mediastinal Traversing Wounds

Hemodynamically Normal
 Treatment

• Mandatory surgical consultation

• Repair identified injuries
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Secondary Survey
Subcutaneous
Emphysema
 Airway injury

 Pneumothorax

 Blast injury
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Secondary Survey
Traumatic Asphyxia
 Petechiae
 Swelling

 Plethora

 Cerebral edema
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Secondary Survey
Sternal, Scapular, and Rib Fracture:
Pathophysiology
 Hemopneumothorax
 Pain Splinting

 Retained secretion
 Associated injuries

 Atelectasis pneumonia
 Impaired ventilation

 Pulmonary contusion
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Secondary Survey
Sternal, Scapular, and Rib Fractures
 Ribs 1- 3

• Severe force
• Associated injuries → High mortality risk
 Ribs 4 – 9
• Pulmonary contusion
• Pneumohemothorax
 Ribs 10 – 12 : Suspect abdominal injury
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Secondary Survey
Sternal, Scapular, and Rib Fractures :
Management

 Chest x – ray  Adequate pain

 Chest tube as relief
 Treat associated
necessary
injuries
 Selective  No constrictive
 ventilation devices
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Secondary Survey
Esophageal Trauma
 Blunt vs penetrating

 Severe epigastric blow

 Pain, shock > injury

 Pneumohemothorax without fracture

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Secondary Survey
Esophageal Trauma
 Chest tube :

Particulate matter
 Mediastinal air

 Contrast swallow,

esophagoscopy
 Operation
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Secondary Survey
Other indication for Tube Thoracostomy
 Suspected, severe lung injury

• Air or ground transfer

• General anesthesia
• Positive pressure ventilation
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Pitfalls
 Simple pneumothorax → tension
pneumothorax
 Retained hemothorax
 Diaphragmatic injury
 Delayed diagnosis of aortic injury
 Severity of rib fractures pulmonary
contusion
 Elderly
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Questions
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Summary
 Common in multiply injured
 Life – threatening injuries
 Develop skills to treat
 Monitoring