NeCK TRAUMA

NECK TRAUMA

The optimal management of patients with

neck injuries is challenging.

Seemingly minor injuries can quickly

become life threatening.

Missed injuries and delayed diagnosis can

result in serious complications and death.
 Overview
 Neck has:
 Complex anatomy
 Many organ systems
 Each requiring evaluation:
 Vascular
 Respiratory
 Digestive
 Neurologic
 Endocrine
 Skeletal
 Mechanism
NECK TRAUMA

• Stab wound
 What you see is what you get

• GSW
 Unpredictable trajectory
 Thermal injury
 Maintain high level of suspicion
 NECK TRAUMA
To guide the clinician for proper
management, the neck is divided into three
zones:
Zone I – from clavicles to cricoid cartilage;
Zone II – from inferior margin of cricoid
cartilage to the angle of the mandibles;
Zone III – from the angles of the mandible to the
base of the skull
 Anatomy: Zones
NECK TRAUMA
 Anatomy: Zones
NECK TRAUMA
 NECK TRAUMA

 Patients with symptoms, hemodynamic

instability, or signs of underlying injury
(e.g., expanding or pulsatile hematoma)
require immediate surgical exploration.

 Management of asymptomatic patients with

penetrating neck trauma generally depends
on the zone injured:
 NECK TRAUMA

A. ZONE I and III injuries: may initially be

evaluated non-operatively.

1. For potential vascular injuries,

angiography or Duplex
Ultrasonography imaging is indicated
for diagnosis.
2. To assess potential injuries to the
oropharynx and esophagus, larynx and
tracheo-bronchial tree, endoscopy is
indicated
 NECK TRAUMA

B. ZONE II injuries are traditionally

managed by performing an urgent neck
exploration, although some centers are
now evaluating some of these patients
non-operatively.
 Cervical Vascular Injury: Signs

• Shock

• Hemorrhage

• Hematoma

• Evolving stroke

• Pulse  differential in upper extremities

• Bruit or thrill
 Vascular Injuries

NECK TRAUMA

• Zone II vascular injuries readily apparent

• Zone I and III injuries more difficult to detect

due to anatomical constraints:
 32% of patients with major Zone I
vascular injury had no localizing findings
 Vascular Injuries
NECK TRAUMA

• Angiography: adjunctive diagnostic tool

• Arteriogram can also be therapeutic with

embolization (works especially well in Zone
III where vessels are smaller)

• Duplex exam:
 In qualified centers may be acceptable
alternative to angiography
 Vascular Injuries: Treatment
NECK TRAUMA

• In general, vessels should be repaired rather

than ligated

• Carotid injuries should be repaired unless there

is an already established dense neurologic deficit
with edema (revascularization may convert
ischemic to hemorrhagic infarct)

• If bypass is needed, PTFE (polytetrafluoroethylene) preferred

over saphenous vein graft
NECK TRAUMA
Management: Vascular Injuries
 Laryngo-tracheal Injury: Signs

NECK TRAUMA

• Subcutaneous emphysema
• Sucking wound
• Hemoptysis
• Dyspnea
• Stridor
• Hoarseness or dysphonia
NECK TRAUMA

Tracheal Injury: Treatment

• Thorough laryngoscopy

• Primary repair is the rule, tracheal

mobility allows closure of defects up to
2-3cm

• Absorbable suture is used

• Tracheostomy rarely indicated, only for

a large defect (increases risk of
infection)
NECK TRAUMA

Esophageal Injury: Signs

• Often clinically silent

• Milder subcutaneous emphysema

• Bloody saliva

• Dysphagia or odynophagia

• Fever (late)
NECK TRAUMA

Esophageal Injury: Treatment

• Early detection of injury is important

 If repaired < 24hrs, survival 90%

 If repaired > 24 hours, survival 64%

• Best detected by combination of

esophagoscopy and esophagography
(sensitivity near 100%)

• Rigid / flexible endoscopy both acceptable

NECK TRAUMA

Esophageal Injury: Treatment

• Operative repair:
 Primary closure is ideal (esp < 24 hrs)
 Close over a T-tube
 Buttress with muscle flaps or pleura
 Divert with esophageal stoma
 Widely drain
• Fistula rate up to 57%
• Consider routine swallow studies
NECK TRAUMA

Spinal Injury: Signs

• Neurologic defect

• Spinal shock
 Hypotensive, often not tachycardic
(but in a hypotensive trauma patient
with tachycardia, always assume
hemorrhagic shock first)
NECK TRAUMA

Spinal Injury: Treatment

• Can only prevent further injury

• Steroids

 Appear to have some benefit in blunt

trauma, but no evidence for routine
use in penetrating trauma
NECK TRAUMA
Spinal Injury: Treatment

• Steroids (Methylprednisolone) I.V.

 Give in the first 24 hours – better to start
within hours
 Start: 30 mg/kg.b.w. to be infused within
one hour
 Then: 5.4 mg/kg.b.w./hour to be infused
during the remaining 23 hours
(Total dose in 24 hours = 154.2 mg/kg.b.w.)
NECK TRAUMA
Algorithm
Soft and Hard Signs of Penetrating Neck Trauma
NECK TRAUMA
Conclusions
• Know the anatomy

• Neck exploration is no longer

mandatory in asymptomatic patients

• Physical examination is probably the

most useful diagnostic tool (especially
Zone II)

• Non-invasive diagnostic / therapeutic

modalities should be utilized
ChesT TRAUMA
 CHEST TRAUMA

 The chest contains the two most vital

of the life sustaining organs, the
heart and lungs.

 Unless these injuries are treated

quickly within a short period of time
death often occurs rapidly.
Pleural Anatomy Visceral Parietal
pleura pleura
Lung

Intercostal Rib
muscles

Normal Pleural Fluid

Quantity: Approx. 10-20
mL per lung
 Pleural Physiology

o The degree of negativity

changes throughout the
respiratory cycle
o Ranges from (–4) to (–10) cm
of water
o On inspiration pressure
drops to (–10) cm water
o On expiration pressure rises
up to (–4) cm water
o It is the pressure variance
that allows the air to move in
and out easily
 CHEST TRAUMA

Chest injuries are particularly serious in patients

with impaired physiologic reserves.
Individuals who fall into this category are:
 The elder
 The obese
 Cardiac subjects
 Those with chronic respiratory diseases:
 Chronic bronchitis, Asthma, Emphysema,
Pulmonary T.B.
 CHEST TRAUMA

 Every injury must be looked upon as

potentially lethal until proved otherwise.
 The most common traumatic problems
requiring urgent relief:
 Immediate life-threatening injuries:
 Are those that can cause death in a matter of
minutes and, therefore, must be rapidly
identified and treated during the initial
evaluation and resuscitation; they are : 
 Immediate life-threatening injuries of the Chest

 Airway obstruction
 Tension Pneumothorax (valve on the lung in 90-95%, or in
the chest wall in 5-10%)
 Open Pneumothorax
 Flail chest – Anterior, Lateral, Posterior
 Massive hemothorax
 Cardiac tamponade - Clinical presentation: includes
hypotension with neck vein distention and decreased heart
sounds (Beck’s triad). Echocardiography plays an important
role in the diagnosis.
Pericardial lacerations from stab wounds tend to seal and cause
tamponade, whereas gunshot wounds leave a sufficient
pericardial opening for drainage into the pleural cavity.
 CHEST TRAUMA

Potentially life-threatening injuries:

Are those that, left untreated, would

likely result in death, but that
usually allow several hours to
establish a definitive diagnosis and
institute appropriate treatment:
 CHEST TRAUMA
: Potentially life-threatening injuries

 Tracheo-bronchial leak
 Aortic disruption
 Diaphragmatic disruption (could be also
immediately life-threatening)
 Esophageal disruption
 Cardiac contusion
 Pulmonary contusion
 CHEST TRAUMA

OTHER INJURIES:

 Soft tissue contusions

 Simple rib fracture

 Closed Pneumothorax – minimal

(marginal), moderate, massive

 Hemothorax – minimal, moderate, massive

 CHEST TRAUMA

OTHER INJURIES:

 Lung laceration

 Lung hematoma
 Thoracic duct injury

The occurrence of chylothorax after trivial

injury should lead one to suspect
underlying malignancy.
 DIAGNOSTIC
APPROACHES
IN
CHEST INJURIES
 Non-penetrating
Defects affecting wounds
outer region Penetrating
Defects affecting wounds
inner region Perforating
Defects affecting wounds
innermost region

Injuries of upper
thoracic zone

Injuries of middle
thoracic zone

Injuries of lower
thoracic zone
 Subcutaneous emphysema

With pneumothorax Without pneumothorax

Inspiration Flail Chest Expiration

Inspiration Open Expiration

Pneumothorax
 Closed Hemothorax Lobar and segmental
atelectasis (secretional
pneumothorax obstruction of lower
(airways

Mediastinal Cardiac Compression

emphysema tamponade atelectasis
 )b( (d)

(a)

)C(

Spreading subcutaneous emphysema: (a) after multiple rib

fractures; (b) after shotgun wound and left pneumothorax;
(c) & (d)are after rupture of bronchus (Pneumomediastinum or
mediastinal emphysema) and left pneumothorax
 a b c

(a) Blunt thoracic trauma with Flail chest; d

(b) Blunt thoracic trauma with head
injury; (c) Open pneumothorax (the right
lung is freely visible through the chest
wound – ‘white arrow’); (d) Penetrating
chest injury by Scissors (which is kept in
place till thoracotomy) with Cardiac
injury.
 CHEST TRAUMA

Tension pneumothorax

Causes:
o Tension pneumothorax is caused by a check-valve
mechanism in which air can escape from the lung
into the pleural space but cannot exit
o Such valve may develop either on the lung surface
(in >90-95%), or in the chest wall (in 5-10%)
o It is a cause of sudden death.
 CHEST TRAUMA
Tension Pneumothorax
 Signs and Symptoms
 Severe respiratory distress
  or absent lung sounds (unilateral usually)
 Hyper-resonance on percussion
  resistance to manual ventilation
 Cardiovascular collapse (shock)
 Asymmetric chest expansion
 Anxiety, restlessness or cyanosis (late)
 Jugular vein engorgement or tracheal deviation
(late)
 Accessory Muscle Use
 Narrowing Pulse Pressures
Tension Pneumothorax
Each time we
inhale,
the lung
collapses
further.
There
is no place for
the air to
escape..
Tension Pneumothorax
Each time we
inhale,
the lung
collapses
further.
There
is no place for
the air to
escape..
Tension Pneumothorax

The trachea is
pushed to
the good side

Heart is being
compressed
Tension Pneumothorax
 TENSION
PNEUMOTHORAX
Rib Fractures with Tension Pneumothorax
 Tension pneumothorax

Treatment:

The thorax must be decompressed with

a needle, which is replaced by an
intercostal tube with underwater seal
and suction.
 Open Pneumothorax

 It is an open wound in the chest wall which

exposes the pleural space to the atmosphere.

Clinical presentation:
 The open wound allows air movement through
the defect during spontaneous respiration
(sucking wound), causing severe cardio-
respiratory disturbance.
Open pneumothorax (the right lung is freely
visible through the chest wound – ‘white arrow’)
Open Pneumothorax
 Open Pneumothorax

Treatment involves:

 Immediate sealing of the wound by an

occlusive pad of Vaseline gauze and
inserting a thoracostomy tube.

 Later, debridement and closure of the

wound will be necessary.
 Closed (or Simple) Pneumothorax

Pneumothorax: is accumulation of air in the

pleural cavity.
 Closed (or simple) pneumothorax is due
to entry of a limited amount of air into
the pleural cavity
It causes:
 Hyper-resonance on percussion
 Absence of breath sounds on
auscultation
 Closed (or Simple) Pneumothorax

Clinical picture will depend on the

amount of air in the pleural
cavity and the condition of the
opposite side lung.
 Closed (or Simple) Pneumothorax

Minimal (marginal): distance between the chest

wall and the lung on X-ray film is up to 1.5 cm
(air occupying <1/3 of the volume of that pleural
cavity).
Moderate: distance is 1.5cm - 5cm; the volume
of air is 1/3 - 2/3 of that pleural cavity.
Massive: distance is more than 5cm; the volume
of air is more than 2/3 of that pleural cavity.
In closed pneumothorax the mediastinum is not
displaced.
Closed (or Simple) Pneumothorax
Closed (or Simple) Pneumothorax
Closed (or Simple) Pneumothorax
Bilateral Pneumothorax
 Pneumo-hydrothorax

Lateral-decubitus Erect position

 Closed (or Simple) Pneumothorax

Treatment:

 In minimal type the air will be rapidly

absorbed spontaneously, so it needs
conservative management with X-ray control.
 In moderate and massive forms under-water-
seal drainage is performed.
 Rib Fractures
 The most common chest injury
 Vary from simple fracture to those with
hemopneumothorax, or to severe multiple
fractures with flail chest and internal injuries.
 With simple fractures, pain on inspiration is the
principal symptom.
 Subcutaneous surgical emphysema is diagnostic,
even if fracture is not seen on x-ray film.
Rib Fractures with Tension Pneumothorax
 Rib Fractures

Treatment:
 Strapping the injured side of the chest wall
with adhesive tape
 Intercostal nerve block and analgesics.
 Particularly in the elderly, multiple fractures
may be associated with voluntarily decreased
ventilation and subsequent pneumonitis.
 Flail Chest

 Blunt chest trauma, causing extensive

anterior and posterior rib fractures (double
fractures) or sterno-costal disconnection

 Results in paradoxical chest wall movement

 The magnitude of the effect depends on the

size of the flail segment and intensity of
pain with breathing.
 Flail Chest

Types of flail chest:

 Anterior
 Lateral
 Posterior
 Flail Chest
Clinical presentation:

 Paradoxical chest wall movement interferes

with the mechanics of respiration and if
severe, causes acute alveolar hypoventilation
and circulatory failure due to decreased
venous return.
 Morbidity is also related to underlying lung
injury.
Flail Chest
 Flail Chest

Treatment:
 For minor cases of flail chest, intercostal
nerve block and analgesics may be adequate
treatment.
 Most cases require ventilatory assistance for
2-3 weeks with a cuffed endotracheal tube
and a mechanical ventilator with aggressive
pulmonary toilet.
 Flail Chest

Treatment:
 External fixation of the chest is less reliable
than positive pressure ventilation for the
average case, but may be useful for severe
sternal flail or other extensive injuries with
chest wall instability, as well as in hospitals
lacking ventilators and anesthetists.
 External compression

Traction

Surgical
fixation
Tracheostomy

Mechanical ventilation
 APPROACH FOR ANTERO-
LATERAL FLAIL CHEST

APPROACH FOR POSTERO-

LATERAL FLAIL CHEST

METHODS OF INTERNAL FIXATION OF RIB FRACTURES

 Hemothorax

Accumulation of blood in the pleural

cavity, is classified according to the
amount of blood:
 Minimal – up to 350-500 ml;
 Moderate - 500-1500 ml;
 Massive - 1500 ml or more.
 Hemothorax

 In minimal hemothorax X-ray shows

blunting of costo-phrenic angle;
 In moderate - fluid shadows up to the apex
of the scapula;
 In massive - more than the moderate.
 If air is also present, the condition is called
pneumo-hemothorax and X-ray film will
show air-fluid level in the pleural cavity.
Hemothorax
Pneumo-hemothorax (in erect position)
Pneumo-hemothorax (lateral decubitus position)
 Hemothorax

 Clinically, there is chest pain with dyspnoea

and signs of pleural effusion.
 Clinical picture will depend on the degree of
hemothorax.
In massive hemothorax:
 Severe shock
 Decreased breath sounds
 Dullness on percussion
 Compromised ventilation (the same effect as
in tension Pneumothorax)
“Tension” hemothorax
 Hemothorax

Treatment:

1) In massive hemothorax – mainly

thoracotomy, which is preceded by
two large-bore thoracostomy tubes
and blood volume restoration.
 Hemothorax

Treatment:
2) In moderate hemothorax – a large-bore tube
thoracostomy should be performed.
 The rate of bleeding after evacuation of
blood is clinically very important:
 Initial drainage of at least 1000 ml, OR
 Continued hemorrhage at the rate of
200 ml/hr for 4 hours is an indication for
thoracotomy.
 Hemothorax
Treatment:
3) In minimal hemothorax –
 Some do nothing other than medical
therapy, as blood may be resorbed,
whereas aspiration may lead to incomplete
evacuation with contamination of the
remaining blood; the needle may also
injure the sub-diaphragmatic organs.
 Others prefer aspiration to avoid
complications of hemothorax, because
blood never absorbs spontaneously.
 Hemothorax

Complications:
If the hemothorax is inadequately drained,
the patient may develop:
 Empyema, OR
 Fibrothorax
 Both would require subsequent
thoracotomy and decortication.
 
Insertion of
Intercostal
Chest Drain
--------------

Needle 
Thoracocen-
tesis through
2nd
intercostal
space at the
Midclavicu-
lar line
 Position - Triangle of safety

Lateral margin of Pectoralis major Muscle

Trans-Nipple
Line

Medial margin of Latissimus dorsi Muscle

 Tube Placement

Choose Explore
site with
finger

Place
Suture
tube
tube to
with
chest
clamp
 Underwater drainage

To suction
Patient
end

Collection
Suction chamber
pressure
Underwater
seal
Underwater Seal Options
Flutter valve (One way)
Portable chest drainage system
Pleur-evac
What about dependent loops?
 CHEST TUBE REMOVAL
TIMING

Improper (late) time of removal of the

chest tube leads to the development of
entrapped lung which will need:
 Decortication of the lung and parietal
pleurectomy
 Such operation is very traumatic and
leads to bleeding and more air leakage.
 PRIMARY SURVEY AND RESUSCITATION

C = Circulation, hemorrhage control and shock

resuscitation

Cardiac Tamponade

It is one of the life threatening causes in patients

with shock; to diagnose this condition requires a high
index of suspicion, particularly if a penetrating
injury is noted medial to the nipples anteriorly or
medial to the scapulae posteriorly.
 Acute Cardiac Tamponade

 Occurs due to rapid accumulation of blood

in the pericardial sac
 Causes compression of the cardiac
chambers, decreased diastolic filling, and
thus, decreased cardiac output
 Tamponade in blunt cardiac trauma is often
due to myocardial rupture or coronary
artery laceration
 Acute Cardiac Tamponade

 Pericardial lacerations from stab wounds

tend to seal and cause tamponade

 Whereas gunshot wounds leave a

sufficient pericardial opening for drainage
into the pleural cavity.
 Acute Cardiac Tamponade

 Gunshot wounds produce more extensive

myocardial damage with massive bleeding
into the pleural space

 Hemothorax, shock, and exsanguination

occur in nearly all cases of cardiac gunshot
wounds
Acute Cardiac Tamponade

Penetrating injury
by a Nail
Acute Cardiac Tamponade
 Pericardial Tamponade
o Blood and fluids
leak into the
pericardial sac
which surrounds the
heart.
o As the pericardial
sac fills, it causes the
sac to expand until
it cannot expand
anymore
pericardial sac
Pericardial Tamponade
o Once the
pericardial sac
can’t expand
anymore, the fluid
starts putting
pressure on the
heart
o Now the heart
can’t fully expand
and can’t pump
effectively.
Pericardial Tamponade
o With poor pumping
the blood pressure
starts to drop.

o The heart rate

starts to increase to
compensate but is
unable

o The patient’s level

of consciousness
drops, and
eventually the
patient goes in
cardiac arrest
 Cardiac Tamponade
Cardiac tamponade is diagnosed clinically
by Beck’s triad:
The presence of decreased heart sounds
Engorged Jugular Vein (absent in post-
hemorrhagic hypovolemia)
Hypotension with very weak pulse
- Echocardiogram shows impaired diastolic
filling of right atrium initially (1st sign) and free
fluid in the pericardial sac
Cardiac Tamponade
 Acute Cardiac Tamponade

Initial treatment:

Decompression by Needle Pericardiocentesis

 Which also confirms the clinical

diagnosis

 Could be life-saving in short term

Fluid resuscitation
Pericardiocenthesis
 Pericardiocentesis

 Puncture the skin 1-2 cm inferior to

xiphoid process
 45/45/45 degree angle
 Advance needle to tip of left scapula
 Withdraw on needle during advance
of needle
 Preferable under ultrasound
guidance or ECG lead V attachment

157
 Pericardiocentesis

 Complications
 Aspiration of ventricular blood
 Laceration of coronary arteries,
veins, epicardium/myocardium
 Cardiac arrhythmia
 Pneumothorax
 Puncture of esophagus
 Puncture of peritoneum

158
 Acute Cardiac Tamponade

Definitive treatment:

Thoracotomy to:

 Stop bleeding as a cause of tamponade

 Make a “pericardial window”

to allow decompression
Procedure – Left Anterolateral
Thoracotomy
 Cardiac Contusion

 It results from direct sternal impact.

 Blunt injury to the heart occurs most often

from compression by a steering wheel in
car accidents.

 It ranges in severity from subendocardial

or subepicardial petechiae to full-thickness
injury.
 Cardiac Contusion

Clinical presentation:
The early clinical findings include:
Friction rubs,
Chest pain,
Tachycardia,
Murmurs,
Arrhythmias, or evidence of low cardiac output.
ECG shows nonspecific RS-T and T wave changes.
Serial tracings should be obtained, since abnormalities
may not appear for 24 hours after injury.
 Cardiac Contusion

Functional complications:
 Arrhythmias
 Myocardial rupture
 Ventricular septal rupture
 Left ventricular failure

Diagnosis is made by:

 ECG,
 Isoenzymes, and
 2-D echocardiogram.
 Cardiac Contusion

Treatment:
Management of myocardial contusion
should be the same as for acute
myocardial infarction and includes:
 Cardiac and hemodynamic monitoring,
 Appropriate pharmacologic control of
arrhythmias,
 Inotropic support if cardiogenic shock
develops.
 Tracheo-bronchial Disruption

 Blunt tracheo-bronchial injuries are often:

 Due to compression of airway between the
sternum and the vertebral column in
decelerating steering wheel accidents

 Usually occur within 2 cm of the carina

 Penetrating tracheo-bronchial injuries may
occur anywhere
 Tracheo-bronchial Disruption
Diagnosis: is made by bronchoscopy
It is suspected if:
 Chest X-ray shows pneumo-mediastinum
 Collapsed lung fails to expand, following
placement of a thoracostomy tube
 Massive air leak persists
 Progressive subcutaneous emphysema is present
 Hemoptysis develops
Treatment: is by primary repair
 Esophageal Disruption
Usually results from penetrating trauma rather
than blunt trauma.

Clinical presentation:
It causes rapidly progressive mediastinitis

The most common symptom of esophageal

perforation is Pain
Fever develops within hours in most patients

Regurgitation of blood, hoarseness, dysphagia, or

respiratory distress may also be present
 Esophageal Disruption
Physical findings:
 Shock
 Local tenderness
 Pneumomediastinum
 Subcutaneous emphysema
 HAMMAN'S sign (i.e. pericardial or
mediastinal "crunch" synchronous with
cardiac sounds)
 Esophageal Disruption
Chest X-ray shows:
 Mediastinal widening and/or hydro-
pneumothorax
 Pneumomediastinum
 Contrast X-rays of the oesophagus
should be performed with water-soluble
material (e.g. gastrografin)
 They are positive in only 70% of proved
cases.
 Esophageal Disruption
Treatment:
 A nasogastric tube should be passed to
evacuate gastric contents
 If recognised within 24-48 hours of injury,
the oesophagus should be repaired and
pleural drainage instituted
 Long standing perforations require special
techniques using pleural or pericardial flaps,
pedicles of intercostal muscles, diaphragm,
or cervical strap muscles and stomach
 Lung Laceration
 Caused by penetrating injuries
 Hemo-pneumothorax is usually present

Treatment:

 Tube thoracostomy
 Since expansion of the lung tamponades the
laceration, most lung lacerations do not
produce massive hemorrhage or persistent
air leaks
 Lung Laceration
Treatment:
 In 85% of hemothorax, tube thoracostomy is the
only treatment required
 If bleeding is persistent, as noted by continued
output from the chest tube, it is more likely to be
from a systemic (e.g. intercostal) than pulmonary
vessels
 When the rate of bleeding is 100-200 ml/hour, or
the total hemorrhagic output exceeds 1000 ml,
thoracotomy should be usually performed
 Pulmonary Contusion

 It is the most common injury seen in

association with thoracic trauma (30%-
75% of all patients have a major chest
injury).

 Causes: It is caused by blunt trauma or

wounding by a high-velocity missile, which
produces capillary disruption with
subsequent intra-alveolar hemorrhage,
edema, and small airway obstruction.
 Pulmonary Contusion

The clinical findings are:

Loose, copious, blood-stained secretions
Chest pain
Restlessness
Dyspnoea, tachypnoea
Cyanosis
Tachycardia.
 Pulmonary Contusion

 Chest X-ray shows patchy parenchymal

opacification or diffuse linear peribronchial
densities that may progress to diffuse
opacification (in 12-24 hours).

 Diagnosis: is made by chest radiograph,

arterial blood gases, and clinical symptoms of
respiratory distress.
 Pulmonary Contusion
Treatment: is often delayed, because clinical
and X-ray findings often do not appear until
12-24 hours later.

It includes:

Adequate analgesia (epidural narcotics)

Fluid restriction
Oxygen
Vigorous chest physiotherapy
 Pulmonary Contusion

Treatment:

Mechanical ventilatory support (in indicated

cases, which permits adequate alveolar
ventilation and the use of enriched oxygen
mixtures)

Chest tube drainage of any associated pleural

space complication

Broad spectrum antibiotics.

 DIAPHRAGMATIC RUPTURE

 3-5% of all abdominal injuries, L>R

 May present with few signs, need high index of
suspicion
 Injury mechanism: compartment intrusion,
deformity of steering wheel, need for
extrication, fall from great height
 Prominence/immobility of left hemithorax
 NG Tube in chest, bowel sounds in thorax
 Diaphragmatic Disruption

Signs and Symptoms

 Abdominal Pain
 Dyspnoea
 Shoulder pain
 There may be abdominal tenderness
 Decreased Breath Sounds on side of
rupture
 Bowel Sounds heard in chest cavity
 Diaphragmatic Disruption

Diagnosis:
 Is by chest radiograph, which shows evidence
of the stomach or colon in the chest
 The diagnosis is often missed, since chest X-
rays are frequently entirely normal (in about
30% of the cases)
 The most common finding is ipsilateral
hemothorax
Diaphragmatic Rupture
 Diaphragmatic Disruption
Diagnosis:
 Pneumothorax is occasionally confused with a
distended herniated stomach !!!!!
 Fluid and air in the herniated stomach or
colon are miss-diagnosed as pneumo-
hemothorax !!!!!
 Such miss-diagnosis will lead to serious and even
lethal complication by performing pleural
drainage and traumatising the herniated stomach
or intestines
 Diaphragmatic Disruption

Treatment:

 The immediate placement of a nasogastric

tube will prevent acute gastric dilatation,
which can produce severe, life-threatening
respiratory distress

 This is followed by urgent trans-abdominal

repair with simultaneous treatment of any
associated intra-abdominal injuries
 Diaphragmatic Disruption
Treatment:

 If rupture is not diagnosed until 7-10 days

later, trans-thoracic repair is recommended
to free any adhesions to the lung that might
exist.
(a) (b) (c)

Blunt Traumatic Rupture of the Diaphragm: (d)

(a) Stomach, Spleen, Splenic flexure of Colon
and portions of omentum are herniated into the
thoracic cavity through 15 by 12 cm. defect of
the left diaphragm; (b) The instruments
demonstrate the defect; (c) The spleen has been
reduced; (d) The hand of the surgeon is in the
thorax - lung parenchyma (white arrow) can be
seen through the rupture.
 a STOMACH
SPLEEN

LUNG
Old traumatic rupture of
the Diaphragm. (a) Left
thoracotomy – reduction
of herniated stomach,
splenic flexure of the
colon, omentum, and
spleen. OMENTUM and
COLON
--------------------------------

 b
(b) Closure of the
diaphragmatic defect by
non-absorbable sutures
(arrow shows atelectatic
part of the lung
 Thoracic Duct Injury

 Penetrating injuries of the neck, thorax,

or upper abdomen can injure the
thoracic duct or its major tributaries

 Chylothorax and chylopericardium are

rare complications of trauma

 The occurrence of chylothorax after

trivial injury should lead one to suspect
underlying malignancy
 Thoracic Duct Injury

Clinical manifestations:

Symptoms are due to mechanical effects of the

accumulations, e.g. shortness of breath from lung
collapse or low cardiac output from tamponade

Injuries below the T5-6 level usually result in a

right-sided chylothorax, whereas injuries above
this level result in left-sided chylous effusions
 Thoracic Duct Injury
The diagnosis is established when the fluid is
shown to have characteristics of chyle:
 Milky appearance of the pleural fluid
 Protein: 2.2-5.9 gm of protein/100 ml (about
50% of plasma)
 A lymphocyte count of 400-6800/mic.l.

 A specific gravity of 1.012-1.025.

 A triglyceride level higher than 110 mg/dl

 Thoracic Duct Injury

Treatment:
 Fat-free, high-carbohydrate, high-protein diet
 Aspiration of the effusion
 Chest tube drainage should be instituted if the
effusion recurs
 Intravenous hyperalimentation with no oral
intake may be effective in persistent leaks
 Thoracic Duct Injury
Treatment:
Three or four weeks of conservative treatment
usually are curative
If daily chyle loss exceeds 1500 ml for 5
consecutive days or persists after 2-3 weeks of
conservative treatment, the thoracic duct should
be ligated via a right thoracotomy.
To visualize the duct a fatty meal with
Methylene blue dye is given before operation