CHEST TRAUMA

 The leading cause of death from physical trauma after

head and spinal cord injury.
 Blunt thoracic injuries are the primary or a contributing
cause of about a quarter of all trauma-related deaths.
 Thoracic trauma is a common cause of significant disability
and mortality.
 Chest trauma is a major contributor with 50% of deaths.
 Most thoracic trauma can be managed nonoperatively.
 Less than 25% of chest injuries require surgical
intervention.
Chest trauma can be classified
By anatomic site
 Chest Wall

 Pleura and lung

 Heart

 Great Vessels

 Mediastinal Viscera

Trachea
Bronchi
Esophagus
By injuring agent
 Penetrating

 Blunt

By physiologic impact
 Stable

 Unstabl
 Specific types of chest trauma include:
• Injuries to the chest wall

– Chest wall contusions or hematomas.

– Rib fractures
– Flail chest
– Sternal fractures
– Fractures of the shoulder girdle
• Pulmonary injury (injury to the lung) and
injuries involving the pleural space
– Pulmonary contusion
– Pulmonary laceration
– Pneumothorax
– Hemothorax
– Hemopneumothorax
• Injury to the airways
– Tracheobronchial tea
• Cardiac injury
– Pericardial tamponade
– Myocardial contusion
• Blood vessel injuries
– Traumatic aortic rupture, thoracic aorta injury
• And injuries to other structures
Esophageal injury (Boerhaave syndrome
Diaphragm injury
 Thoracic trauma can also be divided into
Immediately life-threatening injuries:
are those which can cause death in a matter of minutes and,
therefore, must be rapidly identified and treated during the
initial evaluation and resuscitation.
 Airway obstruction.

 Tension pneumothorax.

 Open pneumothorax.

 Massive hemothorax.

 Cardiac tamponade.

 Flail chest
Potentially life-threatening injuries:
are those which, left untreated, would likely result in death, but
which usually allow several hours to stablish a definitive
diagnosis and institute appropriate treatment.
 Tracheobronchial disruption.

 Aortic disruption.

 Diaphragmatic disruption.

 Esophageal disruption.

 Cardiac contusion

 Pulmonary contusion.

 Thoracic duct disruption

 Etiology

 The most important cause of significant blunt chest trauma is

motor vehicle accidents (MVAs).
MVAs account for 70-80% of such injuries.
Pedestrians struck by vehicles
Falls.
Acts of violence.
Gunshot
Stab wound
Blast injuries.
High-velocity missile
The shocking, “knock-down” effect.
Workup: Initial emergency workup of a patient with multiple
injuries should begin with the ABCs of trauma, with appropriate
intervention taken for each step. Additional workup includes the
following:
 Laboratory Studies

Complete blood cell count: A complete blood cell (CBC) count is

a routine laboratory test for most trauma patients.
The CBC count helps gauge blood loss, although the accuracy of
findings to help determine acute blood loss is not entirely reliable.
Other important information provided includes platelet and white
blood cell counts, with or without differential
 Arterial blood gas: Arterial blood gas (ABG)
analysis, though not as important in the initial
assessment of trauma victims, is important in
their subsequent management.
 ABG determinations are an objective measure of
ventilation, oxygenation, and acid-base status,
and their results help guide therapeutic decisions
such as the need for endotracheal intubation and
subsequent extubation.
Serum chemistry profile: Patients who are seriously injured and
require fluid resuscitation should have periodic monitoring of their
electrolyte status.
This can help to avoid problems such as hyponatremia or
hypernatremia.
Coagulation profile: :The coagulation profile, including prothrombin
time/activated partial thromboplastin time, fibrinogen, fibrin
degradation product, can be helpful in the management of patients
who receive massive transfusions (eg, >10 U packed RBCs).
Patients who manifest hemorrhage that cannot be explained by
surgical causes should also have their profile monitored.
 Blood type and crossmatch
Type and crossmatch are some of the most
important blood tests in the evaluation and
management of a seriously injured trauma
patient, especially one who is predicted to require
major operative intervention.
 Imaging Studies
Chest radiographs:
The chest radiograph (CXR) is the initial radiographic study
of choice in patients with thoracic blunt trauma.
A chest radiograph is an important adjunct in the diagnosis
of many conditions, including chest wall fractures,
pneumothorax, hemothorax, and injuries to the heart and
great vessels (eg, enlarged cardiac silhouette, widened
mediastinum).
In contrast, certain cases arise in which physicians should
not wait for a chest radiograph to confirm clinical
suspicion.
The classic example is a patient presenting with
decreased breath sounds, hyperresonant
hemithorax, and signs of hemodynamic
compromise (ie, tension pneumothorax).
This should be immediately decompressed before
obtaining a chest radiograph.
 Chest CT scan:
 Due to lack of sensitivity of chest radiography to identify
significant injuries, computed tomography (CT) scan of the
chest is frequently performed in the trauma bay in the
hemodynamically stable patient.
 In one study, 50% of patients with normal chest
radiographs were found to have multiple injuries on chest
CT scan.
 As a result, obtaining a chest CT scan in a supposedly
stable patient with significant mechanism of injury is
becoming routine practice
 Helical CT scanning and CT angiography (CTA) are
being used more commonly in the diagnosis of
patients with possible blunt aortic injuries.
 Most authors advocate that positive findings or
findings suggestive of an aortic injury (eg,
mediastinal hematoma) be augmented by
aortography to more precisely define the location
and extent of the injury.
 Aortogram:
 Aortography has been the criterion standard for
diagnosing traumatic thoracic aortic injuries. However, its
limited availability and the logistics of moving a relatively
critical patient to a remote location make it less desirable.
 In addition, with the new generation spiral CT scanners,
which have 100% sensitivity and greater than 99%
specificity, the role of aortography in the evaluation of
trauma patients is declining. However, where spiral CT is
equivocal, aortography can provide a more exact
delineation of the location and extent of aortic injuries.
 Aortography is much better at demonstrating
injuries of the ascending aorta.
 In addition, it is superior at imaging injuries of the
thoracic great vessels.
Thoracic ultrasound: Ultrasound examinations of the
pericardium, heart, and thoracic cavities can be
expeditiously performed by surgeons and
emergency department (ED) physicians within the
ED.
Pericardial effusions or tamponade can be reliably
recognized, as can hemothoraces associated with
trauma. The sensitivity, specificity, and overall
accuracy of ultrasound in these settings are all more
than 90%.
 Contrast esophagogram: Contrast esophagograms
are indicated for patients with possible esophageal
injuries in whom esophagoscopy results are negative.
 The esophagogram is first performed with water-
soluble contrast media.
 If this provides a negative result, a barium
esophagogram is completed.
 If these results are also negative, esophageal injury is
reliably excluded.
 Esophagoscopy and esophagography are each
approximately 80-90% sensitive for esophageal
injuries.
 These studies are complementary and, when
performed in sequence, identify nearly 100% of
esophageal injuries.
Diagnostic Tests and Procedures

 Twelve-lead electrocardiogram: The 12-lead

electrocardiogram (ECG) is a standard test
performed on all thoracic trauma victims.
 ECG findings can help identify new cardiac
abnormalities and help discover underlying
problems that may impact treatment decisions.
Furthermore, it is the most important
discriminator to help identify patients with
clinically significant blunt cardiac injuries
 Patients with possible blunt cardiac injuries and
normal ECG findings require no further treatment
or investigation for this injury.
 The most common ECG abnormalities found in
patients with blunt cardiac injuries are
tachyarrhythmias and conduction disturbances,
such as first-degree heart block and bundle-
branch blocks
 Transesophageal echocardiography
 Transesophageal echocardiography (TEE) has been
extensively studied for use in the workup of possible
blunt rupture of the thoracic aorta.
 Its sensitivity, specificity, and accuracy in the
diagnosis of this injury are each approximately 93-
96%.
 Its advantages include the easy portability, no
requisite contrast, minimal invasiveness, and short
time required to perform
TEE can also be used intraoperatively to help
identify cardiac abnormalities and monitor cardiac
function.
The disadvantages include operator expertise,
long learning curve, and the fact that it is
relatively weak at helping identify injuries of the
descending aorta.
 Transthoracic echocardiography:
 Transthoracic echocardiography (TTE) can help
identify pericardial effusions and tamponade,
valvular abnormalities, and disturbances in cardiac
wall motion.
 TTEs are also performed in cases of patients with
possible blunt myocardial injuries and abnormal
ECG findings.
 Flexible or rigid esophagoscopy: Esophagoscopy
is the initial diagnostic procedure of choice in
patients with possible esophageal injuries.Some
authors prefer rigid esophagoscopy to evaluate
the cervical esophagus and flexible
esophagoscopy for possible injuries of the thoracic
and abdominal esophagus.
Fiberoptic or rigid bronchoscopy: Fiberoptic or
rigid bronchoscopy is performed in patients with
possible tracheobronchial injuries. Both
techniques are extremely sensitive for the
diagnosis of these injuries.
Fiberoptic bronchoscopy offers the advantage of
allowing an endotracheal tube to be loaded onto
the scope and the endotracheal intubation to be
performed under direct visualization if necessary.
INDICATIONS FOR EARLY THORACOTOMY

 Initial drainage of 1500 ml of blood.

 Continued hemorrhage at the rate of 200 ml/hour for 4 hours.

 Drainage of more than 2000 ml in 24 hours.

 Persistent signs of shock after 2-3 liters of fluids and blood been
given.

 Thoracotomy is not advised unless the presence of a

experienced surgeon.
AIRWAY OBSTRUCTION
 quickly leads to hypoxia, hypercapnia, acidosis, and cardiac
arrest.

The highest priority is rapid evaluation and securing the upper

airway by:

Clearing out secretions, blood, or foreign bodies.

Endotracheal intubation.

Cricothyroidotomy
TENSION PNEUMOTHORAX
 Implies that the pleural air collection is under
positive pressure significant enough to cause
marked mediastinal shift away from the
affected side.
It is caused by a check-valve mechanism in
which air continues to leak from an underlying
pulmonary parenchymal injury into the pleural
space but can not be vented increasing
pressure within the affected hemithorax.
Clinical presentation
 Patients are typically in respiratory distress.
 Chest pain due to collapsed lung.
 Shortness of breath.
 Breath sounds are severely diminished to absent.
 The hemithorax is hyperresonant to percussion.
 The trachea is deviated away from the side of the injury.
 The mediastinal contents are shifted away from the affected
side, this results in decreased venous return of blood to the heart.
 The patient exhibits signs of hemodynamic instability, such as
hypotension, which can rapidly progress to complete
cardiovascular collapse and sudden death.
TREATMENT:
 Immediate therapy for this life-threatening
condition includes decompression of the affected
hemithorax by needle thoracostomy.
 A large-bore needle (ie, 14- to 16-gauge) is
inserted through the second intercostal space in
the midclavicular line.
 A tube thoracostomy is then performed.
 Pain control and pulmonary toilet are instituted.
OPEN PNEUMOTHORAX
This injury is more commonly caused by penetrating
mechanisms but may rarely occur with blunt
thoracic trauma and expose the pleural space to
the atmosphere.
Clinical presentation:
 Patients are typically in respiratory distress due to

collapse of the lung on the affected side.

 The open wound allows air movement through

the defect during spontaneous respiration.

 The affected hemithorax demonstrates a
significant-to-complete loss of breath sounds.
 The increased intrathoracic pressure can shift the
contents of the mediastinum to the opposite side,
decreasing the return of blood to the heart,
potentially leading to hemodynamic instability.
TREATMENT:
 Consists of placing a 3-way occlusive dressing over

the wound to preclude the continued ingress of air

into the hemithorax and to allow egress of air from
the chest cavity(became a closed pneumothorax).
 A tube thoracostomy is then performed.

 Debridement and closure of the wound.

 Pain control and pulmonary toilet measures are

applied.
MASSIVE HEMOTHORAX
Is a rapid accumulation of blood within the pleural space.
Causes:
Bleeding from the chest wall.

lacerations of the intercostal vessels.

laceration of the internal mammary vessels.
 Hemorrhage from the lung parenchyma.
 Hemorrhage from major thoracic vessels.
Clinical presentation:
 Chest pain.
 Compromised ventilation.
 Decreased breath sounds.
 Dullness to percussion over the affected area.
 Hypovolemic shock.
 TREATMENT:
 Evacuation using tube thoracostomy.

 Pain control and aggressive pulmonary toilet.

 The chest tube output is monitored closely

because indications for surgery can be based on
the initial and cumulative hourly chest tube
drainage.
CARDIAC TAMPONADE:

It is rapid accumulation of blood in the pericardial sac,

which causes compression of the cardiac chambers,
decreased diastolic filling, and hence, decreased cardiac
output.
Clinical presentation:
 Chest pain.

 Muffled heart tones.

 Jugular venous distension.

 Arterial hypotension.

 Elevated venous pressure.

TREATMENT:
 Rapid pericardiocentesis.
 Surgical creation of a subxiphoid window.
 Repair the cardiac chamber by cardiorrhaphy.
FLAIL CHEST (PARADOXICAL RESPIRATION

 definition: involves 3 or more consecutive rib fractures

in 2 or more places, which produces a free-floating,
unstable segment of chest wall. Costochondral
separation, can also cause flail chest.
Clinical presentation:
 Pain at the fracture sites.
 Pain upon inspiration.
 Dyspnea.
 Tachypnea.
 Paradoxical motion of the flail segment.
 The chest wall moves inward with inspiration and
outward with expiration.
 Tenderness at the fracture sites is the rule.
 Labored respiration due to the increased work of
breathing induced by the paradoxical motion of the
flail segment.
 Associated injuries are common such as pulmonary
contusions
TREATMENT:
 External fixation by compression.

 Internal fixation by placement of plates or pins and

pericostal sutures.
 Pneumatic internal stabilization by mechanical

ventilatory support.
 Pain control by intercostal blocks or epidural

narcotics.
TRAUMATIC ASPHYXIA
 This curious clinical constellation is the result of thoracic
injury due to a strong crushing mechanism, as might occur
when an individual is pinned under a very heavy object.
 Patients present with cyanosis of the head and neck,
subconjunctival hemorrhage.
 Periorbital ecchymosis.
 Petechiae of the head and neck.
 Face frequently appears very edematous or moonlike.
 Epistaxis.
 Hemotympanum.
 Loss of consciousness, seizures, or blindness may be elicited.
 Neurologic sequelae are usually transient.
TREATMENT:
 The head of the patient's bed should be elevated to

approximately 30° to decrease transmission of pressure

to the head.
 Adequate airway and ventilatory status as well as

supplemental oxygen.
 Serial neurological examinations are performed while

the patient is monitored in an intensive care setting.

 No specific surgical therapy is indicated for traumatic

asphyxia.
TRACHEOBRONCHIAL DISRUPTION

Usually occurs within 2 cm of carina.

Diagnosis is made by bronchoscopy and is
suspected when: Collapsed lung fails to expand,
following placement of thoracostomy tube.
Massive air leak persists.
Massive progressive subcutaneous
emphysema is present.

Treatment is by primary repair.

AORTIC DISRUPTION
 is the result of deceleration injury in which the
mobile ascending aorta and arch move forward
while the descending thoracic aorta remains fixed
in position by the mediastinal pleura and
intercostal vessels. This movement causes a tear
at aortic isthmus.
Diagnosis is made by aortogram and is suspected
when: scapular fractures.
first or second rib fractures.
sternal fractures.
steering wheel imprint.
loss of upper or lower extremity pulses.
thoracic spine fractures.
Treatment is by surgical repair
ESOPHAGUEAL DISRUPTION
 Because of the relatively protected location of the
esophagus in the posterior mediastinum, blunt injuries of
this organ are rare,usually results from penetrating injuries.
Clinical presentation:
Subcutaneous emphysema.
Pneumomediastinum.
Pneumothorax.
Intra-abdominal free air.
Rapidly progressive mediastinitis.
If late presentation signs and symptoms of systemic sepsis.
TREATMENT:
Wide mediastinal drainage.
Primary closure with tissue reinforcement( pleura,
intercostal muscle, or stomach).
For patients in poor general condition and those with
advanced mediastinitis esophageal exclusion and
diversion.
Cervical esophagostomy.
A feeding gastrostomy or jejunostomy tube is placed.
DIAPHRAGMATIC DISRUPTION
 Results from blunt trauma to the chest and
abdomen, producing a radial tear in the
diaphragm, beginning at the esophageal hiatus.
Diagnosis: Most diaphragmatic injuries are
diagnosed incidentally at the time of laparotomy
or thoracotomy for associated intra-abdominal or
intrathoracic injuries.
Chest radiograph shows evidence of the stomach
or colon in the chest.
Abnormal location of the nasogastric tube in the
chest. Ipsilateral hemidiaphragm elevation.
Ultrasonography is gaining popularity.
Diagnostic laparoscopy and thoracoscopy have
been successful in the identification of
diaphragmatic injury.
 TREATMENT
is done by surgical repair.
Most injuries are best approached via laparotomy.
An abdominal approach facilitates exposure of the
injury and allows exploration for associated abdominal
organ injuries.
The exception to this rule is a posterolateral injury of
the right hemidiaphragm.
This injury is best approached through the chest
because the liver obscures the abdominal approach.
CARDIAC CONTUSION:

Results from direct sternal impact.

It ranges in severity from subendocardial or
subepicardial petechiae to full-thickness injury.
Functional complications:
Arrhythmias
Myocardial rupture.
Ventricular septal rupture.
Left ventricular failure
Diagnosis is made by electrocardiogram,
isoenzymes, and echocardiogram.
Treatment:
Cardiac and hemodinamic monitoring.
Pharmacologic control of arrhythmias.
Inotropic support.
PULMONARY CONTUSION:
Is the most common injury seen in association with thoracic trauma.
Diagnosis is made by chest radiograph.
Arterial blood gas.
Clinical respiratory distress.
Treatment:
Fluids restriction.
Supplemental oxygen.
Vigorous chest physiotherapy.
Adequate analgesia.
Injuries of the thoracic duct:

No signs or symptoms are specific for this injury.

Diagnosis is usually delayed.
Confirmed when a chest tube is inserted for a
pleural effusion and returns chyle(chylothorax).
Treatment:
Conservative management with chest tube
drainage is successful in most cases.
Chyle production can be decreased by maintaining
the patient on total parenteral nutrition
If a fistula persists after an attempt at nonoperative
management, thoracotomy is performed to
identify and ligate the fistula.
Provision of a meal high in fat content (or ice
cream) the night before the operation increases
the volume of chyle and facilitates identification
of the fistula.
Rib fractures:
 Rib fractures are the most common blunt thoracic
injuries.
 Patients usually report inspiratory chest pain and
discomfort over the fractured rib or ribs.
 Physical findings include local tenderness and crepitus
over the site of the fracture.
 Effective pain control is the cornerstone of medical
therapy for patients with rib fractures.
 For most patients, this consists of oral or parenteral
analgesic agents.
 Intercostal nerve blocks may be feasible for those with
severe pain who do not have numerous rib fractures.
 Patients with multiple rib fractures whose pain is
difficult to control can be treated with epidural
analgesia.
 Early mobilization and aggressive pulmonary toilet.
 Rib fractures do not require surgery.
 Pain relief and the establishment of adequate
ventilation are the therapeutic goals for this injury.
 Complications
• Wound
Wound infection
Wound dehiscence - Particularly problematic in sternal wounds.
• Cardiac

Myocardial infarction
Arrhythmias
Pericarditis
Ventricular aneurysm formation
Septal defects
Valvular insufficiency
Pulmonary and bronchial
Atelectasis
Pneumonia
Pulmonary abscess
Empyema
Pneumatocele, lung cyst
Clotted hemothorax
Fibrothorax
Bronchial repair disruption
Bronchopleural fistula
• Vascular
Graft infection
Pseudo aneurysm
Graft thrombosis
Deep venous thrombosis
Pulmonary embolism
• Neurological

Causalgia - Injuries that involve the brachial plexus

Paraplegia - Spinal cord at risk during repair of ruptured thoracic
aorta
Stroke
Esophageal
Leakage of repair
Mediastinitis
Esophageal fistula
Esophageal stricture- Late
Bony skeleton
Skeletal deformity
Chronic pain
Impaired pulmonary mechanics