Thoracic injuries

Milos Milojkovic M.D.

Clinical Center Nis, Thoracic surgery clinic, Nis, Serbia

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Causes, classification, menagment
COMPRESSION
CHSEST TRAUMA BLUNT .
PENETRATION

Immediately life threatening ( lethal six )

DEADLY DOZEN
Potentially life threatening ( hidden six )
o Airway Obstruction
Immediate o Loss of Oxygenation or Ventilation
DEATH Early . o Exsanguination
Late o Cardiac Failure
o Cardiac Tamponade
 MENAGMENT
o Air Embolism
primary survey by ATLS guideline
resuscitation of vital functions
detailed secondory survey with full examination
defintive care

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Immediate life threatening thoracic
injuries, deadly dozen
 Tension pneumothorax, massive haemothorax
 Open pneumthorax, cardiac disruption / tamponade
 Tracheal disruption, containd aortic dissection

DEADLY DOZEN
Lethal six Hidden six
Airway obstruction Cardiac contusion
Tension pneumthorax Pulmonary contusion
Massive haemothorax Aortic disruption
Flail chest Diaphragmatic rupture
Cardiac tamponade Tracheo bronchial injuries
Open pneumothorax, Oesophageal injuries
sucking wound

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 SIGNS OF LIFE / NO LIFE
 Sponatneus breathing
 Palpable carotide pulse
 Measurable blood pressure
 Electrical cardiac activity
 Pupillary light response
 Spontaneus extremity movement

A MAN HAS GOT TO KNOW HIS LIMITATIONS

 No pulse or blood pressure in the field
 Asystole and no pericardial tamponade
 CPR >15 min
 Massive no survivable injuries
 No thoracic or trauma surgeons within 45 minutes

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 ORIENTATION

THORACIC INJURIES
- orientation -

Injury evaluation

Clinical
opservation Assessement
Airway and
breathe rhythm
Circulatory Injures
status mechanism
Gas analyses
Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 MENAGMENT ON THE FIELD

THORACIC INJURES

PRIORITY EVALUTION CARE

Airway menagment

Ventilation

Cardiocirculatory stabilisation

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Crucial survey diferential I

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Crucial survey diferential II

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Crucial survey diferential III
cardiac tamponade vs tension pneumothorax

Clinical sign Cardiac tamponade Tension pneumothorax

Blood pressure LOW ( PEA ) LOW
Cardiac tones MUFFLED NORMAL
Breath sounds NORMAL ABSENT / collapsed side
DISTENDED
Neck veins FLAT
/ flat in hypovolemia
+
Respirations NORMAL TACHYPNEA
-
Treatment NEEDLE / DRAIN NEEDLE / TUBE
pericardium chest

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Blunt thoracic injury - menagement

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Menagment of SPCI

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Menagment of UPCI

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Airway obstruction
CAUSES
oTracheal tear / transection
oLaryngeal trauma
oExpanding neck haemathomas
oBilateral mandibulae fracture
oDentures, avulsed teeth, tissue,
secretions, blood
oThe tongue
SYMPTOMS
oStridor
oHoaresness of voice
MENAGMENT oSubcutaneus emphysema
Control of airway oAltered mental status
Protect the cervical spine oAccesory muscle working
Early intubation oApnea and cyanosis
Emergency cricothyroidotomy

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 RIB FRACTURE / STERNAL FRACTURE
RIB FRACTURE STERNAL FRACTURE
Most Associated with severe blunt anterior trauma
common chest injuries
4 th to 9 th ribs are commonly most fracutured Typical MOI
1st to 3 th indicate the major trauma Direct Blow (i.e. Steering wheel)
Lower ribs, 8,9 and 10 th coused heaptic, renal and  Incidence: 5-8%
splenic injuries  Mortality: 25-45%
 Myocardial contusion, Pericardial tamponade
 Cardiac rupture, Pulmonary contusion

MENAGMENT
PAIN CONTROL
oral, iv, blocks, epidural anesthesia
PULMONARY TOILET
Aetelectasis Pneumonia Respiratory faliure
TREATMENT OF COMPLITATION

Chest strapping by binders and rib belts are not recommanded

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 FLAIL CHEST
 When 2 or more adjacent ribs are broken on 2 or more mutiple places
 PARADOXAL MOUVEMENT
 Life threating, associated with pulmonary injuries

MENAGMENT
ABC WITH SPINE CONTROL
HIGH FLOW OXYGEN
PAIN CONTROL
PCA and NSAID, epidural
LUNG PROTECTION SYMPTOMS & SIGNS
PNEUMONIA PREVENTION oSevere pain with chest wall movment
MECHANICAL VENTILATION oDecrased ventlatory volume
Respiratory rate over 40/min, P O2 less then 60 mm Hg oUnderlaying lung contusion
RAPID TRANSPORT
oPotentially pneumothorax / haemothorax
TREATMENT OF COMPLICATION
oPotentially flaild sternum
SURGICAL STABILISATION
Cardiac tamponade
Traumatic asphyxia

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 TENSION PNEUMOTHORAX
TRIANGLE OF SAFTY

MENAGMENT
Control of airway
Needle thoracostomy V i.c.s.
Chest tube placement

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 OPEN PNEUMOTHORAX
 CAUSES SYMPTOMS
oDyspnea
o Open chest wall injuries
oTachypnea
o Stab wounds oBubbling wound
o Large open defects on oSubcutaneus emphysema
chest wall oGurgling sound during resp.
oDiminished breath sounds

MENAGMENT
Control of airway
Oxigenation, intubation
Bandage the wound
Immidiate CT insertion to affected side

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Cardiovascular Injuries

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Cardiovascular Injuries
 Myocardial Contusion
 Occurs in 76% of patients with severe blunt chest trauma
 Right atrium and ventricle is commonly injured
 Injury may reduce strength of cardiac contractions and reduced cardiac output
 Electrical disturbances due to irritability of damaged myocardial cells
 Progressive problems
 hematoma, hemoperitoneum, myocardial necrosis, dysrhythmias
 CHF and/or cardiogenic shock
SYMPTOMS & SIGNS
Bruising of chest wall MENAGMENT
Tachycardia and/or irregular rhythm oICU admission
Retrosternal pain similar to MI oO2 therapy to correct hypoxemia
Associated injuries oAntyarrhytmic drugs
 Rib/Sternal fractures oCorrection of hypovolemia guided by CVP
Chest pain unrelieved by oxygen oTretmant of pericardial effusion if present
 May be relieved with rest
 THIS IS TRAUMA-RELATED PAIN
 Similar signs and symptoms of medical chest pain

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Cardiovascular Injuries
Pericardial Tamponade
 Dyspnea, Possible cyanosis
 Beck’s Triad
 Weak, thready pulse, Shock
 Kussmaul’s sign
decrease or absence of JVD during inspiration
 Pulsus Paradoxus MENAGMENT
drop in SBP >10 during inspiration
 High flow O2
due to increase in CO2 during inspiration
 IV therapy
 Consider pericardiocentesis;
 Electrical Alterans rapidly deteriorating patient
P, QRS, & T amplitude changes  surgery
in every other cardiac cycle

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 PENETRATING THORACIC INJURIES

• 40% Penetrating injury involves the thorax

• 15-28% of penetrating thoracic injuries
require thoracotomy

Distribution of organ injury

– Chest Wall 100%

– Lung 65-90%
– Heart 49%
– Diaphragm 30%
– Intra-Abdominal Injury
• Liver 20%
• Stomach 8%
• Small intestine 7%
• Colon 6%
• Kidney 5%
 Emergency resuscitative thoracotomy - ERT
 10-15% of thoracic trauma patients will require
emergency resuscitative thoracotomy ERT

 Indication for ERT  Contraindication to ERT

Penetrating thoracic trauma with
• Blunt trauma without signs of life
– Recent loss of signs of life followed by
– acute hemodynamic deterioration • Penetrating torso trauma without
Penetrating abdominal trauma with signs of life at the scene
– signs of life on admission followed by
– acute hemodynamic deterioration • No cardiac activity in the absence of
tamponade by FAST Exam
Selected Blunt thoracic trauma with
– signs of life on admission followed by
– observed acute hemodynamic deterioration

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 Emergency resuscitative thoracotomy ERT
 OVERALL SURVIVAL
o Overall 0-70%
o Penetrating 9-70%
o Stab wounds 70%
o GSW 9-33%
o Blunt 0-2.5 %

 LOCATION OF CARDIAC INJURY FROM

PENETRATING TRAUMA
o Right Ventricle- 40%
o Left Ventricle- 40%
o Right Atrium 24%
o Left Atrium- 3%
o Coronary arteries- 5%

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.
 CONCLUSION
PRIORITY
ASSESSMENT
MENAGMENT
All major thoracic trauma requires treatment
by a thoracic surgeon.

HAVE A NICE DAY

Serbian Society of Emergency Physicians, The 8th International Congress, Nis, november 2022.