CHEST TRAUMA

By
Dr. Yasser Ali Kamal
Unit of Cardiothoracic Surgery
Faculty of Medicine
Minia University
Epidemiology
• 20% of all trauma patients sustain chest
injuries.
• Chest trauma is a significant cause of
mortality and morbidity.
• Trauma deaths due to chest injury occur
in 76 % in the first day, of which 38 %
takes place in the first hour.
Pathophysiology
• Blunt or penetrating mechanism.
• Fractures and soft tissue injuries are
common.
• Compromised breathing is urgent
clinical concern and demonstrates
common physiologic sign regardless of
cause.
Pathophysiology
• Structures that can be injured include
the protective bony thorax (ribs,
sternum, scapula, and spine), lungs,
tracheobronchial tree, esophagus, heart,
and great vessels.
• Severe cardiovascular compromise can
also result from injury to the chest.
Clinical Presentation
• Chest pain
• Signs of respiratory embarrassment
• Hemodynamic instability
• Presenting symptoms vary
according to the injured structure.
Clinical Presentation
• Symptoms: dyspnea, tachypnea, and pain.
• Signs: contusions, penetrating wounds,
subcutaneous emphysema, distant or
unequal breath sounds on auscultation,
muffled heart sounds, tracheal deviation,
jugular venous distension, absent upper
extremity pulses, and shock.
Diagnostics
• Physical examination including vital signs.
• Chest x-ray.
• Focused assessment with sonography for
trauma ( FAST) ultrasound.
• Chest CT and angiography.
• Esophagoscopy, bronchoscopy, and
esophagography if required.
Diagnostics

Classical physical examination findings

Treatment
• Rapid assessment of the thorax, diagnosis, and
intervention for life-threatening abnormalities.
• ATLS guidelines:
Secure Airway and ensuring adequate Breathing
and Circulation.
• Further management depends on structure-
specific injuries.
 Advanced
Trauma Life
Support
(ATLS)
Diagnostics
In some situations, diagnosis is made
necessarily at the time of therapeutic
intervention as in the placement of a chest
tube for signs of a tension pneumothorax.
Treatment
Chest Tube Insertion:
• 85% of patients can be managed with a closed
tube thoracostomy.
• If the patient's condition permits, tube
thoracostomy should be performed using sterile
technique.
• A large-bore 36-F chest tube should be inserted
in between the fourth and fifth inner costal
space.
Treatment
Chest Tube Insertion:
• The chest tube can be removed when the output
decreases to <200 mL/24 h and there is no
recurrence of pneumothorax on water seal.
• Prophylactic antibiotics (first-generation
cephalosporin), when the chest tube is placed, to
prevent pneumonia and empyema.
Treatment
Thoracotomy:
Treatment
Thoracotomy:
Emergency department resuscitative
thoracotomy:
• An aggressive procedure to save a dying
patient.
• It is reserved for patients with penetrating
injury of the torso who have lost vital signs in
transport to, or shortly after arriving at, the
hospital.
RIB FRACTURES
RIB FRACTURES

• Occur in 10 % of all trauma patients an in 30 % of

patients with significant chest trauma.
• 1st and 2nd ribs suggest severe thoracic trauma
(brachial plexus and subclavian vessels).
• Ribs from 4th – 10th are most frequently
involved.
• Ribs from 8th – 12th (intra-abdominal injuries).
RIB FRACTURES

• Physical Examination: Local tenderness,

crepitus over the site of the fracture, pain,
difficult breathing.
• May bean an indicator for other significant
intrathoracic injuries.
• Management of rib fractures includes: pain
control, adequate oxygenation, and mechanica
ventilation.
FLAIL CHEST
FLAIL CHEST
• Fracture of 3 or more consecutive ribs in two or more levels
resulting in paradoxical movement of chest wall.
• Patients with flail chest have a significant higher need for
mechanical ventilation (accord. to ABG).
• Indications of surgical stabilization (Open fixation) of flail
chest: Persistent pain - Severe chest wall instability -
Progressive deterioration of pulmonary function testing -
When thoracotomy is performed for other concomitant
injuries - Inability of weaning from ventilator.
STERNAL FRACTURE
STERNAL FRACTURE
• The typical sternal fracture is a transverse fracture
located in the upper and mid-portions of the sternal
body.
• The symptoms: localized tenderness, swelling, and
deformity.
• SF can be diagnosed by a lateral view CXR. Rarely
apparent on AP films. The highest sensitivity is by CT
scan.
• Primary management by pain control.
• Severely displaced sternum requires open reduction
Traumatic Thoracic Injuries
Acute Life-Threatening Thoracic Injuries

Tension Pneumothorax
Acute Life-Threatening Thoracic Injuries

Open Pneumothorax (air sucking wound)

Acute Life-Threatening Thoracic Injuries

Massive Hemothorax
Acute Life-Threatening Thoracic Injuries

Pulmonary contusion with flail chest

Pulmonary Contusion Pulmonary Contusion

(Admission CXR) (24 Hours CXR)
Acute Life-Threatening Thoracic Injuries

Pericardial (Cardiac) Tamponade

Potentially Life-Threatening Thoracic
Injuries
Simple Pneumothorax
Potentially Life-Threatening Thoracic
Injuries

Simple Hemothorax
Potentially Life-Threatening Thoracic
Injuries
Tracheobronchial injury

Chest X ray: Fallen lung sign Chest CT: SC emphysema,

Pneumomediastinum, Tracheal injury
Potentially Life-Threatening Thoracic
Injuries
Traumatic Aortic Disruption

Chest X ray: Widened mediastinum, Aortic Angiography: Site of

Obliteration of the aortic knob, Deviation aortic disruption
of the trachea
Potentially Life-Threatening Thoracic
Injuries
Traumatic Diaphragmatic Rupture
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