CHEST TRAUMA

Mechanism of Injury
Penetrating Trauma
– Low Energy
• Arrows, knives, handguns
• Injury caused by direct contact
– High Energy
• Military, hunting rifles & high powered hand guns
• Extensive injury due to high pressure
Blunt injuries
• Either:
– direct blow (e.g. rib fracture)
– deceleration injury
– compression injury
• Rib fracture is the most common sign of blunt thoracic
trauma
• Fracture of scapula, sternum, or first rib suggests
massive force of injury
• Age Factors
• Pediatric Thorax: More cartilage = Absorbs forces
• Geriatric Thorax: Calcification & osteoporosis = More fracture
 Injuries Associated with
Cardio Thoracic Vascular Trauma
• Airway obstruction • Tracheobronchial tree
• Closed pneumothorax lacerations (rupture)
• Open pneumothorax • Esophageal lacerations
(sucking chest wound) • Penetrating cardiac injuries
• Tension pneumothorax • Pericardial tamponade
• Spinal cord injuries
• Pneumomediastinum
• Diaphragm trauma
• Hemothorax (massive)
• Intra-abdominal trauma
• Hemopneumothorax associated organ injury
• Rib fracture (flail chest) • Laceration of vascular
structures (central &
peripheral)
Basic management concept
in traumatic patient
Is
ABCDE

Sub Department of Cardio Thoracic & Vascular Surgery

responsible in ABC
 Airway obstruction
• Clinical finding
– Shortness of breath (dyspnea)
– Stridor
– Apnea
• Management
– Chin lift
– Jaw thrust
– Triple finger manuever
– Evacuate foreign body
– ET insertion
– Cricothyroidostomy
– Tracheostomy
 Tension Pneumothorax
– Ventile phenomenon
– Build up of air under
pressure in the thorax.
– Excessive pressure
reduces effectiveness
of respiration
– Air is unable to escape
from inside the pleural
space
– Progression of Simple
(closed) or Open
Pneumothorax
CXR image
 Tension Pneumothorax (simplify)
• Anx: Progressive shortness of breath
• PE :
– Respiratory distress
– Tracheal deviation (away)
– Absence of breath sound & percusion: hypersonor
– Jugular Vein Distend
– Hypotension
• Treatment :
– Needle thoracocentesis
– Consult : chest tube insertion
Needle thoracocentesis
OPEN (SUCKING) CHEST WOUND
SUCKING CHEST WOUND
SUCKING CHEST WOUND

• Upon exhaling, air in

the chest escapes
through the flutter-type
valve created by taping
3 sides only
• With inhaling, the patch
should suck against the
skin, preventing air
entry
 Pericardial Tamponade
– Restriction to cardiac filling caused by blood or
other fluid within the pericardium
– Occurs in <2% of all serious chest trauma
• However, very high mortality
– Results from tear in the coronary artery or
penetration of myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of
cardiac contractions
– Removing as little as 20 ml can provide relief
 Pericardial Tamponade (simplify)
• Dyspnea • Kussmaul’s sign
• Possible cyanosis – Decrease or absence of
• Beck’s Triad JVD during inspiration
– JVD • Pulsus Paradoxus
– Distant heart tones – Drop in SBP >10 during
inspiration
– Hypotension or
– Due to increase in CO2
narrowing pulse during inspiration
pressure
• Electrical Alterans
• Weak, thready pulse
– P, QRS, & T amplitude
• Shock changes in every other
cardiac cycle
• PEA
CARDIAC TRAUMA
Pericardial or Cardiac tamponade
Cardiac Tamponade
Pericardial Tamponade (ilustrations)
 Crucial 1° Survey Differential Dx:
Cardiac Tamponade vs. Tension
Pneumothorax
Clinical Sign Cardiac Tension
Tamponade Pneumothorax
Blood Pressure Low (PEA) Low
 Cardiac Tones Muffled Normal
 Breath Sounds Normal Absent - collapsed side
 Neck Veins Distended (flat Flat
in hypovolemia)
Respirations ± Normal Tachypnea
Treatment Needle/drain Needle/tube chest
pericardium
 Hemothorax
• Hemothorax
– Accumulation of blood in the pleural space
– Serious hemorrhage may accumulate 1,500 mL of blood
• Mortality rate of 75%
• Each side of thorax may hold up to 3,000 mL
• MASSIVE (criteria)
– Blood loss in thorax causes a decrease in tidal volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax
• Hemopneumothorax
 Hemothorax (simplify)
• Blunt or penetrating chest
trauma
• Shock
– Dyspnea
– Tachycardia
– Tachypnea
– Diaphoresis
– Hypotension  massive
• Dull to percussion over injured
side
• Treatment
Chest tube insertion & consult
CXR Image

Trauma.org
 Flail chest
• Multiple rib fractures produce a mobile
fragment which moves paradoxically with
respiration
• Significant force required
• Usually diagnosed clinically
• Treatment
– ABC
– Analgesia
– Fixation : internal &/ external
PARADOXICAL RESPIRATIONS
Flail Chest - detail
 Tracheobronchial Injury
– MOI
• Blunt trauma
• Penetrating trauma
– 50% of patients with injury die within 1 hr of injury
– Disruption can occur anywhere in tracheobronchial tree
– Signs & Symptoms
• Dyspnea
• Cyanosis
• Hemoptysis
• Massive subcutaneous emphysema
• Suspect/Evaluate for other closed chest trauma
 Tracheal Disruption

Massive subcutaneous
emphysema in chest wall –
displaced trachea
Cervical, facial sub-
cutaneous emphysema
Hemoptysis
Blunt injuries almost always
within 1” carina
 Blunt Thoracic Trauma:
Tracheobronchial Injury
• 2° Blunt injury
• Persistent
pneumothorax
• Huge air leak
• Rare injury 2-3% of
survivors MVA
• Definitive repairs
with pleural flap
Tracheal Disruption
Tracheal Disruption
 Tracheal Disruption
• Blunt or penetrating trauma (extrinsic compression from
hematoma)
– Intra/extra thoracic location (supraglotic, glotic, subglotic
• Presentation
• Massive, sometimes uncontrollable air leak
– Stridor, acute respiratory distress, Δ voice
– Neck, upper chest subcutaneous emphysema – often
massive and disfiguring
• Acutely manage with deep intubation (beyond injury),
scope, sometimes tracheostomy
 Pericardial Tamponade
– Restriction to cardiac filling caused by blood or
other fluid within the pericardium
– Occurs in <2% of all serious chest trauma
• However, very high mortality
– Results from tear in the coronary artery or
penetration of myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of
cardiac contractions
– Removing as little as 20 ml can provide relief
 Pericardial Tamponade (simplify)
• Dyspnea • Kussmaul’s sign
• Possible cyanosis – Decrease or absence of
• Beck’s Triad JVD during inspiration
– JVD • Pulsus Paradoxus
– Distant heart tones – Drop in SBP >10 during
inspiration
– Hypotension or
– Due to increase in CO2
narrowing pulse during inspiration
pressure
• Electrical Alterans
• Weak, thready pulse
– P, QRS, & T amplitude
• Shock changes in every other
cardiac cycle
• PEA
Pericardial or Cardiac tamponade
Pericardial Tamponade (ilustrations)
 Laceration of vascular structures
• General sign
– Shock Hypovolemia (co morbid cardiogenic)
– Penetrating trauma (mostly)
• Internal bleeding
– Thoracic  Chest XR
– Abdominal  FAST or CT
– Pelvicum  CXR
– Femur  expanding hematoma + XR
• External bleeding  thorough examination &
suturing
Coronary Artery Laceration
 Laceration of vascular structures
• Internal bleeding  consult
• External bleeding
Blunt Cardiac Injuries
 Blunt Thoracic Trauma: Cardiac
Contusions

• Blunt anterior chest trauma

• Acute injury pattern (anterior wall: ↑ST’s I, aVL, V2-V4, ↓II,III,
aVF), AF, BBB
• W/U & Rx acute myocardial infarction, inotropes
• Watch for & treat PVC’s aggressively (K+, temp)
• Cardiac echo to assess wall motion, valves
 Other thoracic cases
• Empyema
• Pleural effusion
• Chylothorax
• Cancer
– Lung
– Mediastinal
 Empyema & pleural effusion
• Fluid in pleural cavity
– Empyema  infection material
– Pleural effusion  non infection
– Chylothorax  lymphatic fluid
 Thoracic Tumor cases

Clinical finding: dull area not change by positions

 Immediate Life Threatening Thoracic
Injuries: Aortic Disruption

• Most common at ligamentum

arteriosum but can be
multiple (pendulum effect)
• ~⅓ fatal on site due to free
rupture (uncontained)
• Hypotension, exsanguination
• MVA, falls from height
Contained Injuries to the Aorta
Widened mediastinum (53%
sensitivity, 59% specificity and
83% negative predictive value)
Obliteration of aortic knob
Rightward deviation of trachea
(compare NG tube to trachea)
Depression of left main stem
bronchus
Pleural/apical cap
Left hemothorax (can be bilateral)
Fractures of 1st and/or 2nd ribs
Contained Injuries to the Aorta
 Contained Injuries to the Aorta
• Not a source of multiple hypotensive episodes in
survivors - look for other injuries
• Salvageable tear when hematoma contained
• ~⅓ die per 24 hours without treatment
• Widened mediastinum very unreliable sign on
portable x-ray
• TEE, helical contrast CT scan, MRI, aortogram
• Consider percutaneous stent placement
• Address after life threatening injuries stabilized
 Summary
• Life ending thoracic injuries are common
• Survival depends on proper and immediate
diagnosis and appropriate management
• ED thoracotomy can save lives but expected
survivorship is <10%
• Don’t forget ABC’s of trauma and damage
control principles