Chest Trauma

Surgery dept (MCHAS)

Mboma
 Introduction

 Chest trauma is often sudden and

dramatic
 Accounts for 25% of all trauma deaths
 2/3 of deaths occur after reaching hospital
 Serious pathological consequnces:
-hypoxia, hypovolaemia, myocardial
failure
 Mechanism of Injury
Penetrating injuries
 E.g. stab wounds, GSWs etc.
 Most of the times injury involves Primarily peripheral
lung except to those who realy know the anatomy.
Mostly injury are related with
 Haemothorax-blood in pleural cavity/ space
 Pneumothorax- air in pleural space
 also penetrating injury to Cardiac or great vessel-
thoracic aorta, arch of aorta, vena cava inf or superior or
(oesophageal injury- food or air may enter mediastinum
and develop pneumo-mediastinum or
pneumomediastinitis)
Blunt injuries
 Either:
 direct blow-(fist) (e.g. rib fracture), fall from height,
road traff accidents.
 deceleration injury- sudden brakes in the car the
thoracic organ or tissues can hit themselves to thoracic
cage.
 compression injury
 Rib fracture is the most common sign of blunt thoracic
trauma
 Fracture of scapula- cause has supra,infra and
subscapular space all contains muscles- only great
force can cause fracture, sternum, or first rib suggests
massive force of injury
 Chest wall injuries are of 3
types
 1.Rib fractures only- pt has severe pain when breath
in and out
 2.Flail chest- multiple fracture within same rib, there
is discontinuity of this rib so this one fragment hangs
out due attach on intercostal musclesn behave as its
own on breathing.
 3.Open pneumothorax- open chest wound allows air
to enter direct (due to neg pressure inside)
 1.Rib fractures
 Most common thoracic injury
 Always fracture of 1st and 2nd rib first thing to suspect is
injury to the great vessels due to anatomy, these ribs
are almost flat and injury to these areas-great vessels
are very close to these ribs.
 Most of times its Localised pain, tenderness, crepitus
 CXR to exclude other injuries
 Analgesia avoid taping and bed rest
 Underestimation of effect
 Upper ribs, clavicle or scapula fracture: suspect vascular
injury
 2.Flail chest
 Multiple rib fractures produce a mobile fragment
which moves paradoxically with respiration,
when we do expiration ribs goes down n when
we increase intrathoracic pressure this rib part
goes out due to high pressure inside.
 Significant force required
 Usually diagnosed clinically
 Rx: ABC
Analgesia
strap that of the fracture.
Flail chest
Flail Chest - detail
 3.Open pneumothorax
 Defect in chest wall provides a direct communication
between the pleural space and the outside
environment, normally in the thoracic cavity there is
neg pressure and air eneters in.
 So immediately after seeing this 1st thing you do is put
air tight (close), after this you put a chest drain, doing
this close 1st is to prevent lung collapse- coz collapse
starts at one lung then pushes it till it happens to the
contalateral lung.
 Lung collapse and paroxysmal shifting of mediastinum
with each respiratory effort ± tension pneumothorax
 “Sucking chest wound”
 Rx: ABCs…closure of wound…chest drain
 Lung injury- direct injury to the
lungs
 (Pulmonary) lung contusion- hematoma within the lung
parenchyma risk to develop lung abcess so pt should b in
antibiotics, pt is in severe pain n great risk of developing hypoxia,
since gaseous exchng part is destroyed.
 Pneumothorax- rib fracture bone fragment penetrate the lung and
coz closed pnemothorax or tension pnemothorax rx goes oposite to
open pneumothorax in Rx- in tension Rx is make a hole or perforate
it using a needle.
 Haemothorax-
 Parenchymal injury all these have a great risk for hypoxia
 Injury to (Trachea - at carina) or else where , esophagus and
bronchial injuries causes Pneumomediastinum
 Pneumothorax
 Air in the pleural cavity
 Blunt or penetrating injury that disrupts the parietal or
visceral pleura
 Unilateral signs:  chest movement and breath sounds,
hyperresonant to percussion and reduced tactile vocal
fremitus cause air affect sound waves in travelling. This
is quite differnt from a patient who has consolidation in
the lungs such in pneumonia or hemothorax where
percussion is dull and tactile vocal fremitus is increased-
Rx is chest drain.
 Confirmed by CXR
 Rx: chest drain
 Pneumothorax classification
By side:
 left or right
 in both side
By lung collapse degree:
 Partial (paracostal)
 Subtotal (smaller than 2/3 of lung volume)
 Total (more than 2/3 of lung volume)
By mechanism of formation:
- open
- closed
- tension
Pneumothorax
 Tension pneumothorax
 Air enters pleural space and cannot escape- injury cause a flap
formation which allows air to enter but not escape, when build
pressure to get the air out the flap closes so entered air can not
escape out from pleural space so everytime a pt breath in n out,
pressure builds inside.
 P/C: chest pain, dyspnoea
 Dx: -pt will be in respiratory distress ,compression of great vessels,
pulse pressure in the extrimity is low, distended neck veins due to
pressure in the superior venacava so prevent blood from returning n
the pt is in hypotension coz no blood is coming from chest cavity to
peripheral circulation and if seen at a ward pt will be developing
weakness as time goes on
 - tracheal deviation (away)
 - absence of breath sounds
 Surgical emergency-
 Rx: 1st step is needle puncture to remove air needle
inserted at 2nd intercostal space mid-clavicular line.
emergency decompression before CXR
 Either large bore cannula in 2nd ICS, MCL or insert
chest tube
 CXR to confirm site of insertion
 Haemothorax
 Blunt or penetrating trauma
 Requires rapid decompression and fluid
resuscitation
 May require surgical intervention
 Clinically: hypovolaemia
absence of breath sounds dullness to percussion
 CXR may be confused with collapse
 Decompression always by chest catchment in 7
ICS on middle or posterior axillary line
 Hemothorax classification
By side:
 left or right
 in both side
By blood lost volume :
 Small (< 10% of BCV, or <500 ml)
 Middle (10-20 % of BCV, or 500-1000ml)
 Big (10-20 % of BCV, or 500-1000ml)
 Total ( > 40 % of BCV, or >2000ml)
By bleeding presence:
- stopped
- continues
By clots presence:
- clotted
- unclotted
By infection complication presence:
- non-infected
- infected
 Indication for urgent thoracotomy

 In pneumothorax:
Absence of active air catchment during more
than 2 days (presence of pneumothoraz on CXR)

 In hemothorax:
Evacuation of > 1000ml blood simultaneously
or bleeding continues during 4 hours with blood
loss > 200 ml per hour
 Heart, Aorta & Diaphragm

 Blunt cardiac injury

- contusion
- ventricular, septal or valvular
rupture
 Cardiac tamponade
 Ruptured thoracic aorta
 Diaphragmatic rupture
 Cardiac Tamponade
 Blood in the pericardial sac
 Most frequently penetrating injuries
 Shock, JVP, PEA, pulsus paradoxus
 Classically, Beck’s triad:
- distended neck veins
- muffled heart sounds
- hypotension
 Rx: Volume resuscitation
Pericardiocentesis
Cardiac tamponade
 Aortic rupture

 Usually blunt trauma involving

deceleration forces; especially RTAs
 ~90% die within minutes
 Most common site near ligamentum
arteriosum
 Dx: clinical suspicion, CXR, aortography,
contrast CT or TOE
 Rx: surgical…poor prognosis
 Iatrogenic trauma

 NG tubes: - coiling
- endobronchial placement
- pneumothorax
 Chest tubes: - subcutaneous
- intraparenchymal
- intrafissural
 Central lines: - neck
- coronary sinus
- pneumothorax
Line in jugular vein
Misplaced nasogastric tube
 Chest trauma: summary
 Common
 Serious
 Primary goal is to provide oxygen to
vital organs
 Remember
Airway
Breathing
Circulation
 Be alert to change in clinical condition
 Subcutaneous emphysema- air in the
subcutaneous tissues can be caused by
trauma to the trachea or bronchus or
clostridium perfrinches infection
 On palpation there is basal crackes sound