Chest Trauma I
For Undergraduate
Staff Members of Cardiothoracic Surgery Departments
Egypt
Types of Thoracic Trauma
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•
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Accidental Trauma.
Iatrogenic Trauma.
Chemical Trauma.
Thermal Trauma.
Barotrauma and blast injuries.
Isolated thoracic trauma, Thoraco-abdominal,
Associated with others.
About 20% to 25% of all trauma-related deaths, are
related to chest injuries.
Accidental Trauma
i) Blunt chest trauma
ii) Penetrating chest trauma
• Caused by: RTA, Fall
from a height, Blunt
objects.
• 90% of blunt trauma
can be managed
without thoracotomy
(i.e. with conservative
management or with
intercostal tube
drainage)
• Caused by: 1. Stab wounds by
Knife, Sword, sharp objects.
arme blanche ‫السالح األبيض‬
2. Gunshot injuries by Bullet,
Shot-gun or air-gun and by
Shrapnel. arme à feu ‫الطلق الناري‬
• 70% to 85% of penetrating
trauma can be managed
without thoracotomy ( i.e. with
conservative management or
with intercostal tube drainage).
• Perforating injury has inlet and
exit.
Blunt Trauma - RTA
Penetrating Trauma - Bullet Injury
Bullet Injury (PA&Lat)
Air-gun Injury
Shot-gun Injury
Shrapnel
Shrapnel
Effects or squeals
1. Immediate or direct effects.
2. Delayed effects or complications.
Primary Survey
• Resuscitation phase:
ABCDE (Airway, Breathing, Circulation,
Disability, and Exposure).
• Rapid clinical assessment of:
- Life-threatening thoracic injuries.
- Associated injuries.
Resuscitation phase >>>>>ABCDE
Airway maintenance with cervical spine
protection:
Breathing and ventilation
Circulation with hemorrhage control
Disability/Neurologic assessment
Exposure and environmental control
A-Airway
Assess the airway.
Airway obstruction cleared by:
– Suction (oral, nasopharyngeal, Nasotracheal).
– Oral or nasal Airway
– Endotracheal or endobronchial tube
– Cricothyroidotomy
– Tracheostomy
– Bronchoscopy
B-Breathing
Chest must be examined by inspection, palpation, percussion
& auscultation. Subcutaneous emphysema and tracheal
deviation.
Identify and manage six life-threatening thoracic conditions
as Airway Obstruction, Tension Pneumothorax,
Massive Haemothorax, Open Pneumothorax, Flail
chest segment and Cardiac Tamponade.
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•
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Oxygen inhalation.
Close chest wall defects.
Expand lung by ICTD.
Stabilize chest wall.
Blood gas analysis.
Mechanical Ventilation.
C-Circulation
Hypovolemic shock is caused by significant
blood loss.
• Two large-bore intravenous lines.
• CVP line.
• Volume resuscitation by crystalloid
solution >>>> does not respond >>>> typespecific blood, or O-negative group.
• Stop bleeding (ICTD, Thoracotomy)
• Exclude cardiac tamponade.
D- Disability/Neurologic assessment
• Neurological assessment: known by the
mnemonic AVPU (alert, verbal stimuli
response, painful stimuli response, or
unresponsive).
• Glasgow Coma Scale.
Glasgow Coma Scale
1
2
3
Eye
Opens eyes in
Opens eyes in
Does not open eyes response to painful
response to voice
stimuli
Verbal
Incomprehensible
sounds
Motor
Makes no sounds
Makes no
movements
Utters
inappropriate
words
Extension to painful Abnormal flexion to
stimuli
painful stimuli
(decerebrate
(decorticate
response)
response)
4
5
6
Opens eyes
spontaneously
N/A
N/A
Confused,
disoriented
Oriented, converses
normally
N/A
Flexion /
Withdrawal to
painful stimuli
Localizes painful
stimuli
Obeys commands
The scale is composed of three tests: eye, verbal and motor responses. The three values
separately as well as their sum are considered. The lowest possible GCS (the sum) is 3
(deep coma or death), while the highest is 15 (fully awake person).
E- Exposure and environmental
control
The patient is undressed & Covered
with warm blankets to
prevent hypothermia.
Immediate Life-threatening Injuries
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•
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Airway obstruction;
Tension pneumothorax.
Open pneumothorax.
Massive haemothorax.
Cardiac Tamponade.
Massive flail chest.
Secondary Survey
More thorough examination + investigations
Laboratory Studies:
CBC count
Arterial blood gas & electrolyte status.
Coagulation profile:
Serum troponin levels & CK –MB in patients
with possible blunt cardiac injuries.
Blood type and cross-match:
Imaging:
Chest X-ray.
CT scan.
 MRI.
U/S: FAST & eFAST
ECG & ECHO (TTE & TEE).
Angiography as Aortography
Contrast esophagogram & Upper GIT Studies.
Instrumental
• Flexible or rigid esophagoscopy in patients
with possible esophageal injuries.
• Fiberoptic or rigid bronchoscopy: in patients
with possible tracheobronchial injuries.
Focused assessment with sonography for
trauma (FAST)
• Rapid bedside ultrasound examination
performed as a screening test for blood around
the heart (pericardial effusion) or abdominal
organs (hemoperitoneum) after trauma.
• Four classic areas examined for free fluid are the
perihepatic space (also called Morison's pouch
or the hepatorenal recess), perisplenic
space, pericardium, and the pelvis.
Extended FAST (eFAST)
Examination of both lungs by adding bilateral
anterior thoracic sonography to the FAST exam. For
detection of a pneumothorax.
Advantages of FAST & eFAST:
• Have high sensitivity.
• Fast; can be performed in under a minute.
• Less invasive
• No exposure to radiation
• Cheaper
• Useful in trauma patients who are hemodynamically
unstable or undergoing positive-pressure
ventilation.
Potential life-threatening injuries
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Cardiac contusion
Deceleration aortic injury
Tracheo-bronchial rupture
Diaphragmatic rupture
Oesophageal perforation
Pulmonary contusion
Pneumothorax
Haemothorax
Tertiary survey
• Serial assessments to help
recognize missed injuries.
• The rate of delayed diagnosis
may be as high as 10%.
I- Thoracic Cage Injuries
A-Surgical emphysema
Definition
Presence of air in subcutaneous tissue from
surgical causes.
NB.: Infection with gas forming organisms may cause
subcutaneous emphysema.
Surgical emphysema (cont.)
Aetiology
• Fractured rib injuring underlying lung resulting in closed or
tension pneumothorax.
• Tracheobronchial tears.
• Penetrating chest injury and open pneumothorax.
• Mediastinal emphysema due to ruptured bronchioles or
alveoli without disrupting the visceral pleura following blunt
trauma or barotrauma of ventilators or even spontaneously
esp in asthmatics.
• Ruptured oesophagus.
• After intercostal tube insertion for pneumothorax when the
tube is blocked.
• Rarely after dental surgery and laparoscopy.
Surgical emphysema (cont.)
Presentation:
• Presence of air under the skin with characteristic
crackling sensation (subcutaneous crepitation).
• Localised or rapidly progressive; up to neck and face
closing eyelids, or down to abdomenal wall and
scrotum.
• It causes patient’s discomfort and worry.
• It is benign but may signify serious underlying
problem.
• It is evident in X-ray and CT chest.
Surgical emphysema face
Surgical emphysema scrotum
Surgical emphysema (cont.)
Treatment:
• It will be absorbed spontaneously.
• Find and manage its cause.
• If extensive, evacuated with needles, skin
incisions or subcutaneous catheters.
B-Fracture Ribs
• The most common chest injury.
• Uncommon in children [pliable ribs].
• The 4th to 9th ribs are the most commonly fractured
[thin and poorly protected].
• First Rib Fracture is Dangerous , may be associated
with brachial plexus or subclavian vessels injury.
• Fractures of the upper ribs (1, 2, and 3) indicate
major trauma
• Fractures of the lower ribs(8, 9, and 10) may be
associated with renal, hepatic or splenic injuries.
Fracture Ribs (cont.)
Aetiology:
Usually caused by blunt trauma
1. Direct violence.
2. Indirect violence.
3. Muscular violence.
Effects:
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Fracture ribs → Severe pain → respiratory
movements & ineffective coughing →
Atelectasis & pneumonia.
Injury of underlying pleura and lung.
Injury of intercostal bundle.
Fracture Ribs (cont.)
Clinical Picture:
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Severe pain on inspiration or coughing .
Localized tenderness.
Bruising.
Spring test (Anteroposterior chest compresion
causes pain laterally in the fractured site).
• Crepitus.
• Surgical emphysema.
• Look for associated haemopneumothorax.,
Fracture Ribs (cont.)
Investigations:
• Chest X-ray.
• CT when suspected associated injuries.
• Multi slice CT (Skeleton view).
Plain chest
X-ray
(Rib
view).
Fracture Ribs (cont.)
Treatment:
1. Pain control, by:
i) Systemic analgesics oral or intravenous.
ii) Intercostal nerve block
iii) Epidural anesthesia.
2. Optimization of pulmonary toilet (e.g. incentive
Spirometer, coughing & ambulation) >>>>
prevention of atelectasis.
3. Treatment of complications e.g. hemothorax or
pneumothorax.
N.B. : Chest strapping (by binders or adhesive tape, and rib
belts) is not recommended as they cause reduction of
ventilation of the affected side that promote atelectasis.
C- Flail Chest
Definition:
Paradoxial movement of a segment of chest wall
caused by fractures of three or more successive
ribs broken in two or more places.
Serious, life-threatening chest injury often
associated with underlying pulmonary injury.
Stove-in chest, the fractured ribs are drivin inwards
without exhibiting paradoxical movements.
Aetiology:
• Severe blunt trauma.
Types of flail Chest:
- Anterior
- Lateral.
- Posterior (least
dangerous).
- Flail sternum.
Pathophysiology
4 mechanisms contribute to the pathophysiology of the flail chest:
1- Paradoxical movement of the flail segment:
It moves in with inspiration and out with expiration in paradox with the
other parts of the thoracic cage.
2- Paradoxical respiration:
The lung portion related to the flail segment:
o During normal inspiration, will collapse instead of inflating.
o During normal expiration, will inflate and the expired air from healthy
lung (that contains more CO2) will be transmitted to it according to
pressure changes. This will lead to gas exchange mismatch impairing the
ABGs.
3- Pendular respiration:
This result from the above mentioned paradoxical respiration as shown in
figure, one lung will inflate while the other lung is collapsing.
4- Mediastinal flutter:
Right and left movement of mediastinum this will lead to kinking of great
veins of mediastinum causing decrease of venous return and
subsequently decrease of cardiac output.
Pathophysiology:
In flail chest, Hypoxaemia is due to:
1. Underlying pulmonary contusion with
ventilation perfusion mismatch.
2. Pain of rib fractures → ↓ tidal volume,
accumulate secretions →Atelectasis →↑
pulmonary shunting & ↓functional reserve
capacity.
3. Associated haemopneumothorax or cardiac
trauma.
Pathophysiology (cont.):
4. Hypoventilation of the underlying
lung from paradoxical respiration.
5. Mediastinal flutter with kink of
great vessels.
6. Pendulum-like movement of dead
space air.
Paradoxical movement >>> Mediastinal flutter
& Movement of dead space air
Pathophysiology
(cont.):
Pendulum-like movement of
dead space air.
Presentation:
• Severe blunt trauma.
• Severe chest pain of rib fractures.
• Dyspnoea, tachypnoea and cyanosis.
• Hypotension and tachycardia.
• Paradoxical movement of the flail segment.
• Chest wall contusions ± surgical emphysema.
Diagnosis:
- Inspection of paradoxical movement which is confirmed by
palpation.
- X-ray: Fractured ribs seen and may show complication.
NB: Diagnosis of Flail chest is clinical rather than radiological.
Complication:
Pneumothorax, hemothorax, lung contusion, respiratory
insufficiency.
Investigations
• Chest X-ray.
• CT scan chest.
• Multislice CT (MSCT)
scan chest wall.
• Blood gas analysis.
Prevention
Safer Automobiles, seat belt, air bag design.
Safer roads.
Prognosis
5-10% mortality depending on severity of injury,
age, bilaterality and number of ribs fractured.
Treatment
Oxygen inhalation (Nasal or face mask).
Pain relief: - Systemic analgesics (avoid opiate), patientcontrolled analgesia (PCA) machines. - Intercostal
nerve block. - Epidural catheter.
Intercostal tube drainage of associated hemo or
pneumothorax.
Pulmonary toilet: to clear secretions from the airways
and prevent atelectasis. By suctioning of airways,
nasotracheal suction, bronchoscopy, tracheostomy,
chest physiotherapy, blow bottles, incentive
spirometry, coughing, percussion and positioning in
prone position.
Treatment (cont.):
• External chest wall stabilization by
compressive dressing strapping.
• CPAP (Continuous Positive Airway Pressure) by
mask.
• Mechanical ventilation: IPPV (Intermittent
Positive Pressure Ventilation) indicated for a
respiratory rate over 40 breath / min, blood
gases deteriorate >>> PaO2 < 60mmHg, PaCo2
> 60mmHg despite 60% face mask oxygen.
Treatment (cont.)
• Surgical fixation:
Indicated for cosmetic
chest wall
deformity,
thoracotomy for
other reasons
(hemothorax) and
failed weaning from
ventilation.
By orthopaedic
devices ( Judet
struts, Kirschner
[K-] wires).
. If ABGs are not improving and patient
condition becomes more worse we shift to
mechanical ventilation if the following criteria
were found:
• PaO2< 50 mmHg and PaCO2 > 50 mmHg in
absence of metabolic alkalosis.
• o Internal surgical fixation: this is indicated in:
•
D-Fracture Sternum
• Transverse fractures
generally in the body of
the sternum near the
manibriosternal
junction.
• Diagnosed by lateral Xray chest. CT scan to
exclude associated
injuries. ECG & ECHO to
exclude cardiac injury.
Fracture Sternum (cont.)
• In most cases, analgesia & follow up.
• In severe cases, IPPV &/or operative
reduction.
II-Pleural space injuries
A- Pneumothorax
• Pneumothorax >>> Accumulation of air in the
pleural cavity.
Types of Pneumothorax:
Etiology, Communication, Tension, Recurrence.
1. Etiology:
• Traumatic: blunt, penetrating or iatrogenic (Lung
biopsy, central line insertion, barotrauma during
mechanical ventilation).
• Spontaneous (Primary: without previous lung
disease or Secondary: on top of a previous lung
disease).
A- Pneumothorax Cont.
Etiology: Cont.
Spontaneous pneumothorax cont.
A. Primary: Ruptured apical bleb.
B. Secondary : Associated with :
• Chronic obstructive lung disease (rupture of air-filled bulla
within lung parenchyma).
• Cystic fibrosis.
• Infection: Cavitating nonspecific bacterial, tuberculous,
mycotic and parasitic infections.
• Tumors: Rupture of ischemic primary or metastatic lung
carcinoma, lymphoma, and sarcoma.
• Catamenial: Associated with menstruation (focal pleural
endometriosis).
• Miscellaneous: Associated with many connective tissue and
autoimmune diseases.
Pneumothorax (cont.)
2. Communication:
• Open pneunothorax:
with communication
through the chest wall
to the exterior.
• Closed
pneumothorax:
without
communication.
• Open Pneumothorax:
• Pleural cavity communicates with the atmosphere.
• One of the life threatening complications.
• Wide communication (more than the diameter of
trachea) to the outside results in (as with tension
pneumothprax):
 Total lung collapse on the affected side.
 Mediastinal flutter : The mediastinum is mobile, so
with inspiration the mediastinum moves towards the
healthy side and opposite on expiration. So,
paradoxical respiration in the healthy side occurs
 Impaired venous return
• Closed Pneumothorax:
• No communication to the atmosphere.
• Usually well tolerated.
Pneumothorax (cont.)
3. Tension:
• Simple pneumothorax without tension (mild,
moderate, massive).
• Tension pneumothorax ( presence of one way
valvular mechanism or on positive pressure
ventilation).
4. Recurrence:
• Primary.
• Recurrent.
• Tension Pneumothorax
• Life threatening condition.
• Developed when an injury to the lung or chest
wall allows air to continue to enter the pleural
space with each inspiration without being able
to exit during expiration 9one way valve
mechanism).
• Tension pneumothorax, cont.
Through this valvular mechanism, air
will accumulate in the pleural
cavity with increased positive
pressure.
•
lung collapse on the
affected side with shift of
mediastinum to the other side
•
leads kinking of the caval
veins resulting in impairment of
venous return and low cardiac
output.
•
Compression to the other
lung leads to significant hypoxia.
Pathogenesis of pneumothorax
• Penetration of chest wall.
• Laceration of the lung.
• Perforation of bronchus , trachea or
oesophagus.
• Tear of the lung by driven-in rib fragment.
• Pulmonary interstitial emphysema →
Mediastinal emphysema → Pneumothorax
&/or surgical emphysema.
Pathogenesis of pneumothorax (cont.)
Traumatic Pneumothorax (cont.)
Clinical Picture:
• Symptoms are related to the degree of lung
collapse and underlying pulmonary function.
Asymptomatic or symptomatic (dyspnea, chest
pain, dry cough, severe respiratory distress with
hypoxia, hypercarbia and acidosis).
• Signs:
 Decreased movement on the same side
 Trachea may be central or shifted to the healthy
side.
 Hyper resonance & Tympanetic percussion note.
 Diminished air entry on auscultation.
Tension pneumothorax, cont.
Classic signs:
Shock (hypotension, tachycardia),
Hypoxia,
Distended neck veins.
Tracheal deviation to contralateral
side,
Hyperresonant and reduced
breath sounds,
Hyperexpanded hemithorax with
decreased expansion.
Traumatic Pneumothorax (cont.)
Investigations:
• Chest X-ray (mild → one finger breadth,
moderate → two fingers breadth, massive →
total lung collapse or tension → mediastinal shift
to the other side.) Expiratory film accentuates
small pneumothorax.
• CT scan (can diagnose the smallest amount of
pneumothorax). Differentiates lung cysts and
bullae in the presence of subcutaneous
emphysema, and quantitates the degree of
pneumothorax.
CXR Left
Pneumothorax.
3 Radiologic
Criteria of
Pneumothorax :
1. Jet black
discoloration.
2. Absence of lung
reticulations
(markings).
3. Presence of lung
border.
CXR with right
Pneumothorax:
1. Jet black discoloration
(air).
2. Absence of lung
reticulations
(bronchovascular
markings).
3. Presence of lung border:
The outline of the lung is
seen in the pleural space
(which is the visceral
pleura).
Traumatic Pneumothorax (evidence of
trauma present in CXR)
Notice right shrapnel
Notice associated left rib
fracture
Tension pneumothorax, cont.
• Tension pneumothorax
is a clinical diagnosis
with no time for
investigation
• Chest X-ray: Shows,
collapse of entire lung,
depression of
diaphragm with
flattening of it's dome,
and mediastinal shift.
CXR left
tension
pneumothorax
CT scan of
tension
pneumothorax
Complications:
• Persistent air leak: denotes bronchopleural
fistula.
• Recurrence:
• Tension pneumothorax:
• Hemothorax: From tearing of vascular
adhesion between the lung and chest wall.
• Pneumomediastinum:
Treatment
1. Simple mild cases → Observation.
2. Moderate and severe → Chest-tube drainage
under water seal in the second space mid
clavicular line.
3. Tension → Immediate decompression (livesaving) Emergency wide pore needle under
water seal in the 2nd intercostal space
midclavicular line to releif tension → ICTD.
insertion once available.
4. Open → Close the external wound and
insert ICT.
5. For spontaneous pneumothorax → ICTD →
Pleurodesis: using tetracycline or talc (Chemical
pleurodesis).
6. Failure of lung expansion and continuous air leak
→ Surgery (Thoracotomy or VATS):
• Close site of air leak, resect blebs or bullae, close
bronchopleural fistula and repair major
tracheobronchial tears.
• Mechanical pleurodesis by pleurectomy or
mechanical pleural abrasion.
7. Bronchoscopy: should be done to exclude
endobronchial lesion that prevents re-expansion
of the lung.
B-Hemothorax
Definition :
Accumulation of blood in the pleural space.
Sources of blood:
1-Intercostal and internal mammary vessels. 2-Pulmonary vessels & bronchial
arteries, 3-Heart and great vessels. 4-Mediastinal vessels. 5-Diaphragmatic
vessels. 6- Infra diaphragmatic vessels through diaphragmatic tear.
Etiology:
Trauma (The most common cause):
• Blunt or penetrating injury.
Iatrogenic:
• Postoperative. Thoracocentesis. Needle lung biopsy.
Spontaneous pneumothorax: with tear of vascular adhesions.
Bloody effusion :
• Pulmonary embolus. Neoplasm. Tuberculosis.
Traumatic Haemothorax (cont.)
Pathology:
Isolated hemothorax or hemopneumothorax.
Degree:
-Mild
→ 100-350ml
-Moderate → 350-1500ml
-Severe
→ 1500-3000ml
Traumatic Hemothorax (cont.)
Clinical Picture:
General:
Pallor, tachycardia, tachypnoeia, hypotension and
shock.
Local:
Decreased respiratory movement, Tracheal deviation to
contralateral side in massive hemothorax, Dullness
and Decreased air entry on affected side.
Traumatic Hemothorax (cont.)
Investigations:
Anaemia.
Diagnostic thoracocentesis → blood
CXR (PA and lateral) views:
< 300 ml of blood may be hidden by
diaphragm on erect chest film.
Supine CXR can easily miss hemothorax.
• Mild → obliterated costophrenic angle
• Moderate → till the level of the hilum
• Massive → above the level of the hilum
Traumatic Hemothorax:, cont
• Fast Ultrasound.
• CT scan.
Massive Left Hemothorax
Haemopneumothorax
Traumatic Hemothorax (cont.)
Complications:
-Clotting → clotted hemothorax.
-Organization → fibrothorax and frozen chest.
-Infection → empyema.
Traumatic Haemothorax (cont.)
Treatment:
General supportive measures → blood transfusion &
oxygen inhalation.
• Minimal→Conserve.
• Mild to moderate→Aspiration.
• Moderate to massive→ ICTD
Intercostal tube drainage: Using the 5th or 6th space in
the mid-axillary line. Large bore (32-36 F) chest
drain/s.
Treatment Cont.:
Thoractomy:
indicated in:
• Massive Initial chest tube drainage ˃ 1500 cc with
hemodynamic instability not responding to adequate
resuscitation.
• Continued bleeding through the tube ˃200 -300 ml/hour
(3-5 ml/kg/hour) for 3 successive hours
• Drainage is inadequate with persistent collection on CXR.
• Manage associated intrathoracic injuries or pathology
(bronchopulmonary injury with continued air leak, cardiac
tamponade, traumatic aortic aneurysm,…) .
• Evacuation of clotted hemothorax. After 4-6 weeks clot
organization requires decortication.