ANATOMY OF THORAIC CAVITY

THORACIC TRAUMA
Chest wall trauma is common and can range from an isolated rib fracture to flail
chest , hemopneumothorax, cardiac injury and is found to be responsible for 25% of all
deaths following road traffic accidents. Many of these deaths occur at the site of the
accident following serious chest injuries such as bilateral flail chest, severe lung
contusion

with

deep

refrectory

hypoxia,

and

great

vessel

distruption

and

exsanguinations.
To approach to the treatment must be methodical to rule out the injuries to the
underlying viscera such as lung, heart, liver, and spleen as injuries to these are often
asscociated with chest wall trauma.

CHEST INJURIES
Blunt injury
- Blunt injury may lead to fracture ribs, sternum along with pulmonary and
cardiac contusion or rupture of airway, diaphragm and major vessel
depending upon low impact velocity(direct blow) or high velocity (deceleration
and crush injuries).
Penetrating injury
- Penetrating injury can be used by stab, impalement or gunshot and may lead
to

pericardial

tamponade,

major

vessel

or

intercostal

hemorrhage,

hemopneumothorax or at times esophageal or airway perforation. A high

velocity bullet is always destructive because it creates an immense shock
wave with resultant cavitation.

PATHOPHYSIOLOGY
Most patient with chest injury can be managed by relatively simple measures
(intercostals drain insertion, adequate analgesia, careful fluid management and
physiotherapy) and do not require thoracotomy. If these injuries are not managed
appropriately, the consequences may be fatal. Immediate threats to life are massive

hemorrhage with consequent hypovolemia and low cardiac output. Hypoxia is the most
common pathophysiological process in thoracic trauma and it is therefore crucial to
ensure adequate oxygen delivery to viable sections of lung.

Hypoxia and acidosis may occur secondary

- Hypovolemia caused by blood loss
- Low cardiac output as a result of tamponade
- Pulmonary contusion or cpllapse
- Ventilatory failure
- Displacement of mediastinal structure
Respiratory acidosis results from inadequate ventilation, whereas metabolic
acidosis is causes by tissue hypoperfusion. Untreated chest injuries may cause
an increase in hypoxia and acidosis, which in turn will compound the adverse
effects of other injuries.

PRIMARY SURVEY
The basic principle in resuscitation is securing the airway and restoring the circulating
volume. The primary survey involves simultaneous assessment and treatment of lifethreatening injuries. It follows the ABC(airway,breathing,circulation) principle of
resuscitation, which may also include even emergency thoracotomy.

INJURIES ASSOCIATED WITH PENETRATING THORACIC TRAUMA

1. PNEUMOTHORAX
- Condition in which air can enter the pleural space, either through a breach in
the thin and delicate visceral pleura or through an injury to the chest wall
results in pneumothorax. It could be traumatic, spontaneous or iatrogenic.
2. TENSION PNEUMOTHORAX
- This occurs when air enters the pulmonary cavity during inspiration from
lungs, airway, or chest wall injury that seals or closes during expiration.
Excessive pressure reduces effectiveness of respiration and progression of
simple or open pneumothorax.

The clinical signs of tension pneumothorax are :

Asphyxia
Tachycardia
Hypotension
Tracheal deviation to the contralateral side
Hyperresonance with loss of breath sounds on the affected side
Tension pneumothorax is clinical diagnosis.
TREATMENT
Immediate decompression should be performed by insertion of a cannula into
the second intercostal space in the mid-clavicular line which should be
replaced later on with intercostals tube drain.

3. OPEN PNEUMOTHORAX
Open pneumothorax is also known as sucking chest wound, because air
moves in and out through the chest wall injury with each breath. It also

free passage of air between atmosphere and pleural space.

Sign and symptom
Penetrating chest trauma
Sucking chest wound
Frothy blood at wound site
Severe dyspnea
Hypovolemi

TREATMEANT
Initial management closure of the defect with a sterile occlusive dressing and
placement of intercostals drain should be away from the wound. Surgical closure
can be undertaken when the primary and secondary survey is complete.

4. TRAUMATIC PNEUMOTHORAX
(CLOSED PNEUMOTHORAX)
Pneumothorax due to trauma is usually closed. In this the chest wall is intact and
the visceral pleural damage is caused by a rib fracture. It can happen after a fall
against a hard edge or due to kick. At times, it can be a part of multiple injuries.
5. HEMOTHORAX

Massive hemothorax is defined as the loss of 1500 ml or more commonly caused

by a penetrating injury, it can be associated with blunt trauma of chest wall as
wall.
DIAGNOSIS
The signs are those of hypovolemic shock with absent breath sounds on the
affected side. The neck veins may be full secondary to the mechanical effects of
hemothorax or it may be empty in case the patient is hypovolumic.
Signs and Symptoms
Blunt or penetrating chest trauma
Shock
- Dyspnea
-Tachycardia
-Tachypnea
-Diaphoresis
-Hypotension
Dull to percussion over injured side
TREATMENT
It comprises of continued decompression of the chest and restoration of the
blood volume. A large bore chest drain(32F or larger) should be used. The rapid
infusion of fluid replacement is started through large caliber venous cannula until
type specific or cross-matched blood is available.
If there is continuing blood loss of more than 200ml/hour for more than three
hours, exploratory thoracotomy must be undertaken by an experienced surgeon.
Any penetrating wound medial to the nipple should heighten suspicion of damage
to the heart, great vessel or hilar structure.
6. INTERCOSTAL CHEST DRAINAGE
Underwater seal drainage successfully

treats

most

cases

of

hemopneumothorax. The modern chest drains are made up of clear plastic, are
available in varying diameter, have length markers, have multiple side roles and
have radiopaque stripe to allow confirmation of tube position on radiograph.
THORACOTOMY
Majority of chest injuries are managed conserve by underwater seal drainage.
Oxygen are physiotherapy are the mainstay in the management of blunt chest
trauma. However, some patient may require thoracotomy.

7. RIB FRACTURE
Single fracture of one or more ribs due to direct violence is a common
occurrence in the chest trauma. The degree of pain depends on the number of rib
invoved. Localized tenderness and crepitus are often elicited in examination. Sufficient
analgesia is the treatment of choice to encourage the normal repiratory pattern. At times
intercostal nerve block may be required for persistent pain.
Although the first rib is well protected an requires a considerable force for
fracture, the mortality is high because of its association with injury to major vessels.
Fracture of sternum results from decekeration or seat belt injury. It generally
leads to the injury of the underlying myocardium.

8. FLAIL CHEST
It occurs when several ribs are fractured at two places either on one side of the chest or
on either side of the sternum. The flail segment causes severe disruption of normal
chest wall function with paradoxical movement. It is usually accompanied by underlying
lung contusion and the combination of the two can cause serious hypoxia.
DIAGNOSIS
Careful observations of the respiratory movement which may be un-coordinated, and
the palpation of the chest wall for fracture crepitus are required so that the diagnosis is
not missed. The chest radiograph cannot always be relied onto reveal costochondral
separation or rib fracture.
TREATMENT
Resusciation of a patient with flail chest involves ensuring full expansion of the
lung with good oxygenation, which may require intubation and mechanical ventilation.
Any hemothorax must be drained by an intracostal drain. Adequate analgesia is

important because it allows the patient to self-ventilate completely as well as to clear

their own airway and cope with physiotherapy.
Thoracotomy with fracture fixation is occasionally appropriate when operative
procedure is required for an underlying injury.

9. CARDIAC TAMPONADE
In trauma patient it is usually caused by penetrating injury but disruption of the heart or
great vessels with bleeding into the pericardium may also result from a blunt injury as
well.

DIAGNOSIS
Sign of tamponade are hypotension, muffled sounds and an elevated jugular venous
pulse may be absent in the hypovolemia.
TREATMENT
Immediate pericardiocentesis should be under if tamponade is suspected. In 25% of
patients cardiac tamponade, clotting of blood within pericardium will prevent aspiration.

SECONDARY SURVEY
The aim of the secondary survey is to identify the potential life-threatening injuries and
this too should only begin when patients condition is fully stabilized.
Essential investigations during the secondary survey are:

Electrocardiograph
Chest radiograph
Arterial blood gas

POTENTIAL LIFE-THREATENING INJURIES

A) Pulmonary Contusion
The underlying lung often gets injured in thoracic trauma, which usually resolves
but laceration with persistent air leak, features of bleeding or failure of expansion
of the lung will require surgical intervention can be insidious and intubation and
ventilation may be required at any time.
Close monitoring is essential because the onset of an adult respiratory
distress syndrome like condition can be insidious and intubation and ventilation
may be required at any time.

B) Myocardial Contusion
The diagnosis of myocardial contusion is based on the electrocardiograph
abnormalities . Once the myocardial contusion is diagnosed, the patient should
be treated as if he had sustained myocardial infarction.
C) Aortic Disruption
It is usually occurs as a result of major deceleration injury. Clinical signs are
interscapular pain, murmur hoarseness, radio-femoral delay in arterial pulse.
Arteriography is diagnostic and computed tomography(CT) is of little help. If
complete, it is invariably fatal at the scene, but is the bleeding is slow it needs
early identification and management.
TREATMENT
Once the diagnosis is confirmed formal surgical repair is required and should not
be delayed. Urgent exploration by left thoracotomy through 4 th intercostal space
is undertaken. Control above and below the transection is vital and the aorta is
repaired by direct suture or interposition graft.
D) Diaphragmatic Rupture
At times the blunt trauma produces large radial tears which lead to herniation of
abdominal viscera into the chest. This in turn may cause mediastinal
compression of thoracic organs with its consequent effects.
TREATMENT
Diaphragmatic tears should be repaired with non-absorbable sutures.
E) Tracheal Rupture

Tracheal is susceptive to blunt and penetrating trauma and the immediate

concern is the patency of the airway. Stridor indicates partial obstruction which
may became complete if not managed promptly.
DIAGNOSIS AND TREATMENT
Endoscopy and computed tomography(CT) scanning following stabilization of the
patient. Trachea if found injured should be repaired.
F) Esophageal Rupture
It usually follows a penetrating injury. The resulting mediastinitis often causes an
emphysema,If there is leakage into pleural cavity.
A radiograph is essential for diagnosis. This discloses the presence of air in the
mediastinum or pleural cavity or in the neck which may easily be palpable. Left
pneumothorax or hemothorax in the absence of rib fracture should raise a
suspicion for esophageal rupture. The diagnosis is confirmed by contrast studies
or esophagoscopy. Treatment is initially chest tube drainage followed by formal
repair.

ROLE OF ULTRASOUND AND STANDARD CITY IN THORACIC TRAUMA

Surgeons have found ultrasound to be useful in detection of post-traumatic
hemothorax. The sensitivity and specificity of ultrasound has found to be equivalent to
be portable chest radiograph. The only benefit is that ultrasound examination wan
significantly faster.
The standard thoracic computed tomography(CT) has been always an adjuvant to the
routine chest radiograph. The spiral computed tomography(CT) with contrast has been
found to be useful in detecting blunt rupture of the thoracic aorta.
THORACOSCOPY
The use of video-assisted thoracoscopy continues to increase in major trauma
centers. The indications for thoracoscopy in trauma include early evacuation of a clotted

hemothorax, evaluation of left thoraco-abdominal wounds and repair of pulmonary

lacerations or assistance with pulmonary lobectomy.
APPENDIX
HEMOTHORAX

THORACOTOMY

PNEUMOTHORAX

DIAPHRAGMATIC TEAR

CONCLUSION
At the end of this assignment, the student should be able to understand the
meaning

of

thoracic

cavity

and

thoracic

trauma.

Thoracic

cavity

is

the space within the walls of the chest, bounded below the diaphragm and above by the
neck, and containing the heart and the lungs. The student also can describe the chest
injuries, pathophysiology, primary survey, and the others. Besides, the student can be
explain

the

injuries

associated

with

penetrating

thoracic

trauma

such

as

pneumothorax,hemothorax and others with the treatment.Lastly, the student should be

describe the role of ultrasound and standard city in thoracic trauma and the example is
thoracoscopy.

REFERENCES

Bibliography
UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY. NEW
DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

Bibliography
TOY, S. (2010). CASE FILES EMERGENCY MEDICINE. UNITED STATES OF
AMERICA: LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA.
UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY. NEW
DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

Bibliography
BRENDA G.BARS, S. C. (2010). TEXTBOOK OF MEDICAL SURGICAL NURSING 1.
UNITED STATES OF AMERICA: LIBRARY OF CONGRESS CATALOGING IN
PUBLICATION DATA.
TOY, S. (2010). CASE FILES EMERGENCY MEDICINE. UNITED STATES OF
AMERICA: LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA.
UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY. NEW
DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

Bibliography
BASAVANTHAPPA, B. T. (2011). ESSENTIAL OF MEDICAL SURGICAL NURSING
(1ND EDITION ed.). NEW DELHI: TYPE BROTHERS MEDICAL PUBLISHER(P) LTD.
BRENDA G.BARS, S. C. (2010). TEXTBOOK OF MEDICAL SURGICAL NURSING 1.
UNITED STATES OF AMERICA: LIBRARY OF CONGRESS CATALOGING IN
PUBLICATION DATA.
TOY, S. (2010). CASE FILES EMERGENCY MEDICINE. UNITED STATES OF
AMERICA: LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA.
UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY. NEW
DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

BUDD, DC, COCHRAN , RC, FOUTY, WJ. CHOLECYSTECTOMY WITH AND

WITHOUT DRAINAGE. AM JSURG. 1982