Thoracic Trauma

Overview
General Anatomy
Types of thoracic injuries Exam findings

Treatment

Thoracic Anatomy

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Thoracic Anatomy

http://info.med.yale.edu/intmed/cardio/echo_atlas/references/heart_anatomy.html

Thoracic Anatomy

Thoracic Anatomy

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http://eng-sci.udmercy.edu/courses/bio123/Chapter43/lung%20anatomy.html

Thoracic Anatomy

Thoracic Anatomy

Thoracic Trauma
25% of nonmilitary trauma related deaths.
Mortality 5% for isolated chest trauma Two or more organ systems 1/3 mortality

Nearly all penetrating injuries result in

pneumothorax with hemothorax in more than 75% of cases. Of penetrating trauma, 1/3 will be associated with abdominal injuries. Mechanisms of blunt trauma: compression, direct trauma, and accel/decel forces.

Diagnosing Thoracic Injuries

Symptoms: Chest pain and SOB.
Physical Exam. Look for six major conditions. Think of mechanism of injury. Dont forget about liver and spleen.

Chest Wounds
Lethal six injuries: Airway obstruction Tension pneumothorax Pericardial tamponade Open pneumothorax Massive hemothorax Flail chest The Box: bounded by nipples bilat, costal

margin inferiorly, and thoracic inlet superiorly

Have high suspicion of cardiac injury

Inspection
Chest Wall: look for signs of injury such

as contusions, flail chest, open chest wounds. Neck: Distended neck veins, subcutaneous emphysema, swelling and cyanosis Abdomen: scaphoid abdomen

Physical Exam
Palpation: trachea position, tenderness,

or crepitus. Percussion: dullness for hemothorax and hyperresonance for pneumothorax Auscultation: Equal breath sounds, bowel sounds high in chest.

Pneumothorax
Can cause severe symptoms if: Tensions pneumothorax Occupies >40% of hemithorax Pt in shock or preexisting cardiopulmonary disease.
Occasionally can be delayed. Can repeat film in 6hrs and.

Occult Pneumo: requires chest tube if patient

is going on a ventilator.

Pneumothorax
Traumatic injury

causes rupture of lung parenchyma and air enters the pleural space Negative pressure in pleural space facilitates air escape

Pneumothorax Types
Simple Pneumothorax air seen on

CXR with no vital sign derangements and no mediastinal shift.

Tension Pneumothorax continued air

leakage into closed space causes significant lung collapse, compression of mediastinum, and compression of opposite hemi-thorax

Pneumothorax Types
Open Pneumothorax from penetrating injury If significant enough in size will cause Sucking Chest Wound
Spontaneous Pneumothorax typically occurs

in tall, slender teenagers due to congenital area of lung weakness.

Also seen asthma, COPD, restrictive lung dz

 Sucking Chest

Wound

A:Inspiration B:Experation

Pneumothorax Exam findings

Simple Tension Pneumothorax Pneumothorax JVD Diminished lung Tracheal shift sounds Diminished SpO2 Tachycardia Absent breath sounds Tachypnea Diminished breath Dyspnea sounds on opposite side Pleuritic chest pain Hypotension Hyper-resonant to Narrowing pulse percussion pressure

Pneumothorax Radiographs

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Pneumothorax Radiographs

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Pneumothorax Radiographs

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Pneumothorax Treatment
All types of pneumothorax

ABCs, supportive care, early notification High flow oxygen Rapid transport if unstable vitals
Open pneumothorax

Occlusive dressing placed

Consider securing only on three sides

Watch for signs of tension pneumothorax

Cover site with sterile occlusive dressing taped on three sides

Pneumothorax Treatment
Tension Pneumothorax

Acute life threatening emergency Needle decompression affected side

2nd intercostal space mid-clavicular line -OR4th or 5th intercostal space at mid-axillary line Place above rib to avoid neurovascular bundle

All needle decompressions will need chest tube upon arrival at hospital

Tension Pneumothorax
Clinical diagnosis
Dyspnea, hypoperfusion, distended neck

veins, diminished breath sounds, hyperresonant percussion, tracheal deviation. Decompress with 14 gauge catheter

2nd intercostal space midclavicular line If no improvement then look for other cause (ie Cardiac Tamponade)

Chest Tube

Needle Decompression

Subcutaneous Emphysema
Air from lung

parenchyma or the tracheobronchial tree. Interstitial lung injury through hilum and mediastinum. If extensive then suspect injury to pharynx, larynx, or esophagus. Should be assumed that pt has ptx even if not visible on chest x-ray.

Ruptura trakhea - bronkhus

Ruptur trakhea,

bronkhus sering didaerah Carina ( percabangan), bila ruptur total bisa fatal
Klinis hemoptisis,

sianosis, empisema subkutis, intubasi sulit karena distorsi trakhea.

Hemothorax
Most frequently from lung injury.
5-15% of pts admitted with chest trauma

require thorocotomy. Upright film: 200-300 mL of blood. Treatment: Chest tube.

Chest Tube
Site: anterior axillary line.
2-3cm incision 1-2cm below interspace. Extend down to intercostal muscles.

24F or 28F tube for pnuemothorax.

32F or 40F tube form hemothorax.

Massive Hemothorax
Each hemithorax can hold 40-50% of

blood volume. Defined: 1500 mL or more. Cause: Injury to lung parenchyma, intercostal artery or internal mammary artery

Massive Hemothorax
Life threatening
Hypovolemia Hypoxia

causing inadequate preload

Compresses

the vena cava.

Chest x-ray-Aerated lung surrounded by

fluid. Treat: Chest tube operation

Cardiac Tamponade
Caused by blunt and penetrating

trauma. Stab wounds to midchest most common cause. Pericardial sack has poor compliance.
150-200

mL can result in tamponade.

Cardiac Tamponade
Obstruction of venous return leading to

hypoperfusion and distended neck veins. Becks Triad : JVD,hypotension, muffled hear tones Treat: Fluid bolus and Pericardiocentesis

As little as 5-10 mL can improve cardiac performance

Cardiac Tamponade ECHO

Tamponade jantung

Chest Wall Injuries

Soft tissue with bleeding: control with

pressure. Explore in OR. Open Chest Wounds

If exceeds 2/3 are of trachea then air will enter through chest wall Cover with air tight dressing but may cause tension pneumothorax. Do not insert chest tube through tract.
Tissue loss

Bony Injuries
Simple rib fractures: 50% will not appear on

x-ray. Look for complications:

Hemopneumothorax Contusion

1st and 2nd rib fractures: requires significant

force. Look for other injuries. Multiple: If 9,10,11 then think liver spleen injury. Flail Chest: Segmental fx or 3 or more adjacent ribs. Paradoxical movement. Hypoxemia from underlying contusion.

Flail Chest
Free floating

segment of ribs.

3 or more rib fractures broken in 2 places.

Look for paradoxical

chest wall motion

Inhaleinward Exhaleoutward

Decreased air entry.

Flail Chest Treatment

Analgesia and intercostal nerve block.
Belts and adhesive tape inhibit

expansion. Restrict IV fluids. Ventilatory support: shock, 3 or more injuries, head injury, pulmonary disease, >65 yrs.

Consider Ventilatory Support

Respiratory failure from flail chest.
Shock Multiple injuries

Comatose
Requiring multiple transfusions Elderly Preexisting pulmonary disease RR >30-35 Po2 <50 on room air

Sternal Fractures
Incidence 3%. Normal vitals and normal EKG. Repeat

EKG in 6 hrs

Injuries to Lung
Pulmonary Contusion
Significant

source or morbidity and

mortality. Hemorrhage and edema without laceration. Caused by compression-decompression injury.

Pulmonary Contusion
Pathological changes: capillary damage

causes interstitial and intraalveolar extravasation of blood and edema. First hemorrhage then edema. Pt becomes hypoxic, hypercarbic, and acidotic.

Diagnosis and Treatment

Chest x-ray: areas of opacification seen

within 6 hrs. Maintain adequate ventilation. Usually require support if more than 28% of lung volume.

Pneumomediastinum
Hamman sign: crunching, rasping sound,

synchronous with heartbeat Suspect if subcutaneous emphysema in neck. Traumatic pneumomediastinum is usually asymptomatic. Must look for injury to the larynx, trachea, major bronchi, pharynx or esophagus.

Lung Injuries
Hematoma: parenchymal tears filled

with blood. Can form abscess. Lacerations: major hemorrhage from sharp ends of fractured ribs. Air embolism: air from injured bronchus forced into vessel.

Tracheobronchial Injury
Caused by rapid deceleration.
Expiration against closed glottis or

compression against vertebral column. Signs and Symptom: dyspnea, hemoptysis, Hamman sign, and sternal tenderness. 10% asymptomatic. Injury occurs within 2cm of carina or at origin of lobar bronchi.

Diaphragmatic Injury
Mostly penetrating trauma.
4-5% from blunt trauma. 80-90% on left in blunt trauma. Often Intraop diagnosis in penetrating

trauma.

Penetrating Injury to Heart

Factors affecting survival: weapon used,

size of myocardial injury, artery damage and presence of tamponade. 1/3 can be saved. Signs of life in OR: 70% gunshot and 85% stab wound survival. If no sign of life in field-do not resuscitate.

Heart Injury Cont

Usually rapidly fatal from massive

hemorrhage. <1/4 of patients reach hospital.

Becks triad: distended neck veins,

hypotension, muffled heart tones. Other causes: tension pneumothorax, myocardial dysfunction and systemic air embolism.

Diagnosing
X-ray:most patients have normal

silhouettes. Pericardium is noncompliant. EKG: nonspecific Echo: pericardial fluid

Pericardiocentesis
Paraxiphoid approach
Can direct needle toward left scapula or

right scapula (less likely to damage ventricle). Up and back at 45 degrees for 4-5 cm. Aspirate every 1-2mm. Removal of 5-10 mL can increase stroke volume by 25-50%.

Pericardiocentesis

Pericardiocentesis

Indications For Thoracotomy/Median Sternotomy

Hemodynamic instability with penetrating chest

wound Massive hemothorax >1500cc Persistent htx >200cc/hr x 4hrs or persistent large htx despite chest tube Persistent air leak/tracheobronchial fistula with inability to ventilate patient Cardiac tamponade Esophageal injury Great vessel injury

Thoracotomy Indicated for Cont Bleeding In:

Pts losing more than 1500mL in first 4-

8hrs. Chest tube drains 200-300mL per hour. Chest continues to be more than half full on x-ray with functioning chest tube.