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CLINIC OF THORACIC SURGERY IASI

Dr.Cristina Grigorescu

BLUNT and PENETRATING

INJURIES of the CHEST WALL,

PLEURA, and LUNG


INCIDENCE

 150.000 DEATH/YEAR (USA)


 <40 YEARS OLD,traumatic injury- most
common cause of death.
 THORACIC INJURIES ¼ of deaths
EVALUATION and MANAGEMENT

 Initial evaluation- correcting life-


threatening conditions immediately and
documenting the less serious injury for
later correction.
 Primary survey – airway, breathing and
circulation to be stabilized immediately.
 All parts of the physical examination are
conducted in a focused manner to identify
and correct potentially lethal conditions
immediately.
EVALUATION and MANAGEMENT
 Examination-mouth, neck focuses on identifying any
symptoms of air airway obstruction.
 Neck veins- distention/collapse.
 Respiratory mechanism of chest wall motion- to detect
inhibition due to rib fractures or paradoxical motion
due to flail chest.
 Auscultation- distribution of brath sounds, their
character, any crepitus present in the chest wall.
 Percussion- notes areas of hiperresonance /dullness.
 Palpation – identification of any areas of crepitus,
hematomas, irregularities due to rib fractures, areas of
point of tenderness due to fractures
EVALUATION and MANAGEMENT

 Imaging modalities are used to confirm diagnosis


suspected and to assess the efficacy of therapeutic
interventions .
 Chest X-Ray,
 CT,
 Ultrasonography,
 Blood tests,
 Arterial presure,
 Pulsoximetry
 Arterial blood gases.
Injuries sustained as the result of
thoracic trauma
 Traumatic asphyxia,
 Mediastinal and subcutaneous emphysema
 Rib fractures,
 Sternal fractures,
 Open wounds of the chest wall:sucking wounds,
 Minnor penetrating wound of the thorax’
 Pulmonary contusion,
 Pulmonary hematoma,
TRAUMATIC ASPHYXIA

 Severe blunt injury of the thorax.


 - Facial and upper chest petechiae,
 - subconjuctival hemorrages, cervical cyanosis,
occasionally neurologic symptoms.
 Temporary impairment/loss of vision , presumed
to be due to retinal edema.
 Factors: thoracoabdominal compression after
deep inspiration against closed glottis,results in
venous hypertension in the valveless cervicofacial
venous system.
 No special treatment is required.
Mediastinal and Subcutaneous Emphysema

 Injuries to the traheobronchial


tree,esophagus,and lungs can lead mediastinal
emphysema.
 Rupture of the lung substance leads to a
pneumothorax.
 Severe blunt trauma- lacaration/rupture of a
central airway.
 The air may dissect back along the bronchi,
vessels into mediastinum.
 Large leak- air migration in the subcutaneous
space of the neck, face, chest wall, down to the
inguinal ligament, external genitalia.
Mediastinal and Subcutaneous Emphysema

 Tracheobronchial injury-suspected when a


large amount of mediastinal air is present,
especially if the pneumomediastinum seems to
increase with mechanical ventilation-
inspection of the bronchial tree
(bronchoscopy).
 Treatment and management should address
the etiology of the mediastinal and
subcutaneuos emphysema.(suture of the
bronchia, decompression incisions in the skin)
RIB FRACTURES
 Fracture of the one or two ribs unilaterally
 -identifying any associated injury,
 - chest pain control, to prevent hypoventilation,
 - decreased excursions of the chest wall and poor pulmonary
hygiene may lead: atelectasis,pneumonia,respiratory failure.
 Terapy:epidural analgesia, early mobilization,deep
respiratory efforts, frequent coughing.
 Pulmonary physiotherapy,nasotraheal suctioning,promt
bronchoscopy for the patient enable to clear secretions.
 Intercostal nerve blocks, intrapleural catheter analgesia,
transcutaneous electric nerve stimulation
Fractures of the first and second ribs

 Indicate the possible existence of


additional serious intrathoracic injury.
 Routine aortography-to rule out associated
vascular injuries.
 Mortality rate 36%,concomitant injuries to
the head (53%), abdomen(33%), other
structure within the thorax (64%).
Multiple or bilateral rib fractures

 Prognosis is related to the number of ribs


injured, patient”s age, underlying
pulmonary status.
 Mortality rate in elederly patient with
isolated rib fracture is 10-20%
Flail chest
 Instability of the chest wall from unilateral
bilateral multiple rib fractures, or from
disruptions of the costochondral junctions.
 Paradoxic chest wall motion lead to the reduction
in vital capacity and to ineffective ventilation,
along with associated pulmonary contusion—
ARDS.
 T:external stabilization:sandbags,towel
clips,internal stabilization using PEEP(mechanical
ventilation),
 Operative fixation of flail segment,
 Mortality rate:15-20%, but survivors may have
long-term consequences:impared pulmonary
function: dyspnea(63%),persistent pain(49%).
Sternal fractures
 4% in major motor vehicle crashes.
 Transverse, in the upper or midportions of the
body of the sternum.
 Localized tenderness, swelling, deformity.
 X-ray confirm(in lateral view).
 CT examination injures of the adjacent organs
and others skeletal structures.
 T:pain control and appropiate pulmonary
hygiene.
 Severe displace require open reduction with
internal fixation using cross wires.
Open wounds of the chest wall: sucking
wounds of the chest
 Loss of an area of the entire chest wall.
 Air can freely flow in and out of the pleural space.
 Life-threatening emergencies.
 Associated with devastating intrathoracic injuries.
 Collaps of the ipsilateral lung,open pneumothorax,
 T:cover the defect with an impermeable dressing
till the operative room.
 Operation:removal the devitalized tissue and
foreign bodies and closure the wound with
muscle, musculocutaneous flap or syntetic
materials for chest wall recosntruction.
Pneumothorax

 Simple pneumothorax
 X-ray
 Chest tube drainage
 Large air leak or difficult reexpansion
trahcheobronchial injuries should suspected
(bronchoscopy)
 Tension pneumothorax
 Severe respiratory distress,distended neck veins,
deviated trachea and absent breath sounds on
the affected side.
 X-ray.
 T:needle in the pleural space in emergency, chest
tube drainage.
Hemothorax

 Indication of Thoracoscopy in Thoracic


trauma:
 Persistent minor hemorrhage,

 Retaines hemothorax,

 Empyema,

 Chylothorax,

 Retained foreign bodies,

 Treatment of persistent air leak.


Pulmonary contusion

 Hemorrage into the alveolar and


interstitial spaces.
 Mortality rate : 22-30%.

 CT:pulmonary lacerations, infiltrate,

 T: ventilatory support, fluids (with


diuretics), oxygen,
Pulmonary hematoma

 CT : opacities developed into discrete


mass with distinct margins.
 T: antibiotic prophylactic,antiinflamatory,

 Pain control, hemoptysis control.

 If is large require surgery:pulmonary


resection.

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