Chest Trauma and

Indications for Thoracotomy

Dr.Sami Alnassar
Primary survey
Aim to identify life threatening chest injury
Tension pnemothorax
Massive hemothorax
Cardiac temponade
Flail chest
Open pneumothrax
EXAMINATION
LOOK

FEEL

LIESTEN

PERCUSS
EXAMINATION
LOOK

FEEL

LISTEN

PERCUSS
Examination
Dont forget to examine the back??
DIAGNOSTIC IMIGING
CXR



FAST
secondary survey
Is more detailed and completed
examination to Identified :

Ribs fractures , flial chest
Lung contusion
Simple pneumothorax
Simple haemothorax

Secondary survey
Further diagnostic study :
Chest CT
Broncoscopy
Angiogram
Oesophagoscopy / oesophagram
Tension Pneumothrax
is the progressive build-up of air within the
pleural space
Usually due to a lung laceration
Classical signs :
deviation of the trachea
increased percussion note
hyper-expanded chest
Increase CVP ( may be normal ? )
Tension pneumothrax
These classical signs may be absent
tachycardia and tachypnea, and may be
hypoxia.
These signs are followed by circulatory
collapse with hypotension and PEA
Tension Pneumothorax
The presence of
chest tubes does not
mean a patient
cannot develop a
tension
pneumothorax


Tension Pneumothrax
Tension pneumothorax may also persist if
there is an injury to a major airway
2 or more CT may be needed

in these cases thoracotomy is usually
indicated
Bilateral tension Pneumothorax
Beware also the
patient with bilateral
tension
pneumothoraces
treatment
Needle Thoracostomy

Chest tube placement

Possible thoracotomy
or thoracoscopy
Tracheo-broncheal injury
Its rare ,from 0.2 to 4%

Most victims die prior to ER

80% within 2.5 from carina

Main stem 86%

More common in right side
Tracheo-broncheal injury
Signs and symptoms :
Strider
Hoarseness
Hemptysis
Pnemothorax with major air leak
Up to 10% will not produce any clinical or
radiological signs ( recognized months
after stricture occur
Bronchoscopy is the most reliable test
Tracheo-broncheal injury
Intraoperative airway management :
Coordinate with anesthesiologist
Sterile anesthesia circuit
Double lumen tube
Tracheostomy if needed 2-3 rings above the
injured segment
Postoperative airway management :
Maintained low airway pressure
Allows immediate extubation
Tracheo-broncheal injury
Surgical approach :
Extrathoracic consider collar incision
RT thoracotomy for RT bronchial and proximal left
LT thoracotomy for distal LT bronchial injury
Debriment , mucosa to mucosa, absorbable suture
Reinforce suture line with pericardium, pleura,..
Outcome:
>90 of patient reach hospital alive, have good
outcome

Tracheo-broncheal injury
Tension gastrothorax
may be confused with
a tension
pneumothorax.
There is
haemodynamic
compromise, tracheal
& mediastinal
deviation, and
decreased air entry in
the affected
hemithorax
Open Pneumothorax
occurs when there is a pneumothorax
associated with a chest wall defect
air is entrained into the chest cavity not through
the trachea but through the hole in the chest
wall.

Once the size of the hole is more than 0.75
times the size of the trachea, air preferentially
enters through the thoracic cavity.
Open Pneumothorax
Diagnosis should be
made clinically
Sucking chest wall
wound

managements
Oxygenation and possible intubations if in
distress
Occlusive dressing to the wound
Immediate CT insertion
If no CT available , bandage may be
applied over the wound and taped on 3
sides
OR for closure of the defect
hemothorax
Most hemothoraces are the result of rib
fractures, lung parenchymal and minor
venous injuries
Less commonly there is an arterial injury,
which is more likely to require surgical
repair.
The classic signs of a haemothorax are
decreased chest expansion, dullness to
percussion and reduced breath sounds
hemothorax
CXR is the standard
test

Erect film more
sensitive but it take
400 t0 500 to
obliterate the costo-
phrenic angle
hemothorax
FAST is useful in
unstable patient , it
detect small
hemothorax
CT is more sensitive
test
It detect other
associated injury
managements
CT insertion first

Thoracotomy indicated if immediate
drainage of 1000-1500mls of blood
Or 200ml for 4 hours
However the initial volume of blood
drained is not as important as the amount
of on-going bleeding
Tension hemothorax
Tension hemothorax
Flail chest
occurs when a segment of the thoracic
cage is separated from the rest of the
chest wall.
it defined as at least two fractures per rib ,
in at least two ribs.
Usually associated lung contusion
It result in impaired ventilation
Diagnosis
paradoxical
movement of a
segment of the chest
wall
CXR and CT
established the
diagnosis
Clip
Flail Chest
it directed towered
Protected underling lung
Maintain ventilation
Prevent pneumonia
Analgesia is the main treatment
PCA and NSAID
Epidural is the best option ( elderly )
Intubations and mechanical ventilation is
rarely indicated
managements
Operative Fixation by
wires or plates
indicated in
Patient going for
thoracotomy
Fixed thoracic
impaction
Failure to wean from
ventilator
Operative fixation
Operative fixation(Judet plates )
Operative fixation(Sanchez plates )
Thoracoscopy for trauma patients
(carllio AJS 2005)
DIAGNOSTIC APPLICATIONS :
DIAGNOSIS OF DIAPHRAGMATIC INJURIES
DIAGNOSIS OF PERSISTENT HEMORRHAGE
DIAGNOSIS OF BRONCHOPLEURAL FISTULAS
ASSESSMENT OF CARDIAC AND MEDIASTINAL
STRUCTURES
THERAPEUTIC APPLICATIONS
MANAGEMENT OF RETAINED THORACIC
COLLECTIONS
REPAIR OF DIAPHRAGMATIC INJURIES


Emergency Department
Thoracotomy

Accepted Indications :
Penetrating thoracic injury :
Traumatic arrest with previously witnessed cardiac
activity
Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury
Unresponsive hypotension (BP < 70mmHg)
Rapid exsanguination from chest tube (>1500ml)
Emergency Department
Thoracotomy

Relative Indications :
Penetrating thoracic injury
Traumatic arrest without previously witnessed
cardiac activity
Penetrating non-thoracic injury :
Traumatic arrest with previously witnessed cardiac
activity
Blunt thoracic injuries:
Traumatic arrest with previously witnessed cardiac
activity
Emergency Department
Thoracotomy


Contraindications :
Blunt injuries:
Blunt thoracic injuries with no witnessed cardiac
activity
Multiple blunt trauma
Severe head injury
Emergency Department
Thoracotomy
Rationale

Overall survival of patients undergoing
emergency thoracotomy is between 4 and
33%
The main determinants for survivability
are the mechanism of injury
For penetrating thoracic injury the survival
rate is fairly uniform at 18-33%
Emergency Department
Thoracotomy
Rationale
Blunt trauma survival rates vary between 0 and 2.5%
The presence of cardiac activity, consistently related to
the outcome following emergency thoracotomy
In one study of 152 patients (Tyburski) survival rates
were 0% for those patients arresting at scene, 4% when
arrest occurred in the ambulance, 19% for emergency
department arrest
Survival for blunt trauma patients who never exhibited
any signs of life is almost uniformly zero. Survival for
penetrating trauma patients without signs of life is
between 0 and 5%.
Emergency Department
Thoracotomy
Operative Technique

The primary aims of emergency
thoractomy are:
Release of cardiac tamponade
Control of haemorrhage
Allow access for internal cardiac massage
Secondary manoeuvers
cross-clamping of the descending thoracic aorta.

Emergency Department
Thoracotomy
Operative Technique

Approach :
A supine anterolateral thoracotomy
left sided approach is used in all patients and
with injuries to the left chest
Patients who are not arrested but with
profound hypotension and right sided injuries
have their right chest opened first.
Emergency Department
Thoracotomy
Operative Technique


Emergency Department
Thoracotomy
Operative Technique

Approach :
In both cases it may become necessary to
extend the incision across the sternum
skin incision is made in the 5th intercostal
space
Relief of tamponade :
The pericardium is opened longitudinally to
avoid damage to the phrenic nerve,
Emergency Department
Thoracotomy
Operative Technique

Control of haemorrhage :
Cardiac wounds :
controlled initially with direct finger pressure.
sutured using non-absorbable 3/0 sutures
mattress sutures are used to avoid obstructing
coronary flow
Pulmonary & Hilar injuries.
temporarily controlled with finger pressure at the
pulmonary hilum.
Emergency Department
Thoracotomy
Operative Technique
Control of haemorrhage:
Pulmonary & Hilar injuries :
This may be augmented by placement of a
Satinsky clamp across the hilum
Lesser haemorrhage from the lung parenchymas
can be controlled with a temporary clamp
Great vessel injuries :
Small aortic injuries can be sutured directly using
the 3/0
Emergency Department
Thoracotomy
Operative Technique


Larger injuries, especially to the arch may require
temporary digital occlusion and insitution of cardiac
bypass.
Internal cardiac massage
internal cardiac massage should be started as
soon as possible
A two-handed technique produces a better
cardiac output
Emergency Department
Thoracotomy
Operative Technique

Aortic cross-clamping :
The rationale for clamping the aorta is to
redistribute blood flow to the coronary vessels,
lungs and brain,
Clamp time should ideally be 30 minutes or less.
Cross-clamping is done ideally at the level of the
diaphragm, to maximise spinal cord perfusion
Emergency Department
Thoracotomy
Operative Technique
Emergency Department
Thoracotomy
Operative Technique