Thoracic trauma

Done By : Nadeen Taani

Supervised by : Dr. Shadi
Hamouri

Thoracic trauma include:

Traumatic Pneumothorax (tension & open)

Hemothorax
Flial chest
Rip fractures
Lung contusion
Diaphragmatic rupture
Esophageal rupture
Aortic , cardiac and major vascular injuries
(will not talk about it in this seminar) .

Epidemiology

Ranked 5th overall in total number of deaths in the USA

behind diseases of the heart (IHD) ; malignant neoplasms;
Cerebrovascular diseases; and chronic lower respiratory diseases
(COPD).
And Grouping all injury-related deaths (to include suicide,
homicide, undetermined, and war-related deaths, in addition to
accidents) it would be 3rd most common cause for death
Mortality and morbidity due to traumatic thoracic injuries are
decreasing (as understanding of the disease process improves).
25% of traumatic deaths are secondary to injuries to the thorax.
In penetrating trauma, 40% have a thoracic injury, whereas in
blunt trauma, 33%.

 A transected aorta is thought to be the cause of

death in approximately 12% to 30% of patients
who die at the scene from blunt trauma.
Motor vehiclerelated injuries, firearms,
stabbings, other assaults, and falls account for
more than half of these deaths (58.1%).

Pathophysiology
Thoracic injuries leave little room for error in their
diagnosis and management.
If improperly managed they are frequently fatal,
whereas massive insults can usually be treated
by simple maneuvers with generally excellent
results.
So the understandment of pathophysiologic
processes and the mechanisms of traumatic
injury is crucial in the management of these
patients.

 There is a five separate Mechanisms for early loss of life in

case of thoracic trauma:
Airway obstruction from tracheobronchial injuries,
pulmonary secretions, or hemorrhage.
Loss of oxygenation and ventilation capability from
pneumothorax, hemothorax, or pulmonary contusion.
Exsanguination (blood loss).
Cardiac failure from cardiac contusion or valve rupture.
Cardiac tamponade.
(Beck's triad ;1-Low blood pressureoccurs because of decreased stroke
volume.

2- jugular-venous distension due to impaired venous return to

the heart.
3-mu
3-muffledheart soundsdue to fluid buildup
inside the pericardium.)

Thoracic Trauma mortality

distribution
Seconds to minutes after injury:
Major injury to aorta, heart, brain stem, or
spinal cord, or acute respiratory distress.

Minutes to the few hours after

injury (the so-called golden hour):
epidural or subdural hematoma,
hemopneumothorax, severe liver or spleen
injury, pelvic fractures, or injuries involving
major hemorrhage.

Days to weeks after injury: stems from

multisystem organ failure and infection.

Blunt versus penetrating

injury
This differentiation is important with regard to
multisystem management.
Because of the higher likelihood of multisystem
injury in blunt trauma, its morbidity and mortality
is consequently higher.
Motor vehicle crashes remain the number 1
cause of blunt chest trauma despite the
improvements in vehicle design, airbags, and the
use of seatbelts.
Gunshot and stab wounds account for the
majority of penetrating injuries.

Do the math!

The destruction of tissue on impact is directly

proportional to the absorbed kinetic energy (KE), which is
derived from the formula: KE= M(V-V)
low- vs high-velocity missiles any object or weapon that
is thrown at a target
Lower KE missiles tend to have similar-sized entrance
and exit wounds and cause damage primarily to the
structures that are in the missiles path.
Higher KE missiles are more prone to cavitation,
causing significant injury to tissues surrounding the path
of the missile , and tend to have exit wounds that are
substantially larger than their entrance ones.
Bullets that shatter or tumble have a slower exit velocity and impart
more energy to the affected tissues, thereby resulting in more
cavitation

Cavitation is a momentary
acceleration of tissue in all
directions away from the tract
of a missile, producing a cavity
of subatmospheric pressure.

This cavity collapses because

of the resultant vacuum effect,
then reforms and collapses
several times with diminishing
amplitude until all motion
ceases.

This shockwave that results

from the dispersement of this
rebounding energy acts as the
source of injury to surrounding
structures.

The cavitation results in nerve

damage, thrombosis, or
rupture of vessels and even
fractures of bones within
the vicinity of the missiles
path, although no direct
contact with the missile may
occur.

 Dense organs, such as bone and liver, absorb

more energy resulting in more injury.
Lungs, which have a much lower density,
absorb less energy and suffer less injury .
This explains the low frequency of operative
intervention in penetrating chest trauma!

ASSESSMENT

The surgeon plays a key role in the proper evaluation and

resuscitation. The primary survey constitutes the ABCDE of
trauma care:
Airway maintenance/cervical spine precaution
Breathing/ventilation
Circulation/hemorrhage
Disability/neurological assessment
Exposure/environmental control

The pleural space

The pleural space is a potential
space between the visceral and
parietal pleura.
The accumulation of blood or air
within this space is considered
pathologic and may result from
injury to almost any structure
within the thoracic cavity.
This may be diagnosed by simple
methods including P/E or by plain
radiographic evaluation (CXR).

Placement of a CHEST TUBE is

most often the only therapeutic
intervention necessary for
patients who sustain thoracic
trauma.

Tension Pneumothorax
Potentially lethal condition
Is the result of unevacuated air within the pleural
space in the setting of an injury to the visceral
pleura that continues to fill the space on inspiration
without a route for egress, because the defect in the
visceral pleura functionally acts as a one-way valve
. (positive pressure ventilation may exacerbate this
one-way-valve effect).
(Inspiration generates negative intra-thoracic
pressure , Air flows in one way only so creates
positive pressure (tension) in the pleural space).

 The intrapleural pressure rises and mediastinal

structures begin to shift away from the injured
hemithorax, resulting in obstruct and diminished
venous return to the heart , as the superior vena
cava and inferior vena cava begin to occlude
resulting in circulatory instability and fatal
hypotension , cardiac arrest with pulseless
electrical arrhythmia (PEA) rapidly occurs

 This is a clinical
diagnosis and should be
aggressively treated even
before obtaining the usual
radiographic confirmation.
** A patient will present
with one or more of:
- History of chest trauma
(often penetrating
trauma) with Respiratory
distress, hypoxia,
tachypnea & Air hunger .

-The classical signs of tension

pneumothorax ;
* Tracheal Deviation AWAY from the affected side .

* Increased JVP or distended neck veins .

* Hyper-resonance to percussion on the affected side .
* Diminshed or absent breath sounds on the affected side .
* hyper-expanded chest that move little with respiration,
depression of the hemi-diaphragm .
***But more commonly the patient comes with tachycardia ,
tachypnea and may be hypoxia , followed by circulatory
Trachea
collapsed and hypotension
Expansion(move with respiration)
Percussion note
Breath sounds
Neck veins

Management

Classical management of tension pneumothorax is

emergent chest decompression with needle
thoracostomy .
A 14 gauge , 5cm long needle is inserted into the second
intercostal ,mid-clavicular line (This buys time for definitive
management, which is insertion of a formal chest drain) .
Be sure to use a long enough needle. Cadaveric studies
indicate that at this site, the pleural cavity can be deeper
than perceived, and you are unlikely to cause significant
harm through this procedure .

Open pneumothorax
Diagnosis : a chest wound communicating with
the pleural space that is greater than two thirds the
diameter of the trachea will preferentially draw air
into the thorax (sucking chest wound) .

Treatment : cover with partially occlusive

bandage secured in three sides (securing all four
sides can result in a tension pneumothorax and
should be avoided), preventing air from entering the
thorax but allowing it to exit via the wound if
necessary.
Prompt tube thoracostomy should follow
placement of the partially occlusive dressing .

Extra-anatomic air
subcutaneous air, pneumomediastinum, or
pneumopericardium

** The mechanisms by which the introduction of extraanatomic air into the thoracic cavity can occur include
the following :
Perforation of the trachea, bronchial tree, or esophagus
Injury of the lung
Injury of the face, which tracts through the fascial
planes into the neck
Injury to the retroperitoneal space, which tracts
through the diaphragmatic hiatus
Introduced from the outside as a result of a penetrating
injury

 Blue arrow points to "continuous diaphragm sign." The entire

diaphragm is visualized from one side to the other because air in
the mediastinum outlines the central portion which is usually
obscured by the heart and mediastinal soft tissue structures that
are in contact with the diaphragm.
The red arrow points to the air beneath and posterior to the heart.

Hemothorax
** hemothorax may occur from injury to
the :
Pulmonary parenchyma .
Hilar vessels .
Heart with a communicating defect in the pericardium
and pleura .
Great vessels with an opening in the pleura .
Intercostal vessels .
Internal thoracic arteries .

Lung parenchymal bleeding usually

ceases spontaneously as a result of ;

**

1- the low pressure in the pulmonary vessels .

2- the compressive effect of the shed blood in a
closed space .
3- a high concentration of thromboplastin in the
lung .
* Bleeding ,However, may require prompt operative
intervention

 Each adult chest cavity can hold up to 3 litres

of blood, i.e. the chest cavity can hold their
entire circulating volume. Bleeding from
injuries to the great vessels leads to
haemomediastinum , and will not enter the
pleural space unless there is a concomitant
breach of the pleural membrane or injury occurs
at the lung hilum.
Haemothorax is a double insult to the patient as
there is progressive deterioration of effective
breathing and circulation.

Clinical Signs:
signs of respiratory distress and shock.
Signs of bleeding and haemodynamic instability (e.g. tachycardia,
hypotension) , normally present before symptoms of respiratory
distress.
cyanosis, tachypnoea, tachycardia, tracheal deviation away from
the affected side, decreased chest expansion, dullness to
percussion, and reduced or absent air entry on the affected side.

Should we do an x ray??
Early CXR is a useful adjunct to making the diagnosis but should
not delay management in the unstable patient with suspected
massive haemothorax. At least 400ml blood has to be lost into the
pleural space before blunting of the costo-phrenic angle is seen
on an erect CXR.
Ddx: With blunt trauma one should have a high index of suspicion
for injuries that may mimic massive haemothorax, e.g. massive
lung contusion, diaphragmatic rupture with intrathoracic abdominal
content, and occult tension pneumothorax with small haemothorax.

** In case of large, undrained

hemothorax :
1. Clotting of the blood ,,
2. (7th day postinjury ) fibroblast proliferation at the
periphery of the clotted hemothorax ,,
3. next several weeks, mature fibrous tissue encases
the clot forming a peel (loosely adherent to both
the visceral and parietal pleural surfaces)
4. the peel continues to increase in firmness,
thickness, and adhesiveness to the pleura over
time
5. can cause a significant restrictive defect
(fibrothorax).

blood cell lysis leading to an increased osmotic

load and large serosanguinous pleural
effusion, which develops from a relatively small
amount of retained blood over a few days.
a retained hemothorax may become secondarily
infected . This may present in delayed fashion as
an empyema. require extensive surgical
debridement or resection.

Management
1.
2.
3.
4.

5.

100% oxygen
insertion of intercostal chest drain
maintenance of circulating volume
Following insertion of a chest drain, emergency
thoracotomy is indicated for blood loss of :
>1500 ml blood in chest drain at insertion .
>200 ml/h for 4 consecutive hours .
>100 ml/h for > 6 hours .
Prophylactic antibiotics may decrease the
incidence of empyema and pneumonia

Indications for
thoracotomy
based on physical findings, radiographic and echocardiographic

Imaging :
Acute hemodynamic deterioration with cardiac arrest in the trauma
center.
Cardiac tamponade
Vascular injury at the thoracic outlet or great vessels
Massive air leak from a chest tube
Tracheal or bronchial injury
Esophageal injury
Retained hemothorax or its sequelae
Traumatic diaphragmatic hernia
Traumatic cardiac valvular or aneurysmal lesions
Traumatic thoracic pseudoaneurysms or aortic disruption
Tracheoesophageal fistula

Flail Chest
Rib fractures are the most common injury seen in
blunt trauma victims but are less likely to be seen
in children.
Rib fractures can result in significant chest wall
discomfort. This pain typically limits chest wall
excursion and increases the propensity for
hypoventilation, atelectasis, and eventually
pneumonia.
Elderly patients and those with poor pulmonary
reserve are at the highest risk.

 Life-threatening condition occurs when more than two ribs

are broken in two or more places resulting in a free
floating segment of the chest wall.
Mainly caused when the thoracic cage absorbs high kinetic
energy, and thus it is an important marker for significant intrathoracic injury in the patient with blunt trauma
It is highly associated with:
Pulmonary contusion in about 45% of patients.
Pneumothorax or hemothorax.
Acute respiratory distress syndrome (ARDS) in a third of
these patients
.

Theory of Pendelluft ;
** paradoxical motion of the flial segment during the

respiratory cycle causing recirculation of air from the

affected lung into the contralateral lung during
inspiration and from the contralateral lung into the
affected lung during exhalation.

** During inspiration (-ve intrathoracic pressure) , the

chest wall expand , but the flail segment moves inwards
due to the sucking effect of negative intrathoracic
pressure on the flail segment. (limited lung expansion,
with ineffective ventilation and hypoxia. )

https://www.youtube.com/watch?v=uJHfX1RFkF0

Diagnosis :

(Chest pain & dyspnea)

Flail chest is a clinical anatomical diagnosis.

Clinical examination ; will reveal a patient with
tachypnoea , and signs of blunt trauma to the
chest wall , The flail segment is identified by its
paradoxical movement on spontaneous breathing
and is often more obvious to feel than to see ,
Palpation may identify crepitus from the broken rib
ends , and percussion exacerbates pain.

Management
1- management of underlying pulmonary contusion by fluid
resuscitation and the use of diuretics & 100% oxygen .
2- regular analgesia - consider using rib blocks with local
anaesthetic thoracic epidural analgesia .
3- chest drain(s) for associated pneumothorax or
haemothorax .
4- consider assisted ventilation if there is inadequate
ventilation or the patient is tiring. Ventilatory support is
more likely with:
- large flail segment or one involving the sternum,
- extensive lung contusion.

Thank you