8-Thorasic Trauma DR Ahmad

CHEST TRAUMA
AHMAD AQEL RN, PHD

CHEST TRAUMA
Major chest trauma may occur alone or in combination with
multiple other injuries.
Chest trauma is classified as either blunt or penetrating.
Blunt chest trauma results from sudden compression or positive
pressure inflicted to the chest wall.
Penetrating trauma occurs when a foreign object penetrates the
chest wall.
3/9/2019 DR.AHMAD AQEL 2

Blunt Chest Trauma
Responsible for 20% to 25% of all trauma deaths
More common than penetrating trauma
Often difficult to identify the extent of the damage because the
symptoms may be generalized and vague.
patients may not seek immediate medical attention, which may
complicate the problem.

Blunt Chest Trauma…Pathophysiology
Common causes
◦ Car accident, falls, bicycle crashes
Types
◦ chest wall fractures
◦ Dislocations
◦ barotraumas (including diaphragmatic injuries)
◦ injuries of the pleura, lungs, and aerodigestive tracts
◦ blunt injuries of the heart, great arteries, veins, and lymphatics

Blunt Chest Trauma…Pathophysiology
Injuries to the chest result in the following pathologic conditions:
 Hypoxemia from disruption of the airway; injury to the lung parenchyma, rib
cage, and respiratory musculature ; massive hemorrhage; collapsed lung;
pneumothorax
 Hypovolemia from massive fluid loss from the great vessels, cardiac rupture,
or hemothorax
 Cardiac failure from cardiac tamponade, cardiac contusion, or increased
intrathoracic pressure
These result in impaired ventilation and perfusion leading to acute renal

failure, hypovolemic shock, and death.

Assessment and Diagnostic Findings
Immediate assessment to determine the following:
time elapsed since injury occurred,
mechanism of injury,
level of responsiveness,
specific injuries,
estimated blood loss,
recent drug or alcohol use
prehospital treatment.
Initial assessment includes
 assessment for airway obstruction, tension pneumothorax, open
pneumothorax, massive hemothorax, flail chest, and cardiac tamponade.
These injuries are life threatening and require immediate treatment.

Secondary assessment includes
 assessment for simple pneumothorax, hemothorax, pulmonary contusion,
traumatic aortic rupture, tracheobronchial disruption, esophageal perforation,
traumatic diaphragmatic injury, and penetrating wounds to the mediastinum.

The physical examination includes:
 Inspect the airway, thorax, neck veins, and breathing difficulty.
 assess the rate and depth of breathing, stridor, cyanosis, nasal flaring, the use
of accessory muscles, drooling.
 assess for chest symmetric movement, symmetry of breath sounds, open
chest wounds, entrance or exit wounds, impaled objects, tracheal shift,
distended neck veins, subcutaneous emphysema, and paradoxical chest wall
motion.
 assess chest wall for bruising, petechiae, lacerations, and burns.
 assess for signs of shock (vital signs and skin color)
 Palpate the chest for tenderness and crepitus
 Assess the position of the trachea.

Diagnostic workup
chest x-ray, CT scan, complete blood count, clotting studies, type
and cross-match, electrolytes, oxygen saturation, arterial blood gas
analysis, and ECG.
The patient is completely undressed to avoid missing injuries

Ongoing assessment is essential to monitor the patient’s response
to treatment and to detect early signs of clinical deterioration.

Medical Management
The goals of treatment are
• to evaluate the patient’s condition and to initiate aggressive resuscitation.
Maintain Airway, start oxygen therapy, ETT and MV if needed.
Correct hypovolemia and low CO ---Fluid replacement
Draining intrapleural fluid, air, and blood and the opening is plugged by
sealing it with gauze

Sternal and Rib Fractures
Sternal fractures are most common in motor vehicle crashes with a
direct blow to the sternum via the steering wheel.
Rib fractures are the most common type of chest trauma, occurring
in more than 50% of patients admitted with blunt chest injury.
Most rib fractures treated conservatively;
ribs 4 through 10 are most frequently involved.

Fractures of the first three ribs are rare but can result in a high
mortality rate because they are associated with laceration of the
subclavian artery or vein.
Fractures of the lower ribs are associated with injury to the spleen
and liver
Older adult patients with three or more rib fractures have been
shown to have a fivefold increased mortality rate and a fourfold
increased incidence of pneumonia .

Clinical Manifestations
STERNAL FRACTURES RIB FRACTURES
 anterior chest pain  severe pain
 overlying tenderness  point tenderness
 Ecchymosis  muscle spasm over the area of the
 Crepitus fracture that are aggravated by
coughing, deep breathing, and
 Swelling
movement.
 possible chest wall deformity.
 The area around the fracture may be
bruised.

How to reduce the pain?
Splints the chest by breathing in a shallow manner
Avoids sighs, deep breaths, coughing, and movement.
Inadequate breath due to pain results in:

•diminished ventilation, atelectasis, pneumonitis, hypoxemia,
respiratory insufficiency and failure.

 Evaluate the patient for underlying cardiac injuries.
 Auscultate the chest to detect crackling, grating sound in the thorax
(subcutaneous crepitus)
The diagnostic workup
 chest x-ray,
 rib films of a specific area,
 ECG,
 continuous pulse oximetry
 arterial blood gas analysis.

Medical Management
Goals: relieving pain, avoiding excessive activity, and treating any associated injuries.
Relieving pain by using
 Sedation (avoid over-sedation and suppression of respiratory drive).
 Intercostal nerve block and ice over the fracture site.
 chest binder provide stability to the chest wall and decrease pain.
 apply the binder snugly to provide support, but not to impair respiratory excursion.
The pain subside in 5 -7 days, and discomfort can be relieved with epidural analgesia, patient-
controlled analgesia, or nonopioid analgesia.
Most rib fractures heal in 3 to 6 weeks.
Surgical fixation is rarely necessary

Flail Chest
three or more adjacent ribs are fractured at two or
more sites, resulting in free-floating rib segments.
CAUSES:
 blunt chest trauma from a steering wheel injury.
 fracture of ribs and costal cartilages or sternum.
As a result, the chest wall loses stability, causing

respiratory impairment and usually severe respiratory
distress.

Flail Chest…Pathophysiology
During inspiration
 The flail segment moves in a paradoxical
manner (pendelluft movement), reducing
the amount of air that can be drawn into
the lungs.
During expiration
 Because the intrathoracic pressure exceeds
atmospheric pressure, the flail segment
bulges outward, impairing the patient’s
ability to exhale.
 The mediastinum shifts back to the
affected side
 Paradoxical movement on inspiration
occurs when the flail rib segment is
sucked inward and the mediastinal
structures shift to the unaffected side.
 The amount of air drawn into the
affected lung is reduced.
 On expiration, the flail segment bulges

outward and the mediastinal
structures shift back to the affected
side.

This paradoxical action results in
 increased dead space.
 a reduction in alveolar ventilation, and
 decreased compliance.
 Retained airway secretions and atelectasis
 hypoxemia, respiratory acidosis develops as a result of carbon dioxide
retention.
 Hypotension, inadequate tissue perfusion, and metabolic acidosis often follow
as the paradoxical motion of the mediastinum decreases cardiac output.

MEDICAL MANAGEMENT
The goals of treatment are to control pain, clearing secretions from
the lungs, providing ventilatory support, and to detect and treat the
injury.
-Sedation is used to relieve pain and to allow deep breathing and
coughing.
-A chest binder may be used as supportive treatment to provide
stability to the chest wall and may decrease pain.
-For severe chest injuries, ETT and MV are required

A flail chest creates a free-floating, unstable segment that moves in
opposition to normal chest wall movement.
The flail segment moves in when the patient inspires and out with
exhalation.
The loss of coordinated chest wall movement results in hypoventilation
of both lungs followed by atelectasis and eventually hypoxia.
Usually associated with an underlying pulmonary contusion

PATIENT ASSESSMENT
Rapid assessment and intervention to support (ABCs).
Protection of the cervical spine occurs simultaneously with
assessment of airway patency.
Assessment of rate, depth, and effort of breathing, breath sounds
and inspection for symmetry and chest wall integrity.
Oxygen is administered with a 100% nonrebreather mask or bag-
mask device

PATIENT ASSESSMENT
Life-saving interventions :
 Application of a three-sided occlusive dressing for an open
pneumothorax
 Needle thoracentesis (decompression) for a tension
pneumothorax.
Assessment of circulation is performed with palpation of the

central and peripheral pulses for quality, rate, skin
color/temperature, and capillary refill.

PATIENT ASSESSMENT
Internal bleeding:
Replacement of intravascular volume
Two large-bore intravenous lines should be established and
Warmed crystalloids (0.9% normal saline or lactated Ringer’s)
infused at a rapid rate.

Initial assessment of thoracic trauma
A- AIRWAY WITH CERVICAL SPINE PROTECTION
B- BREATHING
Spontaneous, chest Rise and fall sucking chest wound, subcutaneous
Rate and pattern of breathing (SOB, emphysema, upper abdominal injury)
paradoxical chest movement, stridor) Bilateral breath sounds
Use of accessory muscles, Tracheal deviation and jugular venous
diaphragmatic breathing distention( late signs of airway
Skin color (such as cyanosis) compromise

Initial assessment of thoracic trauma
Circulation Additional considerations
Skin color, temperature, and Pattern of abrasions or
moisture
bruising
Heart sounds
Vital signs Wound size and location
Blood pressure in upper
extremities (equal or asymmetric)
Extremity pulses (equal, diminished,
or absent)

Secondary assessment of thoracic trauma
Assess pain.
Obtain patient history.
Identify mechanism of injury.
Determine time of the injury.
Determine what the patient remembers about the event.

Therapeutic interventions for thoracic
trauma
 Maintain patent airway.  Prepare for auto-transfusion
 Promote adequate ventilation.  Initiate two large-bore IV lines.
 Provide high-flow oxygen.  Facilitate US, X-RAY, CT
 Assist ventilations.  Continuous cardiac monitoring.
 Prepare for intubation.  Monitor BP, RR and effort, pulse oxim.,
 Cover open chest wound. and LOC every hour if indicated.
 Assist with chest tube insertion or  Document urine output and patient
needle thoracentesis. response to therapeutic interventions.
 Monitor bleeding from chest.  Facilitate surgical intervention.

The Focused Assessment Sonography for
Trauma (FAST)
Integral component of the initial assessment for
patients with thorax or abdominal trauma.
Rapid noninvasive, done at the bedside.
Rapid identification of pericardial injury,
pericardial fluid, pneumothorax Four-view study:
Pericardium, Perihepatic
The sensitivity of the FAST for detecting blood in Perisplenic, Pelvic
the pericardial space is 96% to 100%.

Chest Wall Injuries /Rib Fractures
Rib fractures occur most often in the fourth through tenth ribs.
Pain/Tenderness at the fracture site, shallow respirations (splinted)
Hemothorax , pneumothorax, Subcutaneous emphysema or crepitus
may also be present.
CXR assist with diagnosis, only 70% sensitive for detecting rib fractures.
Fractures that separate the sternum from costal cartilage are not
evident on a radiograph.

Rib Fractures
Fractures of the first and second ribs
- rare (protected by clavicle)
- Significant blunt force is required to fracture these ribs; therefore associated
injuries to the underlying structures, the great vessels, and brachial plexus
must be considered.
- Other injuries associated with upper rib fractures include injuries to the
clavicles, scapulae, trachea, and lungs.

Rib Fractures
Lower rib fractures (9 through 12)
associated with injuries to the spleen, liver, kidneys, or other
abdominal contents, depending on location of the fracture(s).

Rib Fractures
Treatment for rib fractures
Pulmonary toilet, coughing, deep breathing, incentive spirometer and
early mobilization.
The use of binders or “strapping” is to be avoided in all patients.
Patients with multiple rib fractures are usually admitted for observation.
Patients with severe injuries (eight or more fractured ribs, massive flail
injury) may require internal fixation with plates and screws.

Rib Fractures
Pain management:
Opioid with NSAID
Intercostal blocks provide complete analgesia.
When rib fractures do occur in children, concurrent thoracic and
abdominal injuries may be severe.
 Children have thin chest walls, and their bony thorax is more cartilaginous
(difficult to fractured) .

Flail Chest
Fractures in two or more
adjacent ribs in two or more
places, or bilateral detachment
of the sternum from costal
cartilage

Flail Chest
A flail chest creates a free-floating, unstable segment that moves in
opposition to normal chest wall movement.
The flail segment moves in when the patient inspires and out with
exhalation.
The loss of coordinated chest wall movement results in hypoventilation
of both lungs followed by atelectasis and eventually hypoxia.
Usually associated with an underlying pulmonary contusion

Flail Chest
 Paradoxical chest wall movement will not be demonstrated in the
mechanically ventilated patient.
Treatment
Ensuring adequate oxygenation,
Fluid administration with caution
• (Fluids are limited because of associated pulmonary contusion and potential development
of acute respiratory distress syndrome (ARDS).
Pain management.

Sternal Fracture
Causes: tremendous force is applied to the chest, as
with steering wheel impact.
Common site of fracture: the junction of the

manubrium and body of the sternum (angle of Louis)
Potential for underlying cardiac and pulmonary

injury, including pulmonary contusion, blunt cardiac
injury, and pericardial tamponade.

Sternal Fracture
Manifestations:
dyspnea and localized pain with movement, Chest wall ecchymosis,
sternal deformity, or crepitus.
Treatment includes
pain relief
(ECG) to evaluate potential blunt cardiac injury
Patients are treated symptomatically.

Laryngeal Injury
Fracture of the larynx is a rare, life-threatening injury.
Symptoms: hoarseness, stridor, hematoma, ecchymosis, laryngeal
tenderness, subcutaneous emphysema, crepitus, or loss of anatomic
landmarks

laryngeal injury
Patient with a laryngeal injury must be evaluated for a
concomitant cervical injury, and
 patients with cervical injury need to be assessed for laryngeal
injury
 Intubation may worsen the preexisting injury
(laceration or tracheal separation may occur during
tube placement).
Tracheostomy is indicated for the patient in respiratory

distress and will be left in place for at least 5 days

Pneumothorax
Accumulation of air in the pleural space resulting in
collapse of the lung.
Common cause
Laceration of lung tissue, often associated with rib
fractures and subsequent air leak

Pneumothorax
Manifestations:
CP and SOB.
Decreased or absent breath sounds on the affected side
Percussion demonstrates hyperresonance.
Tachycardia and tachypnea.

Pneumothorax
MANAGEMENT:
Chest tube, commonly placed in the fourth or fifth intercostal
space, along the anterior axillary line.
A radiograph taken after insertion confirms tube placement.
Oxygen administration, pain management, and serial chest
radiographs to monitor lung reexpansion

Pneumothorax
INDICATIONS OF chest tube PATENCY
Water level in the water seal should fluctuate with breathing (rising with
inspiration and falling with expiration) and is an indicator of chest tube
patency.
If the patient is on mechanical ventilation, this pattern is reversed
because breaths are delivered under positive pressure.
Fluctuations stop when the lung is fully reexpanded or when the tube
is kinked or compressed.

Pneumothorax
MILKING/STRIPPING THE CHEST TUBE
No Vigorous milking or stripping
 create high negative pressures, resulting in mediastinal trauma.
TO CLAMP OR NOT TO CLAMP?

Never clamp a chest tube during patient transport unless the chest
drainage system becomes disrupted during patient movement, and
then only if there is no air leak.

OPEN PNEUMOTHORAX
Open pneumothorax, or sucking chest wound,
occurs when an opening in the chest is more
than two thirds the diameter of the trachea.
Air moves into the chest through the chest wall

rather than through the trachea, escaping and
collecting in the pleural space.
An open chest wound causes loss of the negative

intrathoracic pressure required for effective
ventilation
OPEN PNEUMOTHORAX
Presenting symptoms
 CP, SOB, hemoptysis, and occasionally hypotension.
 Decreased or absent breath sound on the affected side
 A sucking sound may be heard with inspiration.
 Bubbles or froth around the wound.
Immediate treatment:
◦ A sterile, nonporous, three-sided occlusive dressing over the injury.
◦ A chest tube to facilitate reexpansion of the lung

OPEN PNEUMOTHORAX
Definitive treatment : operative closure.
Impaled object must be stabilized and left in place.
NEVER REMOVE the object in the emergency department

TENSION PNEUMOTHORAX
Accumulation of air in one pleural space
forces thoracic contents to the opposite side.
Initial lung injury allows air into the pleural

space with inspiration; however, air cannot
escape with expiration.
The lung on the opposite side, the heart, and

great vessels are compressed as mediastinal
shift occurs.

Signs and symptoms
Decreased or absent breath sounds on the affected side
Chest pain, SOB, and a feeling of impending doom.
Cardiac dysrhythmias, decreases diastolic filling, and decreases CO
The trachea eventually deviates to the unaffected side as mediastinal shift

worsens

Definitive therapy is chest tube insertion
Immediate needle decompression.
Chest tube is inserted into the second intercostal space at the

midclavicular line.

Hemothorax
Free blood in the pleural space
The most common cause
 injury to the intercostal arteries that results in bleeding into
the pleural space.
S&S
CP, SOB
Decreased or absent breath sounds on the affected
side,
Dullness on chest percussion.
Hypovolemic shock and RD
Hemothorax
Treatment:
Chest tube insertion
High-flow oxygen by a nonrebreather mask,
Large-bore intravenous lines for fluid replacement.
Chest drainage carefully monitored and clots that occlude the tube.
If blood return with chest tube insertion is 1000 mL or blood loss is 200
mL/hr for 3 to 4 hours, surgical intervention is indicated.

AUTOTRANSFUSION
Autotransfusion: collecting and reinfusing the patient’s own blood.
Intrathoracic blood loss (more than 350 mL) and wounds that are less
than 4 to 6 hours old are potential indications for autotransfusion
useful when homologous blood is not available or the patient’s

religious convictions forbid homologous transfusion.

AUTOTRANSFUSION
Autotransfusion is not appropriate when
Enteric contamination has occurred or is suspected (e.g., ruptured
diaphragm)
Infection is present
Patient has established coagulopathies
Hepatic/Renal insufficiency
The blood has been in the autotransfuser for greater than 6 hours.

Pulmonary Contusion
Occur when underlying lung parenchyma is damaged, causing
edema and hemorrhage.
Common cause : Concussive and compressive forces from blunt

trauma
Thoracic injuries associated with pulmonary contusion:

• Rib fractures, flail chest, hemothorax, pneumothorax, and scapular fractures.

Pulmonary Contusion
Injury to the lung parenchyma causes ruptures and hemorrhages
into pulmonary tissue, alveoli, and small airways.
Airways collapse
loss of ventilation
pulmonary shunting
hypoxemia.
Pulmonary Contusion
Manifestations:
Dyspnea,
hemoptysis,
hypoxia
?? chest wall abrasion or ecchymosis.
 Contusions usually improve within 72 hours and resolve within 3 to
5 days.

Pulmonary Contusion
Treatment
 SEMI-FOWLER’S position to facilitate lung reexpansion
 Suctioning, and chest physiotherapy.
 Intubation and mechanical ventilation may be required (HYPOXIA)
Intubation may also be required
• PT exhibits signs of shock
• Has fractured eight or more ribs
• Older adult
• Has underlying pulmonary disease

Diaphragmatic Injury
Lateral impact from an MVC is three times more likely than any other type of
impact to cause a rupture.
The resulting large radial tears cause herniation of abdominal contents into
the thorax.
Penetrating trauma can cause small radial tears that may go unnoticed for
several years, until the gradual herniation becomes apparent.

Most injuries occur on the left side of the diaphragm;
◦ the proximity of the right diaphragm to the liver may provide protection.
When injuries do occur on the right, they may be difficult to identify

because of the liver.
Diaphragmatic injuries rarely occur alone.

◦ If herniation occurs, it can cause significant lung compression, leading to
tension pneumothorax
MANIFESTATIONS:
 dyspnea,
 abdominal or epigastric pain that radiates to the left shoulder (Kehr’s sign),
 bowel sounds in the chest
 decreased breath sounds on the affected side suggest a possible ruptured
diaphragm.

The chest radiograph may demonstrate
 An elevated diaphragm,
 Loss of the diaphragmatic shadow,
 Irregularity of the diaphragm, or even a gastric tube noted to pass into
the stomach and then curling into the chest.
In the stable patient, the CT scan of the chest is the diagnostic tool of
choice.
If a diagnostic peritoneal lavage (DPL) is performed, lavage fluid may
leak into the chest drainage system, if present.

 Treatment: prompt surgical repair

Blunt Cardiac Injury
Formerly known as “cardiac contusion” or “cardiac concussion,”
An echocardiogram differentiates the extent of injury.
Extensive myocardial injury is characterized by

 12-lead ECG changes,
 dysrhythmias
 evidence of myocardial dysfunction on the echocardiogram.

Blunt Cardiac Injury
 Clinical presentations range from asymptomatic to cardiogenic
shock.
 Chest pain and skin abrasions or ecchymosis to the anterior chest.
 Dysrhythmias associated with this injury include
 sinus tachycardia, atrial fibrillation/flutter, atrial and ventricular
extrasystoles, and even ventricular tachycardia/fibrillation.
The most common dysrhythmia is premature ventricular contractions.
Treatment: cardiac monitoring for at least 24 hours

Penetrating Cardiac Injuries
Most victims arrive in cardiac arrest or with significant hypotension
secondary to cardiac tamponade or hemorrhage.
The right ventricle is the most frequently injured chamber because

of its anterior position.
Penetrating injuries are associated with a high mortality (83%).

Cardiac Tamponade
 occurs when rapid accumulation of blood in the pericardial sac decreases
ventricular filling.
 Classic signs of cardiac tamponade are a complex of symptoms called

Beck’s triad:
◦ hypotension, muffled heart tones, and distended neck veins.

PERICARDIOCENTESIS
Pericardiocentesis for acute cardiac

tamponade can be performed via a left
subxiphoid or parasternal approach.

Aortic Disruption
The majority of victims with aortic
rupture caused by blunt trauma die at
the scene.
The most common site of injury
 the area of the aorta just distal to the left
subclavian artery adjacent to the
ligamentum arteriosum (the site where the
aorta is relatively fixed in place).
 The innominate artery at the aortic arch
and the aortic valve

Aortic Disruption
Severe chest pain between the scapulae, dyspnea and hemoptysis
and Signs of hemorrhagic shock may be present.
A discrepancy between blood pressure values in the right and left

arms may occur, depending on the level of aortic injury.
Blood pressure and pulse quality in the upper extremities are

elevated, whereas pulses and blood pressure in the lower
extremities are decreased or absent

Aortic Disruption
The most common diagnostic
test used to detect aortic
disruption is a chest radiograph
The most common finding is

mediastinal widening
Definitive treatment for aortic disruption

is immediate surgical repair.

Esophageal Injury
 Rare injury and often lethal,
CAUSES:
• Instrumentation during invasive procedures such as endoscopy or intubation
is the most common cause.
• Caustic ingestions (acids or alkalis), crush injuries, and blast injuries also cause
esophageal injury
 Regardless of the mechanism, the final result is mediastinitis
caused by contamination from saliva and gastric contents.

Esophageal Injury
Chest tube drainage may contain particulate matter.
Diagnosis is confirmed by contrast studies or esophagoscopy.
Urgent surgical repair is indicated.


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CHEST TRAUMA

AHMAD AQEL RN, PHD

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These result in impaired ventilation and perfusion leading to acute renal

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These injuries are life threatening and require immediate treatment.

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The patient is completely undressed to avoid missing injuries

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Inadequate breath due to pain results in:

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As a result, the chest wall loses stability, causing

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 On expiration, the flail segment bulges

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Assessment of circulation is performed with palpation of the

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the pericardial space is 96% to 100%.

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Common site of fracture: the junction of the

Potential for underlying cardiac and pulmonary

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3/9/2019 DR.AHMAD AQEL 40

3/9/2019 DR.AHMAD AQEL 41

Tracheostomy is indicated for the patient in respiratory

3/9/2019 DR.AHMAD AQEL 43

3/9/2019 DR.AHMAD AQEL 44

3/9/2019 DR.AHMAD AQEL 45

3/9/2019 DR.AHMAD AQEL 46

3/9/2019 DR.AHMAD AQEL 47

TO CLAMP OR NOT TO CLAMP?

3/9/2019 DR.AHMAD AQEL 48

Air moves into the chest through the chest wall

An open chest wound causes loss of the negative

3/9/2019 DR.AHMAD AQEL 50

Impaled object must be stabilized and left in place.

NEVER REMOVE the object in the emergency department