Chest Trauma
Chest Trauma - BLUNT
Chest Trauma - PENETRATING
Chest Trauma - INCIDENCE



Sudden and dramatic
Directly => 20 – 25% (1 in every 4)
trauma deaths
Contribute to 25-50% of the remaining
deaths
=> 16,000 deaths per year in USA
Chest Trauma - CARE



Improved pre-hospital & peri-operative
care
=> More pts getting to ER alive
Many die after coming to hospital
Deaths possibly preventable
=> by prompt Dx and Tx
Chest Trauma - HISTORY





3000 BC – treating gladiators chest injuries
1635 - De Vacca => removal of arrowhead
from chest wall
1814 -Larrey reported injuries to subclavian
vessels
1902 - Hill performed first cardiorrhaphy in
US
1934 - Blalock first American to successfully
repair an aortic injury
BOUNDARIES of Chest



Superiorly
=> clavicles
Inferiorly
=> diaphragm
Laterally
=> rib cage
BOUNDARIES of Chest


Anteriorly
=> sternum
Posteriorly
=> vertebral
bodies & ribs
STRUCTURES Injured
Any organ in chest potentially
susceptible
– especially to penetrating trauma
CONTENTS - Thoracic cavity





- Chest wall and
ribs
- Lungs and pleura
- Great and thoracic
vessels
- Heart and
mediastinal
structures
- Diaphragm
CONTENTS - Thoracic cavity



Esophagus
Thoracic duct
Tracheobronchial
system
OTHER ORGANS at risk

Thoraco-abdominal
injury
any wound below
nipples in front
and
 inferior scapula
angles dorsally
 may result in
intra abdominal
injury

OTHER ORGANS at risk
Peritoneal viscera
–
–
–
–
–
Liver
Spleen
Stomach
Colon & small intest.
Biliary system
Retro-peritoneum

kidneys
RESULTING INJURIES
– Rib fractures
– Sternal fractures
– Open or Closed Pneumothorax
- unilateral / bilateral
– Hemothorax
– Hemopneumothorax
RESULTING INJURIES
– Pneumo-mediastinum
– Pulmonary contusion
– Myocardial contusion
– Diaphragmatic rupture
RESULTING INJURIES

Subcutaneous emphysema
CLINICAL CONSEQUENCIES
RELATED TO :
 Mechanism
of injury
– Location of injury
– Associated injuries
– Co-morbidities
Mechanism of Injury
BLUNT

Mostly managed non-operatively
– Simple intubation & ventilation or
– chest tube placement
Mechanism of Injury
PENETRATING
 Low
energy
 Medium energy
 High energy
Penetrating (Low energy)


Impalements
Knife wounds
=> disrupts only
structures
penetrated
Penetrating (Medium energy)

Bullet wounds from most handguns
=> primary tissue damage
< than higher velocity forces
Penetrating (High energy)
From rifles and military weapons
+ Shotguns (low velocity)

Transfers kinetic energy to tissues
=> cavitation
=>

high velocity.
Amount of tissue damage proportional to
amount of energy exchanged between the
penetrating object and the body part.
Pathophysiology
Quite serious
1. HYPOXIA / HYPO-VENTILATION

Primary acute killer of trauma patients
inadequate delivery of O2
to tissues
Signs of HYPOXIA
 Increased
RR
 Change in breathing pattern (shallow)
 Anxious behavior
 Poor air movement
 Diaphoresis
 Dilated pupils
 Cyanosis – (late sign)
2. Hypovolemia

Inadequate intravascular volume
=> BLOOD LOSS
3. Ventilation / Perfusion
Mismatch



Contusion
Hematoma
Alveolar collapse
4. CHANGES IN INTRATHORACIC
PRESSURE RELATIONSHIPS
- Tension pneumothorax
- Open pneumothorax
5. METABOLIC ACIDOSIS

Hypo perfusion of tissues (shock)
MANAGEMENT - Chest Trauma


ABCs
PRIMARY SURVEY
– Most important feature of chest injury evaluation
=> Aim to identify & treat immediately life threatening conditions
MANAGEMENT - Chest Trauma

EARLY INTERVENTIONS geared towards
– identifying / correcting / preventing problems





Tension pneumothorax
Massive hemothorax
Open pneumothorax
Cardiac tamponade
Flail chest
MANAGEMENT - Chest Trauma

Resuscitation of vital functions
REMEMBER :
- Most life threatening injuries txd by
- Airway control
- Chest tube
MANAGEMENT - Chest Trauma
- Detailed Secondary Survey
Influenced by:
Mechanism of
injury
 High level of
suspicion

May show:
Simple pneumothorax
 Hemothorax
 Pulmonary contusion
 Myocardial contusion
 Blunt aortic injury
 Rib fractures
 Diaphragmatic
rupture

MANAGEMENT - Chest Trauma
Definitive care

Usually operative
MANAGEMENT - Chest Trauma
Adjuncts
CXR
=> basis for initiating other investigations
ALL wounds to thoracic cavity bounded back & front by


Neck & umbilicus for stabs
Neck & pelvis for GSW
– MUST HAVE CXR

=> UPRIGHT if possible
Adjuncts - FAST
Focused Abdominal
Sonography for
Trauma (FAST)
- All hemodynamically
unstable blunt
trauma pts
Adjuncts - Cat Scan
- (CT angio)
Becoming a primary diagnostic tool
 fast (spiral)
 allow for reconstruction etc
SPECIFIC CHEST INJURIES
Chest Wall
 Rib fractures
 Most common sign of blunt chest injury
– Fx scapula, first rib, sternum suggest massive
force of injury
– 1st & 2nd rib fx associated with serious other
injuries
– Upper ones => suspect vascular injury
Rib Fractures
Rib fractures
Signs and Symptoms
- Deformity
- Localized pain
- Tenderness
- Crepitus
Rib Fractures
Treatment



Analgesia (PCA)
Pulmonary toilet
Observe for possible pneumothorax
Flail Chest
Segment of chest wall
that does not have
continuity with rest of thoracic
cage
 Usually 2 fractures per rib
in at least 2 ribs
 Segment does not
contribute to lung
expansion
 Disrupts normal pulmonary
mechanics
 Accompanied by pulmonary
contusion in 50% of
patients with flail chest
Flail Chest - Pathophysiology
A major problem is the injury to
the underlying lung
=> Pulmonary Contusion
Flail Chest – Signs & Symptoms







Dyspnea
Chest pain
Paradoxical chest wall
movement
Poor air movement
Crepitus
Hypoxia
Cyanosis
Flail Chest - Treatment




Pain control
Humidified O2
Close observation for respiratory
decompensation
Aggressive pulmonary & physical
therapy
Flail Chest - Treatment
Selective intubation and ventilation:

significant other injuries

respiratory rate > 35

paO2 < 80

paCO2 > 66
Other treatments:

tight fluid resuscitation
Flail Chest - Treatment

Operative fixation not usually required
(historical)
Lung Injuries

Pneumothorax or Hemothorax
– most treated with simple tube
thoracostomy
Pneumothorax
Less than 1-2 cm may be observed in otherwise healthy
pts if stable on f/u CXR 6-8 hrs after
Open Pneumothorax
Open sucking chest
wound
 if opening 2/3 of
diameter of trachea air
will come through
wound (preferentially)
 allows free passage of
air into and out pleural
cavity
=> effective ventilation
impaired
=> hypoxia & hypercarbia
Open Pneumothorax
Signs & Symptoms



Penetrating chest
wound
Decreased breath
sounds
Sucking sounds on
inspiration
Open Pneumothorax
Treatment :



3 sided occlusive
dressing
Observe for tension
pneumothorax
Operative
Tension Pneumothorax

One way valve allows air leak from
lung or chest wall
=> air forced into chest cavity
without escape
Tension Pneumothorax
Collapses ipsilateral lung
Tension Pneumothorax
Displaces mediastinum to opposite side
Tension Pneumothorax
Compresses opposite lung
Tension Pneumothorax
Decreases venous return
Tension Pneumothorax
Signs & Symptoms
–
–
–
–
–
–
–
–
–
air hunger
chest pain
respiratory distress
tachycardia
hypotension
tracheal deviation
absent breath sounds
hyper-resonant percussion
JVD
Tension Pneumothorax
- Treatment
Immediate decompression
– large bore needle
 2nd intercostal space
 midclavicular line
– chest tube as definitive tx
NOTE – may mimic a collapsed lung on the other side
– - i.e. trachea deviates towards the collapsed lung
– - however, one resonant (empty), other tympanic (full)
Pulmonary Contusion




Largest # of pts are those with
blunt trauma
Most common chest injury in children
Usually develops over 24 hours
Can occur with or without laceration of
parenchyma
Pulmonary Contusion
Results from:

Leakage of blood and fluid into interstitial
spaces of lung
- Significant inflammatory reaction
to blood components in the lung
Pulmonary Contusion
- Pathophysiology
Loss of normal lung structure &
function leads to
- poor gas exchange
- increased pulmonary vascular
resistance
- decreased lung compliance
Pulmonary Contusion
- Complications
–
–
–
–
Atelectasis
Pneumonia
ARDS
Respiratory failure
Pulmonary Contusion
- Diagnosis

Parenchymal
infiltrate seen in
CXR adjacent to
injured chest wall
Pulmonary Contusion
- Diagnosis
No real clinical
findings especially
initially
 dyspnea
 chest wall
contusions /
abrasions
 increased RR
 may have
crackles
Pulmonary Contusion
- Diagnosis
Lung gets stiffer causing
dyspnea and increased RR
Blood gases worsen 2-3
days as edema increases
CXR changes may lag 12 48hrs behind

May underestimate the
true extent
CT - very sensitive – can
allow quantifying
Pulmonary Contusion
- Treatment
MOSTLY supportive - usually resolve in
5-8 days
O2 + observation in milder cases
- Pain control to allow:
- adequate ventilation and better
management of secretions
- Fluid restriction
- Intubation + mechanical ventilation
 if respiratory distress present
-
Pulmonary Contusion
Indications for intubation



Respiratory distress
Co-morbidities esp. lung disease
Other injuries
– intra-abdominal
Myocardial contusion



Physical bruising of
the cardiac muscle
Usually associated
with fractures of
the sternum
Any severe anterior
chest injury
Myocardial contusion



Difficult to dx
=> HIGH LEVEL OF
SUSPICION
ALL pts with
pattern of injury
must have an EKG
Myocardial contusion
- Diagnosis





Ectopy
ST elevation
Tachycardia
Friction rub
Enzymes may be normal
Myocardial contusion
- Treatment



Monitor in ICU & treat dysrhythmias
Serial enzymes
Analgesia
Massive Hemothorax




Pleural cavity hold 3 liters blood
200cc – 1L in chest cavity seen on CXR
90% from internal mammary or intercostals
10% from pulmonary vessels
Massive Hemothorax
- Treatment
– Decompression
– Chest tube (most need just that)
– Bleeding may stop when lung re-expands
Aortic Rupture /
Great Vessel Injuries



Abrupt deceleration or
compression injury
Sudden motion of
heart / great vessels
within thorax
Great vessel injury may
occur in 0.3 => 10%
penetrating trauma





Often rapidly fatal
Only 10% survive to
hospital
Only 20% survive > 1
hour
90% who reach
hospital will die
EARLY DX and
aggressive tx best
chance
Aortic Rupture
- Signs and Symptoms
– Hypovolemic shock
– Chest wall ecchymosis
– Marked difference in BP b/l arms
– Fx 1st, 2nd, 3rd ribs especially on left
Aortic Rupture - Diagnosis

Consider
mechanism of
injury
– widened
mediastinum on
CXR
– 40% normalizes
with sitting up
Aortic Rupture - Diagnosis


Mediastinum > 8cm wide
Blurring of aortic knob
Aortic Rupture - Diagnosis

Deviation of NGT to right
Aortic Rupture - Diagnosis

CT with contrast
then angiogram if
abnormal
Aortic Rupture - Treatment


Contained injury
=> BP control
Operative repair
Cardiac Injury


Highly lethal :
fatality rates
- 70 => 80%
Mostly ventricular
– right > left
Cardiac Tamponade


=> Blood in pericardial sac
Occurs most frequently with
penetrating injuries
Cardiac Tamponade
- Signs and Symptoms





Shock
JVD
Dyspnea
PEA
Beck’s triad = minority of pts
- Distended neck veins
- Muffled heart sounds
- Hypotension
Cardiac Tamponade
- Treatment



Volume
resuscitation
Pericardiocentesis
Surgery
- Pericardial window
- sternotomy
- thoracotomy
Diaphragmatic Rupture

Traumatic
herniation of
abdominal contents
into the chest
Diaphragmatic Rupture

Mostly on left side
Diaphragmatic Rupture

Liver “protective” on right side
Diaphragmatic Rupture

Frequent in thoracoabdominal trauma
– 15% stab wounds
– 46% GSW
– 15% greater than 2cm long

May be no immediate herniation of
abdominal contents
Diaphragmatic Rupture
- Signs and symptoms
No distinctive signs /
symptoms seen
High index of suspicion
needed especially with
mechanism of injury
 dyspnea
 cyanosis
 shoulder pain
 bowel sounds in lower
chest
Diaphragmatic Rupture
- Treatment


Up to 13% acute injuries missed initially
85% presenting in 3 years as
- obstruction or with
- decreased cardio / pulmonary reserve
Goal of treatment:
- Maintain adequate oxygenation
=> intubate
- NG decompression of stomach
Diaphragmatic Rupture
- Surgery

Esophageal Injuries

Most due to penetrating trauma
Diagnosis
-
Difficult
If delayed => rapid sepsis & high mortality
Requires aggressive investigation
Radiography
Endoscopy
Thoracoscopy
Treatment
- Thoracotomy, etc.
Thoracic Duct Injuries




Accompany thoracic vessel
injuries
Noted much later i.e. not in
acute phase
Huge morbidity due to
severe nutritional depletion
Mn
– => initially aggressive and
nonoperative


= hyperalimentation =>
TPN
and if not sealed in 5-7
days
– surgical intervention
Emergency Thoracotomies
“ACUTE” THORACOTOMY
 Cardiac tamponade (relieved)
 Vascular injury to thoracic outlet
 Massive air leak
 Endoscopic/radiographic evidence of tracheal or
bronchial injury
 Esophageal injury
 Chest tube output
– immediate evacuation of 1500ml blood
– or > 250cc/ hour
– TREND MORE IMPORTANT than initial output
“ER” THORACOTOMY
– survival rates < 8%
“ER” THORACOTOMY
- To do or NOT to do…
Type of CARDIAC
ACTIVITY
 asystole
 bradycardia
 tachycardia
“ER” THORACOTOMY
- To do or NOT to do…
Type of VITAL SIGNS



electrical cardiac
activity (PEA)
palpable pulse
recordable blood
pressure
“ER” THORACOTOMY
- To do or NOT to do…
LOCATION of LOSS
of vital signs





street
in transit
ambulance/helicopter
unloading area
hallway
resuscitation area
“ER” THORACOTOMY
- Unlikely to benefit if ...
BLUNT injury with arrest
 Arriving without
pulse/BP
Penetrating injury with
arrest
 Better chance
 High likelihood of
– isolated / correctable
intra-thoracic injury
(?GSW?)
– still EXTREMELY RARE
“ER” THORACOTOMY
- Bottom line

ER THORACOTOMY
if presence of
MEASUREABLE
– pulse
– blood pressure
– organized cardiac
activity

(or just lost IN
trauma bay)

MUST consider also
– age
– co-morbidities (ie
infectious diseases)

AVOID if arrest
– occurs OUTSIDE OF
RESUSCITATION
AREA or
– due to BLUNT
trauma.
“ER” THORACOTOMY
- Consider . . .


Be mindful that circulatory arrest
=> cerebral hypoxia
=> permanent neurologic deficits
=> non-functional survivor

occurs in 10 => 15% of survivors
Chest tube insertion



Most common
intervention
Relatively simple
procedure
Definitively manage
> 85% of chest
trauma :
penetrating or blunt




Has significant
complication rate 219%
May be minor but
May require
operative
intervention and
Can result in death
Chest tube insertion
- Indications

Drain contents of
pleural space
–
–
–
–
air
blood
chyle
gastric contents


Prevent
development of
pleural collection
i.e. after
thoracotomy
Prevent tension
pneumothorax in
ventilated pt with
rib fractures
Chest tube insertion
- Indications
Absolute indications Relative indications
– rib fractures and
 pneumothorax
positive pressure
 hemothorax
ventilation
 traumatic
– profound
arrest - (b/l)
hypoxia/hypotension
with penetrating
chest injury
Placement may be diagnostic
or therapeutic

Bright red blood
– suggest arterial injury = possible thoracotomy

Intestinal contents
esophageal, stomach, diaphragm
 intestinal injury


Large air leak
- bronchial disruption

Technique = important to avoid
complications
Chest tube insertion
- Insertion Site



mid or anterior axillary line behind pectoralis major
above 5th rib since on expiration diaphragm rises
that high
count down from sternomanubrial joint (2nd rib)
Chest tube insertion
- Analgesia
Painful especially in muscular pts
– Morpine IV or Ketamine 20mg in adult
– 10-20 ml local analgesia
along line of incision
 perpendicularly thru all layers of chest wall to
rib below space
 up into pleural cavity after aspirating air

Chest tube insertion
- Procedure





Prep and drape
Incise along upper border of the rib below the
intercostal space to be used
Track is to be directed over top of lower rib so as
to avoid intercostal vessels lying below each rib
should be big enough to fit finger
Use curved clamp to develop tract by blunt
dissection only – use to spread the muscle
fibers, develop tract with fingers
On reaching rib, clamp angled upward just above
the rib and dissection continued till pleural
space entered
Chest tube insertion
- Procedure


Finger inserted
into pleural space
and area palpated
32-36 F tube
attached to clamp
and inserted along
track into the
pleural cavity
Chest tube insertion
- Procedure



Connect tube to
underwater seal
and suture in place
Examine chest to
check effect
CXR to check
placement and
position
POSITION - Dependent on
direction of tract
Blunt chest trauma pts
lying flat
– place drain
anteriorly
– prevents blockage
of tube and
development of
tension
pneumothorax
Penetrating
 Posteriorly & basally
directed drain
 Last hole should be
INSIDE the CHEST
CAVITY
 If too far in could
cause severe
intractable pain when
up against
mediastinum
Chest tube insertion
- Underwater Seal




Allows air to ESCAPE but NOT
RE-ENTER chest cavity
Negative pressure dependent upon
level of water
Pleurovac must always be below level
of patient
Persistent bubbling = air leak from
lung
Chest tube insertion
- Underwater Seal


May be connected
to suction (water
level 20cm H2O)
Aid lung
re-expansion
especially if there is
an air leak

CHEST TUBES
SHOULD NEVER
BE CLAMPED =
TENSION
PNEUMOTHORAX
Chest Tube Removal
When?
 When no air leak
 No more fluid draining
How?
 Occlude hole while
pulling tube
 Remove at end of
expiration or at peak of
inspiration
 Avoids air being drawn
into cavity
 Remove rapidly and
close wound quickly
Chest tube insertion
- Complications


“there is no organ in the thoracic or
abdominal cavity that has not been pierced
by a chest drain”
mainly historical since drains used to be
inserted with
- a steel trocar
- excessive force
Chest tube insertion
- Acute complications
Hemothorax – usually
laceration of intercostals
vessel, may require
thoracotomy
Tube placed
subcutaneously – not in
pleural cavity
Lung laceration
especially when
adhesions present
Tube placed too far =
pain
Diaphragm / abdominal
cavity penetration placed too low
Stomach colon injury diaphragmatic hernia
not recognized
Tube falls out = not
secured properly
Chest tube insertion
- Late complications
– blocked tube
= clot, lung
– retained
hemothorax
– empyema
– pneumothorax
after removal
= poor technique
Chest Trauma - Conclusion

Chest trauma is
– COMMON
– SERIOUS

AIM in TREATMENT
– to provide oxygen
to vital organs
– Be alert to
changes in
clinical condition

Managed MOST of
the time with a
CHEST TUBE
CHEST TRAUMA
END