CHEST TRAUMA
CDR JOHN P WEI, USN MC MD
4th Medical Battallion, 4th MLG
BSRF-12
CHEST TRAUMA
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Blunt versus penetrating trauma
Injury dependent on mechanism
Motor vehicle accident
Fall from height
Physical assault
Explosive blast
Gunshot wound
Stab wound
CHEST TRAUMA
Blunt force injuries from
assault or fall from height
Bony fractures
Lung injuries
Cardiac contusion
CHEST TRAUMA
Acceleration : Deceleration Injuries
CHEST TRAUMA
Penetrating injuries:
Gunshot wounds
Stabbing wounds
CHEST TRAUMA
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Improved field diagnosis and treatment
of life threatening conditions
Rapid evacuation to higher level of care
High risk of death despite acute
intervention
Need for prompt diagnosis and
treatment
CHEST TRAUMA
Chest wall and ribs
Lungs and pleura
Great and thoracic
vessels
Heart and
mediastinal
structures
Diaphragm
CHEST TRAUMA
Common Injuries
• Rib fractures
• Sternal fractures
• Open or Closed Pneumothorax
- unilateral / bilateral
• Hemothorax
• Hemopneumothorax
CHEST TRAUMA
Clinical consequences associated with:
• Mechanism of injury
• Location of injury
• Associated injuries
• Co-morbidities
CHEST TRAUMA
Blunt injuries managed non-operatively
Management of airway / oxygenation
Analgesia
Intubation and ventilator support if
needed
Chest tubes if needed for pneumothorax
or hemothorax
CHEST TRAUMA
PENETRATING INJURIES
Trajectory across chest
Mechanism due to knife or gunshot
Type of bullet
CHEST TRAUMA
INITIAL MANAGEMENT
• Airway, Breathing, Circulation
• PRIMARY SURVEY
• Identify & treat immediately life threatening
conditions
CHEST TRAUMA
Early intervention directed toward
diagnosing and treating:
• Tension pneumothorax
• Massive hemothorax
• Open pneumothorax
• Cardiac tamponade
• Flail chest
CHEST TRAUMA
RADIOLOGIC TESTS
Chest X-ray, usually portable
Abdominal KUB and FAST Ultrasound Exam
CAT scan, and CT Angiogram if needed
CHEST TRAUMA
Rib Fractures
Physical Diagnosis:
Deformity
Localized pain
Crepitus
Treatment:
Analgesia (PCA)
Pulmonary toilet
Observe for pneumothorax
CHEST TRAUMA
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
CHEST TRAUMA
Flail Chest Diagnosis:
• Paradoxical chest wall movement
• Poor air movement
• Hypoxia
Therapy:
• Pain control
• Pulmonary & physical therapy
• Intubation and ventilator support if needed
• Fluid restriction if possible
CHEST TRAUMA
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Pneumothorax or Hemothorax
• most treated with simple tube
thoracostomy
CHEST TRAUMA
Decompression of Tension Pneumothorax
• large bore needle
 2nd intercostal space
 midclavicular line
• Chest tube as definitive treatment
PULMONARY CONTUSION
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Common with blunt trauma
May be associated with laceration of
lung parenchyma
Leakage of blood and fluid into
interstitial spaces of lung
Significant inflammatory reaction to
blood components in the lung
PULMONARY CONTUSION
Parenchymal
infiltrate seen on
CXR adjacent to
injured chest wall
PULMONARY CONTUSION
Indications for intubation
• Respiratory distress
• Hypoxia
• Other injuries which compromise
respiratory effort, such as abdominal
or neurologic
MYOCARDIAL CONTUSION
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Physical bruising of
the cardiac muscle
Associated with
fractures of the
sternum
Any severe anterior
chest injury
MYOCARDIAL CONTUSION
DIAGNOSIS:
 Ectopy
 ST elevation
 Tachycardia
 Friction rub
 CPK enzymes, Troponin
Monitor in ICU & treat dysrhythmias
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Serial enzymes
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Analgesia
MASSIVE HEMOTHORAX
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From blunt or penetrating injuries
200cc – 1L in chest cavity seen on CXR
Treat with chest tube, if immediate drainage is
1500 cc or if 250 cc/hr for 4 hours, then
immediate thoracotomy
Bleeding may be from ribs, lung, blood
vessels
AORTIC RUPTURE
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Abrupt deceleration or compression injury
Sudden motion of heart / great vessels in chest
Great vessel injury may occur in 0.3 => 10%
penetrating trauma
Often rapidly fatal
10% survive to hospital
20% survive > 1 hour
90% who reach hospital will die
Early diagnosis and treatment
AORTIC RUPTURE
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mechanism of injury
widened
mediastinum on
CXR
AORTIC RUPTURE
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CT with contrast
angiogram
Contained injury
treat with BP control
Operative repair
CARDIAC INJURY AND
TAMPONADE
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Fatality rates > 80%
Mostly ventricular, right > left
Blood in pericardial sac causes tamponade
Occurs with penetrating injuries
DIAPHRAGM RUPTURE
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Associated with blunt
trauma or blast injury
Can be due to stab wounds
DIAPHRAGM RUPTURE
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Surgical repair to replace herniated contents
back into abdomen
Close muscular diaphragm to restore
pulmonary function
Chest tube to treat pneumothorax
ESOPHAGEAL INJURY
Most due to penetrating trauma
Difficult to diagnosis
If delayed or missed, rapid sepsis & high
mortality
Radiography
Endoscopy
Thoracoscopy
Treatment: surgical repair via thoracotomy
EMERGENCY THORACOTOMY
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
ER THORACOTOMY
survival rates < 8%
ER THORACOTOMY
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BLUNT injury with arrest
Arriving without pulse/BP
Penetrating injury with arrest
High likelihood of isolated / correctable
intra-thoracic injury
• ER THORACOTOMY in presence of :
• pulse
• blood pressure
• organized cardiac activity
CHEST TUBE INSERTION
Insertion Site
• mid or anterior axillary line behind pectoralis
major
• above 5th rib avoid diaphragm
CHEST TUBE INSERTION
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Connect tube to
underwater seal and
suture in place
Examine chest to
check effect
CXR to check
placement and
position
SUMMARY
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Chest trauma may be due to blunt,
penetrating or combination of causes
Organs at risk include bony, hollow, as well
as cardiovascular structures
Immediate life threatening conditions need to
be treated
Maintenance of airway, oxygenation, and
control of hemorrhage are important goals