chest trauma

Cardiothoracic Surgeryfor undergraduate

Prof. Ahmed DeebisHead of Cardiothoracic

Surgery Department - Zagazig University

Cardiothoracic Surgery

I: Thoracic SurgeryA. Chest TraumaB. Surgery of Pleural

DiseasesC. Surgery of Pulmonary

InfectionsD. Tumors of The LungE. Surgery of Mediastinum

II: Cardiac SurgeryA. Cardiac Operations and

Cardiopulmonary bypass.B. Surgery for Valvular Heart

Diseases.C. Surgery for Congenital

Heart Diseases.D. Coronary Artery Bypass

Graft (CABG) Surgery

A: Chest Trauma

• The oldest known medical text for surgical treatment of trauma is the Egyptian Edwin Smith Papyrus in around 1600 BC. In this Papyrus, chest injuries were first described in detail.

• About 20% to 25% of all trauma-related deaths, are related to chest injuries.

Chest trauma

i) Blunt chest trauma• mostly caused by motor

accident, falls from height, and blast Injuries

• 90% of blunt trauma can be managed without thoracotomy ( i.e. with conservative management or with intercostal tube drainage )

ii) Penetrating chest trauma• caused by gunshot, stab

wounds, and shrapnel.

• 70% to 85% of penetrating trauma can be managed without thoracotomy ( i.e. with conservative management or with intercostal tube drainage ).

Primary and Secondary Survey Notes

Primary surveyImmediate life-threatening injuries to be sought and treated:

• Airway obstruction• Tension pneumothorax• Open pneumothorax• Massive haemothorax• Flail chest• Cardiac tamponade

Secondary Survey• This is a more detailed and complete clinical

examination aimed at managing chest wall, pulmonary, mediastinal, diaphragmatic and other injuries.

Investigations

First line investigations performed once the primary survey and management is established include

• X-ray chest (C-spine and pelvis as indicated)• Trans-thoracic echocardiography if pericardial

effusion suspected• CT if there is any suspicion about injury to major

thoracic structures, and the patient is haemodynamically stable

• Aortography if aortic injury is suspected

I: Chest Wall Injuries

(1) Rib fracture: • The most common chest injury• Usually caused by blunt trauma• Uncommon in children [pliable ribs]• The 4th to 9th ribs are the most commonly

fractured [thin and poorly protected].• Fractures of the upper ribs (1, 2, and 3) indicate

major trauma • Fractures of the lower ribs(8, 9, and 10) may be

associated with renal, hepatic or splenic injuries

Diagnosis of Rib fracture

Clinically: • Local tenderness, bruising, pain on inspiration

or coughing.Investigations:

• Chest X-ray, • CT when suspected associated injuries.

Treatment of Rib fracture 1. Pain control, by:

i) Oral or intravenous analgesia, ii) Intercostal nerve block, and/or iii) Epidural anesthesia.

2. Optimization of pulmonary toilet (e.g. incentive Spirometer, coughing & ambulation) prevention of atelectasis.

3. Treatment of complications e.g. hemothorax or pneumothorax.

N.B. :Chest strapping by binders, and rib belts is not recommended as they cause reduction of ventilation of the affected side that promote atelectasis.

(2) Flail chest:

• Multiple adjacent ribs are broken in multiple places, leading to instability to a segment of the thoracic wall that exhibit paradoxical motion locally.

• A serious, life-threatening chest injury • Most commonly seen in cases of significant

blunt trauma. • often associated with underlying pulmonary

injury .

• The flail segment impairs respiratory mechanics, --------hypoventilation, poor pulmonary drainage and atelectasis.

(2) Flail chest: Cont,

Diagnosis:• - Inspection: paradoxical movement is usually

diagnostic which is confirmed by palpation.• - X-ray: Fractured ribs seen and may show

complication.Complication:

• pneumothorax, hemothorax, lung contusion, respiratory insufficiency.

Treatment of Flail chest1. Adequate analgesia.2. Mechanical ventilation:

indicated for a respiratory rate over 40 breath / min., PaO2 less than 60mmHg despite 60% face mask oxygen, shallow. respiration, depressed consciousness and/or associated injuries.

3. Surgical fixation: may be indicated for cosmetic deformity, thoracotomy for other reasons (hemothorax) and failed weaning from ventilation.

4. Treatment of complication.

II: Injuries of Lung Parenchyma and Pleura(1) Pulmonary contusion:

• The most common injury in blunt trauma.• Develops over 24-48hrs• Based on alveolar rupture, oedema and blood

collection.• Generally associated with concomitant

thoracic cage damage and other visceral injuries but they can occur in isolation.

Pulmonary contusion, Cont.

Presentation:• -Classic symptoms include dysnea, tachypnea,

hemoptysis, cyanosis and hypotension.• -Decreased breath sounds and inspiratory rales

on the affected side.Investigation: • Chest X-Ray (patchy opacification, may

underestimate extent).• CT scan is the study of choice.

Pulmonary contusion , Cont.

Management:• Observation on supplementary oxygen. • Chest physiotherapy.• Patients with hypoxia PaO2 < 65 mmHg and SaO2 <

90 % should be intubated and ventilated.• Cautious fluid administration. • If large volumes of fluid necessary for resuscitation,

pulmonary artery catheter should be placed.

(2) Pneumothorax:

• Definition: Accumulation of air in the pleural cavity.

• Either due to blunt trauma, penetrating trauma, or iatrogenic

• Types: i) Open pneumothorax. ii) Closed pneumothorax. iii) Tension pneumothorax.

i) Open Pneumothorax:

• Pleural cavity communicates with the atmosphere• The wide communications to the outside result in: Total lung collapse on the affected side. Mediastinal flutter : The mediastinum is mobile, so

with inspiration the mediastinum moves towards the healthy side and opposite on expiration. So, paradoxical respiration in the healthy side occurs

Impaired venous return

Open Pneumothorax: , Cont.

Diagnosis:• By inspection revealed sucking wound.• Chest X-ray: pneumothorax.

Treatment:• Immediate airtight closure of thoracic wound using

gauze and adhesive tape so converting open to closed pneumothorax but keep in mind the possibility of developing tension pneumothorax so it's better to leave one edge unsealed.

• Then insertion of intercostal tube and closure of the defect

ii) Closed Pneumothorax:

• No communication to the atmosphere.• Usually well tolerated.

Diagnosis:• Decreased movement on the affected side.• Trachea may be central or slightly shifted to

the healthy side.• Hyperresonant on percussion.• Diminished breath sound on auscultation.

ii) Closed Pneumothorax:• Chest X-ray: The outline of the lung

is seen in the pleural space (which is the visceral pleura), lateral to that line jet black air seen with absence of bronchovascular markings.Treatment:

1- Observation if small.2- Chest tube drainage (in the fifth

Intercostal space midaxillary line): the best management even in small

pneumothorax in trauma patients.

iii) Tension Pneumothorax

• Life threatening condition.• Developed when an injury to the lung or chest

wall allows air to continue to enter the pleural space with each inspiration without being able to exit during expiration.

Tension pneumothorax, cont.

• Through this valvular mechanism, air will accumulate in the pleural cavity with increased positive pressure lung collapse on the affected side with shift of mediastinum to the other side that leads kinking of the caval veins resulting in impairment of venous return and low cardiac output.

• Also compression to the other lung leads to significant hypoxia

Tension pneumothorax, cont.

Classic signs: Shock (hypotension, tachycardia), Hypoxia, Distended neck veins.Tracheal deviation to contralateral

side, Hyperresonant and reduced

breath sounds, Hyperexpanded hemithorax with

decreased expansion.

Tension pneumothorax, cont.

• Tension pneumothorax is a clinical diagnosis with no time for investigation

• Chest X-ray: Shows, collapse of entire lung, depression of diaphragm with flattening of it's dome, and mediastinal shift.

Tension pneumothorax, cont.

Treatment:• Immediate decompression (live-saving):

If intercostal tube not available, insertion of wide-bore cannula in the 2nd intercostal space midclavicular line converts tension into open pneumothorax, then intercostal tube insertion once available.

(3)Traumatic Hemothorax:

• Bleeding into pleural space, resulting from both blunt and penetrating chest injuries.

• Usually secondary to: rib fractures, lung trauma, venous injury. Rarely, due to arterial injury.

(3)Traumatic Hemothorax:, cont

Clinically:Dullness on the affected sideDiminished breath sounds on the affected sideDecreased respiratory movement on affected

side. Hemorrhagic shock may be seen in patients with

massive hemothorax Tracheal deviation to contralateral side in massive

hemothorax

(3)Traumatic Hemothorax:, cont

Investigations: • Chest X-ray (posteroanterior

and lateral):< 300 ml of blood may be hidden by diaphragm on erect chest filmSupine CXR can easily miss hemothorax

• Fast Ultrasound. • CT scan.

Treatment of Traumatic Hemothorax:, cont

• High flow O2.• Large bore (28-32F) chest drain/s.• Thoracotomy is indicated for the following:

i) Injury with hemodynamic instability (< 80 mmHg systolic) not responding to adequate resuscitation.ii) Initial drainage of >1500ml from the inserted chest tube.iii) Persistent bleeding (>200-300 ml/h for 4 h).vi) Retained clot (thoracoscopy may suffice).

III: Cardiovascular Injuries

(1) Cardiac contusionIt is any cardiac injury follows blunt trauma

not accompanied by cardiac chamber rupture or injury to intracardiac structures.

It ranges from subepicardial or subendocardial hemorrhages to extended foci of contusion.

Presented with pericardial pain not increased by respiration, tachycardia, arrhythmia

(1) Cardiac contusion, cont.

Treatment• ICU admission• O2 Therapy to correct hypoxaemia• Antiarrhythmic drugs • Correction of hypovolemia guided by CVP.• Treatment of pericardial effusion if present.

(2) Hemopericardium and cardiac tamponade

• Acute accumulation of more than 150ml of blood in pericardium can cause life threatening tamponade, as pericardium is a fibrous structure with very slight elasticity Causes:

• -Right ventricular lacerations more commonly than left ventricular lacerations

• -occasionally injury to coronary vessels or great vessels.

(2) Hemopericardium and cardiac tamponade, cont.

Diagnosis • Classic triad of:

High venous pressure Distant heart sounds Hypotension

• Chest X-ray: not diagnostic • Echocardiography: The diagnostic tool of

choice • Pericardiocentesis: has both diagnostic and

therapeutic role

(2) Hemopericardium and cardiac tamponade, cont

Treatment:• Pericardiocentesis for temporary relief • Emergency thoracotomy is the treatment of

choice Ventricular lacerations are repaired over

pericardial or Teflon pledgets.Atrial lacerations are simply oversewen.Coronary artery injury or intracardiac injuries

require cardiopulmonary bypass.

THANK YOU