Thoracic Trauma

Chest Trauma

• The fact that it has become possible in recent

decades for millions of people to travel at high speed

had led to a phenomenal increase in blunt injury to

the chest - a most lethal type of injury.

EpidemiologyEpidemiology

Everything gets worse at night

Introduction

• Chest trauma is often sudden and dramatic

• Accounts for 25% of all trauma deaths• 2/3 of deaths occur after reaching hospital

• Major thoracic trauma is associated with multisystem injuries in 70% of cases. 16,000 deaths per year in the US

• 2/3 of victims of major blunt trauma suffer from thoracic injury.

• Second leading cause of trauma deaths after head injury (in USA)

•

Introduction to Thoracic Injury

• Vital Structures• Heart, Great Vessels, Esophagus,

Tracheobronchial Tree, & Lungs• 25% of MVC deaths are due to thoracic

trauma• 12,000 annually in US

• Abdominal injuries are common with chest trauma.

• Prevention Focus• Gun Control Legislation• Improved motor vehicle restraint

systems• Passive Restraint Systems• Airbags

Never operate on a patient who is getting rapidly better or rapidly worse

Thoracic Trauma

• Anatomical Injuries• Thoracic Cage (Skeletal)• Cardiovascular• Pleural and Pulmonary• Mediastinal• Diaphragmatic• Esophageal• Penetrating Cardiac

What structures

may be involved with

each injury?

Mechanism of Injury

• Blunt thoracic injuries• Forces distributed over large area

• Penetrating thoracic injuries• Forces distributed over small area• Organs injured usually those that lie

along path of penetrating object

Nothing spoils good results as much as follow-up

CAUSES OF CHEST INJURIES

• BLUNT TRAUMA• Motor vehicle

accidents• Auto vs.

pedestrian• Falls• Blast injuries

• PENETRATING TRAUMA• Gunshot

wounds• Stab wounds• Shrapnel

wounds

Pathophysiology of Thoracic Trauma

• Blunt Trauma• Results from kinetic energy forces• Subdivision Mechanisms

• Blast• Pressure wave causes tissue disruption• Tear blood vessels & disrupt alveolar tissue• Disruption of tracheobronchial tree• Traumatic diaphragm rupture

• Crush (Compression)• Body is compressed between an object and a hard surface• Direct injury of chest wall and internal structures

• Deceleration• Body in motion strikes a fixed object• Blunt trauma to chest wall• Internal structures continue in motion

• Ligamentum Arteriosum shears aorta

• Age Factors• Pediatric Thorax: More cartilage = Absorbs forces• Geriatric Thorax: Calcification & osteoporosis = More fractures

• Either: - direct blow (e.g. rib fracture) -

deceleration injury or - compression injury

• Rib fracture is the most common sign of blunt thoracic trauma

• Fracture of scapula, sternum, or first rib suggests massive force of injury

Blunt injuriesBlunt injuries

Mechanism of Injury

Penetrating injuries• E.g. stab wounds etc.• Primarily peripheral lung• Haemothorax• Pneumothorax• Cardiac, great vessel or oesophageal

injury

Pathophysiology of Thoracic Trauma

• Penetrating Trauma• Low Energy

• Arrows, knives, handguns• Injury caused by direct contact

and cavitation

• High Energy• Military, hunting rifles & high

powered hand guns• Extensive injury due to high

pressure cavitation

Trauma.org

Pathophysiology of Thoracic Trauma

• Penetrating Injuries (cont.)• Shotgun

• Injury severity based upon the distance between the victim and shotgun & caliber of shot

• Type I: >7 meters from the weapon

• Soft tissue injury• Type II: 3-7 meters from weapon

• Penetration into deep fascia and some internal organs

• Type III: <3 meters from weapon

• Massive tissue destruction

The first step is to make a rough estimate of

the status of the circulatory and respiratory

systems. This provides the first diagnostic clues and

often determines which therapeutic action is to be

taken. Specific questions are then posed pertaining to

individual injuries or their consequences.

Assessment of patient with Thoracic injury

• The treatment of polytraumatized patient must follow a certain protocol which includes. • Adequate oxygenation. • Fluid replacement. • Surgical intervention. • Treatment of septic complications. • Adequate caloric and substrate supplementation. • Prevention of stress bleeding. • Finally, be alert of possible complication (CNS,

ARDS, hepatic, renal, coagulation disorders, sepsis.

Management of patients with Thoracic Trauma

• The evaluation of thoracic injuries is only

one aspect of the total assessment of

severely injured patients.

• Both diagnosis and therapy go hand in

hand.

• The basic principle of elective surgery -

“First investigate and make the diagnosis,

then treat the illness” - is a dangerous

illusion.

Assessment of patient with Thoracic injury

Monitoring and evaluating the patient with Thoracic trauma

• Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles).

• Mediastinum (wide or normal) shifted or not.

• Lung parenchyma (Contusion).

• The heart (cardiac tamponade).

• Diaphragm.

• Pneumothorax, hemothorax.

ECGECG CVPCVP Arterial blood Arterial blood

gases. gases. Urine output. Urine output. Lab. Investigations.Lab. Investigations. Others. Others.

Immediately life-threatening; diagnosis

and therapy before taking

roentgenograms

TEN QUESTIONSTEN QUESTIONS to be asked in the initial to be asked in the initial assessment of severe blunt thoracic injuries assessment of severe blunt thoracic injuries

    1. Hypovolemia?

    2. Respiratory insufficiency?

    3. Tension pneumothorax?

    4. Cardiac tamponade

1. Multiple rib fractures? (Paradoxical respiration?)

2. Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?)

3. Hemothorax?

4. Diaphragmatic rupture?

5. Aortic rupture?

6. Cardiac contusion?

TEN QUESTIONSTEN QUESTIONS to be asked in the initial to be asked in the initial assessment of severe blunt thoracic injuries assessment of severe blunt thoracic injuries

If you are not sure, it isn’t

Common Injuries Develop After Blunt Chest Trauma

• Thoracic cage fractures• Lung contusion and tears• Myocardium contusion• Aortic rupture

Thoracic Trauma

• Initial exam directed toward life threatening:• Injuries

• Open pneumothorax• Flail chest• Tension pneumothorax• Massive hemothorax• Cardiac tamponade

• Conditions• Apnea• Respiratory Distress

TRAUMA DEATHS

EARLYEARLY

30%-35%

Within Hours (Golden Hour)

Thoracic Trauma

Liver/Spleen Injuries

Multiple Pelvic Fractures Others

Optimum Initial Care

IMMEDIATEIMMEDIATE

50%

Seconds or Minutes

Spinal Cord Injuries

Severe Brain Injuries

Lesions to Great Vessels

Prevention

Optimum Prehospital Care

LATE

15%-20%

2-3 Weeks

Sepsis

Multiple Organ Failure

Optimum Initial Care

(Future?)

Injuries Associated with Penetrating Thoracic Trauma

• Closed pneumothorax• Open pneumothorax (including

sucking chest wound)• Tension pneumothorax• Pneumomediastinum• Hemothorax• Hemopneumothorax• Laceration of vascular

structures

• Tracheobronchial tree lacerations

• Esophageal lacerations

• Penetrating cardiac injuries

• Pericardial tamponade• Spinal cord injuries• Diaphragm trauma• Intra-abdominal

penetration with associated organ injury

2003-3-31

Imaging Survey

• Chest x-rayChest x-ray : serve as a screening rather than a definite test repeat radiography should be ordered if suspicious

• Computed tomographyComputed tomography : highly sensitive in detecting injuries and superior to routine chest x-ray recommended in patients with multiple trauma and suspected chest trauma

• AngiogramAngiogram : for suspicious great vessel injuries

• Chest ultrasoundChest ultrasound : detect hemothorax, FAST

Massive HemothoraxMassive Hemothorax

• Need for thoracotomy Need for thoracotomy if: if:

• Immediate evacuation Immediate evacuation of 1500 mL of blood of 1500 mL of blood

• steady trend of more steady trend of more than 250 mL/hthan 250 mL/h

Indications for Thoracotomy in Indications for Thoracotomy in Chest TraumaChest Trauma• Cardiac tamponade Cardiac tamponade • Acute hemodynamic deterioration/cardiac arrest in the trauma Acute hemodynamic deterioration/cardiac arrest in the trauma

center center • Penetrating truncal trauma (resuscitative thoracotomy) Penetrating truncal trauma (resuscitative thoracotomy) • Vascular injury at the thoracic outlet Vascular injury at the thoracic outlet • Loss of chest wall substance (traumatic thoracotomy) Loss of chest wall substance (traumatic thoracotomy) • Massive air leak Massive air leak • Endoscopic or radiographic evidence of significant tracheal or Endoscopic or radiographic evidence of significant tracheal or

bronchial injury bronchial injury • Endoscopic or radiographic evidence of esophageal injury Endoscopic or radiographic evidence of esophageal injury • Radiographic evidence of great vessel injury Radiographic evidence of great vessel injury • Mediastinal passage of a penetrating object Mediastinal passage of a penetrating object • Significant missile embolism to the heart or pulmonary artery Significant missile embolism to the heart or pulmonary artery

Big Trouble

• Central lung injuries are deadly because they are difficult to control and repair.

• When confronted control the pulmonary hilum between thumb and forefinger or clamp it.

• Suture , lobectomy or pneumonectomy

Rib Fracture

• Fractures of 1st and 2nd second require high force• Frequently have injury to aorta or bronchi• Occur in 90% of patients with tracheo-

bronchial rupture• May injure subclavian artery/vein• May result in pneumothorax

• 30% will die

Rib Fracture

• Most common chest wall injury from direct trauma

• More common in adults than children

• Especially common in elderly

• Ribs form rings• Possibility of break in two places

• Most commonly 5th - 9th ribs• Poor protection

Pitfalls to Avoid• Elderly do not tolerate relatively minor

chest injuries• Anticipate progression to acute respiratory

insufficiency

• Children may sustain significant intrathoracic injury w/o evidence of thoracic skeletal trauma• Maintain a high index of suspicion

Tracheobronchial Rupture• Assessment Findings

• Respiratory Distress• Dyspnea• Tachypnea

• Obvious SQ emphysema• Hemoptysis

• Especially of bright red blood

• Signs of tension pneumothorax unresponsive to needle decompression

Diaphragmatic Penetration

• Suspect intra-abdominal trauma with any injury below 4th ICS

• Suspect intrathoracic trauma with any abdominal injury above umbilicus

Traumatic Aortic Dissection/Rupture

• Assessment Findings• Retrosternal or interscapular pain• Pain in lower back or one leg• Respiratory distress• Asymmetrical arm BPs• Upper extremity hypertension with

• Decreased femoral pulses, OR• Absent femoral pulses

• Dysphagia

Myocardial Contusion• Assessment Findings

• Cardiac arrhythmias following blunt chest trauma

• Angina-like pain unresponsive to nitroglycerin

• Precordial discomfort independent of respiratory movement

• Pericardial friction rub (late)

Pulmonary Contusion• Management

• Supportive therapy• Early use of positive pressure ventilation

reduces ventilator therapy duration• Avoid aggressive crystalloid infusion• Severe cases may require ventilator

therapy• Emergent Transport

• Hospital

Hemothorax• Assessment Findings

• Tachypnea or respiratory distress• Shock

• Rapid, weak pulse• Hypotension, narrow pulse pressure• Restlessness, anxiety• Cool, pale, clammy skin• Thirst

• Pleuritic chest pain• Decreased lung sounds• Collapsed neck veins• Dullness on percussion

Open Pneumothorax

• Assessment Findings• Opening in the chest wall• Sucking sound on inhalation• Tachycardia• Tachypnea• Respiratory distress• SQ Emphysema• Decreased lung sounds on affected side

CATEGORIES OF CHEST WOUNDS

• OPEN• Tension

pneumothorax• Sucking chest wound• Hemothorax• Impaled object

• CLOSED• Tension

pneumothorax• Hemothorax• Flail chest• Rib fractures

Simple Pneumothorax• Causes

• Commonly a fx rib lacerates lung• Paper bag effect• May occur spontaneously in tall, thin young males

following:

• Exertion• Coughing

Simple Pneumothorax• Incidence

• 10-30% in blunt chest trauma• almost 100% with penetrating chest trauma• Morbidity & Mortality dependent on

• extent of atelectasis• associated injuries

Flail Chest

• Mortality rates 20-40% due to associated injuries

• Mortality increased with• advanced age• seven or more rib fractures• three or more associated injuries• shock• head injuries

Flail Chest

• Usually secondary to blunt trauma• Most commonly in MVC• Also results from

• falls from heights• industrial accidents• assault• More common in older patients

Sternal Fracture

• Uncommon, 5-8% in blunt chest trauma

• Large traumatic force

• Direct blow to front of chest by• Deceleration

• steering wheel• dashboard

• Other object

Cardiac Tamponade

• Beck’s triad:

- hypotension, jugular venous distention, and muffled heart sounds

- causes decreased diastolic ventricular filling and resultant hypotension

- echocardiogram shows impaired diastolic filling of right atrium initially (1st sign)

Cardiac Tamponade

Hemopericardium with tamponade

Troublesome Injuries

• Blunt cardiac trauma - managementBlunt cardiac trauma - management

• Most cases do not require Tx; Symptomatic arrhythmia (2-5%) antiarrthythmics

• Abnormal ECG and cardiac enzymes almost return to normal within one week.

• Patients with abnormal cardiac echo finding or MUGA keep hospitalization till a repeat test show acceptable finding

• Cardiac rupture prompt surgical repair

Troublesome Injuries

• Lung contusionLung contusion• CxR finding may range from minimal

interstitial infiltrate to extensive lobar consolidation

• Chest CT is accurate diagnostic tool but not always mandatory

• Tx : same as flail chestsame as flail chest, but pay attention to avoid overhydration; use of steroid and prophylactic antibiotic are still controversial

Aortic Transection

• Signs:

- widened mediastinum, 1st rib fx, apical capping, left hemothorax, tracheal deviation to right

- widening from bridging veins and arteries, not aorta itself

- need aortic evaluation in pts with significant mechanism (deceleration injuries), usually tears at ligamentum

- 90% of patients die at the scene

Thoracic Aorta Injury

• 90% lethal before receiving emergency care• Usually a transverse laceration of part or all

of aortic circumference• 60% have adventia intact = pseudoaneurysm• Injury to root or ascending aorta is nearly

100% fatal• ~90% occur at aortic isthmus just distal to left

subclavian• 4-10% of cases have concomitant great

vessel injury

Airway Injury• Tracheobronchial tears are uncommon

• < 0.35-1.5% of BCT• bronchial > tracheal • 75% at R mainstem usually within 2.5 cm of carina

• Leads to persistent PTX• Specific Symptom: persistent PTX after chest

tube placement• Finding: “Fallen Lung Sign”,

pneumomediastinum, pneumopericardium, sub cut. Emphysema

• ET Tube balloon inflation >2.8cm implies tracheal rupture

Open Pneumothorax

• Opening in chest cavity that allows air to enter pleural cavity

• Causes the lung to collapse due to increased pressure in pleural cavity

• Can be life threatening and can deteriorate rapidly

TENSION PNEUMOTHORAX

• 33% of preventable combat deaths• Injured chest or lung acts as one-way valve• Air becomes trapped between the lung and

chest wall causing the lung to collapse• The heart is pushed to the other side causing

blood vessels to kink• Death will result if not quickly recognized and

treated with needle decompression• May occur in open and closed chest wounds

Tension Pneumothorax

Air collapses lung and pushes heart to other side

Blood return to heart restricted by kinked vessels, heart unable to pump

Air between lung and chest wall

OTHER SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX

• Difficulty breathing • Chest pain• Unilateral decreased/absent breath sounds• Anxiety or agitation• Increased pulse• Tracheal deviation• Jugular venous distention (JVD)• Cyanosis

NEEDLE CHEST DECOMPRESSION

SUCKING CHEST WOUND (OPEN PNEUMOTHORAX)• Open chest wound allows air entry into chest and escape• Although lung is collapsed (pneumothorax), pressure is

relieved by air escape and tension pneumothorax is avoided

• Tension pneumothorax may develop later • Continually reassess the casualty for signs and symptoms

of tension pneumothorax

OPEN CHEST WOUND

Esophageal Injury

• <10% of esophageal rupture is caused by trauma

• < 1% of BCT’s• Findings:

• Pneumomediastinum• Left PTX• Left pleural effusion• Sub cut emphysema• Left lower lobe atelectasis

Traumatic Asphyxia

MANAGEMENT OF IMPALED OBJECT IN THE CHEST

• Immobilize the impaled object• Stabilize object with support dressings

• Use bulky dressings

• Construct protective structure using splint or sling

• Cover and dress open wounds

ConclusionChest injuries are directly responsible for more than

20% of all traumatic deaths (regardless of mechanism) and account for about 16,000 deaths per year in the United

States. The risk of death can be reduced by early recognition of serious signs and symptoms and rapid

treatment.