Overview and Management of Thoracic Trauma

dr. M Arza Putra, SpBTKV(K)

Departemen Ilmu Bedah
Fakultas Kedokteran Universitas Indonesia/
RSUPN Cipto Mangunkusumo

IMERI – Sabtu, 8 September 2018

10thEmergency in Daily Clinical Practice
Overview and Management
of Thoracic Trauma
Muhammad Arza Putra

Departemen Ilmu Bedah

Fakultas Kedokteran Universitas Indonesia/
RSUPN Cipto Mangunkusumo
Overview
• Introduction of Thoracic trauma
• Thoracic Trauma Assessment
• Prioritizing management in thoracic trauma
• Tube Thoracostomy and Water sealed drainage
Thoracic Trauma
• One of the most common
cause of death in trauma
• Only less than 10% in blunt
trauma & 15 – 30%
penetrating trauma need
operative management
• Majority of the cases can be
stabilized in ER!
Thoracic Trauma: Cause of Death
Contusion,
haematoma, alveolar
Metabolic
collapse, intrathoracic Hypoxia
acidosis
pressure
increasement
Thoracic
Trauma
DEATH
Respiratory
Breathing problems Hypercarbia
acidosis
Thoracic Trauma

Primary
Survey

Airway Breathing Circulation

Primary Survey- Airway Problems
• Airway Obstruction
• Swelling, foreign bodies, bleeding, direct neck trauma, aspiration, etc

• Look!
• Air hunger  intercostal and supraclavicular retraction
• Oropharyngeal inspection

• Listen!
• Air movement
• Stridor  partial obstruction
• Changes in voices (hoarseness)
Airway Interventions
 Maintenance of Airway Patency
– Suction of Secretions
– Chin Lift/Jaw thrust
Dept. of the Army, Wikimedia Commons

– Nasopharyngeal Airway
– Definitive Airway
 Airway Support
– Oxygen
– NRBM (100%) Ignis, Wikimedia Commons
– Bag Valve Mask
– Definitive Airway
 Definitive Airway
– Endotracheal Intubation
 In-line cervical stabilization
– Surgical Crichothyroidotomy
U.S. Navy photo by Photographer's
Mate 2nd Class Timothy Smith,
Wikimedia Commons 8
C-spine Immobilization
 Return head to neutral position
 Maintain in-line stabilization
 Correct size collar application
 Blocks/tape
 Sandbags

Paladinsf
(flickr)
James Heilman, MD, Wikimedia Commons 9
 Primary Survey- Airway Problems
• Tracheobronchial Tree Injury
• Sudden death & high mortality (if one can
reach the hospital…)
• Leads to
• Tension Pneumothorax
• Pneumopericardium
• Sign
• Cervical Subcutaneous Emphysema, hemoptysis,
pneumothorax, cyanosis large air leak during
chest tube insertion (continuous bubble)
• CXR: fallen lung  beware of bronchial rupture
• Management
• Intubation  potentially worsen injury
• Operative treatment
• Fiber-optic bronchoscopy ETT placement
Tracheobronchial
Tree Injury
• Bilateral Tension
Pneumothorax
• Pneumomediastinum
Bronchial Injury
• Fallen Lung  Bronchial Rupture
• Persistent/Continuous Bubble
• Negative pressure can worsen symptom
• Thoracotomy needed
Primary Survey - Breathing Problems

Tension Open
Pneumothorax Pneumothorax

Massive
Haemothorax
(breathing &
circulation problem)
Breathing Problems – Tension Pneumothorax

Compressing the
One way valve  air Shifting the mediastinum, vena
Collapsing the lung
trap! mediastinum cava and opposite
lung

Decreased venous
Death Shock return and cardiac
output
Breathing Problems – Tension Pneumothorax
Breathing Problems – Tension Pneumothorax
• Breathing Assessment!
• Tachypnea
• Chest pain
• Hypotension IMMEDIATE
• Air hunger
• Tracheal deviation DECOMPRESSION!
• HYPERRESONANT
• DECREASED BREATH SOUND
• JUGULAR VEIN DISTENTION
• Cyanosis
 Needle Decompression – Tension Pneumothorax

ATLS the 10th

ATLS the 9th MIDCLAVICULAR
• Adult
LINE
• Midclavicular line • Anterior part of midaxillary
line
• 2nd intercostae muscle • 4th / 5th intercostae muscle
• Pediatric
MIDAXILLARY LINE
• Midclavicular line
• 2nd intercostae
Needle Decompression – Tension
Pneumothorax
• 5 – 8 cm needle
• Using syringe (with 3 – 5 cc of
normal saline to help
identifying bubbles)

• Definitive treatment  chest

tube!
Breathing Problems – Open Pneumothorax
• Chest wound
• Connecting intrapleural cavity with
environment atmosphere
• If the resistance in the wound is
lower than in the airway, air will be
sucked into the pleural cavity
through the sucking chest wound!
Breathing Problems – Open
Pneumothorax/Sucking Chest Wound
• Management
• Three sided occlusive
sterile dressing
• As an initial management
• Definitive treatment 
tube thoracostomy with
WSD
Breathing Problems – Open
Pneumothorax/Sucking Chest Wound
• Quiz
• Should the chest tube be
inserted into the sucking
chest wound?
Circulation Problems

Massive Cardiac
Hemothorax Tamponade

Traumatic
Circulatory
Arrest
Circulation Problem - Massive Hemothorax
• Results from rapid
accumulation of more than
1500 mL of blood/one-third or
more of patient’s blood volume
in the chest cavity.
• Estimated total circulated
blood volume
• 70 mL/kgBW for adults
• 80 mL/kgBW for children.
• Commonly caused by:
• Penetrating injury
• High-force blunt trauma.
Circulation Problem - Massive Hemothorax
Clinical signs:
- Absence of breathing sounds
and/or dullness to percussion
on one hemithorax
- Neck veins may or may not
be distended due to collapsed
vein in hypovolemia OR
associated tension
pneumothorax
Circulation Problem - Massive Hemothorax
• Management
• Restore Blood Volume
• Establish two-lines large-bore IV
catheter
• Infuse warm crystalloid
• Begin transfusion ASAP
• Do auto-transfusion if possible
• Decompress Chest Cavity
• Tube thoracostomy
• Consult for urgent Thoracotomy to
Cardiothoracic Surgeon if:
• > 1500 mL of initial blood
• Continuing blood loss of >200 mL/h
for 2 to 4 hours
• Penetrating wound on “mediastinal
box”
Hemothorax vs Hematopneumothorax
 Circulation Problem - Cardiac Tamponade

Cardiac
Fluid
Diastolic output
accumulation
function ↓ severely
in pericard
decreased!

• Beck’s Triads:
• Jugular vein
distention Management:
• Muffled heart - Subxyphoid
sound Image A. Normal Pericardial Sac B. Cardiac Tamponade
pericardial window
• Hypotension - Pericardiocentesis
• (Becks Triads only
shown positive in
23/63 patients!)
Circulation Problem - Cardiac Tamponade
Circulation Problem - Cardiac Tamponade
Circulation Problem - Traumatic Circulatory
Arrest
• Clinically diagnosed by traumatic patients with unconsciousness and
have no pulse, it be PEA, Ventricular fibrillation, and Asystole.
• Has less than 10% survival rate and requires immediate action.
• Start closed CPR simultaneously with ABC management.
Image Traumatic Circulatory Arrest (cont.)
Image Traumatic Circulatory Arrest (cont.)
Secondary Survey: Potentially Life-Threatening
Condition following Chest Trauma
• Simple Pneumothorax
• Hemothorax
• Flail Chest and Pulmonary
Contusion
• Blunt Cardiac Injury
• Traumatic Aortic disruption
• Traumatic diaphragmatic injury
• Blunt Oesophageal rupture
Intubation and Ventilation in Thoracic Trauma
• Endotracheal intubation
is indicated in the
present of trauma
patient with GCS less
than 8, proven by the
absence of gag and
cough reflex.
• Most common thoracic
trauma needed
Intubation
• Pulmonary contusion
• Flail Chest
Pulmonary Contusion
• Should be suspected to all chest
trauma patient especially if chest
bruise and rib fracture are
found.
• Chest x-ray shows infiltrate in
involved lung but it usually
appears in 4-6 hours after
trauma and could persist for 24
hours.
• If suspected CXR is clean then
repeat it after 6-12 hours.
Pulmonary Contusion Chest x-ray (on admission)

Source: http://www.trauma.org/archive/thoracic/CHESTcontusion.html
Pulmonary contusion Chest x-ray (after 24 hour)

Source:
http://www.trauma.org/archive/thoracic/CHESTcontusion.html
 Flail Chest
• A segment in the rib cage that has a
paradoxical movement
• Indication:
 Segmental fracture (happened in 2 line)
 3 or more costae involved
 The length of the segment must be minimally
twice as the width of the costae
 The segment should be located in the anterior or
lateral chest wall
• Paint management: Intercostal block or
epidural
• Narcotics agent should be avoided as it may
suppress cough reflex and depress respiration.
Tube
Thoracostomy and
Water Sealed
Drainage
Pleural Anatomy
• Normally, there is only
pleural fluid as a lubricant
between parietal and
visceral pleura
Physiology of Pleural Cavity
• Lung is not a muscular organ.
• The inspiration and expiration depend on
chest wall movement.
• Lung is not attached to chest wall, it depends
on negative pressure of pleural cavity to be
able to expand following chest wall
movement.
• If air is present inside pleural cavity the
pressure will increase and the lung will
collapse.

• Tube Thoracostomy/WSD  revert

intrapleural negative pressure
Tools for Chest Tube and WSD System

Tube Trochar
Drainage System
Commercial
Chest Drain Insertion
• Principals in chest drain
insertion:
• Optimal positioning
• Patients comfort
• Hemodynamic monitoring
should be maintained during
procedure!
Chest Drain Insertion
1. Choosing insertion site
2. Dissecting intercostal muscle
3. Introducing the drain/tube
4. Suture
1. Choosing insertion site
• “triangle of safety”
• 5th intercostal space  Nipple
line/mammary fold
• Anterior part of midaxillary line
2. Dissecting intercostal muscle
• Local anesthesia
• Blunt dissection unto the pleural
space
• Dissect above the costae  why?
3. Introduce the drain/tube
• Measure the length required
before introducing the tube
• Initial bubble, water, and blood
should be measured
4. Suture placement
• Place suture to make sure the
chest drain does not get pulled
away
• Connect the tube towards the
WSD system
Thank You
Chest Tube Insertion