CHEST TRAUMA: ASSESSMENT &

MANAGEMENT

By,
Under the guidance of,
Dr Rithesh Kumar P S, HOD & UNIT CHIEF:
Final Year Post Graduate, Professor Dr Pabitha Devi MS
First Surgical Unit, ASSISTANT PROFESSORS:
Department of General Surgery, Dr Jenitta Little Sophy MS
Dr Nambirajan MS
Govt. Tirunelveli Medical
College. Dr Athisayamani MS
 INTRODUCTION
• Thoracic injuries account for 25% of all
severe injuries.

• In most cases, cause of death is

haemorrhage.

• In more than 80% cases, chest injuries

managed conservatively.
PRIMARY SURVERY

ABCDE???
 cABCDE
C: Control of exanguinating external
haemorrhage:
Experience from war zones from past 20
years have shown that control of
exanguinating external haemorrhage from
massive bleeding needs to be controlled
even before airway management.
Application of pressure or packs directly
on wounds.
Haemostatic dressings or application of
torniquets.
A: Airway with cervical spine management:
Airway management by suctioning of secretions and blood, jaw thrust, head
tilt with chin lift and insertion of oropharyngeal or nasopharyngeal airways.
If needed, endotracheal or nasotracheal intubations done.
B: Breathing & Ventillation:
High flow oxygen.
Chest injuries like tension pneumothorax, massive haemothorax and flail chest
managed immediately.
C: Circulation & Haemorrhage Control:
Adequate hydration with atleast 2 large bore IV cannulae.
Central or intraosseous venous access.
If needed, blood transfusion.
D: Disability:
GCS/ Neurological status.
E: Exposure:
Assess for other external injuries.
Log Roll.
FAST???
 FOCUSSED ASSESSMENT WITH SONOGRAM IN TRAUMA
Quadrants assessed:
1)Epigastrium (cardiac tamponade).
2)Right hypochondrium (liver injury)
3)Left hypochondrium (spleen injury)
4)Pelvis

eFAST- EXTENDED FAST

FAST + thoracic cavity assessment.
4 quadrants + (5)right and (5)left thoracic cavity.
AKA BOAST (BEDSIDE ORGAN ASSESSMENT WITH
SONOGRAPHY IN TRAUMA)
 IMMEDIATE LIFE THREATENING
INJURIES
AIRWAY OBSTRUCTION
• Airway obstruction due to haematoma or airway
oedoma.
• PERTHE’S SYNDROME: Traumatic Ashyxia
Severe crushing or compression injury to the chest
(stampede).
Subconjuctival haemorrhage, cervicofacial
cyanosis resulting in purple blue neck, facial
oedema, mucosal petechiae and multiple
ecchymotic haemorrhages of face, neck and upper
chest.
Mx: Oxygenation via face masks or intubation if
needed.
 PNEUMOTHORAX
• Presence of air between the layers of pleura.
• Types:
a) Open pneumothorax.
b) Closed pneumothorax
Simple pneumothorax.
Tension pneumothorax.
• Causes:
1. Traumatic.
2. Spontaneous: Tuberculous/ Non- tuberculous (rupture of bullae/ lung cyst
etc.).
OPEN PNEUMOTHORAX:
• Large open injury in chest
>3cms, leading to immediate
equilibrium between
intrathoracic and atmospheric
pressures.
• If opening > 2/3rd diameter of
trachea, air drawn during
inspiration through this defect
than trachea.
• Air accumulates in
hemithorax leading to lung
collapse and hypoventilation.
• Mx:
First line: Closing the defect with sterile occlusive dressing (OPSITE) on
three sides to act like a flutter valve.
ICD tube drainage.
TENSION PNEUMOTHORAX:
• One way valve air leak occurs either from lung or chest wall.
• Air sucked into thoracic cavity without any means of escape, completely
collapsing and compressing the affected lung.
• Mediastinal displaced to opposite side, causing decreased venous return and
compressing opposite lung.
• Clinical features:
I. Increased respiratory rate (dyspneic, tachypneic).
II. Decreased cardiac output which causes increased heart rate and decreased
stroke volume.
III. Distended neck veins (increased JVP).
IV. Tracheal deviation.
V. On percussion, hyper resonant note.
VI. On auscultation, absent breath sounds.
• Tension pneumothorax is a clinical diagnosis than a radiological diagnosis,
hence immediate management started.
• Dx:
TENSION SIMPLE
• Mx:
o Immediate: NEEDLE
THORACOCENTESIS
Immediate decompression by
rapid insertion of large bore
cannula into 2nd intercostal space
in mid-clavicular line. In current
scenario, decompression done in
triangle of safety, 5th ICS in mid-
axillary line.
o Definitive: Tube Thoracostomy.
 TUBE THORACOSTOMY
• TRIANGLE OF SAFETY:
Posterior: anterior border of latissimus
dorsi.
Anterior: lateral border of pectoralis
major.
Apex: Axilla.
Base: line from nipple going to back or
5th ICS.
• Always inserted at UPPER BORDER
OF LOWER RIB.
• Other end connected to underwater seal.
• Confirm positioning of the chest tube.
 PERICARDIAL TAMPONADE
• Rapid accumulation of blood in pericardial space.
• Occurs commonly in penetrating injuries.
• Minimum of 50ml sufficient.
• Compression of heart and obstruction to venous return resulting in decreased
filling of cardiac chambers during diastole.
• Clinical features: tachycardia, distended neck veins (elevated JVP), shock due
to decreased cardiac output and MUFFLED HEART SOUNDS.
BECKS TRIAD:
Muffled heart sounds.
Increased JVP.
Hypotension.
• Dx:
1. Chest X-ray showing enlarged heart shadow (water bottle sign).
2. E-FAST showing pericardial effusion.
• Mx
Immediate: NEEDLE
PERCARDIOCENTESIS.
Needle inserted in sub-xiphoid area
at 45 degrees towards left shoulder
under USG guidance. Just
aspiration of 10cc of blood will
improve the haemodynamic status.
Definitive: Operative surgery via
sub-xiphoid window or median
sternotomy or left anterolateral
thoracotomy or VATS assisted
surgery.
 MASSIVE HAEMOTHORAX
• Accumulation of blood in pleural space.
• Source: intercostal vessels or internal mammary artery secondary to rib
fracture.
• Patient dypneic, tachypneic due to compression of lung.
• On percussion, dull note.
• On auscultation, absent breath sounds on affected side.
• Decreased cardiac output leading to decreased systolic pressure.
• Dx: Air fluid level or blunting of costo-phrenic angle in chest x-ray.
• Mx: ICD in triangle of safety.
MASSIVE HAEMOTHORAX IS DRAINAGE OF MORE THAN 1.5L
BLOOD ON PUTTING ICD OR ONGOING HAEMORRAGE OF 200ML/HR
OVER 3-4HRS- INDICATION FOR EMERGENCY THORACOTOMY.
 RIB FRACTURES
• Most common blunt thoracic injury.
• Greater number of ribs fractured, more patient’s morbidity and
mortality.

SITE OF FRACTURE PROBABLE INJURIES

1st rib (high velocity impact) Subclavian vessels.

Apex of lung.
Brachial Plexus.
4th – 9th ribs Lung, bronchus, pleura and heart injuries.

Below 9th ribs Liver and spleen injuries.

• Pain, point tenderness and crepitus.
• Dx: Chest Xrays/ CT chest.
• Mx:
Strapping, binders and rib belts were advised
previously.
Now, adequate analgesia- epidural analgesia,
intercostal nerve blocks, intrapleural
analgesia, IV opiates and NSAIDs.
Pulmonary toilet.
 FLAIL CHEST

Bailey Sabiston & Spencer’s

Fracture of 3 or more ribs in Fracture of 4 or more ribs
2 or more places. In 2 or more places.
• Associated with underlying pulmonary contusion.
• PARADOXICAL CHEST WALL MOVEMENT:
On inspiration, loose fragment moves inwards, less air moves into lungs
causing thoracic wall collapse.
On expiration, loose fragment moves upwards, more air moves into lungs
cause chest wall expansion.
• Mx:
Adequate analgesia with thoracic epidural
analgesia.
not responding
Intubation with mechanical ventilation
needed when RR> 40/min or P02
<60mmHg despite 60% face mask oxygen.
not responding.
Stabilization with internal fixation.
 POTENTIAL LIFE THREATENING
INJURIES
THORACIC AORTIC INJURY
• MC Location: distal to ligamentum arteriosum, descending thoracic aorta
(relatively fixed part). Shear force from rapid deceleration causes tear at this
fixed part.
• Types:
I- Intimal tear.
II- Intramural haematoma.
III- Pseudoaneurysm of Aorta.
IV- Free rupture.
• Difference in systolic blood pressure between two upper limbs or upper and
lower limbs and widened pulse pressure.
• Chest Xray:
Mediastinal widening (>10cms).
Loss of aortic knob contour (most significant).
Shift of trachea to right.
• Stable: CT Angiography.
• Unstable: TEE.
• Mx:
PERMISSIVE HYPOTENSION: To maintain end organ perfusion in an
attempt to preserve hemostasis.
Esmolol (beta blocker) used: Goals:
1. Heart rate <80bpm.
2. MAP 60-70mmHg.
Definitive: Endovascular intra-aortic stent or tear repaired directly or using a
graft (DACRON).
 TRACHEOBRONCHEAL INJURIES
• Occurs within 2cms within main carina, since it is a fixed part and susceptible to shear
forces from acceleration and deceleration injuries.
• Most commonly due to antero-posterior compression of chest wall (dashboard
injuries).
• Subcutaneous emphysema, haemoptysis, pneumothorax and air leak upon chest tube
insertion.
• Chest X-ray:
 Pneumothorax.
 Pneumomediastinum.
 Atelectasis in uninflated lung or lobe
due to fractured bronchus (aka)
FALLEN LUNG SIGN OF
KUMPE (lung collapsed outwards and
downwards).
• Mx:
Flexible bronchoscopic examination of
trachea-bronchial tree.
Proximal tracheal injuries managed by
intubation distal to site of injury to
control air leak.
Injuries to main stem bronchus:
1. Double lumen ET tubes used for
selective ventilation of the uninjured
lung.
2. Bronchial blockers or fogarty catheter
used to block the injured lung.
• Definitive Surgery:
Proximal tracheal injuries- cervical collar incision or upper sternal split
incision.
Distal tracheal injuries- right postero-lateral thoracotomy.
Broncheal injuries- postero-lateral thoracotomy.
Simple, clean lacerations sutured in an interrupted manner with 4-0 vicryl.
Lobar bronchus injury- standard or sleeve lobectomy.
Rarely pneumonectomy done.
 DIAPHRAGMATIC INJURIES
• Any penetrating injury below 5th ICS must raise suspicion of diaphragmatic
injury.
• Blunt injury to diaphragm usually caused by compressive forces to abdomen.
• MC side: left since right hemidiaphragm is covered underneath by the liver.
• PHASES:
Acute: original trauma to apparent recovery from other injuries or control of
bleeding or GI spillage, may mask the diaphragmatic injury. Non specific left
upper abdominal quadrant or shoulder pain.
Latent or Interval: undiagnosed or untreated diaphragmatic ruptures enter into
latent phase. Gradual herniation of abdominal contents.
Obstructive phase: herniation and strangulation leading to vascular
compromise, intestinal obstruction, peritonitis, empyema thoracic, sepsis.
• Clinically, paradoxical motion of left upper abdominal quadrant, decreased
intercostal retraction, decreased breath sounds, bowel sounds in chest and shift
of heart sounds.
• Chest X-ray:
Elevated hemidiaphragm.
Air fluid levels in chest.
Abnormal pleural densities.
• CT Chest: frank herniation of viscera
Into chest.
• All penetrating diaphragmatic injuries
repaired via abdomen.
 OESOPHAGEAL INJURIES
• Occurs usually in penetrating injuries, since its location is in posterior
mediastinum and is protected in front by trachea.
• Occurs in barotrauma- Boerhaave’s syndrome like rupture, increased
intraluminal pressure with closed glottis and increased intra abdominal
pressure.
• Rupture into mediastinum causing subcutaneous or mediastinal emphysema,
mediastinitis, aspiration, tachycardia and sepsis.
• Diagnosis by CT and oral contrast studies.
• Definitive management by operative repair through right postero-lateral
thoracotomy.
 CARDIAC INJURIES
• Penetrating cardiac injuries are devastating- gunshot or stab wounds, or
fractured ribs penetrating the heart.
• Management is by airway management, IV access capable of massive volume
resuscitation and immediate thoracotomy through median sternotomy or left
anterolateral approach.
• Ventricular stab wounds sutured by large, full thickness mattress bites across
the wounds- 2-0 ethibond can be used to prevent myocardial tear.
• Repair of atrial injuries using 4-0 polypropylene sutures.
• Mattress sutures beneath the coronary artery attempted whenever the tear is near
the coronaries, without obstructing the coronary flow.
 PULMONARY CONTUSION
• Occurs commonly in blunt trauma.
• Associated with flail chest or fractured ribs.
• Haemoptysis or blood in ET tube are signs of pulmonary contusion.
• CT chest is diagnostic.
• Mild contusion- oxygenation,
Pulmonary toilet and adequate analgesia.
• In more severe cases, mechanical
ventilation may be required.
EMERGENCY THORACOTOMY
INDICATIONS
Haemothorax >1500ml in placing chest tubes.
Icd output >200ml/hr for 3 consecutive hours.
Cardiac tamponade.
Aortic injury.
Tracheobroncheal injuries.
Oesophageal injuries.
 AIMS
Internal cardiac massage.
Control of haemorrhage from heart and lung injuries.
Control of haemorrhage from other thoracic sources.
Control of massive air leak.
Clamping of thoracic aorta to preserve blood supply to heart and brain, and
cutting distal supply in moribund patients.
CONTRAINDICATIONS
CPR > 15mins (no signs of Return Of Spontaneous Circulation) in
penetrating thoracic trauma.
CPR > 10mins in blunt thoracic trauma.
Blunt injury when there is no signs of life at the trauma scene.
THANK YOU