CHEST TRAUMA

Ferdinand P. Kionisala, MD.

Training Officer
Department of Surgery
 OUTLINE
• Definition and classification
• Brief anatomy and pathophysiology of the
chest
• Recognize the types and mechanisms of life
threatening thoracic injuries
• Initial assessment and mx of various thoracic
injuries
• Secondary mx of thoracic injuries and some
unique challenges they can impose
 CHEST
TRAUMA
 Anatomy of the chest
Thoracic Inlet..
Connects thoracic cavity to the root of the Neck.
Thoracic Wall
Anatomy of the chest
Two Lungs (right and left)

Heart

Diaphragm
 BLUNT

CHEST TRAUMA

Classified into 2 broad groups depending on

PENETRATING
wheter a breach in the thoracic wall has
occurred with involvement of intrathoracic
structures
 BLUNT TRAUMA TO THE CHEST

• Acceleration/Decelerati
on Injury
– MVA
– Falls > 3m
– Sports

• Compression ( AP &
transverse )

• Blast Injuries
 PENETRATING CHEST TRAUMA
• High velocity
– Gun shot
– Missile fragments

• Low velocity
– Stab injury
• Injuries that breach the chest wall may impact the body with
significant amount of energy which can result in localized
damage along the wound tract or significant dissipation of
disruptive forces to surrounding through the cavitation effect
producing remote injuries. It might also be the result of a
change in trajectory due to impact on other structures. So
sometimes what you see on the surface belies real badness
beneath. One of the pitfalls in the management of people
with this kind of condition. An awareness and high index
suspicion must always guide mx in this pts.. Geography and
society play a role in determining the pattern we see and
what predominates ie war torn areas, violent societies GSW
and chilled out places MVA, footy injuries
Danger box
• Suspect in any victim with penetrating wound, neck
or upper abdomen. Particularly dangerous site is the
central chest area from clavicles  xiphisternum /
between right nipple and left lateral chest wall
(described as the ‘danger box’)
• Can be seen in blunt trauma in patients on
anticoagulants or antithrombotic drugs
 Epidemiology
• A third of RTA’s have significant chest trauma

• Approx. 80% is blunt chest trauma

• 20 - 25% overall mortality

• Majority of the deaths are preventable

• < 10% of BCT require surgical intervention as

opposed to 15 - 30% in PCT
Immediate deaths are usually due to major disruption of
the heart or of great vessels. Early deaths due to thoracic
trauma occurring within 30 minutes to 3 hours after the
injury are usually secondary to cardiac tamponade,
airway obstruction and aspiration, or rupture of thoracic
aortic tears that have been temporarily contained. Two
thirds of these patients reach the hospital prior to death.
Only 10-15% of blunt trauma require thoracic surgery,
and 15-30% of the penetrating chest trauma require open
thoracotomy. Overall, about 85% of patients with thoracic
trauma can be managed without surgical treatment.
 CLINICAL PRESENTATION
• VARIED
– Polytraumatized with other injury components i.e.
abdominal hemorrhage

• MECHANISM OF INJURY

• HIGH INDEX OF SUSPICION FOR SINISTER

BADNESS BENEATH THE SURFACE
 Initial Management – Primary Survey
(ATLS protocol)
• Airway/spinal stabilization
– Trachea, bronchial disruption

• Breathing
– Chest wall integrity, pneumothorax, flail
– Pulmonary contusions, 02 diffusion block

• Circulation
– Tamponade, hemothorax, tension pneumothorax
– Cardiac, great vessel injury
• The evaluation of the patient's chest trauma is only a part of
the total assessment and the basic ABC’s of the primary
survey and resuscitation cannot be overlooked. It is
important to keep several special factors in mind when
dealing with a patient with potential thoracic injuries
because thoracic injuries are severe and potentially lethal
and the diagnosis and therapy go hand in hand as there can
be unique mechanical factors that cause the alterations in
vital signs. Injuries such as tension pneumothorax can be
rapidly fatal if missed but treated and cured in a matter of
moments when recognized.

• In unstable and critical patients quick decisions based on

check of the following vital signs are required. Airway
patency: in the initial survey is mandatory to control the
airway patency. Patency of the airway does not necessarily
assure adequate ventilation in patients with chest injuries
unless the airway is in continuity with the lungs. Patients may
be ventilated without oxygenating their blood with chest
injuries due to pulmonary contusions or airway disruption.
• All the airway manipulations must be performed with respect to
potential cervical spinal injuries. Breathing: in order to know if patient is
breathing is necessary to check respiratory movement, and their extension
which can be compromised by chest wall integrity. Cyanosis appears very
late in hypoxia due to a thoracic trauma because in shocky patients the
skin blood flow depends on blood redistribution in the body. Circulation:
the state of the circulation is evaluated by assessing patient's pulses
(radial, carotid or femoral). The blood pressure is evaluated by width of
pulse. In hypovolemic shock radial pulse becomes small; may be absent
when blood pressure is below 60 mm/Hg. In thoracic trauma is important
to assess the neck veins that are flat in hypovolemia are distended when
there is cardiac tamponade. But if cardiac tamponade is associated with
hypovolemic shock distension of the neck veins may be absent. Thoracic
cavity is constituted from two structures: the first, rigid, comprehending
the rib cage, clavicle, sternum, scapula and the second comprehending
respiratory muscles. Adequate ventilation and oxygenation depends on an
intact chest wall. Significant injury with fracture and muscular disruption
may allow direct injury to the underlying lungs, heart, great vessels and
upper abdominal viscera. In addition, respiration may be seriously
impaired by effective or paradoxical motion of a portion of the thoracic
cage (as in flail chest) and the result is respiratory insufficiency.
“TREAT LIFE THREATENING
INJURIES AS THEY ARE
IDENTIFIED”
 IMMEDIATE LIFE THREATENING
THORACIC INJURIES
• Cardiac
• Tension disruption/tampo
pneumothorax nade

• Massive • Tracheal
hemothorax disruption

• Contained Aortic
• Open transection
pneumothorax
 Crucial 1° Survey Differential Dx: Cardiac
Tamponade vs Tension Pneumothorax

Clinical Sign Cardiac Tension Pneumothorax

Tamponade
Blood Pressure Low (PEA) Low
Cardiac Tones Muffled Normal
Breath Sounds Normal Absent - collapsed side
Neck Veins Distended (flat in Flat
hypovolemia)
Respirations ± Normal Tachypnea
Treatment Needle/drain Needle/tube chest
pericardium
Identifying cardiac tamponade vs. tension pneumothorax is a critical
differential diagnosis that must be made accurately and almost
instantaneously since both are treatable and curable injuries. Both present
with low or absent blood pressure (PEA) but the physiology is opposite since
tamponade is due to compression of the right heart and tension
pneumothorax is due to absent filling of the right heart. The major
differentials relate to etiology – the neck veins are distended in tamponade
since blood is trying to enter the heart and cant and flat in tension
pneumothorax since there is no blood in the right heart. An important pitfall
in this differential finding is that in hypovolemic patients neck veins can be
flat in both injuries. Cardiac tones are usually muffled in tamponade but this
can be difficult to appreciate in the noisy trauma areas and breath sounds are
usually absent on the affected side in tension pneumothorax but this can also
be had to hear. Generally patients are very tachypnic when alert with a
tension pneumothorax but patients in shock are all tachypnic so this can also
be an unreliable indicator. Both can be worsened by positive pressure
ventilation since both are functions of right heart physiology and the
treatment for both is a needle – one into the chest the other into the
pericardium. The use of e-FAST might be helpful
 TENSION PNEUMOTHORAX

Lung collapse, Hemi-diaphragmatic depression, Increased separation of ribs, Increased

thoracic volume Loss of lung markings, Possibly reduced heart sounds?)
 Needle Decompression

www.health-nurses-
7/25/2017
doctors.blogspot.com
MASSIVE HEMOTHORAX
Massive hemothorax is common in both penetrating and blunt chest injuries.
Patients who sustain acute hemothorax are at risk for hemodynamic
instability due to loss of intravascular volume and compromised central
venous return due to increased intrathoracic pressure. Lung compression due
to massive blood accumulation may also cause respiratory compromise.
Sources of hemothorax are: lung, intercostal vessels, internal mammary
artery, thoracicoacromial artery, lateral thoracic artery, mediastinal great
vessels, heart, abdominal structures (liver, spleen) when diaphragmatic
hernia.
The diagnosis is readily made from the clinical picture and X-ray evidence of
fluid in the pleural space. Primary thoracentesis is carried out to confirm the
diagnosis. Optimal therapy consists of the placement of a large (36 French)
chest tube. A moderate size hemothorax (500-1500 ml) that stops bleeding
after thoracostomy can generally be treated by closed drainage alone.
However, a hemothorax of greater than 1500 to 2000 ml as with continued
bleeding of more than 100 to 200 ml per hour is an indication for emergency
thoracotomy or thoracoscopy.
A small percentage of hemothoraces proceed to clot and cannot be
evacuated by thoracentesis. Massive clots may lead to respiratory difficulty
and infection, and should be evacuated surgically. Small clots will probably be
resorbed and do not require operative removal.
Hemothorax is common in both penetrating and non-penetrating injures to
the chest. If the hemorrhage is severe, it may not only cause hypovolemic
shock but also dangerously reduces vital capacity by compressing the lung on
the involved side. Persistent hemorrhage usually arises from an intercostal or
internal thoracic (internal mammary) artery and less frequently from the
major hylar vessels. Bleeding from the lung generally stops within a few
minutes, although initially it may be profuse. In some cases hemothorax may
come from a wound of the heart or from abdominal structures such as the
liver or spleen if the diaphragm has been lacerated. Hypovolemic shock and
hemomediastinum can derive from a thoracic great vessels injury that may be
result of penetrating or blunt trauma. The most common etiology is
penetrating trauma; however, the descending thoracic aorta, the innominate
artery, the pulmonary veins, and the vena cavae are susceptible to rupture for
blunt trauma.
Application of Pulmonary Hilar Cross Clamp
Pulmonary Tractotomy

Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy, Partial Lobectomy,

and Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades, MD, PhD;
Jeremy Goodman; James A. Murray, MD; Juan A. Asensio, MD

Arch Surg. 1999;134:186-189.

Pulmonary Tractotomy

Lung-Sparing Surgery After Penetrating Trauma Using Tractotomy, Partial Lobectomy, and
Pneumonorrhaphy
George C. Velmahos, MD, PhD; Craig Baker, MD; Demetrios Demetriades, MD, PhD; Jeremy
Goodman; James A. Murray, MD; Juan A. Asensio, MD

Arch Surg. 1999;134:186-189.

 OPEN PNEUMOTHORAX
• “Sucking” chest wound

• Respiratory distress

• Preferential path of air

when hole ≥ ⅔ diameter of
trachea

• Cover 3 sides

• EMERGENCY ICC
INSERTION
• An open pneumothorax occurs when there is a
pneumothorax associated with a chest wall defect, such that
the pneumothorax communicates with the exterior.
• During inspiration, when a negative intra-thoracic pressure is
generated, air is entrained into the chest cavity not through
the trachea but through the hole in the chest wall. This is
because the chest wall defect is much shorter than the
trachea, and hence provides less resistance to flow. Once the
size of the hole is more than 0.75 times the size of the
trachea, air preferentially enters through the thoracic cavity.
• This results in inadequate oxygenation and ventilation, and a
progressive build-up of air in the pleural space. The
pneumothorax may tension if a flap has been created that
allows air in, but not out.
• Diagnosis should be made clinically during the primary
survey. A wound in the chest wall is identified that appears to
be 'sucking air' into the chest and may be visibly bubbling -
this is diagnostic.
• Breathing is rapid, shallow and laboured. There is reduced expansion of
the hemithorax, accompanied by reduced breath sounds and an increased
percussion note. One or all of these signs may not be appreciated in the
noisy trauma room.
• 100% oxygen should be delivered via a facemask. Consideration should be
given to intubation where oxygenation or ventilation is inadequate.
Intubation should not delay placement of a chest tube and closure of the
wound.
• The definitive management of the open pneumothorax is to place an
occlusive dressing over the wound and immediately place an intercostal
chest drain.
• Rarely, if a chest drain is not available and the patient is far from a
definitive care facility, a bandage may be applied over the wound and
taped on 3 sides. This, in theory, acts as a flap-valve to allow air to escape
from the pneumothorax during expiration, but not to enter during
inspiration. This dressing may be difficult to apply to a large wound and
it's effect is very variable. As soon as possible a chest drain should be
placed and the wound closed.
Occlusive Dressing
TRACHAEL DISRUPTION
Most tracheal injuries are cervical and range from crush injuries to compete
tracheal separation.
Can be missed on CXR usually a massive emphysema in the neck and chest wall
and even sub-diaphragmatic regions
Only 50% of patients will have a pneumothorax with this injury, and
hemothorax is uncommon
Only 1/3 of patients are diagnosed in the first 24 hours, and only 1/2 within the
first month·
If endotracheal intubation is not possible, a surgical airway should be obtained
Primary repair of tracheal lacerations or separation should be performed, if
possible
Blunt trauma typically causes a circumferential laceration of either main
bronchus with complete separation
Early repair is the preferred treatment if the diagnosis is made, and requires
thoracotomy with intubation of the uninjured bronchus
Late strictures from incomplete tears or parenchymal isolation from complete
tears can be repaired with bronchoplastic procedures, but may require
pulmonary resection.
Laryngotracheal injuries constitute only a small fraction of
admissions in a major trauma centre. The frequency has been
reported to be as low as 0.3 percent. However, mortality is
reported as high as 24 percent. Complete disruption of trachea is
amongst the rarest injuries with only a few cases reported in
literature. Seuvre (cited by Papamicheal is credited with the first
description of traumatic tracheal disruption. Direct blows are more
likely to be associated with fractures of cartilaginous frame work
of the larynx(7). The signs and symptoms are often subtle even in
complete transections of trachea. The two ends may be held in
close approximation by peritracheal connective tissue and soft
tissues of the neck.
Clinical features include subcutaneous surgical emphysema, pneumothorax,
respiratory distress, hemoptysis and loss of palpable landmarks8. Most of
these features were present in our cases except pneumothorax which was
seen only in the first case. The signs and symptoms are non specific and
correlate poorly with the severity of the underlying injury(9). Therefore, a
high degree of suspicion and a more aggressive approach towards diagnosis
and management is required as delayed treatment may prove fatal as in our
second case.
Neck and chest radiographs though essential cannot be completely relied
upon. CT scan or MRI if available can give accurate diagnosis, otherwise direct
laryngoscopy and bronchoscopy can be utilized to confirm the diagnosis as
delay leads to a poor prognosis.
Management includes, tracheostomy and early surgical repair. The best
results are obtained with a complete repair of the larynx and trachea with
end to end anastomosis of disrupted trachea which avoids a permanent
tracheostomy and patient retains a good voice. The second best option is a
permanent tracheostomy which means a loss of voice.
 TRACHAEL DISRUPTION
• Blunt or penetrating trauma

– Intra/extra thoracic location (supraglotic, glotic, subglotic

• PRESENTATION
– Massive, sometimes uncontrollable air leak
– Stridor, acute respiratory distress, voice change
– Neck, upper chest subcutaneous emphysema – often massive
and disfiguring

• Acutely manage with bronchoscopy, deep intubation (beyond

injury) and sometimes tracheostomy
• Most tracheal injuries are cervical and range from crush injuries to compete tracheal
separation
· If endotracheal intubation is not possible, a surgical airway should be obtained
· Primary repair of tracheal lacerations or separation should be performed, if possible
· Blunt trauma typically causes a circumferential laceration of either main bronchus with
complete separation
· Only 50% of patients will have a pneumothorax with this injury, and hemothorax is
uncommon
· Only 1/3 of patients are diagnosed in the first 24 hours, and only 1/2 within the first month
· Early repair is the preferred treatment if the diagnosis is made, and requires thoracotomy
with intubation of the uninjured bronchus
· Late strictures from incomplete tears or parenchymal isolation from complete tears can be
repaired with bronchoplastic procedures, but may require pulmonary resection.
•
• Laryngotracheal injuries constitute only a small fraction of admissions in a major trauma
centre. The frequency has been reported to be as low as 0.3 percent. However, mortality is
reported as high as 24 percent. Complete disruption of trachea is amongst the rarest injuries
with only a few cases reported in literature. Seuvre (cited by Papamicheal is credited with
the first description of traumatic tracheal disruption. Direct blows are more likely to be
associated with fractures of cartilaginous frame work of the larynx(7). The signs and
symptoms are often subtle even in complete transections of trachea. The two ends may be
held in close approximation by peritracheal connective tissue and soft tissues of the neck.
• Clinical features include subcutaneous surgical emphysema,
pneumothorax, respiratory distress, hemoptysis and loss of
palpable landmarks8. Most of these features were present in our
cases except pneumothorax which was seen only in the first case.
The signs and symptoms are non specific and correlate poorly with
the severity of the underlying injury(9). Therefore, a high degree of
suspicion and a more aggressive approach towards diagnosis and
management is required as delayed treatment may prove fatal as in
our second case.
• Neck and chest radiographs though essential cannot be completely
relied upon. CT scan or MRI if available can give accurate diagnosis,
otherwise direct laryngoscopy and bronchoscopy can be utilized to
confirm the diagnosis as delay leads to a poor prognosis.
• Management includes, tracheostomy and early surgical repair. The
best results are obtained with a complete repair of the larynx and
trachea with end to end anastomosis of disrupted trachea which
avoids a permanent tracheostomy and patient retains a good voice.
The second best option is a permanent tracheostomy which means
a loss of voice.
Management Algorithm for Penetrating
Mediastinal Trauma

(72)
CARDIAC TRAUMA
• Cardiac tamponade is usually due to penetrating cardiac injuries and is a leading
cause of trauma death in urban areas.
• Patients with penetrating wounds of the heart can be classified in 3 general groups:
• 1. patients who have received extensive lacerations or large-caliber
gunshot wounds, that die almost immediately, as a result of rapid and
voluminous blood loss
• 2. patient with small wounds of the heart, caused by ice picks, knives or other
small agents who because of the development of cardiac tamponade, reach the
hospital alive. Cardiac tamponade, by bringing pressure to bear on the bleeding
heart wall, also plays an important role in controlling the hemorrhage;
• 3. patient with associated serious injuries in the chest and/or elsewhere in the
body which, in themselves, may contribute to death.
• The condition of the patient, when he is admitted to the hospital, must
not be used as an index of the severity of the injury. There are moribund
patients with no blood pressure and nonperceptible pulse, who survive
operation and recover; on the other hand there are patients in fair
condition, with a systolic blood pressure ranging from 70 mmHg to normal
and fair-to-good pulse, who die before surgery. The immediate cause of
death is either exanguination, cardiac tamponade or interference with
the conduction mechanism.
Diagnosis generally is easy if the physician maintains a high degree of
suspicion of heart injury in every chest wound he encounters. The safest
approach is to remove the patient's clothing and survey the entire body
surface quickly for evidence of multiple injuries. Auscultation of the thorax
is performed specifically to evaluate the clarity of heart tones and breath
sounds. Muffled heart tones are an indication of blood in the pericardium.
A systolic - to diastolic gradient of less then 30 mmHg, associated with
hypotension is consistent with cardiac tamponade. Neck veins are
distended. Central venous pressure is elevated. The X-ray film may
demonstrate a widening of the cardiac silhouette. The ultrasound scan
shows presence of blood in pericardial space. Electrocardiograph is not
particularly helpful. Prompt definitive therapy is imperative. This includes
antishock therapy, pericardiocentesis (possibly under U.S. guide),
emergency thoracotomy and suture of the wound.
• Treat with VOLUME immediately to raise the CVP greater than the
intrapericardial pressure and shock trousers then proceed with
percutaneous and ultimately surgical decompression of the
pericardium.
• Cardiac tamponade requires prompt recognition and treatment.
Signs and symptoms range from rarely stable to Beck’s triad of
hypotension, CVP above 12cc of water and muffled heart sounds –
all three findings are present in fewer than 40% of patients with
tamponade. An elevated CVP is the most significant diagnostic
finding. Only 60ml of haemopericardium is necessary for a
tamponade to occur in adults. A vicious cycle is set in motion i.e.
•  LVEDV   S.V.   CO  compensatory tachycardia   cardiac
work   O2 demand  hypoxia and lactic acidosis.
• An enlarged cardiac silhouette on CXR and / pericardial effusion as
demonstrated by echocardiography help to confirm the clinical
suspicion and diagnosis.
Distribution of Penetrating Cardiac Trauma
PERICARDIAL TAMPONADE
CT AXIAL VIEW
PERICARDIOCENTESIS
Using aseptic technique, Insert at least 3” needle at the
angle of the Xiphoid Cartilage at the 7th rib
Advance needle at 45 degree towards the lt shoulder
while aspirating syringe till blood return is seen
Continue to Aspirate till syringe is full then discard blood
and attempt again till signs of no more blood
Closely monitor patient due to small amout of blood
aspirated can cause a rapid change in blood pressure
ED Thoracotomy (EDT)
Indicated to resuscitate
trauma patients who have
sustained a witnessed
arrest or are on the verge
of a cardiac arrest.
LEFT ANTERIOR THORACOTOMY
 Rationale for EDT
• Resus agonal pt with PCT

• Evacuation of pericardial tamponade

• Control intra-thoracic hemorrhage

– X-clamp to DTA
– X-clamp the hilum of the lung

• Perform open CPR

• Repair cardiac injuries

Asensio JA, et.al. An evidence-based critical appraisal of emergency department thoracotomy, Evidence-Based Surgery
2003: 1(1) 11-21.
• It allows for both diagnosis and treatment, it
provides direct access to the heart, lungs and
great vessels enabling effective resus ie
evacuation of pleural and pericardial
collections. Open cardiac massage and cross
clamping of the hilar or descending aorta. It
also facilitates repair cardiac injuries
 FORMIDABLE UNDERTAKING
• Uncontrolled set up

• Iatrogenic injury from sharps

• Transmission of communicable diseases

– HIV, HEPATITIS

• DISTRACTING e.g requires significant resources

Survival data suggest it is
better in those patients
with penetrating injury
preferably with isolated
stab injury who show
signs of life @
presentation in the event
of deterioration they
should have very brief
period of CPR with
SR/PEA
Eastern Association For the Surgery of
Trauma Guidelines (EAST)

• Patient manifest signs of life in the field or the hospital

• Patient has PCT and is hemodynamically unstable despite

appropriate fluid resuscitation OR has required CPR for <
15 mins

• A thoracic or trauma surgeon is available within 45 mins

 SIGNS OF LIFE
• Spontaneous breathing • Pupillary light response

• Palpable carotid pulse • Spontaneous extremity

movement
• Measurable BP

• Electrical cardiac
activity
 Contra-indications for EDT

• NO PULSE OR BP IN THE FIELD

• ASYSTOLE AND NO PERICARDIAL TAMPONADE

• CPR > 15mins

• MASSIVE NON SURVIVABLE INJURIES

• NO THORACIC OR TRAUMA SURGEON WITHIN 45 mins

Application of Aortic Cross Clamp
Esophagus

Aorta

Spine

Diaphragm
Vertical Pericardial Incision
LIM
A
Internal Paddles for Direct Cardioversion
Laceration Adjacent to Coronary Artery
Laceration Adjacent to Coronary Artery
Coronary Artery Laceration
Ventricular Laceration
Ventricular Lacerations and Repairs
Ventricular Lacerations and Repairs
Atrial Lacerations and Repairs
 Immediate Life Threatening Thoracic Injuries:
Aortic Disruption
• Occurs commonly @
Ligamentum arteriosum

• ≅ ⅓ fatality on site due to

free rupture

• Exsanguination

• Rapid acceleration-
deceleration ( i.e. MVA,
falls from height > 3m)
• Up to 15% of all deaths following motor vehicle collisions
are due to injury to the thoracic aorta. Many of these
patients are dead at scene from complete aortic
transection. Patients who survive to the emergency
department usually have small tears or partial-thickness
tears of the aortic wall with pseudoaneurysm formation.
• Most blunt aortic injuries occur in the proximal thoracic
aorta, although any portion of the aorta is at risk. The
proximal descending aorta, where the relatively mobile
aortic arch can move against the fixed descending aorta
(ligamentum arteriousm), is at greatest risk from the
shearing forces of sudden deceleration. Thus the aorta is
a greatest risk in frontal or side impacts, and falls from
heights. Other postulated mechanisms for aortic injury
are compression between the sternum and the spine,
and sudden increases in intra-luminal aortic pressure at
the moment of impact.
Contained Injuries to the Aorta
• Widened mediastinum

• Obliteration of aortic knob

• Right deviation of trachea

• Depression of LMS bronchus

• Pleural/apical cap

• Left hemothorax (can be bilateral)

• Fractures of 1st and/or 2nd ribs

• On CXR look for these signs but they are VERY unreliable on a portable AP
CXR and diagnosis requires a high index of suspicion often based on nature
of injury.
• Mediastinal width of more than 8cm at the level of the aortic arch is
considered abnormal and an indication for further imaging.
• A widened mediastinum is reported as having a 53% sensitivity, 59%
specificity and 83% negative predictive value for traumatic aortic injury.
• To maintain spinal precautions in blunt trauma patients, most AP chest
radiographs are taken in the supine position.
• This will lead to fluid shifts that may cause a widened mediastinum. Some
authors recommend repeating the radiograph with the patient erect
• if the spine can be cleared prior to this. Around 40% of widened
mediastinums will 'normalize' with the patient in the erect position.
• Other less sensitive signs of mediastinal great vessel injury include
depression of the left main-stem bronchus, deviation of the naso-gastric
tube to the right,
• apical pleural haemoatoma (cap), disruption of the calcium ring in the
aortic knob (broken-halo).
• None of these 'classic' signs have any useful sensitivity to use them as
a screening for blunt aortic injury.
• Thus the 'funny-looking' mediastinum remains the best indicator of
the need for further imaging and should be examined with these
other findings to judge the risk of aortic injury:
• Widened mediastinum (least reliable)
• Obliteration of aortic knob
• Rightward deviation of trachea
• Rightward deviation of esophagus (look for NG tube)
• Depression of left main stem bronchus
• Pleural/apical cap
• Left hemothorax (can be bilateral)
• Fractures of 1st and/or 2nd rib(s)
• On CT scan the diagnosis is correct 97% of the time look for peri-
aortic hematoma, pleural effusions and aortography is correct in
about 97-98% of the time.
 Contained Injuries to the Aorta

On CT scan the diagnosis is correct 97% of the

time look for peri-aortic hematoma, pleural
effusions and aortography is correct in
about 97-98% of the time.
 Contained Injuries to the Aorta
• Not a source of multiple • TEE, helical contrast CT scan,
hypotensive episodes in MRI, aortogram
survivors - look for other
injuries

• Salvageable tear when • TEVAR

hematoma contained

• ~⅓ die per 24 hours without

treatment

• Widened mediastinum very • Address after life threatening

unreliable sign on portable x- injuries stabilized
ray
• Most blunt aortic injuries surviving to hospital are partial-
transections, and should be managed with blood pressure
control until the defintivie repair. Thus the priority in the
management of hemodynamically unstable patients with
potential aortic injury is to rapidly identify and control on-
going hemorrhage from other sites, and to avoid over-
resuscitation. Sites of concealed hemorrhage are identified
with Chest and Pelvis radiographs and FAST ultrasound or
Diagnostic Peritoneal Lavage.
• The caveat to these cases is the patient with and aortic tear
and impending rupture. These patients classically present as
'meta-stable' - ie they respond to fluid resuscitation and then
drop their blood pressure in a cyclical manner. It is important
to recognize this futile cycle early and avoid aggressive cyclical
resuscitation, as this will ultimately lead to free rupture of the
aorta and an iatrogenic hypothermia & coagulopathy. Beware
the 'meta-stable' patient with a widened mediastinum and a
left-sided hemothorax!
 POST TRAUMATIC PNEUMOTHORAX

• ≥ 15% OF THE THORAX

• Intercostal tube drain

• Eighty percent of chest trauma including PCT

managed by ICC
 Rib Fractures
• Isolated or multiple

• Segmental > 3 ribs

• 1st to 3rd rib involvement underlying

intrathoracic visceral involvement
– Uncommon
• Significant morbidity and even mortality
– Poor pain control
– Underlying lung disease
– Elderly

• Atelectasis  PneumoniaRespiratory failure

• Thromboembolism
 Flail chest
• 3 or more adjacent ribs
# @ 2 or more places

• Cautious fluid resus.

• Analgesia

• EVOLVING
PULMONARY
CONTUSIONS
• May not be initially obvious in young adult where
muscles splint the fractured ribs; in these situations
paradoxical movement will be apparent only if the
victim becomes exhausted, the flail is large (>6 ribs)
or is central (involving sternum).

• Intercostal blocks, epidural analgaesia and opioid /

ketamine infusions or patient-controlled analgaesia
should be considered later during the secondary
survey, depending on the expertise available. Some
patients require tracheal intubation and controlled
ventilation.
SURGICAL FIXATION vs CONSERVATIVE
MX
• PAIN CONTROL

•  VENTILATORY REQUIREMENTS

• SHORTER ICU & HOSPITAL STAY

• IMPROVED POST-OP RESP FUNCTION

 STERNAL FRACTURES
• Significant impacting force

• MVA with steering wheel impact or seat belt

injury

• UNDERLYING CARDIAC CONTUSION

– CXR, e-FAST, ECG and serial troponin
Blunt Cardiac Injuries
 Cardiac Contusions

• Acute injury pattern (ant STEMI I, aVL, V2-V4, ↓II,III, aVF), LBBB

• Watch for & treat PVC’s aggressively (K+, temp)

• Rx acute myocardial infarction, inotropes

• Cardiac Echo to assess wall motion, valves

 TUBE THORACOSTOMY
• Almost 90% of chest trauma

• Maintain or regain respiratory and

hemodynamic stability

• Within 48h of trauma

– Tension pneumothorax
– Traumatic symptomatic pneumothorax
– Worsening occult pneumohemothorax
Triangle Of Safety
 Contra- Indications
• Absolute…. Need for emergency Thoracotomy

• Relative
– Bleeding Diathesis
– Anti-coagulation
– Adhesions
– Loculations
– Pulmonary bullae

93
 Complications of Chest Tube
• Hemorrhage

• Infection

• Trauma to the Liver, Spleen, Diaphragm, Aorta, Heart.

• Minor complications
Subcut hematoma, Cough, Dyspnea.

• Improper placement
INSERTION OF A CLOSED THORACOSTOMY TUBE
 Summary
• Life ending thoracic injuries are common
• Survival depends on proper and immediate
diagnosis and appropriate management
• ED thoracotomy can save lives but expected
survivorship is <10%
• Don’t forget ABC’s of trauma and damage
control principles