Thoracic trauma
Prepared by
Miss Fatima Hirzallah
INTRODUCTION
Thoracic injuries are directly
responsible for 25% of all trauma
deaths and are a major contributory
factor to mortality in a further 25%.
INTRODUCTION
The majority (approximately 90%) of
all patients who sustain thoracic
trauma can be managed
conservatively, with no more than a
chest drain, monitoring and
analgesia.
PATHOPHYSIOLOGY
OF CHEST TRAUMA
The main consequences of chest
trauma occur as a result of its
combined effects on respiratory
and haemodynamic function.
PATHOPHYSIOLOGY
OF CHEST TRAUMA
The commonest manifestation of thoracic
trauma is hypoxia, the causes of which
include:
haemorrhage
lung collapse and compression
ventilatory or cardiac failure
pulmonary contusion
changes in intrathoracic pressure; and
mediastinal displacement.
The aim of early intervention is to
restore adequate delivery of oxygen
to the tissues. This includes :
the maintenance of an open airway,
administration of a high
concentration of inspired oxygen
re-expansion of the lung by insertion
of a chest drain.
ASSESSMENT
The sequence of questions in the
hand-over to hospital care can be
remembered as 'MIST':
Mechanism of injury
Injuries found and suspected
Signs (respiratory rate, SpO2, pulse,
blood pressure)
Treatment given pre-hospital
CHEST INJURIES
Immediately life-threatening injuries
There are six specific thoracic injuries which will be
fatal if they are not recognized and treated
immediately:
airway obstruction
tension pneumothorax
open pneumothorax
massive haemothorax
flail chest
cardiac tamponade.
TENSION
PNEUMOTHORAX
A tension pneumothorax develops
when air enters the pleural space
secondary to a laceration of the lung,
bronchus or chest wall.
in a tension pneumothorax the
airflow is unidirectional, causes a
progressive accumulation of air in
the pleura with collapse of the lung,
producing hypoxia and eventually
shift of the mediastinum to the
opposite side.
Tension pneumothorax is a clinical
diagnosis, and is recognized by:
respiratory distress
over-inflated hemithorax
hyper-resonant percussion note
reduced or absent breath sounds
tracheal deviation
distended neck veins.
Treatment
The treatment of tension
pneumothorax is immediate needle
decompression, which should not be
delayed to perform a chest
radiograph
intravenous access is obtained and a
formal intercostal drain should be
placed through the fifth intercostal
space anterior to the midaxillary line
OPEN PNEUMOTHORAX
When a penetrating chest wall injury
creates a direct communication
between the thoracic cavity and the
external environment, an open
pneumothorax results. (sucking chest
wound)
The clinical signs are those :
pneumothorax
reduced breath sounds
a resonant percussion note
decreased expansion, together with a
penetrating chest wall injury.
Treatment
The defect should be covered with a
sterile waterproof dressing secured on
three sides to act as a flutter valve.
An intercostal drain should be placed
away from the open wound.
Surgical debridement and closure of
the wound will be necessary later.
MASSIVE HAEMOTHORAX
Massive haemothorax is usually
caused by penetrating injury, but it
can also result from blunt trauma.
A life-threatening haemothorax may
result from major lung parenchymal
laceration, injury to the pulmonary
hilum, or from direct cardiac
laceration.
A massive haemothorax is usually
defined as the presence of more than
1500 ml of blood in the hemithorax,
or 200 ml per hour (3 ml/kg/h) from
the chest drain.
The signs of massive haemothorax
are those of hypovolaemic shock
together with:
dullness to percussion
absent or reduced breath sounds
decreased chest movement
Treatment
Infusion of fluids through large-
calibre intravenous lines must be
started before any attempt is made
to drain a massive haemothorax
Blood should be given as soon as it is
can be typed.
A large-bore intercostal drain
(28French gauge or larger) is
required for adults
FLAIL CHEST
Severe direct chest wall injury may cause
extensive disruption, with multiple rib and
sternal fractures.
When two or more adjacent ribs are
broken in two or more places), it becomes:
flail, will move paradoxically on respiration
reducing tidal volume
compromising ventilation
pulmonary contusion.
The diagnosis is usually clinical, by
observation of abnormal chest wall
movement and the palpation of
crepitus.
Treatment
If respiratory compromise is present,
this may be initially managed by
stabilization of the chest wall.
Pain managment
CARDIAC TAM POMADE
Although penetrating injuries are
usually responsible for cardiac
tamponade, blunt trauma may
damage the heart or great vessels,
causing bleeding into the
pericardium.
The characteristic features are those
of Beck's triad :
Elevated central venous pressure
Hypotension
Muffled heart sounds.
Treatment
The ideal management of cardiac
tamponade is surgical
decompression and exploration.
Pericardiocentesis
Potentially life-threatening
injuries
potentially life-threatening thoracic injuries:
Cardiac contusion
Aortic disruption
Diaphragmatic rupture
Major airway injury
Oesophageal injury
Pulmonary contusion
Simple pneumothorax
Haemothorax.
PULMONARY CONTUSION
All patients with significant chest wall trauma
are likely to have underlying pulmonary
contusion.
Contusion usually develops clinically and
radiographically over the first 1-3 days, but in
severe trauma there may be ventilatery failure
Spiral CT is more sensitive than chest Xradiography for detecting early pulmonary
contusions
Treatment
Treatment involves high-flow oxygen
therapy
serial blood gas analysis
appropriate analgesia
fluid replacement and physiotherapy
In some patients a period of
mechanical ventilation is required.
DIAPHRAGMATIC
RUPTURE
Penetrating injuries cause small
diaphragmatic perforations that are
rarely of immediate significance. By
contrast, blunt trauma produces
large radial tears of the diaphragm
and easy herniation of abdominal
viscera.
The right hemidiaphragm is relatively
protected by the liver, and left-sided
ruptures are therefore more
common,
The chest radiograph can be
misinterpreted as showing a raised
hemidiaphragm, acute gastric
dilatation or a loculated
pneumothorax.
Contrast radiography, or locating an
abnormal position of the stomach.
Treatment
Unless intracranial injuries or potentially
fatal haemorrhage require immediate
surgery ,repair of the diaphragm should
not be delayed.
This is often performed through a
laparotomy for associated abdominal
injuries, but may equally be performed
through a thoracotomy or thoracoscopy.
TRAUMATIC AORTIC
DISRUPTION
Tears of the aorta are immediately fatal
in approximately 90% of cases. They
occur as a result of blunt or
deceleration injuries, typically in a road
traffic accident or fall from a height.
The aorta may be completely or
partially transected, or may have a
spiral tear.
Radiographic signs of aortic
disruption
Widened mediastinum
Fractured first or second rib
Elevation of the right main bronchus
Depressed left main bronchus
Tracheal deviation to the right
Left haemothorax*
Treatment
The survival of patients after reaching
hospital depends on early diagnosis,
followed by urgent surgical repair.
If transfer is necessary the patient should
be mechanically ventilated and the systolic
blood pressure kept below 100 mmHg,
using infusions of propanolol or sodium
nitroprusside, or both.
policy of 'hypotensive' fluid
resuscitation is essential in this
condition.
The cardiothoracic surgeons should
be contacted immediately for both
advice and management of the
patient.
THANKS
