1. Dr Mukhilesh R MS PG

2. CHEST
TRAUMA

3. Salient Features of Chest Trauma
• Most commonly missed injury
• Most common cause of death in thoracic injury is hemorraghe
• Clinical examination + chest radiography – to detect chest injury
• USG supplements the diagnosis
• Resuscitation to be done , without waiting for radiological
investigations.
• Chest drain – therapeutic as well as diagnostic

4. Chest Anatomy
• 12 pair of ribs with intercostal muscles.
• The lungs occupy the majority of the
thoracic volume.
• Mediastinum - heart and great vessels.
• Diaphragm
Mechanisms of Injury
– Blunt Injury
• Deceleration
• Compression
– Penetrating Injury
– Both

5. Red flag signs of chest injury
 Hemoptysis.
 Chest wall contusion.
 Flail chest.
 Open wounds.
 Jugular vein distention
(JVD).
 Subcutaneous empysema.
 Tracheal deviation.
Respiratory rate and effort: Lung sounds:
Tachypnea Absent or
Bradypnea decreased
Labored Unilateral
Retractions Bilateral
Progressive respiratory Bowel sounds in
distress
chest.

6. Assess the Chest Wall
 Contusions.
 Tenderness.
 Asymmetry.
 Open wounds or
impaled objects.
 Crepitation.
 Paradoxical movement.
 Compare both sides of the chest at the
same time when assessing for asymmetry.
Lung sounds – Percussion.
Hyperresonance
Pneumothorax
Tension pneumothorax
Hyporesonance (hemothorax)

7. “DEADLY DOZEN” Threats to life from chest injury

9. Opening pneumothorax - Sucking Chest Wound
• Defect in chest > 3cm
• Not to be fully closed
• Closed on three sides – acts as one way
valve
• Controlled chest drain must
• Formal debridment and closure.

10. Tension pneumothorax – oneway valve
CLINICAL DIAGNOSIS – NO NEED FOR RADIOLOGICAL DEMONSTRATIONS
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..
Clinical features
tacypnoea/dyspnoea
distended neck veins
hyperresonance
absent breath sounds

11. Contd..
Immediate decompression – needle 2nd IC space midclavicular line
Definitive Rx
Chest tube drain – 5th intercostal space

12. Pericardial tamponade
Penetrating injury near heart + Shock – R/O Tamponade
Pericardial sac – non distensible
BECK’S TRIAD
increased CVP
fall in BP
muffled heart sounds
CXR – widened heart shadow
ECHO
Central venous line – increased CVP
Sternotomoy / thoracotomy – repair of heart

13. Hemothorax
Most common in blunt injury
Intercostal vessel & internal mammary art
Clinical features
Shock with flat neck veins
Absent breath sounds
dull on percussion
Mediastinal shift – respiratory distress
ICD

14. Flail Chest
Segment of chest wall doesnot have bony
continuity with the rest of thoracic cage
3 0r more ribs # in 2 or more places
Clinical diagnosis
paradoxical chest wall movement
Rx
analgesia
O2
intrapleural local anesthetics
ventilator support
internal fixation

15. Thoracic aorta disruption – DIRE EMERGENCY
Sudden death in chest injury
Relatively fixed distal to ligamentum
arterisoum
Sudden impact – disrupt intima and media
Tunica adventia intact – pt may be stable
Interscapular pain
RF delay / assymetrical BP
CXR – widened mediastinum
CECT mediastinum / Transesophageal
ECHO
Rx
endovascular intra-aorticc stent
tear can be repaired surgically
dacron graftin

16. Tracheobronchial injury
• Severe subcutaneous empysema with respiratory compromise
• Hemoptysis
• Immediate chest drain
• Early intubation.
• Bronchoscopy is diagnostic
• Operative repair – definitvie RX

17. Oseophageal injuries
• Mostly from penetrating trauma
• HIGH INDEX OF SUSPICION
• C/F
• Odynophagia
• Mediastinal emphysema / mediastinitis
• Unexplained fever within 24 hours
• OGD – confirms diagnosis
• Operative repair and drainage
Mediastinal emphysema – evidence of aerodigestive tract injury until proved
otherwise

18. Blunt myocardial injury
• Most common
finding – ECG
abnormality
• ACUTE MI
• Hypotension
• 2 D ECHO
• Tranesophageal
ECHO
• Increased risk of
arrhythmia – first 24
hours
hence ICU observation necessary

19. Diaphragmatic Injuries
• Penetrating injuries to or below 5th IC space – R/O diaphramatic and
abdomen injury
• Dyspnoea / absent breath sounds
• Hollow abdomen/absent bowel sounds in abdomen
• No single standard investigation
• CXR with NG tube
• Contrast studies / CECT
• VATS / D- LAP – most accurate assesment
• Operative repair – Abdominal approach

20. Pulmonary contusion
• Most common cause for hypoxia
• Hemorrhage into lung parenchyma
• Hemoptysis + blood in ET tube = R/O Lung contusion
• Worsening hypoxemia
• CXR – delayed finidings
• CECT – Confirms
• Rx
• Nasal O2
• Analgesia
• Antibiotics
• Pulmonary toileting
• Ventilator support - PEEP.

21. Rib fractures
Most common finding in chest injury
1st and 2nd rib –
Violent injuries
Rule out vascular injuries
5th to 9th ribs most commonly affected
10th to 12th rib fracture – R/O abdomen injuries
Rx
adequate analgesia
O2
conservative management.
ROLE OF ICD IN RIB FRACTURE????

22. Operative treatment for chest injuries
• Initial tube thoracostomy - >1000ml (penetrating injury) or >1500ml
(blunt injury)
• >200ml/hr for 3 consecutive hours
• Caked hemothorax
• Great vessel injury (endovascular option)
• Pericardial tamponade
• Cardiac herniation
• Massive air leak from the chest tube
• Open pneumothorax
• Esophageal perforation
• Tracheal or main stem bronchial injury diagnosed by endoscopy or
imaging

23. Emergency room thoracotomy – life threatening bleeding
Indications
Internal cardiac massage
Control of hemorrhage – heart / lung or other sites
Control of massive air leak
Hemodynamically unstable patient as a last resort – usually unsuccessful
Left anterolateral thoracotomy
Usually futile :
CPR >10 minutes
blunt trauma with no signs
of life at scene

24. Clamshell thoracotomy
• Bilateral anterolateral thoracotomy + transverse sternotomy = "clamshell"
incision
• The largest incision commonly used in thoracic surgery.