Chest injuries ranks 3rd after head injuries and extremity injuries in a case of multisystem trauma.It is of two types blunt chest trauma and peneterating chest trauma.The main cause of blunt chest trauma is road side accidents due to vehicles. Peneterating chest trauma is more dangerous and is common in war injuries and civilian terroism.In this ppp I have discussed some useful uncommon and important aspects of chest injuries

1. Chest Injuries
Dr R S Dhaliwal
MS,MNAMS (Surgery ) MCh,DNB (CTVS),
FACS, FCCP,FAMS,FICA,FNCCP,FIACS
Former , Prof & HOD, CTV Surgery, PGIMER ,
Chandigarh

2. CHEST INJURIES
1. Blunt Injuries
2. Penetrating Injuries

3. Blunt Chest Injuries
• Rank Third after Head and Limb Injuries
• Commonest Cause – RSA -Vehicular
Accidents ( 70%) , Other causes are fall from
height , compression of body
• 4 - 10 % Mortality in isolated Blunt Chest
Injury
• Directly cause 25% mortality in Vehicle
Accidents

4. Chest Injuries
• The earliest recorded reference to thoracic
trauma - Edwin Smith Surgical Papyrus was
written around 3000 BC.
• Closed I/C chest tube drainage
developed around 1st world war made
marked impact on out come of pts
• Thoracotomy for clotted hemothorax and
empyema started in IInd world war with
very good results

5. Blunt Chest Injuries
• Blunt chest Injury fatal in about 10%
cases
• Incidence of mortality rises to 50% if there
are associated injuries
• Chest injury is the cause of death in 25% of all
deaths due to trauma
• . Respiratory problems following chest
injuries contribute to 75% of deaths

6. Incidence of Specific Thoracic
Organ Injury
Chest wall 31
Flail chest 13
Pneumothorax 18
Hemothorax 19
Pulmonary 16
Miscellaneous 17

7. Incidence of Injuries In Vehicle
Accidents
Extremities 34%
Head and neck 31%
Chest 21%
Abdomen 14%

8. How children are different
• The chest wall is more compliant due to more
elasticity of ribs, so fractures are less common
and internal organs injury is more common
• They have more cardiopulmonary reserve and it
may mask hypovolemia and respiratory dist ress,
drop in B.P. is very late sign indicating imminet
death
• Aerophagia is common response to injury
causing acute gastric dilatation and ileus, this
compromise respiratory functions further.

9. How old patients are different
• Old patients are fragile biologically and
physiologically so a minor trauma can cause #
ribs easily and flail chest is more common
• Medical disease are quite common in elderly like
CAD, COPD, BHP , hearing and vision problems.
All these effect the treatment and prognosis of
old patients
• Cerebral problems -confusion ,Ch hematomas
are common. Osteoprosis leads to fractures of
spine or ribs and limb bones easily.

10. Surgical Emphysema
• Air collection in subcutaneous tissues due to
inury of lung parenchyma or tracheo - bronchial
tree or oesophagus
• Mediastinal Emphysema in Tracheo-Bronchial
or Oesophageal injury
• “Present in about 27% of patients with blunt or
penetrating chest injury”
• Patient’s appearance quite distorted & puffy
• No Specific treatment, Treat the cause

11. Surgical Emphysema

12. Life threatening Chest injuries –The
Deadly Dozen
• Immediate life threatening
Airway obstruction Tension pneumothorax
Cardiac injury – Frank bleeding or Pericardial
tamponade , Massive Hemothorax,
Open pneumothorax, Flail Chest
• Potentially life threatening
Aortic rupture Tracheobronchial injury
Myocardial contusion Diaphragm tear
Oesophageal injury Pulmonary contusion
/laceration

14. Flail Chest - Treatment
• WITH RESPIRATORY FAILURE
Selective Endotracheal Intubation
and Mechanical Ventilation
• NO RESPIRATORY INSUFFIENCY
Analgesics , Oxygen inhalation ,
Fluid Restriction , Colloids,
Steroids ,Chest Physiotherapy

15. Flail Chest

16. Indications For Ventilation
• Respiratory Failure
• Clinically Severe Shock
• Associated head injury with need for
hyperventilation
• Associated Injury requiring Surgery
• Airway Obstruction
• Significant associated COPD

17. Diaphragmatic Injury
• More common after blunt chest injury
• More common to left diaphragm ,
abdominal organ injuries common
• Respiratory distress, bowel sounds in chest ,
mediastinal shift, visceral obstr.
• Xray chest, CT Scan, Contrast study
• Treatment - Laparotomy > Left Acute
Thoracotomy - Rt side Chronic

18. Traumatic Diaphragmatic Rupture

19. PENETRATING CHEST INJURIES {PCI}
• Due to Gun Shots, Stab
injuries with Sharp
Objects & Sharpnels
• Common in wars,
civialian teroism
• Central or Peripheral
• Superior or Inferior

20. Patterns of P C I
• Pneumothorax and
Hemothorax more common
along with Sucking Wounds
• Pericardial Tamponade-
common in P C I
Becks Triad (Pulsus paradoxus,
rasised JVP, quiet precordium)
only in 40% cases
• 2-D ECHO diagnostic for it
• Sub Xiphoid Pericardiostomy in
OT is both diagnostic and
therapeutic

21. Subxiphoid pericardial window

22. RESUSCITATION
• A B C PRINCIPLE
• A- ESTABLISHMENT OF A FUNCTIONAL AIRWAY
- Clear mouth and pharynx of blood & secretions
- Check for tongue falling back -Mouth gag
- Oral Or Nasal Intubation
- Cricothyroidotmy or Tracheostomy

23. Resuscitation
• B- RESTORE MECHANICS OF BREATHING
- Artificial Breathing ,
- Drainage of Pneumo or Hemothorax
- Stabilize Chest Wall - in flail
- Mechanical Ventilation

24. Resuscitation
C- CARDIOVASCULAR RESUSCITATION
- Volume Replacement - Central Line
- Ionotropic (Dopamine ,Adrenaline drip)
Support for low B.P.
- Correction of Acid Base Status &
Electrolytes
- External or Internal Cardiac Massage
- Control of major life threatening hemmorhage
Emergency Thoracotomy

25. Resusciation
THOROUGH EXAMINATION
OF PATIENT
Look for -
- Head injury , orthopedic(limb) injuries or
abdominal trauma
• Past history of significant Medical Disease
IHD, DM, Hypertension, Renal problem
Drug allergy, alcohol or narcotic use

26. Primary survey and resuscitation
ABCD of Trauma Care
This is the core of ATLS system by ACS
• A- Airway maintaince and Cervical spine
protection
• B - Breathing and ventilation
• C - Circulation with hemorrhage control
• D - Disability ; neurological status
• E - Exposure – Thorough examination of pt
after complete undressing

27. ABCD of Trauma care
• Airway assessment -
. Check verbal response
. Clear mouth and airway with sucksion
. If GCS < 8 consider deffinite airway
. Breathing and ventilation -
. Give 100% oxygen at high flow
. Check for tension pneumothorax , if
suspected immediate decompression

28. ABCD of trauma care
• Circulation and control of bleeding .
Circulation assessment and warning signs -
Deteriorating concious level, Increasing pallor,
Rapid thready pulse . Control the ongoing bleeding
quickly instead of giving fluid and blood aggressively
• Disability and neurological status
The Glassgow Coma Score (GCS) gives a rapid assessment
of patient’s conciousness level and is a good prognostic
indicator Hypoglycema, alcohol and drug abuse also alter
the level of conciousness and must be excluded in trauma
pts.
• Exposure - Patient should be fully exposed and
examined front and back, keeping in mind cervical spine
injury . Hypothermia is common after trauma and should
be treated in time properly

29. Adjuncts to primary survey
• Full blood count ,urea and electrolytes,
coagulation studies , blood group and cross
match, toxicology
• 12 lead ECG
• Two wide bore IV canulae or Central line
• Urinary catheter and Ryle,s tube placement
• Xrays of Chest and cervical spine –once pt is
stable hemodynamically

30. Secondary Survey
• This is done once primary survey and initial
resuscitative measures have been completed
• Review of patient,s history – AMPLE
. Allergy . Past medical history .
Medication taken- Tetanus status . Last meal
taken . Event of incidence
• Re-evaluation- urine out put 0.5-1ml/kg/hr
Pulse oximetry . Analgesia
• Documentation and legal consideratins
• Transfer and definitive care - Once intial resusci tation
is done and pt is stable, transfer may be required for
specilised care like Cardiothoracic or Neuro surgical
interventation

31. INTERCOSTAL CHEST TUBE DRAINAGE
• INDICATIONS - Pneumothorax, Hemothorax
Empyema Pleural Effusion
• SITE - Decided from Chest X-ray or Ultra sound
4th -5TH I/C space in midaxillary line .
Use artery Forceps and Finger
- Avoid Trocar & Canula
- Chest Tube Size 26- 32 F
--Basal - for blood & fluid - Apical for air

32. Intercostal Chest Tube- IC D

33. Emergency Thoracotomy
• Required in 5% patients of Blunt Chest trauma ,
more common in P C I
• Acute Pericardial Tamponade -Cardiac Injury PCI
• Massive Hemothorax - >1500 CC after I/C D or > 300
ml/hr for 3 hrs
• Cardiac arrest – In presence of Fracture Sternum or
Flail Chest
• IInternal cardiac massage- failed External Massage
• Massive intra- abdominal bleeding – cross clamp of
intathoracic aorta

34. Urgent Thoracotmy
• Intrathoracic great vessel injury
• Thoracic inlet vascular injury
• Esophageal Injury
• Traumatic diaphragmatic hernia (Acute)
• Bullet embolism and systemic air embolism
• Mediastinal traversing Injury
• Massive air leakage
Tracheobronchial Injury
Lung parenchymal Injury

35. Delayed Thoracotomy
• Clotted hemothorax
• Chronic empyema
• Chronic traumatic diaphragmatic hernia
• Cardiac septal or valvular lesions
• Missed Tracheobronchial injury
• Traumatic A.V. fistula
• Delayed Aneurysms
• Non closing thoracic duct fistula
• Infected intrapulmonary hematoma

36. CONTRAINDICATIONS TO THORACOTOMY
• Small volume hemothorax
• Pneumomediastinum
• Tension or simple pneumothorax
• Bullet or pellet in chest wall or lung
parenchyma or a major vesssel

37. SURGICAL INCISIONS
• Anterolateral Thoracotomy
• Midsternotomy
• B/L Transternal Thoracotomy
• Posterolateral Thoracotomy
• Subxiphoid Pericardiostomy
• Neckincision + Midsternotomy
• Division or partial removal of Clavicle

38. Surgical Incisions
• Incisions

39. Anterio lateral thoracotomy -Lt

40. Midsternotomy

41. Useful Measures
• Autotransfusion
• CP Bypass & IABP, LVAD, RVAD
• ECMO– Extra Corporeal Memberane Oxygenation
• Thoracoscopy
• Digital Exploration ?

42. COMPLICATIONS OF CHEST TRAUMA
• Lung Atelectasis ( lobe)
• INFECTION
– Bronchopneumonia
– Empyema
– Clotted Hemothorax
– Br Pl Fistula
– Bronchial Stenosis
– Chylothorax

43. CONCLUSIONS
• Blunt Chest injuries more common than
peneterating injuries, road traffic accidents
commonest cause , young mobile males
• 80- 85% Chest injuries can be managed
conservatively in small hospitals
• Only 10-15% Chest injury Pts require
Thoracotomy , more in PCI
• Flail Chest - selective use of Ventilation

44. RECOMMENDATIONS
• Desperate need for more trauma centers
• Educating public about traffic rules and
importance of safe driving
• Training children in schools about this

45. RECOMMENDATIONS
• Strict implementation of rules against
driving after consuming alcohol &/or
narcotics
• Quick transportation - efficient ambulance
services, More blood banks
• Widespread C P R training to people

46. How this is allowed ?

48. THANK YOU