CHEST TRAUMA COURSE

1. CHEST TRAUMA
Dr BAYISENGA Justin, MD, MMed
SURGERY

2. Introduction
• About ¼ of deaths due to trauma are attributed
to thoracic injury.
• Immediate deaths (1st peak) are essentially due to
major disruption of the heart or of great vessels.
• Early deaths (2nd peak) due to thoracic trauma
include airway obstruction, cardiac tamponade or
aspiration.

3. Introduction cont’d
• Most patients with thoracic trauma can be
managed by simple maneuvers.
• Others require surgical treatment.
• REMEMBER: Chest trauma may be BLUNT or
PENETRATING and each of this type relates to
its management

4. Etiologies of chest trauma
 Penetrating trauma.
– GSW( Gun Shoot Wound) or stab wounds
– Concentrates forces over smaller area
– Bullet trajectories unpredictable
 Blunt trauma.
– Force distributed over larger area
– Visceral injuries occur from:
• Deceleration
• Compression
• Sheering forces
• Bursting

8. SIGNS INDICATIVE OF CHEST INJURY
 Hypotension and tachycardia.
 Cyanosis.
 Hemoptysis.
 Chest wall contusion.
 Paradoxal respiration.
 Open wounds.
 Jugular vein distention (JVD).
 Tracheal deviation
 Hypersonority/ Dullness

9. The chest trauma may result in:
• Pneumothorax (simple, tension, open)
• Haemothorax
• Pulmonary contusion
• Rib fractures
• Flail chest
• Pericardial tamponade
• Myocardial contusion
• Diaphragmatic injury

10. PNEUMOTHORAX
SIMPLE PNEUMOTHORAX:
• It is accumulation of air in pleural space
• It is not a life threatening unless it becomes
huge (tension pneumothorax)
• Chest X-Ray to confirm and size
• Chest drain is the treatment

11. Tension pneumothorax
• Air enters continuously the pleural space but
cannot leave
• Intrathoracic pressure increases progressively
• Mediastinal shift
• ↓ venous return + ↓ cardiac output
• Respiratory distress
• Hypoxia

12. Tension pneumothorax con’t
• Life threatening emergency
• Clinical diagnosis
• Urgent Chest Needle Decompression
• If you delay, you loose the patient

13. SIGNS of TENSION PNEUMOTHORAX
• Respiratory distress
• Tachycardia
• Hypotension
• Distended neck veins
• Resonant percussion note
• Tracheal deviation (Late sign)
• ↓ air entry/ none air entry

14. MANAGEMENT
Immediate decompression with :
• Large bore needle (G14/G16)
• Second intercostal space
• Mid clavicular line
• Formal chest drain to follow
• NB: The Chest needle decompression is not
definitive management, it makes tension
pneumothorax into simple one treated by
chest tube insertion

15. OPEN PNEUMOTHORAX
It is Sucking” wound of the chest
• Other signs of pneumothorax present
• Occlude wound (3 sides only)
• Air escapes on expiration
• Urgent insertion of chest drain

17. Pulmonary contusion
• The pulmonary paranchyma is contused
It may be associated with
• Rupture of trachea or major bronchi which is a serious
injury with an overall estimated mortality of at least
50%. Most (80%) of the ruptures of bronchi are within
2.5 cm of the carina. The usual signs of tracheo-
bronchial disruption are the followings:
Haemoptysis
Dyspnoea
Subcutaneous and mediastinal emphysema

18. Haemothorax
• Blood is accumulated in the pleural cavity
• More common in penetrating than in blunt
injuries to the chest.
• If the haemorrhage is severe:
Hypovolaemic shock
 Respiratory distress due to the compression
of the lung on the involved side.

19. Haemothorax cont’d
• The extent of internal injuries cannot be
judged by the appearance of a skin wound.
• It is managed by chest tube insertion
• NB: Thoracotomy is indicated in haemothorax
if: 2000ml -3000ml of blood is immediately
drained from the chest or if 200ml – 300ml/hr.

20. Flail chest
• There are more than 1# on one rib
• When the patient inspires, the chest expands
while the frail section sink in and the
mediastinum moves towards the normal side
• When he/she expires the frail section moves
out and the mediastinum moves to the other
side.

21. Management of flail chest

22. Management of flail chest cont’d
• As it may lead to severe respiratory distress:
• Adequate analgesia is vital
• Give oxygen
• Consider intubation
• As it may be associated with other chest
injuries; the chest tube insertion may be
necessary

23. Pericardial tamponade
• Penetrating cardiac injuries are a leading cause of
death. (It is rare to have pericardial tamponade with
blunt trauma).
CLINICAL PRESENTATION:
• Shock
• Distended neck veins
• Cool extremities and no pneumothorax
• Muffled heart sounds.
TREATMENT :Pericardiocentesis to be performed early.

24. MYOCARDIAL CONTUSION
101

25. Myocardial contusion cont’d
• Blunt chest trauma is the most cause
• It is associated with fractures of the sternum
or ribs.
• The diagnosis is supported by abnormalities
on ECG (T wave inversion) and elevation of
serial cardiac enzymes if these are available.
• It can stimulate a myocardial infarction

26. Myocardial contusion management
• Patient must be submitted to observation with
cardiac monitoring
• This type of injury is more common than we
think
• It may be a cause of sudden death well after
the accident.

27. Diaphragmatic injuries
• Should be suspected in any penetrating
thoracic wound:
• Below 4th intercostal space anteriorly
• 6th interspace laterally
• 8th interspace posteriorly
• The diagnosis is often missed.

29. CHEST TUBE INSERTION

30. Indications for chest tube insertion
• Pneumothorax in any ventilated patient
• Tension pneumothorax (NB. After initial needle relief)
• Persistent or recurrent pneumothorax after simple
aspiration
• Large secondary spontaneous pneumothorax in patients
over 50 years
• Malignant pleural effusion
• Empyema and complicated parapneumonic pleural effusion
• Traumatic haemo/ pneumothorax
• Perioperative :Thoracotomy, oesophagectomy, cardiac
surgery

31. Equipment for chest drain insertion
• Sterile gloves and gown
• Skin antiseptic solution, e.g. iodine or chlorhexidine in
alcohol
• Sterile drapes
• Gauze swabs
• A selection of syringes and needles (21–25 gauge)
• Local anesthetic, e.g: Lidocaine 1% or 2%
• Scalpel
• Suture (e.g. Nylon 1)
• Instrument for blunt dissection (e.g. curved clamp)

32. The position of the patient
• The preferred position of the patient for drain
insertion is on the bed, slightly rotated, with
the arm on the side of the lesion behind the
patient’s head to expose the axillary area.
• An alternative is for the patient to sit upright
leaning over an adjacent table with a pillow
• In the lateral decubitus position.

33. SAFETY TRIANGLE
• Insertion should be in the “safe triangle”
(usually 5th intercostal space in mid-axillary
line) illustrated.
• This position minimizes risk to underlying
structures such as the internal mammary
artery and avoids damage to muscle and
breast tissue.

34. SAFE TRIANGLE

35. REMEMBER
• If you drain air (Pneumothorax), put the tip of
chest tube apically
• If fluids (Haemo/ pyothorax or any pleural
effusion) to be drained put the tip basally

36. Other considerations
• Aseptic technique should be employed
• Local anaesthetic should ALWAYS be infiltrated
prior to drain insertion
• Substantial force should NEVER be used
• Trocars should NEVER be used. Blunt dissection
into the pleural space should be performed prior
to drain insertion
• Prophylactic antibiotics should be given in trauma
cases

37. Chest Drain removal
• The chest tube should be removed while the
patient performs a Valsalva manoeuvre.
• This creates a high intrathoracic pressure and
gives the operator time to remove the drain and
tie the suture.
• The timing of removal is dependent on the
original reason for insertion and clinical progress:
• In the case of pneumothorax, the drain should
not usually be removed until bubbling has ceased
and chest radiography demonstrates full lung
inflation.

38. THANK YOU VERY MUCH!!!!