Thoracic Trauma

Muhammad Arza Putra

Consultant Cardiothoracic Surgeon
RSUI/FMUI
Overview
• Introduction of Thoracic trauma
• Thoracic Trauma Assessment
• Prioritizing management in thoracic trauma
• Water sealed drainage
Trauma: Scale of the Global Problem
Thoracic Trauma
• One of the most common cause of
death in trauma (25%)
• Only less than 10% in blunt trauma & 15
– 30% penetrating trauma need
operative management
• Majority of the cases can be stabilized in
ER!
Mechanism of Injury
Blunt chest injury
• Pulmonary contusion
• Rib/sternal fractures/flail chest
• Traumatic Aortic Dissection
Penetrating chest injury
• Stab wound
• Impalement
• Gun shot wound
Thoracic Organ Involvement
• Blunt chest injury
• Pulmonary contusion (more common)
• Mucus production ↑
• Mucus and blood clearance ↓
• Altered surfactant stabilization & lung compliance
• V/Q mismatch
• Rib fractures/flail chest (more severe)
• Altered cohesive function of chest wall to provide negative
pressure allowing full lung expansion
• Penetrating chest injury
• Lung Laceration
• Great Vessels Rupture
• Heart wall injury
 Thoracic Trauma: Cause of Death
Contusion,
haematoma, alveolar
Metabolic
collapse, Hypoxia
acidosis
intrathoracic
pressure increased
Thoracic
Trauma
Breathing problems Hypercarbia
Respiratory Death
acidosis

Heart injury, major Hemorrhagic

thoracic vessel injury shock
Thoracic Trauma

Primary
Survey

Airway Breathing Circulation

Primary Survey – Airway Problems
• Airway Obstruction
• Swelling, foreign bodies, bleeding, direct neck trauma, aspiration, etc
• Look!
• Air hunger  intercostal and supraclavicular retraction
• Oropharyngeal inspection
• Listen!
• Air movement
• Stridor  partial obstruction
• Changes in voices (hoarseness)
Airway Interventions
• Maintenance of Airway Patency
• Suction of Secretions
• Chin Lift/Jaw thrust
• Nasopharyngeal Airway
• Definitive Airway
• Airway Support Dept. of the Army, Wikimedia Commons
Ignis, Wikimedia Commons
• Oxygen
• NRBM (100%)
• Bag Valve Mask
• Definitive Airway
• Definitive Airway U.S. Navy photo by Photographer's

• Endotracheal Intubation Mate 2nd Class Timothy Smith,

Wikimedia Commons
• In-line cervical stabilization
• Surgical Crichothyroidotomy
Primary Survey – Airway Problems
Primary Survey – Airway Problems
• Tracheobronchial Tree Injury
• Sudden death & high mortality (if one can reach
the hospital…)
• Leads to
• Tension Pneumothorax
• Pneumopericardium
• Sign
• Cervical Subcutaneous Emphysema, hemoptysis,
pneumothorax, cyanosis large air leak during chest
tube insertion (continuous bubble)
• CXR: fallen lung  beware of bronchial rupture
• Management
• Intubation  potentially worsen injury
• Operative treatment
• Fiber-optic bronchoscopy ETT placement
Tracheobronchial Tree Injury
• Bilateral Tension Pneumothorax
• Pneumomediastinum
Bronchial Injury
• Fallen Lung  Bronchial Rupture
• Persistent/Continuous Bubble
• Negative pressure can worsen symptom
• Thoracotomy needed
Primary Survey - Breathing Problems

Tension
Open Pneumothorax
Pneumothorax

Massive
Haemothorax
(breathing &
circulation problem)
Breathing Problems – Tension Pneumothorax
Compressing the
One way valve  Collapsing the Shifting the mediastinum,
air trap! lung mediastinum vena cava and
opposite lung

Decreased
venous return
Death Shock
and cardiac
output
Breathing Problems – Tension Pneumothorax
Breathing Problems – Tension Pneumothorax
• Breathing Assessment!
• Tachypnea
• Chest pain
• Hypotension
IMMEDIATE
• Air hunger
• Tracheal deviation DECOMPRESSION!
• HYPERRESONANT
• DECREASED BREATH SOUND
• JUGULAR VEIN DISTENTION
• Cyanosis
Needle Decompression – Tension Pneumothorax
ATLS the 9th ATLS the 10th
• Midclavicular line • Adult
• 2nd intercostae muscle • Anterior part of midaxillary
line
• 4th / 5th intercostae muscle
• Pediatric
• Midclavicular line
• 2nd intercostae
Needle Decompression – Tension Pneumothorax

MIDCLAVICULAR
LINE

MIDAXILLARY
LINE
Needle Decompression – Tension Pneumothorax
• 5 – 8 cm needle
• Using syringe (with 3 – 5 cc of
normal saline to help
identifying bubbles)

• Definitive treatment  chest

tube!
 22

Tube Thoracostomy
• Insertion site
• 5th intercostal space,
• Anterior axillary line
• Sterile prep, anesthesia with
lidocaine
• 2-3 cm incision along rib margin
with #10 blade
• Dissect through subcutaneous
tissues to rib margin
Author unknown,
• Puncture the pleura over the rib
http://www.trauma.org/images/image_li
brary/chest0051a.jpg • Advance chest tube with clamp
and direct posteriorly and apically
• Observe for fogging of chest tube,
blood output
• Suture the tube in place
• Complications of Chest Tube
Placement
• Injury to intercostal nerve, artery,
vein
• Injury to lung
• Injury to mediastinum
• Infection
• Allergic reaction to lidocaine
• Inappropriate placement of chest
tube
Drainage System
Commercial
Breathing Problems – Open Pneumothorax
• Chest wound
• Connecting intrapleural cavity with
environment atmosphere
• If the resistance in the wound is
lower than in the airway, air will be
sucked into the pleural cavity
through the sucking chest wound!
Breathing Problems – Open Pneumothorax/Sucking Chest Wound

• Management
• Three sided occlusive
sterile dressing
• As an initial management
• Definitive treatment 
tube thoracostomy with
WSD
Breathing Problems – Open Pneumothorax/Sucking Chest Wound
• Quiz
• Should the chest tube be
inserted into the sucking
chest wound?
Circulation Problems

Massive Cardiac
Hemothorax Tamponade

Traumatic
Circulatory
Arrest
Circulation Problem - Massive Hemothorax
• Results from rapid
accumulation of more than
1500 mL of blood/one-third or
more of patient’s blood volume
in the chest cavity.
• Estimated total circulated
blood volume
• 70 mL/kgBW for adults
• 80 mL/kgBW for children.
• Commonly caused by:
• Penetrating injury
• High-force blunt trauma.
Circulation Problem - Massive Hemothorax
Clinical signs:
- Absence of breathing sounds and/or
dullness to percussion on one hemithorax
- Neck veins may or may not be distended
due to collapsed vein in hypovolemia OR
associated tension pneumothorax
Circulation Problem - Massive Hemothorax
• Management
• Restore Blood Volume
• Establish two-lines large-bore IV catheter
• Infuse warm crystalloid
• Begin transfusion ASAP
• Do auto-transfusion if possible
• Decompress Chest Cavity
• Chest tube insertion
• Refer to Cardiothoracic Surgeon for urgent Thoracotomy if:
• > 1500 mL of initial blood
• Continuing blood loss of >200 mL/h for 2 to 4 hours
• Penetrating wound on “mediastinal box/precordial”
Hemothorax VS Hemopneumothorax
 Circulation Problem - Cardiac Tamponade
Fluid Cardiac
accumulation Diastolic output
in pericardial function ↓ severely
cavity decreased!

• Beck’s Triads:
• Jugular vein
distention Management:
• Muffled heart sound - Subxyphoid pericardial Image
• Hypotension window A. Normal Pericardial Sac B. Cardiac Tamponade
• (Becks Triads only shown - Pericardiocentesis
positive in 23/63
patients!)
Circulation Problem - Cardiac Tamponade
 34

Pericardiocentesis
• Puncture the skin 1-2 cm inferior to xiphoid process
• 45/45/45 degree angle
• Advance needle to tip of left scapula
•
Author unknown,
http://www.trauma.org/i Withdraw on needle during advance of needle
mages/image_library/ch
est0054_thumb.jpg • Preferable under ultrasound guidance or EKG lead V
attachment
• Complications
• Aspiration of ventricular blood
• Laceration of coronary arteries, veins, epicardium/myocardium
Author unknown, • Cardiac arrhythmia
www.brooksidepress.org • Pneumothorax
/ProductsTrauma_Surger
y?M=A • Puncture of esophagus
• Puncture of peritoneum
Circulation Problem - Cardiac Tamponade
Circulation Problem - Traumatic Circulatory Arrest
• Clinically diagnosed by traumatic patients with unconsciousness and have
no pulse, it could be PEA, Ventricular fibrillation, and Asystole.
• Has less than 10% survival rate and requires immediate action.
• Start closed CPR simultaneously with ABC management.
 37

Circulation
• A word about cardiac arrest . . .
• Care of the trauma patient in cardiac arrest
• CPR
• Bilateral Tube Thoracostomy
• Pericardiocentesis
• Volume Resuscitation
• Traumatic cardiac arrest due to blunt injury
has very low survival rate (< 1%)
• No point for emergency thoracotomy
• Selected cases of cardiac arrest due to
penetrating traumatic injury may benefit from
emergent thoracotomy
Author unknown,
http://www.trauma.org/images/image_library/chest0046.jpg
• Pericardial tamponade
• Cross clamp aorta
Image Traumatic Circulatory Arrest (cont.)
Image Traumatic Circulatory Arrest (cont.)
 Secondary Survey – Potentially Life-
Threatening Condition following Chest Trauma
• Simple Pneumothorax
• Hemothorax
• Flail Chest and Pulmonary
Contusion
• Blunt Cardiac Injury
• Traumatic Aortic Dissection
• Traumatic diaphragmatic injury
• Blunt Esophageal rupture
 Intubation and Ventilation in Thoracic Trauma
• Endotracheal intubation is indicated in
the present of trauma patient with
GCS less than 8, proven by the absence
of gag and cough reflex.
• Most common thoracic trauma needed
Intubation
• Pulmonary contusion
• Flail Chest
 Flail Chest
• A segment in the rib cage that has a
paradoxical movement
• Indication:
• Segmental fracture (happened in 2 line)
• 3 or more costae involved
• The length of the segment must be minimally
twice as the width of the costae
• The segment should be located in the anterior or
lateral chest wall
• Paint management: Intercostal block or
epidural
• Narcotics agent should be avoided as it may
suppress cough reflex and depress respiration.
Pulmonary Contusion
• Should be suspected to all chest trauma
patient especially if chest bruise and rib
fracture are found.
• Chest x-ray shows infiltrate in involved
lung but it usually appears in 4-6 hours
after trauma and could persist for 24
hours.
• If suspected CXR is clean then repeat it
after 6-12 hours.
• Maintain airway patency and bronchial
clearance, painkiller and avoid fluid
overload
• Complication may leads to pneumonia,
respiratory failure and ARDS
Pulmonary Contusion Chest x-ray (on admission)

Source: http://www.trauma.org/archive/thoracic/CHESTcontusion.html
Pulmonary Contusion Chest x-ray (after 24 hour)

Source: http://www.trauma.org/archive/thoracic/CHESTcontusion.html
What should you do for initial treatment?
Terima Kasih