Trauma Surgery [CHEST TRAUMA]

1) Rib Fracture
Caused by blunt trauma to the chest, it produces sharp strands
of bone that can cause penetrating type injuries. Rib fractures
hurt but are rarely deadly on their own. In the elderly, who may
not breathe enough (because it hurts to do so), atelectasis and
pneumonia may develop (and kill them). Treat the pain, but don’t
go overboard with opiates because they also cause respiratory
depression.

2) Pneumothorax Chest Tube High (air floats)

A product of penetrating trauma, air rushes into the pleural
space and compresses the lung. This causes super-atelectasis and
resulting dyspnea. The lung sounds will be decreased on the Vertical Air-Lung Level
effected side with hyperresonance. X-ray shows vertical lung
shadows inside the chest. The thing you should learn is
thoracostomy (place a chest tube) to take out the air and re- Pleural space full of air
expand the lung. It’s possible to use needle aspiration if it’s small, (Resonant to percussion)
or use high flow oxygen if it is teeny-tiny. For the test, pick chest
tube.
Penetrating trauma Air fills pleural space
3) Hemothorax pops the lung
Also caused by penetrating trauma, blood rushes in instead of
air. Theoretically this could also be a chylothorax but
management is identical. There will be decreased lung sounds and
it will be dull to percussion. An x-ray will show a horizontal
lung shadow with a meniscus (air fluid level). Place a chest tube Horizontal Air-Fluid
(thoracostomy) and drain the blood. Here is where pneumothorax Level
is different. Surgical exploration (thoracotomy) for the source of Pleural space full of blood
bleeding is required if the chest tube produces > 1500mL
(Dull to percussion)
(20cc/kg) on insertion OR 200mL/hr (3cc/kg/hr), indicating the
bleeding is peripheral arterial bleeding and will not stop on its Penetrating trauma Chest Tube Low (Blood sinks)
own (instead of pulmonary vasculature). The pulmonary causes a bleed
vasculature is a low-pressure system and clots easily.

4) Sucking Chest Wound

Caused by an externally penetrating trauma a flap of skin forms
a one-way valve, allowing air to enter the pleural space on
inhalation, but then trapping the air on exhalation. This trapped
air accumulates, which can produce a tension pneumothorax. X- Air Trapping
ray shows the pneumo, visual inspection shows the sucking
wound. If tension pneumo, do a decompression then place
dressing. If no tension, place an occlusive dressing (like cyran
wrap) taped on 3 sides, then place a chest tube. Valve open on inhale Valve closes on exhale

5) Flail Chest
This requires two or more ribs broken in two or more places,
which means pretty significant blunt trauma. The effected piece
moves paradoxically to the rest of chest (sucks in on inhale,
protrudes on exhale). It’s necessary to keep the ribs aligned to
heal, so use wraps or weights to do so. This may cause dyspnea
so monitor with pulse oximetry and ventilation. The real problem
is the fact that the patient suffered an impact so severe it caused a
flail chest. Look for and be cautious to treat more severe disease:
pulmonary contusion, cardiac contusion, and aortic
dissection. Any flail chest, scapular fracture or sternal fracture Two or more ribs broken in multiple places
implies significant trauma and should increase the index of
suspicion for underlying disease.

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 Trauma Surgery [CHEST TRAUMA]

6) Pulmonary Contusion
A contused lung already has leaky capillaries. It then becomes
sensitive to fluid shifts. Because it may not be immediately
apparent, look for clues of severe trauma (scapular fracture,

sternal fracture, flail chest) and treat as though they have it. Avoid
crystalloids (LR + NS) and fill the vascular volume with colloids
(blood and albumin). Use diuretics and be PEEP. Be cautious
not to miss heart failure (a contused myocardium may lead to
pump failure). The original x-ray may be normal, but a repeat
chest X-ray will show white out 48hrs after injury. It’s
effectively ARDS (leaky capillaries, non-cardiogenic) that
improves with time.

7) Myocardial Contusion
You know when to look for pulmonary contusions. At the same
time, look for myocardial contusions with serial EKGs and
Troponins. They’ll be elevated from the beginning. The only
thing to be done is stabilize and treat arrhythmias and heart
failure as they occur - just like an MI (MONA-BASH). Do a
FAST assessment when they walk in the door to make sure they
don’t have a pericardial effusion, which can lead to tamponade.

8) Traumatic Dissection of Aorta Flail Chest

Scapular Fracture
The aortic arch is held in place by the ligamentum arteriosum,
Sternal Fracture
the former ductus arteriosum. Most of the aorta is freely floating.
In a deceleration injury (i.e. a front-end car crash) the visceral Ø Widened + Widened
↓ IOS CXR ↑ IOS
organs continue forward except for the one attachment site at the Mediastinum Mediastinum
arch, which shears the aorta. Full transections are almost
instantly fatal and are found dead at the scene. Partial CT Scan
transections develop an adventitial hematoma, which are
asymptomatic until they rupture and the patient dies. The first + For -Disease -Disease
step is to do an X-ray. If there’s a widened mediastinum the Disease ↑ IOS ↓ IOS
index of suspicion is high. Now do a CT scan. If positive, go to
surgery for repair. If negative and low index of suspicion, it’s Transection Angiogram No Disease
ok to stop. If the person can’t have a CT Angio because of renal Surgery Observe
failure, use MRI or TEE (you won’t have to choose between
them). An angiogram can be done if suspicion is high and the CT
is negative.

Injury Trauma Patient Dx Tx Other

Rib Blunt Pain on inspiration CXR = Fx Pain control, avoid Ø
Fracture atelectasis à PNA
Pneumo Penetrating Dyspnea, Hyperresonant CXR = Vertical Lung Chest Tube Needle Asp if small
thorax lung sounds, ↓ breath sounds, Lines Oxygen if tiny
Ø Tracheal Deviation Air is Dark Tension = Decompress
Hemo Penetrating Dyspnea, Dull Percussion, CXR = Horizontal lung Chest Tube > 200mL/hr or
thorax ↓ breath sounds, shadow, Meniscus >1500mL on insertion,
Ø Tracheal Deviation Blood is white do surgical exploration
Sucking Blunt Skin flap valve Shows Pneumothorax, Occlusive Dressing Taped on 3 sides to
Chest Hyperresonant visual inspection shows avoid tension pneumo
Wound Tension Pneumo sucking wound
Flail Chest Blunt Paradoxical movement of chest wall CXR = Multiple ribs Banding or weights Look for contusions
with multiple fractures and ruptures
Pulmonary Blunt Hidden, appears 48 hrs later CXR = White out Colloids to maintain Exquisitely sensitive
Contusion (days later) BP, Diuretics to fluid
Myocardial Blunt Hidden, appears immediately, EKG + Troponins Chase Arrhythmias Ø
Infarction dyspnea and Heart Failure

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