COMPREHENSIVE CLINICAL APPROACH OF

THORACIC TRAUMA
THORACIC
2023 Here is where your presentation begins

Taufik Nur Yahya, MD

Thoracic, Cardiac, and Vascular Surgeon
Introduction

Blunt trauma

Penetrating trauma
 Epidemiology
• Comprises 20–25% of all traumas worldwide
• 3rd most common cause of death after abdominal injury and head
trauma in polytrauma patients
• Directly accounts for approximately 25% of trauma-related mortality
and is a contributing factor in another 25% of such cases
• Blunt thoracic injuries >penetrating injuries
• Most frequent causes: motor vehicle accidents, falls and crush injuries

Beshay, M., Mertzlufft, F., Kottkamp, H.W. et al. Analysis of risk factors in thoracic trauma patients with a comparison of a modern trauma centre: a mono-centre study. World J
Emerg Surg 15, 45 (2020). https://doi.org/10.1186/s13017-020-00324-1
What to do?
• Primary survey (ABCDEs) with
immediate resuscitation of patients
with life-threatening injuries
• Adjuncts to the primary survey and
resuscitation
• Consideration of the need for patient
transfer
• Secondary survey (head-to-toe
evaluation and patient history)
• Adjuncts to the secondary survey
• Continued post-resuscitation
monitoring and reevaluation
• Definitive care
 Primary survey
• Airway maintenance with
Primary survey restriction of cervical spine
(ABCDEs) with motion
immediate • Breathing and ventilation
resuscitation of • Circulation with hemorrhage
patients with life- control
threatening • Disability (assessment of
injuries neurologic status)
• Exposure/Environmental control
 The deadly dozen
Of thoracic trauma

Life threatening injury Potentially Life threatening injury

DEADLY SIX HIDDEN SIX
Airway obstruction Simple pneumothorax
Tracheobronchial injury Hemothorax
Open pneumothorax Flail chest
Tension pneumothorax Pulmonary contusion
Massive hemothorax Blunt cardiac injury
Cardiac tamponade Aortic disruption
Diaphragmatic injury
Esophageal rupture
LETHAL SIX
Airway obstruction
Tracheobronchial injury
Open pneumothorax
Tension pneumothorax
Massive hemothorax
Cardiac tamponade
Airway obstruction
- Foreign body, blood, aspirated vomitus, swelling,
subcutaneous emphysema

- Evaluation:
- Look : foreign body, air hunger
- Listen: air movement or stridor
- Feel: crepitation

- Action:
- Clear airway ➔ suction
- If necessary ➔ definitve airway
Tracheobronchial tree injury
Evaluation: hemoptysis,
subcutaneous emphysema, tension
pneumothorax, and/or cyanosis

Action:
• Chest tube insertion as
needed
• Endotracheal intubation might
be difficult due to the
anatomic distortion
• Selective intubation for the
unaffected bronchus and
immediate surgery might be
needed
• Patients with airway injuries (levels I and II) and who are
clinically stable, that is, breathing spontaneously, or those who
require minimal ventilator support and have tracheal tears less
than or equal to 2 cm
 Open pneumothorax
Large opening (>2/3 tracheal
diameter) in the chest wall
• Inspiration pulls air through the
wound into pleural space ➔
sucking wound
• Air does not flow through the
trachea into the lungs
• Ventilation ineffective ➔ Lethal
hypoxia and respiratory failure
Tension Pneumothorax
General condition:
• Air hunger, respiratory distress
• Decreased SpO2
• Distended neck vein
• Hypotension
Inspection
• Tachypnea
• Assimetrical chest movement
• Use of accessory breathing muscle
Palpation
• Tracheal deviation
Percussion
• Unilateral hyperresonance
Auscultation
• Absence of unilateral breath sound
TENSION PTX SHOULD BE
DIAGNOSED CLINICALLY!!!!
Needle decompression
Finger decompression
MASSIVE HEMOTHORAX
• Hemothorax: Presence of
blood in pleural cavity
• “Massive”: rapid blood
accumulation of ≥ 1500 mL

Emergency thoracotomy if:

• Initial bleeding is >1500 mL
(or initial 700 mL in
Indonesia’s patient)
• Bleeding is > 200 mL/hour
(or 3-5 mL/kgBW/hour) for >
2 to 4 hours and causes
respiratory or hemodynamic
compromise or the need for
repeated blood transfusions
CARDIAC TAMPONADE
Beck’s Triad
• Hypotension with a
narrowed pulse
pressure
• Jugular venous
distention
• Muffled heart sounds
 • Insertion: 1 cm inferior to the left
xiphocostal angle, 30 degrees with the
patient’s chest
• Direction: Towards left mid-clavicle. If
unsuccessful, retract the spinal needle and
redirect 10 degrees towards the patient’s
right
• Continuous EKG monitor!
• ST-elevations will be apparent on
the EKG if the myocardium is
touched.
• If ST-elevations are noted ➔ retract
the needle.

Pericardiocentesis
USG-guided pericardiocentesis
Simple pneumothorax

HIDDEN SIX
Hemothorax
Flail chest
pulmonary contusion
Blunt cardiac injury
Aortic disruption
Diaphragmatic injury
Esophageal rupture
Flail chest

• a segment of the chest wall does not have bony continuity with
the rest of the thoracic cage.
• multiple rib fractures ➔ two or more adjacent ribs fractured in
two or more places
Rib fixation
pulmonary contusion

• involving injury to the alveolar

capillaries, without any tear or cut in
the lung tissue (lung “bruising”) ➔
accumulation of fluid and/or blood in
the lung tissue ➔ ineffective
ventilation
• May occur with OR without rib
fracture or flail chest
• Decreasedd localized breath sound
V:Q mismatch
 The main complications of pulmonary contusion

ARDS • ARDS of 17% of patients

• Pneumonia 20% of patients
 Blunt cardiac injury
• Blunt cardiac injury can
result in myocardial muscle
contusion, cardiac chamber
rupture, coronary artery
dissection and/or
thrombosis, and valvular
disruption. Cardiac rupture
typically presents with
cardiac tamponade and
should be recognized during
the primary survey.
However, occasionally the
signs and symptoms of
tamponade are slow to
develop with an atrial
rupture.
Aortic disruption

• A, stretch effect with vertically distributed forces (arrows) by the cranial pull by the arch vessels with a hyperextended neck;
• B, shear force due to tugging (dashed arrows) at the site of aortic fixations;
• C, pinch effect due to osseous compression (blue arrow) of the aorta between the rigid sternocostal cage anteriorly and vertebral column
posteriorly; and
• D, thump effect, which involves intravascular pressurization (double arrows) of the aortic blood column akin to a water hammer.
Pain control ➔ analgetics
If no contraindications exist:
• heart rate control target <80 BPM
• Blood pressure control target MAP 60-70 mmHg
Hypotension is contraindication

Management
TEVAR
Diaphragmatic injury

Diaphragmatic injuries are frequently

missed initially when the chest film is
misinterpreted as showing an elevated
diaphragm, acute gastric dilation,
loculated hemopneumothorax, or
subpulmonic hematoma
Right sided diaphragm tear
Diaphragm repair
 Esophageal rupture
• Esophageal trauma most
commonly results from
penetrating injury.
• Gastric content leakaged to
mediastinum ➔
mediastinitis

The image shows a 2-mm tear of the right mid

esophagus with extensive pneumomediastinum and
subcutaneous gas at the base of the neck
Esophageal repair
Thorax trauma severity score (TTSS)

A score of 7 points or above was associated with increased morbidity,

and a score of 20 points or above predicted a fatal prognosis and
prolonged mechanical ventilation.
 Thank You!

Let’s fix broken heart! Literally.