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Chest Trauma

Thoracic surgery
Introduction
■ Chest trauma is often sudden and dramatic
■ Accounts for 25% of all trauma deaths
■ 2/3 of deaths occur after reaching hospital
■ Serious pathological consequnces: -
hypoxia, hypovolaemia, myocardial
failure
Mechanism of Injury
Penetrating injuries
■ E.g. stab wounds etc.
■ Primarily peripheral lung
■ Haemothorax
■ Pneumothorax
■ Cardiac, great vessel or
oesophageal injury
Blunt injuries
■ Either: - direct blow (e.g. rib fracture)
- deceleration injury or -
compression injury
■ Rib fracture is the most common sign of
blunt thoracic trauma
■ Fracture of scapula, sternum, or first rib
suggests massive force of injury
Chest wall injuries

■ Rib fractures
■ Flail chest
■ Open pneumothorax
Rib fractures
■ Most common thoracic injury
■ Localised pain, tenderness, crepitus
■ CXR to exclude other injuries
■ Analgesia..avoid taping
■ Underestimation of effect
■ Upper ribs, clavicle or scapula
fracture: suspect vascular injury
Flail chest
■ Multiple rib fractures produce a
mobile fragment which moves
paradoxically with respiration
■ Significant force required
■ Usually diagnosed clinically
■ Rx: ABC Analgesia
Flail chest
Flail Chest - detail
Open pneumothorax
■ Defect in chest wall provides a direct
communication between the pleural space
and the environment
■ Lung collapse and paroxysmal shifting of
mediastinum with each respiratory effort ±
tension pneumothorax
■ “Sucking chest wound”
■ Rx: ABCs…closure of wound…chest drain
Lung injury
■ Pulmonary contusion
■ Pneumothorax
■ Haemothorax
■ Parenchymal injury
■ Trachea and bronchial injuries
■ Pneumomediastinum
Pneumothorax
■ Air in the pleural cavity
■ Blunt or penetrating injury that disrupts
the parietal or visceral pleura
■ Unilateral signs: ↓movement and breath
sounds, resonant to percussion
■ Confirmed by CXR
■ Rx: chest drain
Pneumothorax
Tension pneumothorax
■ Air enters pleural space and cannot
escape
■ P/C: chest pain, dyspnoea
■ Dx: - respiratory distress - tracheal
deviation (away) - absence of breath
sounds - distended neck veins -
hypotension
■ Surgical emergency
■ Rx: emergency decompression
before CXR
■ Either large bore cannula in 2nd
ICS, MCL or insert chest tube
■ CXR to confirm site of insertion
Haemothorax
■ Blunt or penetrating trauma
■ Requires rapid decompression and fluid
resuscitation
■ May require surgical intervention
■ Clinically: hypovolaemia absence of
breath sounds dullness to percussion
■ CXR may be confused with collapse
Heart, Aorta & Diaphragm
■ Blunt cardiac injury
- contusion
- ventricular, septal or valvular
rupture
■ Cardiac tamponade
■ Ruptured thoracic aorta
■ Diaphragmatic rupture
Cardiac Tamponade
■ Blood in the pericardial sac
■ Most frequently penetrating injuries
■ Shock, ↑JVP, PEA, pulsus paradoxus
■ Classically, Beck’s triad: - distended
neck veins - muffled heart sounds -
hypotension
■ Rx: Volume resuscitation
Pericardiocentesis
Cardiac
tamponade
Aortic rupture
■ Usually blunt trauma involving
deceleration forces; especially RTAs
■ ~90% die within minutes
■ Most common site near ligamentum
arteriosum
■ Dx: clinical suspicion, CXR,
aortography, contrast CT or TOE
■ Rx: surgical…poor prognosis
Aortic rupture
Iatrogenic trauma
■ NG tubes: -coiling -endobronchial
placement -pneumothorax
■ Chest tubes: - subcutaneous -
intraparenchymal - intrafissural
■ Central lines: - neck - coronary
sinus - pneumothorax
Line in jugular
vein
Misplaced nasogastric
tube
Chest trauma: summary
■ Common
■ Serious
■ Primary goal is to provide oxygen to
vital organs
■ Remember Airway Breathing
Circulation
■ Be alert to change in clinical
condition