CHEST TRAUMA

Traumatic asphyxia due to blunt chest trauma

• A 44-year-old Caucasian man was working under a car when the
vehicle’s transmission system fell on his chest, squeezing his torso
between the heavy item and the ground.
• After an unknown time, he was found in an unconscious state by a
relative, who called for medical aid. It was estimated that at least one
hour elapsed before our patient received medical care.

http://www.jmedicalcasereports.com/content/6/1/257
• On arrival to our emergency department, our patient had a gasping
breath without foreign bodies in his oronasal cavities, palpable
regular pulses with a rate of 130 beats per minute and an arterial
pressure of 80/40mmHg.
• On pulse oxymetry he had a saturation of 80% on room air. His GCS
score was 8 (absent eye opening, unintelligible voice responses and
limp withdrawal to painful stimuli), his papillae were isochoric and
light reflexes were bilaterally present.
• Because of his altered consciousness and impending respiratory
failure, our patient was urgently intubated and put under controlled
mechanical ventilation
• The rest of the physical examination revealed that his face, the front part of
his neck and the upper part of his chest were congested, edematous and
covered with numerous petechiae, especially on the conjunctivae and the
periorbital skin.
• In a later bedside ophthalmologic examination, mild bilateral periorbital
swelling, severe bilateral subconjunctival hemorrhages, chemosis, mild
exophthalmos and mild optic disc edema were observed.
• Ecchymotic bruises were also noted on the back part of his neck and the
upper part of both shoulders.
• His tympanic membranes were clear and there were no mucosal
hemorrhages of his upper airways.
• Absence of breathing sounds over both lung apices in combination
with palpable subcutaneous emphysema over his neck pointed
towards the existence of bilateral pneumothorax.
• Moreover, bloody fluid was drained through the endotracheal tube,
indicating possible lung contusions.
• The physical examination of his heart and abdomen was
unremarkable and electrocardiogram was normal.
• Thoracic X-ray examination
revealed bilateral pneumothorax
and multiple rib fractures
• Chest X-ray taken after tube
thoracostomies were inserted.
Note: multiple rib fractures,
subcutaneous emphysema,
multiple lung opacities,
particularly on the right,
corresponding to sites of lung
contusion and residual
pneumothorax on the left side.
• In this respect, bilateral tube thoracostomies were inserted, draining
air and blood and eliciting major improvement in his hemodynamic
parameters.
• In subsequent X-rays, bilateral lung opacities were evident, which
were consistent with the clinical suspicion of lung contusions.
• Fiberoptic bronchoscopy was not performed due to the bilateral
pneumothorax.
• Subsequently, our patient was transferred to our intensive care unit
(ICU).
Pulmonary artery laceration after blunt chest
trauma
• A 69-year-old male unrestrained driver was involved in a motor
vehicle collision where he collided with the back of a bus.
• The patient was hemodynamically unstable both at the scene and
upon arrival in the trauma bay.
• Examination in the trauma bay revealed a pulse of 115/min, systolic
blood pressure of 80 mm Hg, and a respiratory rate of 10/min with no
gross neurologic deficits.
• He had a Glasgow coma scale score of 11 and the remainder of the
assessment was unremarkable.
The Annals of Thoracic Surgery
Volume 70, Issue 3, Pages 955-957
• Examination of the chest revealed a well-healed median sternotomy
scar (the result of coronary artery bypass grafting performed
approximately one year previously), multiple rib fractures bilaterally,
and decreased air entry in the left hemithorax.
• Diagnostic peritoneal lavage was negative.
• A portable chest roentgenogram revealed
a wide mediastinum with a left pleural
effusion.
• A left chest tube was inserted and drained
300 ml of blood.
• The patient was subsequently transported
to the radiography department to evaluate
his abnormal chest findings.
• A chest computed tomographic scan
revealed a large mediastinal hematoma
with active extravasation from the main
pulmonary artery.
A computed tomography (CT) scan of the chest reveals tear in
the main pulmonary artery (small black arrow), extravasation
of CT contrast dye (solid white arrow), and a large mediastinal
hematoma (outline white arrow)
• The image also revealed persistence of hemothorax, in spite of the
presence of a functioning chest tube, which by the end of the
procedure had drained a total of 1200 ml of blood.
• The patient was emergently taken to the operating room. A left
thoracotomy showed an expanding hematoma with a laceration
involving half of the circumference of the main extrapericardial
pulmonary artery.
Flail chest from blunt thoracic trauma
• A 56-year-old male smoker sustained non-penetrating left-sided chest
trauma, following a 2-m fall onto a flat-topped wooden post.
• He was in severe pain and respiratory distress in the Emergency
Department, with a dramatic degree of flail and marked
subcutaneous emphysema.

BMJ Case Reports 2011; doi:10.1136/bcr.04.2011.4068

• A left side tube CT thorax showing left-sided
thoracostomy was inserted haemopneumothorax,
subcutaneous emphysema and
urgently with marked tube thoracostomy.
improvement in respiratory
parameters.
• Subsequent CT thorax
confirmed left-sided
haemopneumothorax,
subcutaneous emphysema,
multiple rib fractures and
adequate chest tube
position
CT thorax showing marked left
sided subcutaneous
emphysema.
• Analgesia was provided by thoracic
epidural infusion of local anaesthetic
and fentanyl.
• This allowed early chest
physiotherapy and mobilisation, and
helped prevent hypoventilation and
sputum retention which may have led
to respiratory infection and delayed
recovery.
• The chest tube was removed on day
3 and the patient was discharged
home on day 5. He has since made a Chest radiograph showing complete
resolution 2 months postinjury.
full recovery. Chest radiograph at 2
months.