Thoracic Trauma

Pre test
 Gambarkan anatomi thorax : dinding,
rongga, organ.
 Gambarkan traktus respiratorius
 Apa itu pneumothorax
 Apa itu hematothorax
 Apa itu cardiac tamponade
 Apa itu flail chest
Overview
 General Anatomy
 Types of thoracic injuries
 Exam findings
 Treatment
Thoracic Anatomy

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 Thoracic Anatomy

http://info.med.yale.edu/intmed/cardio/echo_atlas/references/heart_anatomy.html
Thoracic Anatomy
 Thoracic Anatomy

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http://eng-sci.udmercy.edu/courses/bio123/Chapter43/lung%20anatomy.html
Thoracic Anatomy
Thoracic Anatomy
Thoracic Trauma
 25% of nonmilitary trauma related deaths.
 Mortality 5% for isolated chest trauma
 Two or more organ systems 1/3 mortality
 Nearly all penetrating injuries result in
pneumothorax with hemothorax in more than
75% of cases.
 Of penetrating trauma, 1/3 will be associated
with abdominal injuries.
 Mechanisms of blunt trauma: compression,
direct trauma, and accel/decel forces.
Diagnosing Thoracic Injuries
 Symptoms: Chest pain and SOB.
 Physical Exam.
 Look for six major conditions.
 Think of mechanism of injury.
 Don’t forget about liver and spleen.
 Chest Wounds
 Lethal six injuries:
 Airway obstruction
 Tension pneumothorax
 Pericardial tamponade
 Open pneumothorax
 Massive hemothorax
 Flail chest
 The Box: bounded by nipples bilat, costal
margin inferiorly, and thoracic inlet superiorly
 Have high suspicion of cardiac injury
Inspection
 Chest Wall: look for signs of injury such
as contusions, flail chest, open chest
wounds.
 Neck: Distended neck veins,
subcutaneous emphysema, swelling
and cyanosis
 Abdomen: scaphoid abdomen
Physical Exam
 Palpation: trachea position, tenderness,
or crepitus.
 Percussion: dullness for hemothorax
and hyperresonance for pneumothorax
 Auscultation: Equal breath sounds,
bowel sounds high in chest.
Pneumothorax
 Can cause severe symptoms if:
 Tensions pneumothorax
 Occupies >40% of hemithorax
 Pt in shock or preexisting cardiopulmonary
disease.
 Occasionally can be delayed.
 Can repeat film in 6hrs and.
 Occult Pneumo: requires chest tube if patient
is going on a ventilator.
Pneumothorax
 Traumatic injury
causes rupture of
lung parenchyma
and air enters the
pleural space
 Negative pressure in
pleural space
facilitates air escape
Pneumothorax – Types
 Simple Pneumothorax – air seen on
CXR with no vital sign derangements
and no mediastinal shift.
 Tension Pneumothorax – continued air
leakage into closed space causes
significant lung collapse, compression of
mediastinum, and compression of
opposite hemi-thorax
Pneumothorax – Types
 Open Pneumothorax – from penetrating injury
 If significant enough in size will cause “Sucking
Chest Wound”

 Spontaneous Pneumothorax – typically occurs

in tall, slender teenagers due to congenital
area of lung weakness.
 Also seen asthma, COPD, restrictive lung dz
 Sucking Chest
Wound
 A:Inspiration
 B:Experation
Pneumothorax – Exam
findings
 Simple  Tension Pneumothorax
Pneumothorax  JVD
 Diminished lung  Tracheal shift
sounds  Diminished SpO2
 Tachycardia  Absent breath sounds
 Tachypnea  Diminished breath
 Dyspnea sounds on opposite side
 Pleuritic chest pain  Hypotension
 Hyper-resonant to  Narrowing pulse
percussion pressure
 Pneumothorax – Radiographs

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 Pneumothorax – Radiographs

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Pneumothorax – Radiographs

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 Pneumothorax – Treatment
 All types of pneumothorax
 ABCs, supportive care, early notification
 High flow oxygen
 Rapid transport if unstable vitals

 Open pneumothorax
 Occlusive dressing placed
 Consider securing only on three sides
 Watch for signs of tension pneumothorax
Cover site with
sterile occlusive
dressing taped on
three sides
Pneumothorax – Treatment
 Tension Pneumothorax
 Acute life threatening emergency
 Needle decompression affected side
 2nd intercostal space mid-clavicular line -OR-
 4th or 5th intercostal space at mid-axillary line
 Place above rib to avoid neurovascular bundle
 All needle decompressions will need chest
tube upon arrival at hospital
Tension Pneumothorax
 Clinical diagnosis
 Dyspnea, hypoperfusion, distended neck
veins, diminished breath sounds,
hyperresonant percussion, tracheal deviation.
 Decompress with 14 gauge catheter
 2nd intercostal space midclavicular line
 If no improvement then look for other cause (ie
Cardiac Tamponade)
 Chest Tube
Needle Decompression
Subcutaneous Emphysema
 Air from lung
parenchyma or the
tracheobronchial tree.
 Interstitial lung injury
through hilum and
mediastinum.
 If extensive then suspect
injury to pharynx, larynx,
or esophagus.
 Should be assumed that
pt has ptx even if not
visible on chest x-ray.
 Ruptura trakhea - bronkhus
 Ruptur trakhea,
bronkhus sering
didaerah Carina (
percabangan), bila
ruptur total bisa
fatal

 Klinis hemoptisis,
sianosis, empisema
subkutis, intubasi
sulit karena distorsi
trakhea.
 Next time..
Hemothorax
 Most frequently from lung injury.
 5-15% of pts admitted with chest trauma
require thorocotomy.
 Upright film: 200-300 mL of blood.
 Treatment: Chest tube.
Chest Tube
 Site: anterior axillary line.
 2-3cm incision 1-2cm below interspace.
 Extend down to intercostal muscles.
 24F or 28F tube for pnuemothorax.
 32F or 40F tube form hemothorax.
Massive Hemothorax
 Each hemithorax can hold 40-50% of
blood volume.
 Defined: 1500 mL or more.
 Cause: Injury to lung parenchyma,
intercostal artery or internal mammary
artery
Massive Hemothorax
 Life threatening
 Hypovolemia causing inadequate preload
 Hypoxia
 Compresses the vena cava.
 Chest x-ray-Aerated lung surrounded by
fluid.
 Treat: Chest tube  operation
Cardiac Tamponade
 Caused by blunt and penetrating
trauma.
 Stab wounds to midchest most common
cause.
 Pericardial sack has poor compliance.
 150-200 mL can result in tamponade.
Cardiac Tamponade
 Obstruction of venous return leading to
hypoperfusion and distended neck veins.
 Becks Triad : JVD,hypotension, muffled hear
tones
 Treat: Fluid bolus and Pericardiocentesis
 As little as 5-10 mL can improve cardiac
performance
Cardiac Tamponade – ECHO
Tamponade jantung
Chest Wall Injuries
 Soft tissue with bleeding: control with
pressure. Explore in OR.
 Open Chest Wounds
 If exceeds 2/3 are of trachea then air will enter
through chest wall
 Cover with air tight dressing but may cause
tension pneumothorax.
 Do not insert chest tube through tract.

 Tissue loss
Bony Injuries
 Simple rib fractures: 50% will not appear on
x-ray. Look for complications:
 Hemopneumothorax
 Contusion

 1st and 2nd rib fractures: requires significant

force. Look for other injuries.
 Multiple: If 9,10,11 then think liver spleen
injury.
 Flail Chest: Segmental fx or 3 or more
adjacent ribs. Paradoxical movement.
Hypoxemia from underlying contusion.
Flail Chest
 Free floating
segment of ribs.
 3 or more rib
fractures broken in 2
places.
 Look for paradoxical
chest wall motion
 Inhaleinward
 Exhaleoutward
 Decreased air entry.
Flail Chest Treatment
 Analgesia and intercostal nerve block.
 Belts and adhesive tape inhibit
expansion.
 Restrict IV fluids.
 Ventilatory support: shock, 3 or more
injuries, head injury, pulmonary disease,
>65 yrs.
Consider Ventilatory Support
 Respiratory failure from flail chest.
 Shock
 Multiple injuries
 Comatose
 Requiring multiple transfusions
 Elderly
 Preexisting pulmonary disease
 RR >30-35
 Po2 <50 on room air
Sternal Fractures

 Incidence 3%.
 Normal vitals and normal EKG. Repeat
EKG in 6 hrs
Injuries to Lung
 Pulmonary Contusion
 Significant source or morbidity and
mortality.
 Hemorrhage and edema without laceration.
 Caused by compression-decompression
injury.
Pulmonary Contusion

 Pathological changes: capillary damage

causes interstitial and intraalveolar
extravasation of blood and edema.
 First hemorrhage then edema.
 Pt becomes hypoxic, hypercarbic, and
acidotic.
Diagnosis and Treatment
 Chest x-ray: areas of opacification seen
within 6 hrs.
 Maintain adequate ventilation.
 Usually require support if more than
28% of lung volume.
Pneumomediastinum
 Hamman sign: crunching, rasping sound,
synchronous with heartbeat
 Suspect if subcutaneous emphysema in neck.
 Traumatic pneumomediastinum is usually
asymptomatic.
 Must look for injury to the larynx, trachea,
major bronchi, pharynx or esophagus.
Lung Injuries
 Hematoma: parenchymal tears filled
with blood. Can form abscess.
 Lacerations: major hemorrhage from
sharp ends of fractured ribs.
 Air embolism: air from injured bronchus
forced into vessel.
Tracheobronchial Injury
 Caused by rapid deceleration.
 Expiration against closed glottis or
compression against vertebral column.
 Signs and Symptom: dyspnea, hemoptysis,
Hamman sign, and sternal tenderness.
 10% asymptomatic.
 Injury occurs within 2cm of carina or at origin
of lobar bronchi.
Diaphragmatic Injury
 Mostly penetrating trauma.
 4-5% from blunt trauma.
 80-90% on left in blunt trauma.
 Often Intraop diagnosis in penetrating
trauma.
Penetrating Injury to Heart
 Factors affecting survival: weapon used,
size of myocardial injury, artery damage
and presence of tamponade.
 1/3 can be saved.
 Signs of life in OR: 70% gunshot and
85% stab wound survival.
 If no sign of life in field-do not
resuscitate.
Heart Injury Cont…
 Usually rapidly fatal from massive
hemorrhage.
 <1/4 of patients reach hospital.

 Beck’s triad: distended neck veins,

hypotension, muffled heart tones.
 Other causes: tension pneumothorax,
myocardial dysfunction and systemic air
embolism.
Diagnosing
 X-ray:most patients have normal
silhouettes. Pericardium is
noncompliant.
 EKG: nonspecific
 Echo: pericardial fluid
Pericardiocentesis
 Paraxiphoid approach
 Can direct needle toward left scapula or
right scapula (less likely to damage
ventricle).
 Up and back at 45 degrees for 4-5 cm.
 Aspirate every 1-2mm.
 Removal of 5-10 mL can increase
stroke volume by 25-50%.
Pericardiocentesis
Pericardiocentesis
Indications For Thoracotomy/Median
Sternotomy
 Hemodynamic instability with penetrating chest
wound
 Massive hemothorax >1500cc
 Persistent htx >200cc/hr x 4hrs or persistent large htx
despite chest tube
 Persistent air leak/tracheobronchial fistula with
inability to ventilate patient
 Cardiac tamponade
 Esophageal injury
 Great vessel injury
Thoracotomy Indicated for Cont
Bleeding In:
 Pts losing more than 1500mL in first 4-
8hrs.
 Chest tube drains 200-300mL per hour.
 Chest continues to be more than half
full on x-ray with functioning chest tube.