Introduction to Thoracic Injury

By BGMN 1
 Thoracic Injury
• Vital Structures
– Heart, Great Vessels, Esophagus, Tracheobronchial Tree,
& Lungs
• Vertebrae and spinal cord
• Abdominal injuries are common with chest trauma.
• Prevention Focus
– Mencha Control Legislation
– Improved motor vehicle restraint systems
• Passive Restraint Systems

By BGMN 2
By BGMN 3
Immediate Life Threatening Thoracic Injuries: Cardiac Trauma

By BGMN 4
Injuries Associated with Penetrating Thoracic Trauma
• Closed pneumothorax
• Open pneumothorax (including
sucking chest wound)
• Tension pneumothorax
• Pneumomediastinum
• Hemothorax
• Hemopneumothorax
• Laceration of vascular
structures
• Tracheobronchial tree
lacerations
• Esophageal lacerations
• Penetrating cardiac injuries
• Pericardial tamponade
• Spinal cord injuries
• Diaphragm trauma
• Intra-abdominal penetration
with associated organ injury

By BGMN 5
Pathophysiology of Thoracic Trauma Chest Wall
Injuries
• Contusion
– Most Common result of blunt injury
– Signs & Symptoms
• Erythema
• Ecchymosis
• DYSPNEA
• PAIN on breathing
• Limited breath sounds
• HYPOVENTILATION
– BIGGEST CONCERN = “HURTS TO BREATHE”
• Crepitus
• Paradoxical chest wall motion

By BGMN 6
 Rib Fractures
– >50% of significant chest trauma cases due to blunt trauma
– Compressional forces flex and fracture ribs at weakest
points
– Ribs 1-3 requires great force to fracture
• Possible underlying lung injury
– Ribs 4-9 are most commonly fractured
– Ribs 9-12 less likely to be fractured
• Transmit energy of trauma to internal organs
• If fractured, suspect liver and spleen injury
– Hypoventilation is COMMON due to PAIN

By BGMN 7
 Sternal Fracture & Dislocation
– Associated with severe blunt anterior trauma
– Typical MOI
• Direct Blow (i.e. Steering wheel)
– Incidence: 5-8%
– Mortality: 25-45%
• Myocardial contusion
• Pericardial tamponade
• Cardiac rupture
• Pulmonary contusion
– Dislocation uncommon but same MOI as fracture
• Tracheal depression if posterior

By BGMN 8
 Flail Chest
– Segment of the chest that becomes free to move with the
pressure changes of respiration
– Three or more adjacent rib fracture in two or more places
– Serious chest wall injury with underlying pulmonary injury
• Reduces volume of respiration
• Adds to increased mortality
– Paradoxical flail segment movement
– Positive pressure ventilation can restore tidal volume

By BGMN 9
 Simple Pneumothorax
• Closed Pneumothorax
• Progresses into Tension Pneumothorax
– Occurs when lung tissue is disrupted and air leaks into the
pleural space
– Progressive Pathology
• Air accumulates in pleural space
• Lung collapses
• Alveoli collapse (atelectasis)
• Reduced oxygen and carbon dioxide exchange
• Ventilation/Perfusion Mismatch
– Increased ventilation but no alveolar perfusion
– Reduced respiratory efficiency results in HYPOXIA
– Typical MOI: “Paper Bag Syndrome”

By BGMN 10
 Open Pneumothorax
– Free passage of air between atmosphere and pleural
space
– Air replaces lung tissue
– Mediastinum shifts to uninjured side
– Air will be drawn through wound if wound is 2/3
diameter of the trachea or larger
– Signs & Symptoms
• Penetrating chest trauma
• Sucking chest wound
• Frothy blood at wound site
• Severe Dyspnea
• Hypovolemia

By BGMN 11
 Immediate Life Threatening Thoracic Injuries

Tracheal Disruption Open Pneumothorax

By BGMN 12
 Tension Pneumothorax
– Buildup of air under pressure in the thorax.
– Excessive pressure reduces effectiveness of
respiration
– Air is unable to escape from inside the pleural
space
– Progression of Simple or Open Pneumothorax

By BGMN 13
 Tension Pneumothorax Signs & Symptoms

• Dyspnea • Diminished then absent

– Tachypnea at first breath sounds on injured
• Progressive side
ventilation/perfusion • Cyanosis
mismatch • Diaphoresis
– Atelectasis on • JVD
uninjured side • Hypotension
• Hypoxemia • Hypovolemia
• Hyperinflation of injured • Tracheal Shifting
side of chest – LATE SIGN
• Hyperresonance of
injured side of chest

By BGMN 14
 Hemothorax
– Accumulation of blood in the pleural space
– Serious hemorrhage may accumulate 1,500 mL of
blood
• Mortality rate of 75%
• Each side of thorax may hold up to 3,000 mL
– Blood loss in thorax causes a decrease in tidal
volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax
• Hemopneumothorax

By BGMN 15
 Hemothorax Signs & Symptoms
• Blunt or penetrating chest trauma
• Shock
– Dyspnea
– Tachycardia
– Tachypnea
– Diaphoresis
– Hypotension
• Dull to percussion over injured side

By BGMN 16
 Pulmonary Contusion
– Soft tissue contusion of the lung
– 30-75% of patients with significant blunt chest trauma
– Frequently associated with rib fracture
– Typical MOI(means of injury)
• Deceleration
– Chest impact on steering wheel
• Bullet Cavitation
– High velocity ammunition
– Microhemorrhage may account for 1- 1 ½ L of blood loss in
alveolar tissue
• Progressive deterioration of ventilatory status
– Hemoptysis typically present

By BGMN 17
 Myocardial Contusion
– Occurs in 76% of patients with severe blunt chest trauma
– Right Atrium and Ventricle is commonly injured
– Injury may reduce strength of cardiac contractions
• Reduced cardiac output
– Electrical Disturbances due to irritability of damaged myocardial cells
– Progressive Problems
• Hematoma
• Hemoperitoneum
• Myocardial necrosis
• Dysrhythmias
• CHF & or Cardiogenic shock

By BGMN 18
 Myocardial Contusion Signs & Symptoms
• Bruising of chest wall
• Tachycardia and/or irregular rhythm
• Retrosternal pain similar to MI
• Associated injuries
– Rib/Sternal fractures
• Chest pain unrelieved by oxygen
– May be relieved with rest
– THIS IS TRAUMA-RELATED PAIN
• Similar signs and symptoms of medical chest pain

By BGMN 19
 Pericardial Tamponade
• intra-pericardial pressure
exceeds filling pressure of
right heart
• Impairs venous return and
cardiac filling leading to
hypotension, narrow pulse
pressure, Pulseless electrical
Activity (PEA)
• Restriction to cardiac filling
caused by blood or other fluid
within the pericardium
• Signs and symptoms masked
by hypovolemia
• Occurs in <2% of all serious
chest trauma
By BGMN
– However, very high mortality
• A vicious cycle is set in motion i.e.
  LVEDV   S.V.   CO 
compensatory tachycardia   cardiac
work   O2 demand  hypoxia and
lactic acidosis.
• Results from tear in the coronary artery
or penetration of myocardium
• Blood seeps into pericardium and is
unable to escape
• 200-300 ml of blood can restrict
effectiveness of cardiac contractions.
• Only 60ml of haemopericardium is
necessary for a tamponade to occur in
adults
– Removing as little as 20 ml can provide
relief
LVEDV=Left ventricular End Diastolic Volume
20
 Pericardial Tamponade Signs & Symptoms

• Dyspnea • Kussmaul’s sign

• Possible cyanosis
• Beck’s Triad
– JVD
– Distant heart tones
– Hypotension or narrowing
pulse pressure
• An elevated CVP is the most
significant diagnostic finding
• Weak, thready pulse
• Shock
– Decrease or absence of JVD
during inspiration
• Pulsus Paradoxus
– Drop in SBP >10 during
inspiration
– Due to increase in CO2
during inspiration
• Electrical Alterans
– P, QRS, & T amplitude
changes in every other
cardiac cycle

By BGMN 21
 Myocardial Aneurysm or Rupture
– Occurs almost exclusively with extreme blunt thoracic
trauma
– Secondary due to necrosis resulting from MI
– Signs & Symptoms
• Severe rib or sternal fracture
• Possible signs and symptoms of cardiac tamponade
• If affects valves only
– Signs & symptoms of right or left heart failure
• Absence of vital signs

By BGMN 22
Traumatic Aneurysm or Aortic Rupture
– Aorta most commonly injured in severe blunt or penetrating
trauma
• 85-95% mortality
– Typically patients will survive the initial injury insult
• 30% mortality in 6 hrs
• 50% mortality in 24 hrs
• 70% mortality in 1 week
– Injury may be confined to areas of aorta attachment
– Signs & Symptoms
• Rapid and deterioration of vitals
• Pulse deficit between right and left upper or lower extremities

By BGMN 23
 Other Vascular Injuries
– Rupture or laceration
• Superior Vena Cava
• Inferior Vena Cava
• General Thoracic Vasculature
– Blood Localizing in Mediastinum
– Compression of:
• Great vessels
• Myocardium
• Esophagus
– General Signs & Symptoms
• Penetrating Trauma
• Hypovolemia & Shock
• Hemothorax or hemomediastinum

By BGMN 24
 Traumatic Esophageal Rupture
– Rare complication of blunt thoracic trauma
– 30% mortality
– Contents in esophagus/stomach may move into
mediastinum
• Serious Infection occurs
• Chemical irritation
• Damage to mediastinal structures
• Air enters mediastinum
– Subcutaneous emphysema and penetrating trauma
present

By BGMN 25
 Tracheobronchial Injury
– MOI
• Blunt trauma
• Penetrating trauma
– 50% of patients with injury die within 1 hr of injury
– Disruption can occur anywhere in tracheobronchial tree
– Signs & Symptoms
• Dyspnea
• Cyanosis
• Hemoptysis
• Massive subcutaneous emphysema
• Suspect/Evaluate for other closed chest trauma

By BGMN 26
 Traumatic Asphyxia
– Results from severe compressive forces applied to
the thorax
– Causes backwards flow of blood from right side of
heart into superior vena cava and the upper
extremities
– Signs & Symptoms
• Head & Neck become engorged with blood
– Skin becomes deep red, purple, or blue
– NOT RESPIRATORY RELATED
• JVD
• Hypotension, Hypoxemia, Shock
• Face and tongue swollen
• Bulging eyes with conjunctival hemorrhage

By BGMN 27
 Assessment of the Thoracic
Trauma Patient
• Scene Size-up
• Initial Assessment
• Rapid Trauma Assessment
– Observe
• JVD, SQ Emphysema, Expansion of chest
– Question
– Palpate
– Auscultate
– Percuss
– Blunt Trauma Assessment
– Penetrating Trauma Assessment
• Ongoing Assessment

By BGMN 28
 Epidemiology
• Thoracic trauma accounts for 20-
25% deaths due to injury in US
• 16,000 deaths per year due to
chest injury
• Rate of thoracic injuries 12 per
million population per day (~30/day
in Miami)
• About 50% fatalities of MVA have
sustained some chest injury
• Ratio penetrating/non penetrating
variable usually about 75-85%
blunt injuries
 Road Traffic Accidents are major
cause of long term morbidity and
mortality in developing nations
– In the first quarter of 2009, 372
deaths in Ghana from Road
Traffic Accidents
– 25% increase from previous year
By BGMN
 WHO predicts that by 2020, Road
Traffic Accidents will be second
leading cause of loss of life for
world’s population
 High Morbidity = Loss of income to
society
 Challenges in Developing Countries
– Technological Advances in
Trauma Care
– Lack of Infrastructure for Trauma
Management
 EMS
 Pre-hospital notification
 MD/RN Training in trauma
care
29
 Epidemiology
• RTA in Ethiopia (Dr Teferi, 2019):
– of the 123 causalities, 28 (22.8%) were fatal.
– RTA-related causalities are extremely high in Ethiopia.
– Male young adults and vulnerable road users are at increased risk of RTAs
– Type of injury was not specified
– What about Mencha related injuries? Needs to be studied

By BGMN 30
Injury: Scale of the Global Problem

• 5.8 million deaths/year

• 10% of worlds deaths

Source: Global Burden of Disease, WHO, 2004

• 32% more deaths than HIV, TB and
Malaria combined

31
 Injury: Scale of the Global Problem

Source: World Report on Road Traffic Injury Prevention 2004 32

World Health Organization, who.int
 Epidemiology
Trimodal Distribution of Trauma Deaths

 Golden Hour = 80% of trauma

50% deaths in first hour after injury
 Rapid trauma care has greatest level
of impact in these patients

30%
20%

Immediately Hours Days/Weeks

33
 Management of the Chest Injury Patient
General Management
• Ensure ABC’s
– High flow O2 via non-rebreather mask (NRB)
– Intubate if indicated
– Consider relative strength index (RSI)
– Consider overdrive ventilation
• If tidal volume less than 6,000 mL
• Bag valve mask (BVM) at a rate of 12-16
– May be beneficial for chest contusion and rib fractures
– Promotes oxygen perfusion of alveoli and prevents atelectasis
• Anticipate Myocardial Compromise
• Shock Management
Fluid Bolus: 20 mL/kg
– AUSCULTATE! AUSCULATE! AUSCULATE!

By BGMN 34
 Management of the Chest Injury
Patient
• Rib Fractures
– Consider analgesics for pain and to improve
chest excursion
• Morphine Sulfate
– CONTRAINDICATION
• Nitrous Oxide
– May migrate into pleural or mediastinal space and
worsen condition

By BGMN 35
 Management of the Chest Injury
Patient
• Sternoclavicular Dislocation
– Supportive O2 therapy
– Evaluate for concomitant injury
• Flail Chest
– Place patient on side of injury
• ONLY if spinal injury is NOT suspected
– Expose injury site
– Dress with bulky bandage against flail segment
• Stabilizes fracture site
– High flow O2

– DO NOT USE SANDBAGS TO STABILIZE FX

By BGMN 36
 Management of the Chest Injury
Patient
• Open Pneumothorax
– High flow O2
– Cover site with sterile occlusive dressing taped
on three sides
– Progressive airway management if indicated

By BGMN 37
 Management of the Chest Injury
Patient
• Tension Pneumothorax
– Confirmation
• Auscultaton & Percussion
– Pleural Decompression
• 2nd intercostal space in mid-clavicular line
– TOP OF RIB
• Consider multiple decompression sites if patient remains
symptomatic
• Large over the needle catheter: 14ga
• Create a one-way-valve: Glove tip or Heimlich valve

By BGMN 38
 Management of the Chest Injury
Patient
• Hemothorax
– High flow O2
– 2 large bore IV’s
• Maintain SBP of 90-100
• EVALUATE BREATH SOUNDS for fluid overload
• Myocardial Contusion
– Monitor ECG
• Alert for dysrhythmias
– IV if antidysrhythmics are needed

By BGMN 39
 Management of the Chest Injury Patient
• Pericardial Tamponade
– High flow O2
– IV therapy
– Treat with immediate volume replacement to ↑ CVP,
– pericardial decompression
– Consider pericardiocentesis; rapidly deteriorating patient
• Aortic Aneurysm
– AVOID jarring or rough handling
– Initiate IV therapy
• Mild hypotension may be protective
• Rapid fluid bolus if aneurysm ruptures
– Keep patient calm

By BGMN 40
Distribution of Penetrating Cardiac Trauma and ED Thoracotomy

Rationale for EDT

•Resuscitate agonal patient with
penetrating cardiothoracic
injuries
•Evacuation of pericardial
tamponade
•Control intra-thoracic hemorrhage
•Perform open CPR
•Repair cardiac injuries
•Apply x-clamp to thoracic aorta
•Apply hilar x-clamp to lung
•Aspirate air embolism

By BGMN 41
 Management of the Chest Injury
Patient
• Tracheobronchial Injury
– Support therapy
• Keep airway clear
• Administer high flow O2
– Consider intubation if unable to maintain patient airway
• Observe for development of tension pneumothorax and SQ
emphysema
• Traumatic Asphyxia
– Support airway
• Provide O2

– 2 large bore IV’s

– Evaluate and treat for concomitant injuries
– If entrapment > 20 min with chest compression
• Consider 1mEq/kg of Sodium Bicarbonate

By BGMN 42
 Summary
• Chest Injuries are common and often life threatening in trauma
patients.
• So, Rapid identification and treatment of these patients is
paramount to patient survival.
• Airway management is very important and aggressive
management is sometimes needed for proper management of
most chest injuries.

By BGMN 43