Thoracic Trauma

Departemen Bedah RSMH/FK Unsri
Pendidikan Dokter Spesialis-1 Ilmu Bedah

Pendidikan Dokter Spesialis-1 Orthopaedi dan Traumatologi
Thoracic Trauma:
Pneumothorax, Haemothorax, Caridac
Tamponade
dr. Davin Caturputra Setiamanah
Thoracic Trauma
• Primary mechanism  blunt or penetrating trauma to the chest

• Most common: hemothorax and pneumothorax
• MoI: MVC, falls, vehicle striking pedestrians, violence and blast
injures
• Associated with musculoskeletal injury in the chest, may be
secondary to compressive strain
• Ribs fracture cause: (1) compressive strain (outer aspect) or even
(2) tensile strain (inner aspect)
• Physiologic consequences  hypoxia, hypercarbia, and acidosis
Thoracic Trauma
Physiology of The Lung
• Pleural cavity pressure is negative compared to lung and

atmospheric pressure
• Pressure gradient prevents the lung from collapsing
In pneumothorax  the pressure gradient is disrupted  air

movement from lung to pleural space  progressive rise in
intrapleural pressure
Leading to
Compresses and decrease volume of the lung
Lung function failure reduced ventilation, and hypoxemia
Tension Pneumothorax
• Tension pneumothorax  one way valve, air leaks occurs from the
lung or through the chest
• Occurs secondarily due to penetrating or blunt chest trauma
• Air cannot escape from pleural space, collapsing the lung
• Obstructive shock due to decrease in venous return and reduction
in cardiac output
• Most common cause  mechanical PPV in visceral pleural injury
• Clinical signs: air hunger, tachypnea, chest pain, tachycardia,

hypotension, tracheal deviation (away from injury), unilateral
breath sound absent, distended neck vein, elevated hemithorax,
cyanosis
• Immediate decompression  large over the needle at the 5th Intercostal space,
slightly anterior to the mid-axillary line
• Successful rate based on chest wall thickness, 90% success using 8 cm over the
needle catether
• This procedure will convert the tension to simple pneumothorax
Open Pneumothorax
• Large injuries to the chest wall w/ presentation of Sucking Chest

Wound
• Direct equilibrium of intrathoracic pressure and atmospheric
pressure  air will pass through the chest wall defect during
inspiration
• Hypoxia and hypercarbia due to ineffective ventilation
• Initial Management  close the defect w/ sterile dressing being
taped on 3 sides only (preventing air from entering)
• Place the Chest tube remote from the wound as soon as possible
Open Pneumothorax
Chest X-Ray can be performed when the patient is haemodinamically

stable.
Chest X-Ray in Pneumothorax
• Evaluation of a thin line representing the edge of cvisceral pleura
• Complete ipsilateral lung collapse
• Mediastinum shift
• Subcutaneous emphysema
• Tracheal deviation
• Flattening of the diaphragm
Treatment
• In patients with chest trauma  Follow the ATLS protocols
• Penetrating chest wound is covered with clean-sterile bandage
• Oxygen administration helps to create a diffusion gradient for
nitrogen  accelerating pneumothorax resolution
• Avoid PPV before chest tube thoracostomy procedures are taken
• Haemodynamically unstable  needle decompression  chest
tube  immediate CXR to assess pneumothorax resolution
Massive Hemothorax
• Accumulation of >1500mL of blood or 1/3 of patient blood volume in chest

• Causing mediastinal shift due to blood accumulation, respiratory distress,
hypovolemic shock
• Flat neck vein due to severe hypovolemia, or can be distended due to severe
hypovolemia
• Physical Findings: dullness on percussion, absent of breath sounds
• Blood from chest tube after decompression can be used as autotransfusion (if
being stored in a specific device)
• 28-32F single chest tube slightly anterior to the midaxillary at the 5 th ICS
Massive Hemothorax
Penetrating anterior chest wound at the mediastinal box (medial to the nipple
line and medial to the scapula)  risk of great vessels, hilar structure, and heart
damage
Massive Hemothorax
A thoracotomy is required for the management of a massive

hemothorax:
1. defined as greater that 1500 cc of blood on insertion of a chest
tube or in the first 15–30 minutes
2. more than 200 cc of blood per hour for the first four hours (2-4
hours) after trauma  200cc/hour in 2-4 hours post trauma
3. Persistent need of blood transfusion
Cardiac Tamponade
• Caused by pericardial fluid buildup  haemopericardium in trauma
cases
• Decreased cardiac output due to decreased inflow to the heart
• MoI  penetrating injury or blunt injury
• Beck’s Triad: muffled heart sound, persistent hypotension (until
decompressed), distended neck vein
• Kussmaul’s sign  increase in venous pressure with inspiration
when breathing spontaneously
• DD/ Left side tension pneumothorax; presence of hyperresonance
on percussion
Cardiac Tamponade
• Normal pericardial sac fluid  10-50 cc  >50cc suggestive for pericardial effusion
• FAST 90-85% accurate in identifying pericardial fluid
• Definitive treatment: emergency thoracotomy or sternotomy; IV fluid
resuscitation
• Th/ subxiphoid pericardiocentesis, Seldinger technique
• Ultrasound guiding can facilitate insertion of over the needle catether
Cardiac Tamponade
Indications for emergency department thoracotomy for resuscitation
1. Salvageable postinjury cardiac arrest (e.g., patients who have witnessed
cardiac arrest with high likelihood of intrathoracic injury, particularly
penetrating cardiac wounds)
2. Severe postinjury hypotension (i.e., systolic blood pressure 60 mm Hg) due to
cardiac tamponade, air embolism, or thoracic hemorrhage
EKG Findings
• Low voltage in the limb leads alone: defined as a QRS amplitude less than 5 mm
in all limb leads,
• Low voltage in the precordial leads alone: defined as a QRS amplitude less than
10 mm in all precordial leads
• Low voltage in all leads: defined as a QRS amplitude less than 5 mm in all limb
leads plus a QRS voltage less than 10 mm in all precordial leads.
Cardiac Tamponade – Treatment

• O2 supplementation, bed rest
• Avoid PPV
• Treatment  needle pericardiocentesis at bed site  landmark:
subxiphoid window or pont of care echo to guide needle placement
• Removal of small amount of fluid may help reduce the symptoms
References
• The Committee on Trauma. 2018. ATLS: Advanced
Trauma Life Support, Student Manual Course, Ed.
10th. American College of Surgeons: Chicago
• Mattox KL, Moore EE, Feliciano DV. 2013. TRAUMA
ed. 7th. McGrawHill: Texas
• Sahota RJ, et al. Tension Pneumothorax. StatPearls
[Internet]. 2022
• Ang KP, et al. Diagnostic value of electrocardiogram in
cardiac tamponade. Med J Malaysia. 2019;7(1):51-56

Thoracic Trauma

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Thoracic Trauma

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Departemen Bedah RSMH/FK Unsri

Pendidikan Dokter Spesialis-1 Ilmu Bedah

• Primary mechanism  blunt or penetrating trauma to the chest

Physiology of The Lung

• Pleural cavity pressure is negative compared to lung and

In pneumothorax  the pressure gradient is disrupted  air

• Clinical signs: air hunger, tachypnea, chest pain, tachycardia,

• Large injuries to the chest wall w/ presentation of Sucking Chest

Chest X-Ray can be performed when the patient is haemodinamically

• Accumulation of >1500mL of blood or 1/3 of patient blood volume in chest

A thoracotomy is required for the management of a massive

Cardiac Tamponade – Treatment

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