BED SIDE

TEACHING

THORACIC TRAUMA
SUPERVISOR: dr. Marshal, Sp.B, Sp.BTKV

THORACIC, CARDIAC, AND VASCULAR SURGERY DIVISION

DEPARTMENT OF SURGERY
FACULTY OF MEDICINE UNIVERSITAS SUMATERA UTARA – GENERAL
HOSPITAL HAJI ADAM MALIK
MEDAN
THORACIC WALL
THORACIC
VISCERA
PHYSIOLOGY OF BREATHING
 DEFINITION AND
EPIDEMIOLOGY
Thoracic Trauma
Injury to thoracic cavity or thorax as a whole that may cause
damage either to thoracic wall or organs inside thoracic cavity.
• 20-25% of all trauma patients
• Highest mortality after head injury

BLUNT TRAUMA
Blunt trauma comprises 90% of all thoracic trauma
PENETRATING
TRAUMA
 PATHOPHYSIOLOGY
PERTUBATION
Injuries to the Bony Thorax
• Rib fractures

Injuries to the thoracic spine

Other thoracic bony injuries

Lung injury
• Pulmonary contusion, penetrating lung injury, tracheobronchial injuries

Cardiac injury
• Blunt cardiac injury, penetrating cardiac injury

Aortic injury and injuries to other great vessels

Special considerations (pneumothorax and hemothorax)

THE LETHAL SIX AND HIDDEN
SIX
PRIMARY SURVEY: AIRWAY
AIRWAY OBSTRUCTION
Airway Obstruction ATLS

• Laryngeal injury can accompany • Identify air hunger (muscle retraction)

major thoracic trauma or result from a • Inspect obstruction and air movement
direct blow to the neck or a shoulder • Listen to stridor and crepitus
restraint that is misplaced across the • Reduce dislocation
neck.
• Clear blood/vomitus from airway
• Posterior dislocation of the clavicular
head occasionally leads to airway
obstruction
• Penetrating trauma involving the neck
or chest can result in injury and
bleeding, which produces obstruction
PRIMARY SURVEY: AIRWAY
TRACHEOBRONCHIAL INJURY
Injury to the trachea or a major bronchus is an unusual but potentially fatal condition.
The majority of tracheobronchial tree injuries occur within 1 inch (2.54 cm) of the
carina
Prognosis of this kind of injury were bad
MECHANISM OF INJURY
1. Rapid deceleration following blunt 1. Hemoptysis
2. Cervical/subcutaneous
trauma emphysema
2. Penetrating trauma produces injury 3. Tension pneumothorax
through direct laceration, tearing, or 4. Cyanosis
transfer of kinetic injury with 5. Incomplete expansion of the
cavitation lung and continue large air leak
post chest tube
Diagnosis and Treatment
• Placement of multiple chest tube
• Bronchoscopy as diagnostic tool
• Placement of definitive airway (refer to
surgery)
 PRIMARY SURVEY:
BREATHING
TENSION PNEUMOTHORAX
Tension pneumothorax
develops when a “one-way
valve” air leak occurs from
the lung or through the chest
wall

The mediastinum is displaced to the opposite side, decreasing venous

return and compressing the opposite lung.
PRIMARY SURVEY:
BREATHING
TENSION PNEUMOTHORAX
Sign and symptom

• Chest pain
• Air hunger
• Tachypnea
• Respiratory distress
• Tachycardia
• Hypotension
• Tracheal deviation away from the side of the injury
• Unilateral absence of breath sounds
• Elevated hemithorax without respiratory movement
• Neck vein distention
• Cyanosis (late manifestation)
PRIMARY SURVEY:
BREATHING
TENSION PNEUMOTHORAX
Diagnostics
• Physical examination: percussion, deviated trachea, distended
neck veins, and absent breath sounds
• Arterial saturation
• Ultrasound (eFAST)
Treatment
• Needle decompression
• Chest tube/tube thorachostomy
PRIMARY SURVEY:
BREATHING
OPEN PNEUMOTHORAX
Large injuries to the chest wall that remain open can result in an open pneumothorax,
also known as a sucking chest wound
PRIMARY SURVEY:
BREATHING
OPEN PNEUMOTHORAX
The clinical signs and symptoms are pain,
difficulty breathing, tachypnea, decreased breath
sounds on the affected side, and noisy movement
of air through the chest wall injury.

For initial management of an open pneumothorax,

promptly close the defect with a sterile dressing
large enough to overlap the wound’s edges.
• Tape it securely on only three sides to provide a flutter-valve
effec
AFTER IT BECOME SIMPLE
PNEUMOTHORAX...

An upright expiratory chest x-ray

aids in the diagnosis. Patients with
blunt polytrauma are not candidates
for this evaluation, although patients
with penetrating chest trauma may
be.
Any pneumothorax is best treated
with a chest tube placed in the fifth
intercostal space, just anterior to the
midaxillary line
 PRIMARY SURVEY:
BREATHING AND
CIRCULATION
MASSIVE
Massive HEMOTHORAX
hemothorax results from the rapid accumulation of more than 1500 mL of blood or
onethird or more of the patient’s blood volume in the chest cavity

The primary cause of

hemothorax is laceration
of the lung, great
vessels, an intercostal
vessel, or an internal
mammary artery from
penetrating or blunt
trauma.
PRIMARY SURVEY:
BREATHING AND
CIRCULATION
MASSIVE HEMOTHORAX
It is most commonly caused by a
penetrating wound that disrupts the
systemic or hilar vessels, although massive
hemothorax can also result from blunt
trauma.

In patients with massive hemothorax, the Treatment

neck veins may be flat due to severe
hypovolemia, or they may be distended if • Restoring blood volume
there is an associated tension pneumothorax
• Decompresing chest cavity
(chest tube
A massive hemothorax is suggested when
shock is associated with the absence of • Urgent thoracotomy
breath sounds or dullness to percussion on
one side of the chest.
DIFFERENTIATE
PNEUMOTHORAX AND
HEMOTHORAX
PRIMARY SURVEY:
CIRCULATION
CARDIAC TAMPONADE
Cardiac tamponade is This results in decreased
compression of the heart cardiac output due to
by an accumulation of decreased inflow to the
fluid in the pericardial sac. heart.

The classic clinical triad of muffled heart sounds, hypotension,

and distended veins is not uniformly present with cardiac
tamponade
Kussmaul’s sign (i.e., a rise in venous pressure with inspiration when breathing
spontaneously) is a true paradoxical venous pressure abnormality that is
associated with tamponade.
 Diagnosis Treatment

• USG • Emergency
• Echocardiography thoracothomy/sternotomy
• Intravenous fluid
• Pericardiocentesis  not
definitive, risky
SECONDARY SURVEY:
FLAIL CHEST
A flail chest occurs when a segment
of the chest wall does not have bony
continuity with the rest of the
thoracic cage

This condition usually results from

trauma associated with multiple rib
fractures (i.e., two or more adjacent
ribs fractured in two or more places)
SECONDARY SURVEY
PULMONARY CONTUSION
A pulmonary contusion is a bruise of the lung, caused by thoracic trauma.

Blood and other fluids accumulate in the lung tissue, interfering with
ventilation and potentially leading to hypoxia

Pulmonary contusion can occur without rib fractures or flail chest,

particularly in young patients without completely ossified ribs.
SECONDARY SURVEY:
FLAIL CHEST AND
PULMONARY CONTUSION
Initial treatment of flail chest and pulmonary contusion includes
administration of humidified oxygen, adequate ventilation, and
cautious fluid resuscitation.

Definitive treatment of flail chest and pulmonary contusion

involves ensuring adequate oxygenation, administering fluids
judiciously, and providing analgesia to improve ventilation.
SECONDARY SURVEY:
BLUNT CARDIAC INJURY
Blunt cardiac injury can
result in myocardial Cardiac rupture typically
muscle contusion, cardiac presents with cardiac
chamber rupture, tamponade and should be
coronary artery dissection recognized during the
and/or thrombosis, and primary survey
valvular disruption.

Key: evaluation of cardiac enzyme may be useful, evaluation by

ECG can diagnose conduction abnormalities
SECONDARY SURVEY
TRAUMATIC AORTIC
DISRUPTION
• Those patients with the best
Traumatic aortic possibility of surviving tend to
have an incomplete laceration
rupture is a near the ligamentum arteriosum
of the aorta
common cause of • Blood may escape into the
mediastinum, but one
sudden death after characteristic shared by all
a vehicle collision survivors is that they have a
contained hematoma
or fall from a great • Persistent or recurrent
hypotension is usually due to a
height. separate, unidentified bleeding
site. A
SECONDARY SURVEY
TRAUMATIC AORTA
DISRUPTION
Radiographic Sign

• Widened mediastinum
• Obliteration of the aortic knob
• Deviation of the trachea to the right
• Depression of the left mainstem bronchus
• Elevation of the right mainstem bronchus
• Obliteration of the space between the pulmonary artery and the aorta
(obscuration of the aortopulmonary window)
• Deviation of the esophagus (nasogastric tube) to the right
• Widened paratracheal stripe
• Widened paraspinal interfaces
• Presence of a pleural or apical cap
• Left hemothorax
• Fractures of the first or second rib or scapula
 Diagnostics Treatment

• CT-scan • Heart rate and blood pressure control

• Transesophageal echocardiography can decrease the likelihood of rupture
• If no contraindications exist, heart
rate control with a short-acting beta
blocker to a goal heart rate of less
than 80 beats per minute (BPM) and
blood pressure control with a goal
mean arterial pressure of 60 to 70
mm Hg is recommended
• Open repair, endovascular repair
THANK YOU