Committee on Trauma Presents

Thoracic
Trauma

Initial Assessment and Management

 Case Scenario

● 27-year-old male brought to trauma center

● Unrestrained driver in high-speed, frontal-
impact collision
● Prolonged extrication at scene
 Case Scenario

● Blood pressure: 90/70; heart rate: 110;

respiratory rate: 36
● Initial assessment: GCS score 15, patent
airway

What features suggest that this patient may

have thoracic injuries?
 Objectives

● Identify and treat life-threatening

injuries found during the primary
survey.
● Identify and treat potentially life-
threatening injuries found during the
secondary survey.
 Thoracic Trauma

●Significant cause of mortality

●Blunt: < 10% require operation
●Penetrating: 15-30% require operation
●Majority: Require simple procedures
●Most life-threatening injuries are identified
during the primary survey
 Thoracic Trauma

What are the immediately life-threatening chest

injuries?

●obstruction
Laryngeotracheal injury / Airway

●Tension pneumothorax
●Open pneumothorax
●Flail chest and pulmonary contusion
●Massive hemothorax
●Cardiac tamponade
 Thoracic Trauma

What are the pathophysiologic consequences of

these chest injuries?

●Hypoxia
●Hypoventilation Manage in the
●Acidosis primary
● Respiratory survey as

● Metabolic identified

●Inadequate tissue
perfusion
 Laryngeotracheal Injury

Airway Obstruction

●Rare
●Hoarseness
●Subcutaneous emphysema
●Manage in the primary survey as
soon as possible
● Intubate cautiously
● Tracheostomy
 Tension Pneumothorax

●Respiratory distress
●Shock
●Distended neck veins
●Unilateral decrease in
breath sounds

●Hyperresonance
●Cyanosis (late sign)
 Tension Pneumothorax

●Clinical diagnosis, not

by x-ray

●Immediate
decompression
● Needle
● Chest tube
Open Pneumothorax
 Open Pneumothorax

●3-sided cover over

defect

●Chest tube
●Definitive operation
Flail Chest and Pulmonary Contusion
 Flail Chest and Pulmonary Contusion

●Oxygen
●Reexpand lung
●Intubate as indicated
●Judicious fluids
●Analgesia
 Massive Hemothorax

●Systemic / pulmonary
vessel disruption

●> 1500 mL blood loss

●Flat vs. distended neck
veins

●Shock with no breath

sounds and/or percussion
dullness
 Massive Hemothorax

●Rapid volume
restoration

●Chest decompression
and x-ray

●Autotransfusion
●Operative intervention
 Cardiac Tamponade

●Decreased arterial
pressure Radio antenna

●Distended neck veins

●Muffled heart sounds
●Pulseless electrical
activity
Cardiac Tamponade

A Secure airway

B Ventilate and oxygenate

C Volume resuscitation

FAST, operation
 Resuscitative Thoracotomy

When should I consider resuscitative

thoracotomy?
 Resuscitative Thoracotomy

When should I consider resuscitative

thoracotomy?

●Patients with penetrating thoracic injury

arriving with PEA may be a candidate

●When a surgeon with appropriate skills is

present

●ED thoracotomy not indicated in blunt

trauma with PEA
 Thoracic Trauma

What are the potentially life-threatening chest

injuries?

How do I identify them?

When and how do I correct the problem?

 Thoracic Trauma

What are the potentially life-threatening chest

injuries?

●Tracheobronchial tree injury

●Simple pneumothorax
●Pulmonary contusion
●Hemothorax
 Thoracic Trauma

What are the potentially life-threatening chest

injuries?

●Blunt cardiac injury

●Traumatic aortic disruption
●Blunt esophageal rupture
●Traumatic diaphragmatic injury
 Thoracic Trauma

How do I identify potentially life-threatening

thoracic injuries?

●Physical examination
●Chest x-ray
●Pulse oximetry
●ABG
●ECG
 Tracheobronchial Tree Injury

●Often missed
●Blunt or penetrating
●Persistent pneumothorax
●Bronchoscopy
●Treatment
● Airway and ventilation
● Tube thoracostomy
● Operation
 Simple Pneumothorax

●Penetrating / blunt trauma

●Ventilation / perfusion
defect

●Hyperresonance
●Decreased breath sounds
●Tube thoracostomy
 Pulmonary Contusion

●Common
●Oxygenate and
ventilate

●Selective intubation
●Delayed X-ray
changes
 Hemothorax

●Chest wall injury

●Lung / vessel
laceration

●Tube thoracostomy
 Blunt Cardiac Injury

●Injury spectrum
●Abnormal ECG / monitor changes
●Echocardiography
●Treat
● Dysrhythmias
● Perfusion
● Complications
 Traumatic Aortic Disruption

●Rapid acceleration /
deceleration
mechanism

●X-ray signs
●High index of
suspicion

●Surgical consult
 Traumatic Aortic Disruption

Diagnosis by Helical CT or Aortography

 Blunt Esophageal Rupture

●Blunt vs. penetrating injury

●Severe epigastric blow
●Pain / shock out of proportion to
injury

●Left pneumothorax or hemothorax

without rib fracture
 Esophageal Injury

●Chest tube: Particulate

matter

●Mediastinal air
●Contrast swallow,
esophagoscopy

●Operation
 Diaphragmatic Injury

●Most diagnosed on left

●Blunt: Large tears
●Penetrating: Small
perforations

●Misinterpreted x-ray
●Contrast radiography
●Operation
 Traumatic Asphyxia

●Petechiae
●Swelling
●Plethora
●Cerebral edema
 Subcutaneous Emphysema

●Airway injury
●Pneumothorax
●Blast injury
●Iatrogenic
 Fractures and Associated Injuries

Sternum, Scapular, and Rib

Ribs 1-3
●Severe force
●Associated injuries have high mortality risk
Ribs 4-9
●Pulmonary contusion and pneumothorax
Ribs 10-12
●Suspect abdominal injury
 Pitfalls

Pitfalls

●pneumothorax
Simple pneumothorax converts to tension

●Retained hemothorax
●Diaphragmatic injury
●contusion
Severity of rib fractures / pulmonary

●Extremes of age
 Summary

●Common in multiply injured patients

●Life-threatening injuries
●Potentially-lethal injuries
●Initial stabilization by simple techniques in the
majority of cases

Goal: Restore normal gas exchange and perfusion