CHEST TRAUMA

BY:
ABISINIYA(MD)

09/15/23 CHEST TRAUMA 1

 CHEST ANATOMY
Heart
Lungs
Major vessels
Thoracic Cage
Ribs, thoracic
vertebrae and
sternum

09/15/23 CHEST TRAUMA 2

09/15/23 CHEST TRAUMA 3
 CAUSES OF CHEST
INJURIES
BLUNT TRAUMA PENETRATING
◦ Blast injuries TRAUMA
◦ Motor vehicle accidents ◦ Gunshot wounds
◦ Auto vs. pedestrian ◦ Stab wounds
◦ Falls ◦ Shrapnel wounds

09/15/23 CHEST TRAUMA 4

Pathophysiology of Chest Trauma
hypovolemia

ventilation-
perfusion Inadequate oxygen
mismatch delivery to tissues

changes in
intrathoracic TISSUE
pressure HYPOXIA
relationships
09/15/23 CHEST TRAUMA 5
Pathophysiology of Chest Trauma
Tissue hypoxia
Hypercarbia
Respiratory acidosis: inadequate ventilation
Metabolic acidosis: tissue hypoperfusion (e.g.,
shock)

09/15/23 CHEST TRAUMA 6

Blunt trauma

09/15/23 CHEST TRAUMA 7

Penetrating trauma

09/15/23 CHEST TRAUMA 8

 Immediate Life Threats:-
Airway obstruction
Tension pneumothorax
Open pneumothorax
“sucking chest wound”
Massive hemothorax
Flail chest
Cardiac tamponade

09/15/23 CHEST TRAUMA 9

 Potential Life Threats:-
Lung contusion
Heart contusion
Aorta rupture
Diaphragm rupture
Tracheobronchial tree injury - larynx, trachea, bronchus
Esophagus trauma

09/15/23 CHEST TRAUMA 10

 Other Associated Injuries
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures

09/15/23 CHEST TRAUMA 11

Initial assessment and management
Primary survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care

09/15/23 CHEST TRAUMA 12

Initial assessment and management

•Hypoxia most serious problem: early interventions aimed at reversing

•Immediate life-threatening injuries treated quickly and simply, usually

with tube or a needle

•Secondary survey guided by high suspicion for specific injuries

09/15/23 CHEST TRAUMA 13

Airway Obstruction
Airway obstruction at alveolar level: assessed and managed during 2o
survey

Upper airway obstruction  immediate life threat which must be dealt

with in primary survey

Most common cause: patient’s tongue

09/15/23 CHEST TRAUMA 14

How do you manage the Airway
Obstruction management?

Chin-lift:- fingers under mandible,

lift forward so chin is anterior

09/15/23 CHEST TRAUMA 15

 Airway Obstruction con’t…
Jaw thrust:- Grasp angles of
mandible and bring jaw
forward

09/15/23 CHEST TRAUMA 16

 Airway Obstruction con’t…
Oropharyngeal airway:- Insert into mouth
behind tongue

DO NOT push tongue further back

09/15/23 CHEST TRAUMA 17

 Airway Obstruction con’t…
Nasopharyngeal airway:- Gently
insert well-lubricated “trumpet”
through nostril

Surgical airways
◦ Cricothyrotomy
◦ Tracheostomy

09/15/23 CHEST TRAUMA 18

 Airway Obstruction con’t…

Definitive Airway
Management:- tube in trachea
through vocal cords with
balloon inflated

09/15/23 CHEST TRAUMA 20

Tension pneumothorax
Air leak through lung or chest wall
“One-way” valve  lung collapse
Mediastinum shifts to opposite side
Inferior vena cava “kinks” on diaphragm decreased venous return 
cardiovascular collapse

09/15/23 CHEST TRAUMA 21

 Inferior vena cava

09/15/23 CHEST TRAUMA 22

Tension pneumothorax
Tension pneumothorax is not an x-ray diagnosis – it MUST be
recognized clinically

Treatment is decompression – needle into 2nd intercostal space of mid-

clavicular line - followed by thoracotomy tube

09/15/23 CHEST TRAUMA 23

 Insert needle here

09/15/23 CHEST TRAUMA 24

Open pneumothorax
“Sucking Chest Wound”
Normal ventilation requires negative intra-thoracic pressure
Large open chest-wall defect  immediate equilibration of intra-
thoracic and atmospheric pressures
If hole >2/3 tracheal diameter, air prefers chest defect

09/15/23 CHEST TRAUMA 25

Open pneumothorax

09/15/23 CHEST TRAUMA 26

Open pneumothorax

Initial treatment: seal defect and secure on three sides (total occlusion
may lead to tension pneumothorax

Definitive repair of defect in O.R.

09/15/23 CHEST TRAUMA 27

 Massive hemothorax
Rapid accumulation of >1500 cc blood in chest cavity
Hypovolemia & hypoxemia
Neck veins may be:
◦ Flat: from hypovolemia
◦ Distended: intrathoracic blood

Absent breath sounds, DULL to percussion

09/15/23 CHEST TRAUMA 28

09/15/23 CHEST TRAUMA 29
Massive hemothorax: treatment

Large-bore (32 to 36 F) tube to drain blood

If moderate sized (500 to 1500 ml) and stops bleeding, closed drainage
usually sufficient

If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN

THORACOTOMY indicated

09/15/23 CHEST TRAUMA 30

 Chest tube

09/15/23 CHEST TRAUMA 31

 Flail chest
“Free-floating” chest segment, usually from
multiple ribs fractures

Pain and restricted movement paradoxical

movement” of chest wall with respiration

09/15/23 CHEST TRAUMA 37

09/15/23 CHEST TRAUMA 38
 Flail treatment
Ventilate well
Humidify oxygen
Resuscitate with fluids
Manage pain (!!)
Stabilize chest
◦ Internal  ventilator
◦ External  sand bags (rare)

09/15/23 CHEST TRAUMA 39

Cardiac tamponade
Usually from penetrating injuries
Classic “Beck’s triad”
◦ elevated venous pressure - neck veins
◦ decreased arterial pressure - BP
◦ muffled heart sounds

Blood in sac
prevents cardiac
activity

09/15/23 CHEST TRAUMA 40

Cardiac tamponade
May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in
systolic BP during inspiration

Systolic to diastolic gradient of less than 30 mm Hg also suggestive

09/15/23 CHEST TRAUMA 41

 Cardiac tamponade
Treatment is removal of small amount of
blood – 15 to 20 ml may be sufficient –
from pericardial sac

09/15/23 CHEST TRAUMA 42

 Pericardiocentesis

09/15/23 CHEST TRAUMA 43

6 Potential Life Threats
Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture (TAR)
Traumatic diaphragmatic rupture
Tracheobronchial tree injury: larynx, trachea, bronchus
Esophageal trauma

09/15/23 CHEST TRAUMA 44

Pulmonary contusion
Potentially life-threatening condition with insidious onset
Parenchymal injury without laceration
More than 50% will develop pneumonia, even with treatment
Up to 50% have only hemoptysis as presenting symptom

09/15/23 CHEST TRAUMA 45

Traumatic aortic rupture

Disruption occurs at ligamentum arteriosum (ductus arteriosus)

Contained hematoma of 500 to 1000 ml of blood

09/15/23 CHEST TRAUMA 46

 Traumatic aortic rupture
Radiographic signs Elevated mainstem bronchus with
shift to right
Wide mediastinum (>8cm)
Esophagus shifted to right (NG at T4)
Fractured 1st & 2nd rib
Obliterated aortic knob
Trachea deviated to right

09/15/23 CHEST TRAUMA 47

09/15/23 CHEST TRAUMA 48
Subcutaneous emphysema

May result from

◦ airway injury
◦ lung injury
◦ blast injury

No treatment
required  address underlying problem

09/15/23 CHEST TRAUMA 49

Rib fractures
Most frequent thoracic cage injury

Most commonly injured: 4th  9th

If 10th / 11th / 12th  suspect liver or spleen injury

If 1st / 2nd / 3rd worry about injury to head, neck, spinal cords, lungs,
great vessels

09/15/23 CHEST TRAUMA 50