Bedsite Teaching

Thoracic Trauma
Kelompok B1:
Abdalia Zubara Siregar 210131092
Cj Randas Senggado 210131143
Siti Maghfirah 210131173
Rio Wahyudi Panggabean 210131247
Ziqka Afriza Zuzafni 210131252

Dosen Pembimbing: dr. Marshal, Sp.B, Sp.BTKV(K)

Introduction
Introduction
• Thoracic trauma is responsible for 25% of all trauma deaths.

• Motor vehicle crashes account for 70-80% of blunt chest trauma cases.

• Pulmonary contusions, pneumothorax and haemothorax occur in 30-50% of patients with severe
blunt chest trauma.

• The initial assessment and management of patients presenting with chest trauma consists of the
primary survey with appropriate interventions as per Advanced Trauma Life Support
(ATLS)/Early Management of Severe Trauma (EMST) guidelines.

Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534843/
Anatomy
 Anatomy
The thorax consists of:
● Thoracic vertebrae (12) and intervertebral
discs.
● Costae (12 pairs) and costal cartilages.
● Sternum.
 Anatomy
Chest Wall Muscles
• M. Sternocleidomastoid
• M. Scalenus
• M. Pectoralis major and minor
• M. Serratus anterior
• M. External Intercostal
• M. Internal intercostals
• M. External and Internal Obliques
• M. Transversus Abdominis

Diaphragm
Vascularization of the thoracic cavity

Arteries: Posterior and anterior intercostal arteries, originating from the aorta and the internal thoracic
artery, where as the internal thoracic artery arises from the subclavian artery.

Veins: The intercostal veins eventually drain into the internal thoracic venous system, which are
connected to the brachiocephalic veins.
Anatomy of the thoracic cavity

The thoracic cavity is a cavity covered by the thoracic wall,

which consists of 3 compartments:
• The two lateral compartments are the "pulmonary cavity"
which contains the lungs and pleura.
• One central compartment is the "mediastinum".
Mediastinum
Definition
 Definition
Thoracic trauma includes secondary sequelae of
the trauma to all thoracic organs:
• Heart
• Large blood vessels
• Lungs
• Trachea and Bronchus
• Esophagus
• Diaphragm
• Chest wall
Epidemiology
Epidemiology
• Blunt chest trauma is more common than penetrating trauma and directly comprises 20% to
25% of trauma deaths.

• Poorer outcomes are also seen in patients with advanced age and higher injury severity
scores (ISS).

• Despite its higher incidence, less than 10% of patients suffering blunt trauma to the thorax
require operative intervention, whereas 15 to 30% of patients sustaining penetrating chest
injuries will need operative intervention.

Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure
Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534843/
Etiology
Etiology
• Thoracic trauma is broadly categorized by mechanism into
blunt or penetrating trauma.

• The most common cause of blunt chest trauma is motor vehicle

collisions (MVC) which account for up to 80% of injuries.

• Other causes include falls, vehicles striking pedestrians, acts of

violence, and blast injuries.

• The majority of penetrating trauma is due to gunshots and

stabbings, which together account for 20% of all major trauma
in the United States.

Demirhan, R.; Onan, B.; Oz, K.; Halezeroglu, S. (2009). Comprehensive analysis of 4205 patients with chest trauma: a 10-year experience. Interactive
CardioVascular and Thoracic Surgery, 9(3), 450–453. doi:10.1510/icvts.2009.206599
Edgecombe L, Sigmon DF, Galuska MA, et al. Thoracic Trauma. [Updated 2023 Feb 7]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing;
2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK534843/
Deadly Dozen
Deadly Dozen
Lethal Six Hidden Six

• Airway Obstruction • Thoracic aortic disruption

• Tension Pneumothorax • Tracheobronchial disruption

• Cardiac Tamponade • Myocardial contusion

• Open Pneumothorax • Traumatic diaphragmatic tear

• Massive Hemathorax • Esophageal disruption

• Flail Chest • Pulmonary contusion

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
Airway Obstruction
Airway Obstruction
• Airway obstruction results from swelling, bleeding, or vomitus that is aspirated into the airway,
interfering with gas exchange.

• The most common causes of airway obstruction are the tongue, avulsed teeth, dentures, secretions, and
blood.

• But, expanding hematomas that cause compression of the trachea, and thyroid cartilage or cricoid
fractures resulting in hemorrhage and edema may also be sources of obstruction.

• Upon clinical evaluation, patients present with signs of anxiety, hoarseness, stridor, air hunger,
hypoventilation, use of accessory muscles, sternal and supraclavicular retractions, diaphragmatic
breathing, altered mental status, apnea, and cyanosis (sign of preterminal hypoxia).

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 64

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
 Airway Obstruction
• Patients with airway obstruction may be treated with
clearance of the blood or vomitus from the airway by
suctioning.

• Indications for surgical cricothyroidotomy are edema of the

glottis, fracture of the larynx, or severe hemorrhage
obstructing the airway.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 64

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
Airway Obstruction
Key issues in managing airway difficulty include the following:

1. Delivering adequate oxygen to vital organs

2. Maintaining a patent airway

3. Ensuring adequate ventilation

4. Protecting the cervical spine

5. Recognizing the need for endotracheal intubation

6. Knowing how to utilize rapid sequence intubation

7. Being proficient in surgical airway techniques

8. Preventing hypercarbia is critical!

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
Tension Pneumothorax
Tension Pneumothorax
• Tension pneumothorax develops when a “one-way valve” air leak occurs from the lung or through the chest wall

• Tension pneumothorax is a life-threatening situation that requires immediate recognition and treatment.

• Air is forced into the pleural space with no means of escape, eventually collapsing the affected lung.

• The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung

• The most common cause of tension pneumothorax is mechanical positive-pressure ventilation in patients with
visceral pleural injury.

• Do not delay treatment to obtain radiologic confirmation.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 65-66
Tension Pneumothorax
Tension pneumothorax is characterized by some or all of
the following signs and symptoms:

• 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 Injured tissue forms a one way valve into pleural space 
• Cyanosis (late manifestation) inspiration  air enter pleural space  air cannot leave  pressure
increases inside lung  lung collapses  no air entry

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 66

Tension Pneumothorax
• Pleuritic chest pain
History Taking • Dyspnea
• Tension pneumothorax = diaphoresis, cyanosis, weakness, symptoms oh
hypotension and cardiovascular collapse

Physical • Tachypnea, tachycardia * Hiperresonance * Vocal fremitus (-)

• Tracheal deviation (tension pneumothorax) * Distended neck veins
Examination • Decreased breath sound * Decreased saturation

• Hypoxia, hypocapnia
Laboratorium • ECG = axis deviation, non specific ST segment changes, invertion of T wave

• Extended FAST (eFAST) examination

Imaging • Chest radiograph (PA and Lateral)
• CT scan
CT Scan :
Pneumothorax, Collapse
Lung
Chest Radiograph :
Tension Pneumothorax
Tension Pneumothorax
Management
• Supplemental oxygen is provided

• Immediate decompression is accomplished by inserting a 12-14

gauge angiocatheter into the second intercostal space in the
midclavicular line of the affected hemithorax.

• A chest tube is inserted in the fourth intercostal space in the

midaxillary line, to allow lung re-expansion, and to prevent
further episodes.

• Pain management and pulmonary toileting are also initiated at

this point.

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care
Nursing Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
Cardiac Tamponade
 Cardiac Tamponade
• Cardiac tamponade is compression of the heart by an
accumulation of fluid in the pericardial sac.

• The classic clinical triad of muffled heart sounds, hypotension, and

distended veins also known as Beck’s Triad.

• cause (80%–90%) of cardiac tamponade in trauma patients is

penetrating injuries such as stab wounds, bullets, or rib fractures,
which produce lacerations of the pericardium that seal from fatty
tissues or by the formation of clots.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 69-70
 Sign and Symptom

Signs Symptoms

• Hypotension
• Jugular venous distention • Dyspnoea
• Muffled heart sounds • Chest discomfort
• Tachycardia
• Peripheral oedema
• Pulsus paradoxus
• Fatigue
• Decreased ECG voltage with electrical alternans
• Enlarged cardiac silhouette on chest X-Ray with
• Tachypnoea
slow accumulating effusions

Jensen J.K, S.H., P. and Henning, M. (2017) ‘Cardiac tamponade: a clinical challenge’, E-Journal of Cardiolgy Practice, 15(17), pp. 1–9.
 Diagnosis

• Clinical Presentation
• Beck’s triad (hypotension, distant heart sound, jugular vein
distention)
• Laboratory findings
• Analyse the pericardial fluid for white blood cell count,
haematocrit, malignant cells and protein content
• ECG
• Low QRS voltage in
• The limb leads alone
• The precordial leads alone
• All leads
• PR segment depression
• Electrical alternans
• Sinus tachycardia.

Jensen J.K, S.H., P. and Henning, M. (2017) ‘Cardiac tamponade: a clinical challenge’, E-Journal of Cardiolgy
Practice, 15(17), pp. 1–9.
Ang KP, Nordin RB, Lee SCY, Lee CY, Lu HT. Diagnostic value of electrocardiogram in cardiac tamponade.
Med J Malaysia. 2019 Feb;74(1):51-56. PMID: 30846663.
 Diagnosis

• Chest X-Ray
• Cardiac silhouette
• Echocardiography
• Transparent separation between the parietal and visceral pericardium
during the cardiac cycle
• CT scan
• Not necessary
• Second-line imaging in cases of complex or loculated effusions and
evaluation of associated or extracardiac diseases or findings.

Jensen J.K, S.H., P. and Henning, M. (2017) ‘Cardiac tamponade: a clinical challenge’, E-Journal of Cardiolgy Practice, 15(17), pp. 1–9.
De Carlini, C. and Maggiolini, S. (2017) ‘Pericardiocentesis in cardiac tamponade: indications and practical aspects’, e-Journal of Cardiology Practice, 15(19), p. 1.
Treatment
Conservative with careful follow up, monitoring and therapy to underlying cause
1
Needle paracentesis with echocardiography/fluoroscopy guidance
2
Open Surgical Drainage
3
Pericardiocentesis

4
Surgical pericardiectomy

Jensen J.K, S.H., P. and Henning, M. (2017) ‘Cardiac tamponade: a clinical challenge’, E-Journal of Cardiolgy Practice, 15(17), pp. 1–9.
Open Pneumothorax
Open Pneumothorax
• Open pneumothorax is caused when a penetrating chest
trauma opens the pleural space to the atmosphere, leading
to a collapsed lung and a sucking chest wound.

• 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.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 66-67
Treatment
Three sided wound dressing
1
Chest tube
2
Tracheal intubation and positive pressure ventilation

3 Evaluation and treatment of associated injuries

4
Massive Hemothorax
 Massive Hemothorax
• Massive hemothorax results from the rapid accumulation of more
than 1500 mL of blood or one-third or more of the patient’s blood
volume in the chest cavity.

• A massive hemothorax is commonly due to penetrating trauma

with hilar or systemic vessel disruption

• Patients with hemothorax typically present with decreased breath

sounds unilaterally or bilaterally with dyspnea, tachypnea, and
dullness to percussion over the affected side.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 68-69
 Treatment
• Supplemental oxygen therapy.

• Establish large caliber intravenous lines, infuse crystalloid, and begin

transfusion of uncrossmatched or type-specific blood as soon as possible.
When appropriate, blood from the chest tube can be collected in a device
suitable for autotransfusion.

• In most cases, the insertion of a large (28-32 French) chest tube (tube
thoracostomy) just anterior to the midaxillary line at the fourth or fifth
intercostal space to allow for chest decompression.

• A moderate-size hemothorax (500– 1500 mL) that stops bleeding after a

thoracostomy is usually treated with a closed drainage system.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 68-69
Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing Quarterly,
28(1), 22–40. doi:10.1097/00002727-200501000-00004
Flail Chest
 Flail Chest
• Flail chest is a traumatic condition of the thorax. It may occur when
3 or more ribs are broken in at least 2 places, leading to a floating
segment of chest wall.

• Clinical: hypoxia, pain, paradoxical chest wall motion, overlying

chest wall injury, bony step-offs, splinting.

• Imaging: Three consecutive rib fractures in ≥2 places on CXR or

CT, underlying pulmonary contusion.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 73-74
 Treatment
• Airway management,

• Supplemental oxygen therapy to maintain the PaO2 at levels of 80

to 100 mmHg

• pain control

• Intubation/tracheostomy and mechanical ventilation are indicated

if the respiratory rate is faster than 35 bpm, or less than 8 bpm

• For segments larger than 4 to 6 in, or multiple flail segments,

positive pressure ventilation is the optimal solution.

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
Thoracic Aortic Disruption
 Thoracic Aortic Disruption
• Traumatic aortic rupture is a common cause of sudden death after a vehicle
collision or fall from a great height.

• Blood may escape into the mediastinum, but one characteristic shared by all
survivors is that they have a contained hematoma.

• Specific signs and symptoms of traumatic aortic disruption are frequently

absent.

• No mediastinal or initial chest x-ray abnormality is present in patients

with great-vessel injury.

• Treatment: Pain  analgesics, Heart rate and blood pressure control  a

short-acting beta blocker (esmolol) or calcium channel blocker (nicardipine),
and Endovascular repair (most common option).

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 75-76
Tracheobronchial disruption
 Tracheobronchial disruption
• The majority of tracheobronchial tree injuries occur within 1 inch
(2.54 cm) of the carina.

• Patients typically present with hemoptysis, cervical subcutaneous

emphysema, tension pneumothorax, and/or cyanosis.

• Bronchoscopy confirms the diagnosis.

• Intubation can potentially cause or worsen an injury to the trachea

or proximal bronchi.

• For such patients, immediate operative intervention is indicated

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 64-65
Myocardial contusion
 Myocardial contusion

• Patients with blunt myocardial injury may report

chest discomfort, but this symptom is often attributed
to chest wall contusion or fractures of the sternum
and/or ribs

• The presence of cardiac troponins can be diagnostic

of myocardial infarction.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 75

Traumatic Diaphragmatic Tear
 Traumatic Diaphragmatic Tear

• Traumatic diaphragmatic ruptures are more commonly diagnosed

on the left side, perhaps because the liver obliterates the defect or
protects it on the right side.

• Appearance of an elevated right diaphragm on a chest x-ray may

be the only finding of a right-sided injury.

• Minimally invasive endoscopic procedures (e.g., laparoscopy and

thoracoscopy) may be helpful in evaluating the diaphragm.

• Treatment is by direct repair.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 76-77
Esophageal Disruption
 Esophageal Disruption

• Esophageal trauma most commonly results from penetrating injury.

• Although rare, blunt esophageal trauma, caused by the forceful

expulsion of gastric contents into the esophagus from a severe
blow to the upper abdomen, can be lethal if unrecognized.

• Contrast studies and/or esophagoscopy confirm diagnosis.

• Treatment of esophageal rupture consists of wide drainage of the

pleural space and mediastinum with direct repair of the injury.

ATLS (Advanced Trauma Life Support). 2018. 10th ed., pp. 76-77
Pulmonary Contusion
 Pulmonary contusion

• A pulmonary contusion is an injury to the lung

parenchyma in the absence of laceration to lung tissue or
any vascular structures.

• Signs and symptoms of respiratory distress: dyspnea, and

PaO2 less than 60 on room air. Auscultation of breath
sounds may reveal decreased breath sounds, rales, and
wheezing over the next 24 hours. Other signs are chest
pain and ineffective cough with hemoptysis.

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
 Pulmonary Contusion

• Chest x-ray reveals consolidation and pulmonary infiltration at

the area of injury, but these findings may lag 12 to 24 hours. CT
scan more sensitive than x-ray for diagnosis and evaluation.

• Initial treatment of pulmonary contusion includes supplemental

oxygen therapy, monitoring oxygen saturations, aggressive
pulmonary toilet to help clear bloody secretions from the
airway, and administration of analgesics.

Yamamoto, Linda; Schroeder, Crissy; Morley, Derek; Beliveau, Cathie (2005). Thoracic Trauma. Critical Care Nursing
Quarterly, 28(1), 22–40. doi:10.1097/00002727-200501000-00004
TERIMA KASIH