CHEST TRAUMA

BY
DR ALLAH NAWAZ
MBBS(K.E),FCPS(PAK)

Consultant general & laparoscopic surgeon

Assistant Professor surgery
S-II DHQ Hospital (UOS)
• Chest trauma accounts for 20 – 25% of
all trauma related deaths

• Early deaths caused hypoxaemia,

hypovolemia & temponade
 PRIMARY SURVEY

• Primary survey of patient with thoracic trauma

begins with airway

• major problems should be

corrected as they are identified
AIRWAY

• Positioning of head

• Removal of blood / secretions

• Oropharyngeal airway / intubation

BREATHING
• INSPECTION: dyspnoea, engorged
neck veins, external evidence of trauma
• PALPATION: trachea, tenderness,
crepitus, decreased respiratory
movements
• PERCUSSION: dull / hyper-resonant
• AUSCULTATION: decreased / absent
breath sounds
•
TENSION
PNEUMOTHORAX
CLINICAL FEATURES

• Dyspnoea, engorged neck veins

• Tachycardia, hypotension, tracheal shift

• Hyper-resonant percussion

• Absent breath sound

MANAGEMENT
SUCKING CHEST
WOUNDS
CLINICAL FEATURES

• Tachypnoea, open wound on chest

• reduced respiratory movements

• hyper-resonant percussion

• reduced breath sounds

MANAGEMENT

• Sterile occlusive dressing

• Chest tube insertion

FLAIL CHEST
CLINICAL FEATURES

• Tachypnoea, paradoxical respiratory

movements

• reduced breath sounds

MANAGEMENT
• If hemodynamically stable - adequate
analgesia, humidified oxygen inhalation &
adequate fluid resuscitation

• If hemodynamically unstable - intubation

with PEEV

• Rarely open reduction, internal fixation

CIRCULATION
• Monitor quality, rate & regularity of pulse

• B.P & pulse pressure should be measured

MASSIVE
HEMOTHORAX
• Rapid accumulation of > 1500ml on chest
tube insertion

• Accumulation of 200 – 300ml/hr for 3 hrs

CLINICAL FEATURES
• Dyspnoea, distended neck veins may
be present.
• tachycardia, hypotension, cold clammy
skin, mediastinal shift may be present
• Dull percussion note
• reduced breath sounds
MANAGEMENT

• Large caliber IV lines & rapid crystalloid

fluids, blood transfusion,

• Single chest tube insertion

• Thoracotomy
CARDIAC
TEMPONADE
CLINICAL FEATURES

• Classic diagnostic Beck’s triad consists of

venous pressure elevation, decline in
arterial pressure& muffled heart sounds.
• Pulsus paradoxus on inspiration.
MANAGEMENT

• Pericardiocentesis

• Subxyphoid pericardial window /

thoracotomy with pericardiotomy
SECONDARY SURVEY

• Secondary survey requires further in-

depth physical examination
INJURIES TO CHEST
WALL
RIB FRACTURE
• Most commonly 4th - 10th rib are fractured

• Pain on breathing, local tenderness,

crepitus, x-rays for diagnosis

• Pain control with analgesics/ intercostal

nerve block / epidural analgesia

• Effective breathing exercises

 STERNAL FRACTURE
• Indicates singnificant trauma to anterior chest
• Pain over sternum, local tenderness, crepitus,
hematoma

• If stable –manage conservatively & monitoring

with ECG, serial cardiac enzymes

• In instable – open reduction, internal fixation

PULMONARY
PARENCHYMAL INJUIES
PULMONARY LACERATION

• Simple lacerations are common after

penetrating trauma

• Patient present with pneumo /

hemothorax

• Chest tube intubation

PULMONARY CONTUSION

• Follows blunt trauma / sometimes

penetrating injuries

• Diagnosis: low Po2, x-rays

• i/v fluids, O2 inhalation, pain control,

intubation & mechanical ventilation
INJURIES TO MEDIASTINAL
STRUCTURES
 TRACHEOBRONCHIAL
INJURY
• Unusual but fatal injuries
• Patient presents with hemoptysis,
subcutaneous emphysema, tension
pneumothorax, mediastinal shift
• Chest intubation, opposite main stem
intubation
• If < 1/3rd circumference involved – observe
• If > 1/3rd - repair
BLUNT CARDIAC INJURY
• Results in myocardial contusion/
chamber / valvular disruption
• If myocardial contusion – chest pain,
conduction defects on ECG
• If chamber disruption – cardiac
temponade
AORTIC DISRUPTION
• Common cause of death in automobile
collision
• X-Ray show wide mediastinum, indistinct
aortic knob, left pleural effusion, deviation
of NG tube to right
• Treatment – primray repair / resection of
injured area & grafting
ESOPHAGEAL INJURY

• Mostly caused by penetrating injuries

• Suspected if 1) left hemo /

pneumothorax without rib fracrure. 2)
blow to lower sternum & patient in
shock out of proportion. 3) particulate
matter in chest tube after blood begins
to clear
• Wide drainage of pleural space &
mediastinum with direct repair of injury
after thoracotomy (within few hours)
DIAPHRAGMATIC INURY

• Common on left side

• Lead to diaphragmatic hernia if large
enough
• Treatment is repair of defect
TRANSMEDIASTINAL GUNSHOT
WOUND

• Hemodynamically unstable – exploratory

thoracotomy

• Hemodynamically stable – evaluation by

different modalities