Thoracic Trauma

Hesham Ahmed, MD
Assistant Professor of Surgery
Introduction
Trauma 3rd leading cause of death in the
U.S.
Trauma is the leading cause of death in
those under 40 yr
There are 100,000 accidental deaths/yr and
9,000,000 disabling injuries yearly in the
U.S.
25% of deaths from blunt trauma are due
solely to chest injuries
Introduction to Thoracic Injury
Vital Structures
Heart, Great Vessels, Esophagus,
Tracheobronchial Tree & Lungs
25% of MVC deaths are due to thoracic trauma
12,000 annually in US
Abdominal injuries are common with chest
trauma.
Prevention Focus
Improved motor vehicle restraint systems
Passive Restraint Systems
Airbags
-Gun Control Legislation
Anatomy
Injuries of chest
Simple/Closed
Pneumothorax
Open
Pneumothorax
Tension
Pneumothorax
Flail Chest
Hemothorax
Esophageal injury
Cardiac Tamponade
Traumatic Aortic
Rupture
Traumatic Asphyxia
Diaphragmatic
Rupture
Tracheal/ bronchial
injury
Blunt Chest Trauma
Higher mortality than penetrating
trauma
More frequent simultaneous injuries of
multiple organs
MVA: leading cause of chest trauma
with 50,000 deaths and 2 million
disabling injuries/year
Blunt Trauma
Results from kinetic energy forces
Subdivision Mechanisms
Blast
Pressure wave causes tissue disruption
Tear blood vessels & disrupt alveolar tissue
Disruption of tracheobronchial tree
Traumatic diaphragm rupture
Crush (Compression)
Body is compressed between an object and a hard surface
Direct injury of chest wall and internal structures
Deceleration
Body in motion strikes a fixed object
Blunt trauma to chest wall
Internal structures continue in motion
Ligamentum Arteriosumshears aorta
Age Factors
Pediatric Thorax: More cartilage = Absorbs forces
Geriatric Thorax: Calcification & osteoporosis = More fractures
Penetrating Chest
Injuries
Majority are stab
wounds or gunshot
wounds (GSW).
Lower mortality
rates.
85% of
penetrating chest
wounds can be
treated with tube
thoracostomy .
Pathophysiology of
Thoracic Trauma
Penetrating Trauma
Low Energy
Arrows, knives, handguns
Injury caused by direct
contact and cavitation
High Energy
Military, hunting rifles &
high powered hand guns
Extensive injury due to high
pressure cavitation
Trauma.org
High Velocity Missile
Injuries
Cavitation phenomenon:
causes damage to structures
distal to the path of the
missile.
Striking and shattering bone
and other tissue may add to
the damage
Associated injuries to the large
vessels and bronchi is common
Severe pulmonary contusion
Vietnam experience
Pathophysiology of
Thoracic Trauma
Penetrating Injuries (cont.)
Shotgun
Injury severity based upon the distance between the
victim and shotgun & caliber of shot
Type I: >7 meters from the weapon
Soft tissue injury
Type II: 3-7 meters from weapon
Penetration into deep fascia and some internal
organs
Type III: <3 meters from weapon
Massive tissue destruction
Chest Trauma
History & PE
ATLS protocol
A,B,C,D,Es
Contusions, diminished or absent breath
sounds, SQ emphysema
PE..
PE
AMPLE
A Allergies
M Medications (Anticoagulants,
insulin and cardiovascular medications
especially)
P Previous medical/surgical history
L Last meal (Time)
E Events /Environment surrounding
the injury; ie. Exactly what happened
Radiological studies
CXR- fast, easy, least expensive for
initial evaluation
Ultrasound-may soon replace CXR as
initial radiographic study in chest
trauma
CT Scan VS Angiography
ECO VS Transesophogeal
Echocardiography
FAST
Normal CXR
Pneumothorax
Iatrogenic PTX from NG
Simple Pneumothorax
Closed Pneumothorax
Progresses into Tension Pneumothorax
Occurs when lung tissue is disrupted and air leaks
into the pleural space
Progressive Pathology
Air accumulates in pleural space
Lung collapses
Alveoli collapse (atelectasis)
Reduced oxygen and carbon dioxide exchange
Ventilation/Perfusion Mismatch
Open Pneumothorax
Free passage of air between atmosphere and
pleural space
Air replaces lung tissue
Mediastinum shifts to uninjured side
Air will be drawn through wound if wound is 2/3
diameter of the trachea or larger
Signs & Symptoms
Penetrating chest trauma
Sucking chest wound
Frothy blood at wound site
Severe Dyspnea
Management of the Chest
Injury Patient
Open
Pneumothorax
High flow O2
Cover site with
sterile occlusive
dressing taped on
three sides
Progressive airway
management if
indicated
Tension Pneumothorax
Buildup of air under pressure in the
thorax.
Air is unable to escape from inside the
pleural space
Progression of Simple or Open
Pneumothorax
Tension Pneumothorax
Tension Pneumothorax
Inhale
Tension Pneumothorax
Exhale
Tension Pneumothorax
Inhale
Tension Pneumothorax
Exhale
Tension Pneumothorax
Inhale
Tension Pneumothorax
Inhale
Tension Pneumothorax
Heart is being
compressed
The trachea is
pushed to
the good side
S/ S of Tension
Pneumothorax
Anxiety/Restlessness
Severe Dyspnea
Absent Breath
sounds on affected
side
Tachypnea
Tachycardia
Accessory Muscle
Use
J VD
Narrowing Pulse
Pressures
Hypotension
Tracheal Deviation
(late if seen at all)
Management of the Chest
Injury Patient
Tension Pneumothorax
Confirmation
Auscultaton & Percussion
Pleural Decompression
2
nd
intercostal space in
mid-clavicular line
TOP OF RIB
Consider multiple
decompression sites if
patient remains
symptomatic
Large over the needle
catheter: 14ga
Chest Tube
Operative intervention
Massive or persistent
bleeding
Massive air leak
Tracheobronchial
injuries
Esophageal perforation
Cardiac or great vessel
injuries
Post-traumatic
empyema
Subcutaneous
Emphysema
Subcutaneous
Emphysema
Trauma.org
Hemothorax
Hemothorax
Accumulation of blood in the pleural space
Serious hemorrhage may accumulate 1,500 mL
of blood
Mortality rate of 75%
Each side of thorax may hold up to 3,000 mL
Blood loss in thorax causes a decrease in tidal
volume
Ventilation/Perfusion Mismatch & Shock
Typically accompanies pneumothorax
Hemopneumothorax
Hemothorax Signs & Symptoms
Blunt or penetrating chest trauma
Shock
Dyspnea
Tachycardia
Tachypnea
Diaphoresis
Hypotension
Dull to percussion over injured side
Operative Intervention for
Hemothorax
Hemothorax:
massive = initial
drainage more
than 1,000 cc or
Continuous
bleeding of 200
cc/hr for 2 hrs
Fractured Ribs: Chest
Wall Trauma
Rib fxs are found in
52% of patients with
documented cardiac
contusion
Mortality doubles with
there are 3 or more
ribs
( age related)
Blunt trauma with
chest injury increases
mortality rate by 27%
than without chest
injuries.
Associated risk for
death increases:
1-Pneumo by 38%
2-Hemothorax by
42%
3-Pulmonary
contusion by 56%
4-Flail chest by 69%
Flail Chest
Segment of the chest that becomes free to move
with the pressure changes of respiration
Three or more adjacent rib fracture in two or more
places
Serious chest wall injury with underlying pulmonary
injury
Reduces volume of respiration
Adds to increased mortality
Paradoxical flail segment movement
Positive pressure ventilation can restore tidal volume
Flail Chest
Flail chest
Combination of pulmonary contusion
and flail chest has a mortality of
42%
Pulmonary contusion with flail chest: 75%
require ventilation
Flail chest ALONE: 48% require
ventilation tx
Aggressive chest PT and pain control
Pulmonary Contusion
30-75% of patients with significant blunt chest
trauma
Frequently associated with rib fracture
Typical MOI
Deceleration
Chest impact on steering wheel
Bullet Cavitation
High velocity ammunition
Microhemorrhage may account for 1- 1 L of blood
loss in alveolar tissue
Progressive deterioration of ventilatory status
Hemoptysis typically present
Pulmonary Contusion
Inspiratory rales, decreased air entry
Patchy alveolar infiltrates due to intra-alveolar
hemorrhage
Intrapulmonary bleeding reaches maximal
extent within 6 hrs
Progression of a pulmonary contusion on X-ray
after 48 hrs should raise suspicion that
aspiration, bacterial pneumonitis or ARDS has
developed
Management of lung
contusion
ABCs
High flow O2 via NRB
Intubate if indicated
Consider RSI
Mechanical ventilation
Hypoxia
If VC less than 500 mL
Anticipate Myocardial Compromise
Shock Management
Chest Wall Injuries
Sternal Fracture & Dislocation
Associated with severe blunt anterior trauma
Typical MOI
Direct Blow (i.e. Steering wheel)
Incidence: 5-8%
Mortality: 25-45%
Myocardial contusion
Pericardial tamponade
Cardiac rupture
Pulmonary contusion
Dislocation uncommon but same MOI as fracture
Tracheal depression if posterior
Chest wall injuries
Scapular fractures
3% of blunt trauma cases
54% have pulmonary
contusions
11% have associated
ipsilateral subclavian,
axillary or brachial artery
injury
Over 1/3 are missed on initial
evaluation
Blunt Cardiac Injury
Myocardial Contusion
Occurs in 76% of patients with severe blunt chest trauma
Right Atrium and Ventricle is commonly injured
Injury may reduce strength of cardiac contractions
Reduced cardiac output
Electrical Disturbances due to irritability of damaged myocardial
cells
Progressive Problems
Hematoma
Hemoperitoneum
Myocardial necrosis
Dysrhythmias
CHF & or Cardiogenic shock
Myocardial Contusion Signs &
Symptoms
Bruising of chest wall
Tachycardia and/or irregular rhythm
Retrosternal pain similar to MI
Associated injuries
Rib/ Sternal fractures
Chest pain unrelieved by oxygen
May be relieved with rest
THIS IS TRAUMA-RELATED PAIN
Similar signs and symptoms of medical chest pain
Blunt Cardiac Injury
EKG (for any blunt chest injury,
persistent tachycardia, ST-T changes
or ectopy)
Cardiac enzymes (CPK, CK-MB and
Troponin I) [see EAST guideline]
Echocardiography (TEE)
Pericardial Tamponade
Restriction to cardiac filling caused by blood or
other fluid within the pericardium
Occurs in <2% of all serious chest trauma
However, very high mortality
Results from tear in the coronary artery or
penetration of myocardium
Blood seeps into pericardium and is unable to escape
200 ml of blood can restrict effectiveness of cardiac
contractions
Pericardial Tamponade
Signs & Symptoms
Dyspnea
Possible cyanosis
Becks Triad
J VD
Distant heart tones
Hypotension or
narrowing pulse
pressure
Weak, thready pulse
Shock
Kussmauls sign
Decrease or absence of
J VD during inspiration
Pulsus Paradoxus
Drop in SBP >10 during
inspiration
Electrical Alterans
P, QRS, & T amplitude
changes in every other
cardiac cycle
PEA
Myocardial Aneurysm or
Rupture
Occurs almost exclusively with extreme blunt
thoracic trauma
Secondary due to necrosis resulting from MI
Signs & Symptoms
Severe rib or sternal fracture
Possible signs and symptoms of cardiac tamponade
If affects valves only
Signs & symptoms of right or left heart failure
Absence of vital signs
Traumatic Aortic injury
Aorta most commonly injured in severe blunt
85-95% mortality
Injury may be confined to areas of aorta attachment
Signs & Symptoms
Rapid and deterioration of vitals
Pulse deficit between right and left upper or lower
extremities
Traumatic Esophageal
Rupture
Rare complication of blunt thoracic trauma
30% mortality
Contents in esophagus/stomach may move into
mediastinum
Serious infection occurs
Chemical irritation
Damage to mediastinal structures
Air enters mediastinum
Subcutaneous emphysema and penetrating
trauma present
Tracheo-bronchial Injury
Blunt trauma
Penetrating trauma
50% of patients with injury die within 1 hr of
injury
Disruption can occur anywhere in
tracheobronchial tree
Signs & Symptoms
Dyspnea
Cyanosis
Hemoptysis
Massive subcutaneous emphysema
Suspect/ evaluate for other closed chest trauma
Traumatic Asphyxia
Results from severe compressive forces applied
to the thorax
Causes backwards flow of blood from right side
of heart into superior vena cava and the upper
extremities
Signs & Symptoms
Head & Neck become engorged with blood
Skin becomes deep red, purple, or blue
NOT RESPIRATORY RELATED
J VD
Hypotension, Hypoxemia, Shock
Face and tongue swollen
Bulging eyes with conjunctival hemorrhage
Management of Traumatic
Asphyxia
Support airway
Provide O2
2 large bore IVs
Evaluate and treat for concomitant injuries
If entrapment > 20 min with chest
compression
Consider 1mEq/kg of Sodium Bicarbonate
Treatment summary
ATLS protocol:
A,B,C,D,Es
Emergency
management
Needle
thoracentesis
Tube thoracostomy
Subxiphoid
pericardotomy
Video assisted
thoracic surgery
(VATS)
ER Thoracotomy
Questions?