Pathophysiology

Derangements in the flow of air, blood, or both

in combination
Chest wall injures rib fractures
Direct lung injures lung contusions
Space-occupying lessions pneumothoraces,
hemothoraces, hemopneumothoraces
Cardiac injures chamber rupture
Severe great vessels injures thoracic aortic
disruption
TRAUMA THORAX
RAPIDLY LETHAL LESION
ie. Lesion that could kill the patient in a matter of minutes
airway obstruction
tension pneumothorax
open pneumothorax
massive haemothorax
flail chest
cardiac tamponade
Potensially lethal lesions,
.i.e. lesions that can kill the patient in matter of hours
pulmonary contusion
aortic rupture
tracheobronchial rupture
oesophageal rupture
diaphragmatic rupture
myocardial contusion
NON IMMEDIATELY LIFE THREATENING
LESIONS
Haemothorax
simple pneumothorax
rib fractures
sternal fractures
soft tissue lesions
traumatic chylothorax
intrathoracic foreign bodies
subcutaneous emphysema
others.
Clinical Presentation
Varies widely from minor report to florish shock
Clinical history time of injury, mechanism,
velocity&deceleration, assosiated injury, silent
future
3 broad categories : (1) chest wall fracture,
dislocation, and barotrauma (including
diaphragmatic injury); (2) blunt injuries of the
plaurae,lungs, and aerodigestive tracts; and (3)
blunt injuries of the heart, great vessels
Imaging studies
CXR should not wait CXR for diagnose
emergency measurement
Chest CT-scan should restricted to
undetected or occult injury is considered
Aortogram standard for diagnosis of blunt
aortic injures
Thoracic US pericardial effusions or
tamponade
Contrast Esophagogram for esophageal
injures
Rib Fractures
Most common blunt thoracic injuries, rib 4-10
most frequently involved
Inspiratory chest pain, pain over the fractures
site
Tenderness and crepitus over the site of
fracture
Mostly do not need surgery, pain control
the goal of treatment
Early mobilization and aggressive pulmonary
toilet
Surgical Hemostasis if lacerates intercostal
artery
Flail Chest
>3 ribs fractures in >2 places free floating and
unstable chest wall or Costochondral separation
Pain over fracture site, pain upon inspiration, dyspnea.
Paradoxal inspiration (sucking chest) chest wall
move inward with inspiration and outward with
expiration
Labored respiration due to paradoxal motion
respiratory distress

Treatment : Flail Chest
Endotreacheal intubation and positive
pressure mechanical ventilation
Stabilize chest wall internal fixation
Clavicular fracture
Tenderness and tenderness over the site
Proximal segment displaced superiorly
action sternocleidomastoideus
Mostly can be managed without surgery
Immobilization figure eight, clavicle
strap, sling.
Oral analgesia
Sternal Fracture
Inspiratory pain, local tenderness, swelling,
ecchiymosis, crepitus
Associated injuries : rib fractures, long bone fracture,
close head injury
Blunt cardiac injury 20%
No therapy specifically analgesia and minimize
activities of pectoral and shoulder muscle
Most important exclude blunt myocardial injury
Open reduction & fixation badly displaced wire
suturing and placement of plates and screw
Scapular fracture
Uncommon
Associated injury : head, chest, abdomen
Exclude major vascular injury
Shoulder immobilization sling or
shoulder harness
Early ROM exercise prevent shoulder
contracture
Blunt diaphragmatic injuries
Mostly left side
Must considered abdominal injury
with dyspnea and respiratory distress
Hypovolemic shock major splenic or
hepatic injury
Approached laparotomy suture with
polypropylene or dacron
Pneumothorax
Rib fracture or barotrauma
Dyspnea, decreased breath sound and
hyperresonance to percussion
Chest tube + suction sistem -20 cmH2O
(pleur-evac) WSD if the lung
remains fully expanded chest tube
remove CXR
Tension pneumothorax
Ventile mechanism lungs collaps
respiratory distress
Diminished or absent of breath sound,
hemithorax hyperresonant to percussion,
trachea deviated
Immediate decompression with needle
thoracostomy (large bore nedle 14-16G)
Chest tube
Pain control
Open Pneumothorax
Caused by penetrating trauma
rarely due to blunt trauma
Respiratory distress lung
collaps
Placing occlusive dressing over
wound chest tube
Hemothorax
Accumulation of blood within the
pleural space
Lacerations internal mammary
vessels or other major thoracic
vessels
Chest tube, massive (1500mL or 200-
300 mL/h) thorachotomy
Pulmonary contusion and other
parenchymal injures
Transmition of force to the lung parenchym
lung contusion with hemorrage into the lung
tissue
Clinical finding depent to the extent of the
injury
Pain control, pulmonary toilet, sumplemental
oxygen (intubation with mecanical ventilation)
Surgical haemostatis laceration or avulsion
Blunt tracheal injury
Fracture, lacerations, and disruptions
Respiratory distress, cannot speak, stridor, other
sign associated w pneumothorax n subcutaneous
emphysema
Many die before can reach defenitive care life
trheatening require immediate surgical repair to
establishment of an adequate airway
Endotracheal intubation flexible bronchoscope
tube placed distal site of injury
Always prepared to perform emergency
trecheotomy
Surgical repair restoration of airway continuity w
primary end-to-end anstomosis
Blunt bronchial injuries
Laceration, tear, or disruption of a major
bronchus is life threatening many die
before treatment
Respiratory distress n physical sign consistent
w pneumothorax
Require surgical repair secure airway
Ipsilateral thoracotomy on the affected side w
single-lung ventilation debridemant n end-
to-end ansstomosis
Blunt esophageal injuries
Rare because protected location in posterior
mediastinum
Caused by a sudden increase intraluminal
pressure from a forceful blow to the
epigastrium
Spillage GI contents into the chest
Upper abdo & thoracic pain ass w thypnea,
tachycardia, subcutaneus emphysema.
Treatment : Blunt esophageal injuries
Fluid resuscitation n broad-spectrum iv antibiotic
n anaerob AB
Surgery debridemant w primary anatomosis
well-vascularized autologous tissue (parietal
pleura n intercostal muscle) Thal Patch
Poor general condition esophageal diversion (a
cervical esophagostomy), the distal esophagus
stapled, gastrostomy for decompression, and
wide mediatinal drainage w chest tube.
Blunt cardial injuries
Cause by : MVA (most common), falls,
crush injuries, violent, sport injury, ect
Range varies from mild trauma ass w
arrythmias to severe rupture valve,
septum or myocardial
Clinical varies from chest pain to cardiac
tamponade to complete cardivascular
collaps
Treatment cardiosintesis to
cardiorrhapy w cardiopulmonar by pass
Blunt injuries of the thoracic aorta and
major thoracic arteries
Mechanism injury: rapid deceleration
sharing force, direct compression
Many die before reaching defenitive care
Treatment: endovascular stent grafts,
arteriorraphy w cardiopulmonary by pass
Blunt injury of the superior vena cava and
major thoracic veins
Rare, usually ass w injuries other major
thoracic vascular structures
Treatment : venorrhaphy w
cardiopulmonary by pass
Injured subclavian or azigous veins if
difficult to repair can be ligated