CHEST TRAUMA

Majid Pourfahraji

ANATOMY

TRAUMA
Trauma, or injury, is defined as cellular disruption caused by an
exchange with environmental energy that is beyond the body's
resilience.
Trauma remains the most common cause of death for all individuals
between the ages of 1 and 44 years and is the third most common cause
of death regardless of age.

PRIMARY SURVEY

The initial management of seriously injured patients consists of

performing the primary survey (the "ABCs"Airway with cervical
spine protection, Breathing, and Circulation); the goals of the primary
survey are to identify and treat conditions that constitute an immediate
threat to life.

MAIN CAUSES OF CHEST TRAUMA

Blunt Trauma: Blunt force to chest.

Penetrating Trauma: Projectile that enters chest causing small or
large hole.

Compression Injury: Chest is caught between two objects and chest

is compressed.

TRAUMA TO THE CHEST

Chest wall
* Rib fracture
* Flail chest
Airway obstruction
Pneumothorax
* Simple/Closed
* Open Pneumothorax
* Tension Pneumothorax

Hemothorax
Flail Chest and Pulmonary Contusion
Cardiac Tamponade
Traumatic Aortic Rupture
Diaphragmatic Rupture

RIB FRACTURE

Blunt And Penetrating

PAIN
Shallow breathing
Atelectasis
Shunt: lack of ventilation
respiratory and metabolic acidosis

ANATOMY

Intercostal nerve block

SIMPLE PNEUMOTHORAX

Opening in lung tissue that leaks air into chest cavity

Blunt trauma is main cause
May be spontaneous : Cough
Usually self correcting

S/S

Chest Pain
Dyspnea
Tachycardia
Tachypnea
Decreased Breath Sounds on Affected Side

TREATMENT FOR SIMPLE/CLOSED

ABCs with C-spine control

Airway Assistance as needed
If not contraindicated transport in semi-sitting position
Provide supportive care
Contact Hospital and/or ALS unit as soon as possible

TREATMENT FOR
SIMPLE/CLOSED

Thoracocentesis

Chest Tube or throcostomy

!!CHEST TUBE

OPEN PNEUMOTHORAX

An open pneumothorax or "sucking chest wound" occurs with fullthickness loss of the chest wall
Causes the lung to collapse due to increased pressure in pleural cavity
Can be life threatening and can deteriorate rapidly
Results in hypoxia and hypercarbia

Complete occlusion of the chest wall defect without

a
tube thoracostomy may convert an open
pneumothorax to a tension pneumothorax
Temporary management of this injury includes covering the wound
with an occlusive dressing that is taped on three sides.
Definitive treatment requires closure of the chest wall defect and tube
thoracostomy remote from the wound.

OCCLUSIVE DRESSING

ASHERMAN CHEST SEAL

S/S OF OPEN PNEUMOTHORAX

Dyspnea
Sudden sharp pain
Subcutaneous Emphysema
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound

TENSION PNEOMOTHORAX

Respiratory distress
Tachypnea
Tachycardia
Poor Color
Anxiety/Restlessness
Accessory Muscle Use
*Hypotension* But JVP +
Tracheal deviation away from the affected side
Lack of or decreased breath sounds on the affected side
Subcutaneous emphysema on the affected side
Hypotension qualifies the pneumothorax
Needle thoracostomy with a 14-gauge angiocatheter in the second intercostal
space in the midclavicular line
Tube thoracostomy should be performed immediately

TENSION PNEOMOTHORAX

The normally negative intrapleural pressure becomes positive, which

depresses the ipsilateral hemidiaphragm and shifts the mediastinal structures
into the contralateral chest
the contralateral lung is compressed and the heart rotates about the
superior and inferior vena cava; this decreases venous return and ultimately
cardiac output, which results in cardiovascular collapse

TENSION PNEOMOTHORAX

NEEDLE TORACOSTOMY

NEEDLE DECOMPRESSION

NEEDLE THORACOSTOMY

FLAIL CHEST

* Flail chest occurs when TWO or more contiguous ribs are fractured in at
least two location
* additional work of breathing and chest wall pain caused by the flail
segment is sufficient to compromise ventilation
* it is the decreased compliance and increased shunt fraction caused by the
associated pulmonary contusion that is typically the source of post injury
pulmonary dysfunction
* Treatment is intubation and mechanical ventilation (PEEP mode)
The patient's initial chest radiograph often underestimates the extent of the
pulmonary parenchymal damage
Must chest tube if bleeding!

FLAIL CHEST

FLAIL CHEST

HEMOTHORAX

life-threatening injury number one

A massive hemothorax is defined as >1500 mL of blood or, in the pediatric
population, one third of the patient's blood volume in the pleural space
tube thoracostomy is the only reliable means to quantify the amount of
hemothorax
After blunt trauma, a hemothorax usually is due to multiple rib fractures
occasionally bleeding is from lacerated lung parenchyma
a massive hemothorax is an indication for operative intervention
Indication of emergency toracotomy

HEMOTHORAX

HEMOTHORAX PHYSICAL
FINDINGS

RIB FRACTURE WITH

HEMOTHORAX

RIB FRACTURE WITH

HEMOTHORAX

CARDIAC TAMPONADE
life-threatening injury number two
Acutely, <100 mL of pericardial blood may cause pericardial tamponade
The classic diagnostic Beck's triaddilated neck veins, muffled heart tones,
and a decline in arterial pressureoften is not observed in the trauma
Increased intrapericardial pressure also impedes myocardial blood flow,
which leads to subendocardial ischemia
Best way to diagnose is ultrasound of the pericardium
Early in the course of tamponade fluid administration
a pericardial drain is placed using ultrasound guidance
Pericardiocentesis is successful in decompressing tamponade in
approximately 80% of cases : 15 to 20 cc

CARDIAC TAMPONADE

BECKS TRIAD

PERICARDIAL TAMPONADE
PHYSICAL FINDINGS

PERICARDIOCENTESIS