CHEST TRAUMA

Nader Saad, PGY2 Thoraco-Vascular Surgery

INTRODUCTION
 Blunt thoracic trauma produces damage by direct injury, compression, and forces of
acceleration or deceleration.
 Penetrating thoracic trauma causes direct injury along the path of a stab wound or projectile.
 Patients with penetrating injuries who survive to reach the hospital have better outcomes than
those who have sustained blunt injuries.
 Presume penetrating chest injuries in the “cardiac box”, an area bounded by the sternal notch,
xiphoid process, and nipples, to involve the heart or great vessels until proven otherwise.
 In polytrauma patients, thoracic trauma is the third leading cause of death after abdominal
trauma and head trauma.
ANATOMY
CLINICAL APPROACH
 Rapidly perform the physical examination during the primary and secondary surveys to detect life-threatening
injuries.

1. Inspection:
Contusions, abrasions
Seat belt sign, rule out vascular injury (deceleration injury)
Paradoxical segments or flail chest
Intrathoracic bleeding or open chest wounds
JVD, rule out tension pneumothorax or tamponade or air emboloism.
Swollen or cyanotic face, rule out SVC compression.
Subcutaneous emphysema, rule out lung laceration or bronchial injury.
Scaphpoid abdomen, rule out diaphragmatic injury.
CLINICAL APPROACH
2. Auscultation:
Unilaterally decreased breath sounds, rule out pneumothorax or hemothorax or bronchial
injury or bronchial foreign body.
Bowel sounds in thorax, rule out diaphragmatic injury.

3. Palpation:
Localized tenderness to ribs or sternum, rule out fractures.
CLINICAL APPROACH

 Perform an extended FAST examination as an adjunct to the secondary survey because it can
rapidly diagnose both pneumo- and hemothorax with excellent sensitivity and specificity.
PULMONARY CONTUSION
 Defined as direct injury to the lung resulting in both hemorrhage and edema in the absence of
a pulmonary laceration.
 The most common cause of pulmonary contusions is a compression-decompression injury to
the chest, such as seen in high-speed motor vehicle crashes.
 Patients who have a contusion >20% of lung volume have up to an 80% risk of developing
acute lung injury.
 Treatment: maintenance of adequate ventilation and pain control.
 Patients with less than one fourth of total lung volume involvement (about one lobe) usually
do not require mechanical ventilation.
HEMOTHORAX
 Bleeding from direct lung injury is the most common cause of hemothorax

 Bleeding into the hemithorax may arise from mediastinal, diaphragmatic, pulmonary, pleural,
or chest wall injuries.

 Bleeding of venous origin usually tamponades without intervention.

 Damage to intercostal or internal mammary arteries or pulmonary vessels causes more severe
bleeding and almost always requires invasive management.
HEMOTHORAX
Diagnosis:
1. CT chest:
CT has the highest sensitivity and specificity for detecting hemothorax.
2. Xray:
Fluid collections >200 to 300 mL can usually be seen on upright or decubitus chest radiographs.
If the patient is supine, >1000 mL of blood may be missed due to posterior layering of blood,
producing only diffuse haziness on that side.
3. POCUS:
May be used in critically ill patients, showing a fluid density between the visceral and parietal
pleura.
HEMOTHORAX
HEMOTHORAX
HEMOTHORAX
Treatment:
1. Chest tube:
If the hemothorax is judged large enough to drain (>200 to 300 mL), tube thoracostomy remains
the standard of care.
Bleeding from multiple small intrathoracic vessels often stops fairly rapidly after the
hemothorax is completely evacuated.
2. Operative treatment:
Fewer than 5% of patients will require operative management.
Consider surgical exploration in the following circumstances: >1500 mL of blood is evacuated
immediately after tube thoracostomy, chest tube drainage of blood at 150 to 200 mL/h for 2 to 4
hours, or persistent blood transfusion is required to maintain hemodynamic stability.
HEMOTHORAX
Massive Hemothorax:
Common causes of massive hemothorax include injury to the lung parenchyma, intercostal
arteries, or internal mammary arteries.
Each hemithorax can hold 40% of a patient’s circulating blood volume.
A massive hemothorax is defined in the adult as a volume of at least 1500 mL
Suggestive findings include decreased or absent breath sounds and no chest movement with
respiratory effort.
Life threatening due to: hypovolemia, hypoxia, vena cava and lung compression.
Diagnosed by CXR or POCUS.
Treatment is tube thoracostomy and replacement of blood products as clinically indicated.
PNEUMOTHORAX
 Pneumothorax is found in approximately 20% of patients with significant chest trauma.

 Traumatic pneumothorax can be open, closed, or occult.

 In an individual without preexisting cardiopulmonary disease, an isolated pneumothorax

usually does not cause severe symptoms unless it occupies >40% of the hemithorax.

 Occult pneumothoraces may complicate the management of patients who are emergently taken
to the operating room because intubation and positive-pressure ventilation may convert a small
occult pneumothorax into a tension pneumothorax.
PNEUMOTHORAX
Diagnosis:
Although chest radiography remains the most common diagnostic tool for detecting
pneumothorax in the ED, it will miss between 17% and 80% of pneumothoraces for upright and
supine chest radiographs, respectively.
POCUS is more sensitive than a supine radiograph and is rapid and accurate for detecting
pneumothorax. (absence of lung sliding, bar code side on M mode)
Occult pneumothoraces are detected by CT
Pneumothorax after a stab wound may be delayed for up to 6 hours  repeat chest imaging in 4
to 6 hours is indicated in these patients or at any time when symptoms worsen.
A common practice is to observe patients with asymptomatic thoracic stab wounds, repeat the
chest radiograph in 4 to 6 hours, and discharge the patient if no delayed pneumothorax is seen in
the absence of other concerns.
PNEUMOTHORAX
PNEUMOTHORAX
Treatment:
Occult pneumothorax usually do not require chest tube drainage unless the patient requires
mechanical ventilation.
Avoid unnecessary tube thoracostomy because there is a 22% risk of major insertional,
positional, or infective complications.
In general, small- or moderate-sized pneumothoraces, once treated, do not cause significant
problems unless there is a continuing air leak or preexisting cardiopulmonary disease.
If a pneumothorax persists or there is a large air leak, perform emergency bronchoscopy to
examine and clear the bronchi or to identify and repair any damage to the tracheobronchial tree.
Continued large air leakage or failure of the lung to adequately expand, despite bronchoscopy ,
is an indication for early thoracotomy.
PNEUMOTHORAX
Tension pneumothorax:
Diagnose and treat tension pneumothorax clinically, before the chest radiograph is obtained.
Classic presentation: distended neck veins, hypotension or evidence of hypoperfusion,
diminished or absent breath sounds on the affected side, and tracheal deviation to the
contralateral side.
Perform immediate needle decompression, usually in the fourth intercostal space at the
anterior axillary line or the second intercostal space at the midclavicular line, followed by
chest tube insertion.
Patients requiring assisted ventilation with a tension pneumothorax are more likely to be
hypoxic, be hypotensive, and experience cardiac arrest than those who are breathing
spontaneously.
PNEUMOTHORAX
PNEUMOTHORAX
Open pneumothorax:
Open pneumothorax is a communication between the pleural space and surrounding atmospheric
pressure.
This is sometimes referred to as a “sucking chest wound,” but also may be due to small rents in the
parietal pleura or small air passages without an obvious penetrating injury.
Respiratory distress is due to lung collapse and subsequent inability to ventilate the affected lung.
The initial therapeutic maneuver to treat a sucking chest wound is to cover the wound with a three-
sided dressing such that air can exit but not enter the chest.
Avoid complete occlusion, as this may convert the injury into a tension pneumothorax.
Do not insert a chest tube through the trauma wound, as it is likely to follow the missile or knife
tract into the lung or diaphragm.
PNEUMOTHORAX
RIB FRACTURES
 Rib fractures are the most common bony injuries in chest trauma and are diagnosed in
approximately 50% of patients admitted to the hospital following chest trauma.
 Rib fractures are painful injuries, heal slowly, and are closely associated with mortality and
morbidity.
 In the patient with severe chest trauma or significantly displaced rib fractures or in the
presence of other injuries, perform serial chest imaging to evaluate for developing
pneumothoraces or other injuries.
 Assume the presence of rib fractures in any patient with localized pain and tenderness over
one or more ribs after chest trauma
 Up to 50% of rib fractures (especially those involving the anterior and lateral portions of the
first five ribs) are not apparent on conventional radiography, particularly in the first few days
after injury.
RIB FRACTURES
 With the exception of direct local trauma, it takes great force to fracture the first and
second ribs, given their short length, relative immobility, and protection by other structures in
the upper chest. Such fractures can be associated with significant injuries to underlying organs
such as blunt myocardial injury, bronchial tears, or a major vascular injury, with 15% to 30%
associated with poor outcome, usually from head injury or rupture of a major vessel.

 In patients with multiple fractured ribs of the middle (ribs 5 to 8) and lower segments (ribs 9 to
12), unexplained hypotension may be the result of intra-abdominal bleeding from the liver or
spleen  consider CT abdomen-pelvis.
RIB FRACTURES
 Adequate analgesia is critical to maintain normal respiratory function during the healing
process. A combination of opioids, benzodiazepines, topical lidocaine patch, and NSAIDs
provides the most effective analgesia for mild to moderate chest wall pain.

 Patients with multiple fractured ribs will often have difficulty coughing or adequately clearing
secretions and should be considered for 24- to 48-hour observation unit admission, especially
the elderly or those with preexisting pulmonary disease.
FLAIL CHEST
 Segmental fractures of three or more adjacent ribs anteriorly or laterally often result in an
unstable chest wall physiology known as flail chest.
 This injury is characterized by a paradoxical inward movement of the involved chest wall
segment during spontaneous inspiration and out- ward movement during expiration.
 These patients may fatigue rapidly as a vicious cycle of decreasing ventilation, increased work
of breathing, and hypoxemia may develop, resulting ultimately in sudden respiratory arrest.
 Treatment: analgesia and ventilatory support.
 Indications for early ventilatory support include shock, severe head injury, comorbid
pulmonary disease, fracture of eight or more ribs, other associated injuries, age >65
years, or arterial partial pressure of oxygen (Po2) <80 mm Hg despite supplemental
oxygen.
THANK YOU!