This document discusses the management of chest trauma. Some key points: - Chest injuries are a leading cause of death from trauma, accounting for 25% of trauma-related deaths. - Types of chest injuries include rib fractures, pneumothorax, hemothorax, lung contusions, and injuries to the heart or great vessels. - Life-threatening injuries requiring immediate treatment are termed the "lethal six" and include tension pneumothorax, massive hemothorax, open pneumothorax, flail chest, cardiac tamponade, and airway obstruction. - Assessment involves identifying these injuries through physical exam, chest x-ray, and CT scan. Tube

1. Management of Chest trauma
Dr.Elamaran.E
Assistant Professor
Department of CTVS
MGMC&RI
Puducherry

2. Chest trauma
• Lethality due to an Isolated chest traumas - 5% to 8%.
• Of all deaths caused in relation to chest injuries- 25%
(2nd leading cause of death)
• Role of surgery – 10% -15%
• Important factor - Total morbidity and mortality in
traumatized emergency patients
J Emerg Trauma Shock. 2011 Apr-Jun

3. Anatomy – Trauma
Grays Anatomy textbook

4. Types of Thoracic Trauma
• By Mechanism
– Blunt
– Penetrating
• By severity
– Life threatening
– Stable
Trauma - By David Feliciano, Kenneth Mattox, Ernest Moore

5. Types of Thoracic Trauma
Skeletal 1.Rib fracture
2.Sternal fracture
3.Scapular fracture
Pulmonary Injury 1.Pneumothorax
2.Hemothorax
3.Pulmonary Contusion
4.Trachea-Bronchial Injury
Cardiac & Great Vessels 1.Aortic Injury
2.Cardiac Contusion
Diaphragmatic Injury 1.Herniation
J Emerg Trauma Shock. 2011 Apr-Jun

6. Assessment in Thoracic Trauma

7. Lethal Six
• Tension Pneumothorax
• Massive Hemothorax
• Open Pneumothorax
• Flail chest
• Cardiac Tamponade
• Airway Obstruction

8. Hidden Six
• Aortic rupture
• Lung contusion
• Tracheo-bronchial injury
• Blunt cardiac injury
• Diaphragmatic herniation
• Esophageal perforation

9. Rib fracture
• Common ribs fracture – 3rd
to 8th
• 1st and 2nd rib fracture - High
velocity injury
• Any level of rib fracture, the
risk of Pneumothorax and
pulmonary contusion exists
• More than two rib fractures -
at significant risk of
complications.
J Emerg Trauma Shock. 2011 Apr-Jun

10. Flail Chest
• Fractures of more than two adjacent ribs at two different
locations
• Thorax instability with paradoxical motion.
• Underlying pulmonary parenchymal injury
• Elevated respiratory effort, dyspnea and hypoxemia and
can be life threatening
J Emerg Trauma Shock. 2011 Apr-Jun

13. Pneumothorax
• Injuries of the lungs or the thoracic wall can create a
pleural injury - collection of air in the pleural space, which
is associated with a collapse of the lung
• The closed form, or a small pneumothorax, is mostly
inconspicuous
J Emerg Trauma Shock. 2011 Apr-Jun

14. Thorax drainage should be performed except in
asymptomatic patients with occult pneumothorax
Source Pleural status

15. Tension Pneumothorax
• Amount of air in the pleural space increases and the loss of
air is impaired or impossible due to a valve mechanism.
• Tension Pneumothorax is purely a clinical diagnosis
• Reducing cardiac output.
– Displacement of the mediastinal structures and the
lungs
– Reduction of venous flow to the heart,
J Emerg Trauma Shock. 2011 Apr-Jun

16. Treated with immediate decompression of the pleural space -
Open thoracostomy alone is appropriate.
Formal tube thoracostomy can then be performed once the
patient reaches an appropriate setting
J Emerg Trauma Shock. 2011 Apr-Jun

17. • Needle thoracocentesis
– Technique of last resort during hospital and trauma
reception
• Significant failure rates
• Delay in providing formal pleural decompression,
caused due to incorrect needle placement
J Emerg Trauma Shock. 2011 Apr-Jun

18. • Large-bore cannula
(14G/16G)
• Skin is punctured just
above the third rib
• Perpendicular to the skin
until the pleura is entered

19. Open Pneumothorax

20. Sterile waterproof dressing
secured on three sides to act as a
flutter valve
Tube thoracostomy should be
placed away from the open
wound

21. Hemothorax or
Hemopneumothorax
• Sources of massive bleeding
– Aortic rupture
– Myocardial rupture
– Injuries to hilar structures.
– Other sources could be injuries to the chest wall with
lesions on intercostal or mammary blood vessels.
J Emerg Trauma Shock. 2011 Apr-Jun

23. • Thoracic drainage is the therapy of choice.
– Drainage and quantification of blood
– Removal of possible coexisting Pneumothorax
– Tamponade of the bleeding source
J Emerg Trauma Shock. 2011 Apr-Jun

24. Lung contusion
• Lung contusion is the most frequent intrathoracic injury
resulting from blunt trauma
• Isolated lung contusions - Benign
• In the early phase of injury, the impairment of oxygenation
seems to correlate with the involved lung tissue
• Clinically, gas exchange impairment is obvious.

25. • Chest x-ray - no indication of the severity of contusion and
cannot lead to a reliable prognosis.
• Thorax CT scan and blood gases - Better indicators of the
grade of lung contusion

26. Management
• Respiratory relief
– Sufficient pain management
– Physiotherapy and Pulmonary drainage
– Positive-pressure ventilation
– Impaired gas exchange, intubation and mechanical
ventilation
J Emerg Trauma Shock. 2011 Apr-Jun

27. Management
• Pain reduction - critical to optimizing patient ventilation.
– Painkillers
– Regional anesthesia
• Intercostal blockade
• Pleural catheters
• Thoracic epidural catheter
• Paravertebral blockade
J Emerg Trauma Shock. 2011 Apr-Jun

28. Chest Tube Insertion
• The optimal tube size depends on the air leakage rate
• Tube size of 28 or 32 French is normally sufficient
• Triangle of safety – 4th or 5th ICS
J Emerg Trauma Shock. 2011 Apr-Jun

29. Surgery -role
• Massive hemothorax (> 1,500 mL blood returned on
insertion of chest tube)
• Ongoing bleeding from chest (>200 mL/hour for ≥ 4 hours)
• Evidence of cardiac Tamponade
• Penetrating transmediastinal chest wounds with unstable
hemodynamics
Trauma Manual

30. • Chest wall disruption or impalement wounds to the chest
• Massive air leak from the chest tube or major
tracheobronchial injury seen on bronchoscopy
• Mediastinal hematoma or radiographic evidence of great
vessel injury with unstable hemodynamics
Trauma Manual

31. Subcutaneous Emphysema
• Result from airway injury, lung injury, etc; rarely, blast
injury.
• Although it does not require treatment, the underlying
injury must be addressed.
• If positive pressure ventilation is required - Tube
thoracostomy should be considered on the side of the
subcutaneous emphysema in anticipation of a
Pneumothorax (tension).

32. Take home message
• Avoid under estimating blunt pulmonary injury severity.
• Can present as a wide spectrum of clinical signs, often not
well correlated with chest x-ray findings
• Aggressive pain control without respiratory depression is
the key management principle.
• Careful monitoring of ventilation, oxygenation, and fluid
status is required, often for several days.

33. • A simple Pneumothorax should not be ignored or
overlooked. It can progress to a tension Pneumothorax.
• A simple hemothorax, not fully evacuated, can result in a
retained, clotted hemothorax with lung entrapment or, if
infected, develop into an empyema.

34. Thank You