Chest trauma schwartz principle of surgery 10th edition

2. CHESTTRAUMA
Supervisor:Dr. Kachooei
Provisioner:Dr. Shater
Qom University of Medical Sciences And Health Services
Medical School

3. ABCs
Airway
■ Ensuring a patent airway is the first priority in the primary survey. This is essential,
because efforts to restore cardiovascular integrity will be futile unless the oxygen
content of the blood is adequate
■ all patients with blunt trauma require cervical spine immobilization until injury is
excluded.
■ a hard collar or placing sandbags

4. ABCs
Airway
■ In general, patients who are conscious, without tachypnea, and have a normal voice
are unlikely to require early airway intervention. Exceptions are:
1. penetrating injuries to the neck with an expanding hematoma
2. evidence of chemical or thermal injury to the mouth, nares, or hypopharynx
3. extensive subcutaneous air in the neck
4. complex maxillofacial trauma
5. airway bleeding

5. ABCs
Airway
■ chin lift or jaw thrust
■ oral airway or a nasal trumpet

6. ABCs
Airway
■ Establishing a definitive airway (i.e., endotracheal intubation) is indicated in patients with:
1. Apnea
2. inability to protect the airway due to altered mental status
3. impending airway compromise due to inhalation injury
4. Hematoma, facial bleeding, soft tissue swelling, or aspiration
5. inability to maintain oxygenation
■ nasotracheal, orotracheal, or operative routes.
■ Cricothyroidotomy (In patients under the age of 11, cricothyroidotomy is relatively
contraindicated)
■ Emergent tracheostomy

7. Cricothyroidotomy

8. Emergent tracheostomy

9. ABCs
Breathing andVentilation
■ All injured patients should receive supplemental oxygen and be monitored by pulse
oximetry.
■ Critical state should be R/O:
1. Tension pneumothorax
2. Open pneumothorax
3. Flail chest with underlying pulmonary contusion, and massive air leak.

10. Tension pneumothorax
 any patient manifesting respiratory distress and hypotension in combination with any
of the following physical signs:
■ tracheal deviation away from the affected side
■ lack of or decreased breath sounds on the affected side
■ subcutaneous emphysema on the affected side.
■ Patients may have distended neck veins due to impedance of venous return, but the
neck veins may be flat due to concurrent systemic hypovolemia
 Treatment: (out/in)

11. Open pneumothorax
 An open pneumothorax or “sucking chest wound” occurs with full-thickness loss of the
chest wall, permitting free communication between the pleural space and the
atmosphere.
 hypoxia and hypercarbia
 Treatment: (out/in)

12. TubeThoracostomy (ChestTube)

13. Flail chest ,pulmonary contusion and massive air leak
 Flail chest occurs when three or more contiguous ribs are fractured in at least two
locations. Paradoxical movement of this free-floating segment of chest wall is usually
evident in patients with spontaneous ventilation, due to the negative intrapleural pressure
of inspiration. tracheal deviation away from the affected side.
 it is the decreased compliance and increased shunt fraction caused by the associated
pulmonary contusion that is the source of acute respiratory failure.
 Pulmonary contusion often progresses during the first 12 hours
■ The patient’s initial chest radiograph often underestimates the extent of the pulmonary
parenchymal damage close monitoring and frequent clinical re-evaluation are warranted
 Massive air leak occurs from major tracheobronchial injuries.(type I,II)
 Treatment

14. ABCs
Circulation with Hemorrhage Control
■ Two causes of life-threatening injuries:
1. Massive hemothorax
2. Cardiac tamponade

15. Massive hemothorax
 A massive hemothorax (life-threatening injury number one) is defined as >1500 mL of
blood or, in the pediatric population, >25% of the patient’s blood volume in the pleural
space.
 CXR vs ChestTube.

16. Massive hemothorax
 Indication for operative treatment

17. Cardiac tamponade
 Cardiac tamponade (life-threatening injury number two) occurs most commonly after
penetrating thoracic wounds, although occasionally blunt rupture of the heart,
particularly the atrial appendage, is seen.
 The classic Beck’s triad—dilated neck veins, muffled heart tones, and a decline in
arterial pressure.
 Diagnosis of hemopericardium is best achieved by bedside ultrasound of the
pericardium
 treatment

18. ResuscitativeThoracotomy (RT)

19. Secondary Survey
ChestTrauma
 Any patient who undergoes an intervention in the ED—endotracheal intubation, central
line placement, tube thoracostomy—needs a repeat chest radiograph to document the
adequacy of the procedure.
 Patients with persistent pneumothorax, large air leaks after tube thoracostomy, or
difficulty ventilating should undergo fiber-optic bronchoscopy to exclude a
tracheobronchial injury or presence of a foreign body.
 CT scan:
■ high-energy deceleration motor vehicle collision with frontal or lateral impact (> 30 mph
frontal impact and >23 mph lateral impact)
■ motor vehicle collision with ejection
■ falls of >25 ft,
■ direct impact (horse kick to chest, snowmobile or ski collision with tree).

20. Secondary Survey
ChestTrauma
 Widening of the mediastinum(left-sided hematomas are associated with descending
torn aortas, whereas right-sided hematomas are commonly seen with innominate
injuries).
 CT scan , CTA

21. Secondary Survey
ChestTrauma
 Descending thoracic aortic
 injuries may require urgent if not emergent
intervention
 pharmacologic therapy with a selective β1 antagonist,
esmolol, should be instituted in the trauma bay, with a
target SBP of <100 mm Hg and heart rate of <100/min.
 subclavian artery injury
 brachial-brachial indices should be measured,
 CTA

22. Secondary Survey
ChestTrauma
 penetrating thoracic trauma
 For penetrating thoracic trauma, physical examination, plain posteroanterior and lateral
chest radiographs with metallic markings of wounds, pericardial ultrasound, and CVP
measurement will identify the majority of injuries.
 Finally, with wounds identified on the chest, penetrating trauma should not be presumed
to be isolated to the thorax. Injury to contiguous body cavities (i.e., the abdomen and neck)
must be excluded; plain radiographs are a rapid, effective screening modality
 Hemodynamically stable patients with transmediastinal gunshot wounds should undergo
CT scanning to determine the path of the bullet
 Trachea
 Bronchoscopy should be performed to evaluate the trachea in patients with a persistent air
leak from the chest tube or mediastinal air.
 Intubation, fistula
 Esophagus
 Because esophagoscopy can miss injuries following an apparent normal endoscopy,
patients at risk should undergo soluble contrast esophagraphy followed by barium
examination to look for extravasation of contrast to identify an injury

23. Secondary Survey
ChestTrauma
 Heart
 Blunt and penetrating cardiac injuries have widely differing presentations and
therefore disparate treatments.
 Survivable penetrating cardiac injuries consist of wounds that can be repaired
operatively; most are stab wounds.
 Occasionally, interior structures of the heart may be damaged. Intraoperative
auscultation or postoperative hemodynamic assessment usually identifies such
injuries. Echocardiography (ECHO) can diagnose the injury and quantitate its effect on
cardiac output. Immediate repair of valvular damage or septal defects rarely is
necessary and would require cardiopulmonary bypass, but structural intracardiac
lesions may progress and, thus, patients must have a follow-up ECHO.

24. Secondary Survey
ChestTrauma
 Heart
 Patients with blunt cardiac injury typically present with persistent tachycardia or
conduction disturbances, but occasionally present with tamponade due to atrial or right
ventricular rupture.
 There are no pathognomonic ECG findings, and cardiac enzyme levels do not correlate
with the risk of cardiac complications.
 Stable: monitored for dysrhythmias for 24 hours by telemetry.
 Unstable: should undergo ECHO to evaluate for wall motion abnormalities, pericardial
fluid, valvular dysfunction, chordae rupture, or diminished ejection fraction. If such findings
are noted or if vasoactive agents are required, cardiac function can be continuously
monitored using a pulmonary artery catheter and serial SICU transthoracic or
transesophageal ECHO.

25. Secondary Survey
ChestTrauma
 Lung Parenchyma
 The majority of pulmonary parenchymal injuries are suspected based upon
identification of a pneumothorax; the vast majority is managed by tube thoracostomy.
 Occasionally, tractotomy reveals a more proximal vascular injury that must be treated
with formal lobectomy. Injuries severe enough to mandate pneumonectomy usually
are fatal because of right heart decompensation.

26. Secondary Survey
ChestTrauma
 Lung Parenchyma
■ posttraumatic pulmonary pseudocyst (pneumatocele):
 Traumatic pneumatoceles typically follow a benign clinical course and are treated with
aggressive pain management, pulmonary toilet, and serial chest radiography to
monitor for resolution of the lesion.
 If the patient has persistent fever or leukocytosis, however, chest CT is done to
evaluate for an evolving abscess, because pneumatoceles may become infected.
 Abscess.:AB + CT guided catheter drainage + (Surgery ranging from partial resection
to anatomic lobectomy)

27. Secondary Survey
ChestTrauma
 Lung Parenchyma
 Empyema:
 The most common complication after thoracic injury
 Tap(PH,Glc, LDH)
 Management is based on CT diagnostic criteria
 single loculation without appreciable rind:Percutaneous drainage
 multiple loculations or a pleural rind of >1 cm:Early decortication via video-assisted
thoracic surgery(VATS)
 Antibiotic treatment is based on definitive culture results, but presumptive antibiotics
should cover MRSA in the SICU.

28. Secondary Survey
ChestTrauma
 Scapular and sternal fractures
 rarely require operative intervention but are markers for significant thoracoabdominal
force during injury
 significant displacement may benefit from sternal plating

29. Secondary Survey
ChestTrauma
 clavicle fractures
 often are isolated injuries and should be managed with pain control and
immobilization.
 The exception is posterior dislocation of the clavicular head, which may injure the
subclavian.

30. Secondary Survey
ChestTrauma
 Diaphragm
 Blunt diaphragmatic injuries usually result in a linear tear, and most injuries are large,
whereas penetrating injuries are variable in size and location depending on the agent
of injury.
 Regardless of the etiology, acute injuries are usually repaired through an abdominal
approach to manage potential associated intraperitoneal visceral injury. After
delineation of the injury, the chest should be evacuated of all blood and particulate
matter, and thoracostomy tube placed if not previously done.