THORACIC TRAUMA

Surgical anatomy considerations

Thorax is the part of the body between the neck and abdomen. It consists of the rib cage, an osteocartilaginous structure (which houses the vital organs like lungs, heart and large vessels) and soft tissues (muscles, fascia, tendons, skin). On the front of the chest mammary glands are located. The osteoacartilaginous elements are represented by twelve thoracic vertebrae, sternum and ribs with costal cartilages. Between ribs there are 11 intercostal spaces, which are occupied by the Intercostal muscles and intercostal vessels and nerves. The role of this cage is to protect vital organs and also to confer the rigidity necessary for ventilation.

During trauma, any of these anatomical structures can suffer injuries. The less likely are the vertebrae, which are protected by the paravertebral muscles. The most fragile are the ribs and cartilages, structures that break most often. Types of bone lesions and their location depend much on the nature, strength and direction of the traumatic force. Bone fractures have two important consequences: broken edges may injure the nearby anatomic structures (intercostal vessels, pleura, lung, heart) and also alter the most important function of the thorax, namely the respiratory function, endangering the patient's life.
The thorax cage is like a rigid box, feature which is very important in respiration. Altering the rigidity of the cage especially after ribs fractures will alter the respiratory function also.

The thoracic cavity is separated from the abdominal cavity by the diaphragm which is the most important respiratory muscle. It acts like a piston. During its contraction it lowers decreasing the intra-thoracic pressure allowing the inspiration. During relaxation the diaphragm moves upward leading to a higher pressure in the thoracic cavity, inducing expiration. Intercostal muscles are the other respiratory muscles which by contraction elevate the ribs and increase the thoracic diameter and the depth of inspiration. Accessory muscles of breathing are considered: the sternocleidomastoid, scalene, serratus, pectoralis, trapezius, latissimus dorsi, and others. If a breathing disorder exists, the accessory muscles of inspiration may become overused.

Expiration is a passive action based on elastic recoil of the lungs. In forced expiration as well in certain condition when lung elasticity is affected the abdominal muscles and the internal intercostal muscles help expel air.

Another important aspect that must be understand is that between the two pleural layers (parietal and pulmonary) there is a virtual space with negative pressure (lower than the atmospheric pressure) so that traumatic lesions of these layers and beneath anatomical structures will be followed by rapid accumulation of fluids or gas (or both) into the pleural space which will lead to lung collapse and possible mediastinum dislocation. All these will impair more or less rapidly or dramatically the respiratory and cardiac function.
Often there is no direct relationship between the extent of injury and the physiopathological disorders. There are many cases when minimal gestures such as thoracocentesis, with fluid or gas evacuation, can save the patients life.

Traumas represent a principal cause of deaths in peacetime but especially in wartime. Chest and head trauma are the most dangerous. Chest trauma represents about a quarter of trauma in general, and greatly contributes (9-10%) to the general mortality of about 25%-50%. In most cases, chest injuries are part of polytrauma. Nowadays the most common injuries are caused by road traffic accidents. Thoracic trauma is estimated to be responsible for approximately 16,000 deaths per year in the United States. Estimates of thoracic trauma frequency indicate that injuries occur in 12 persons per million population per day. Approximately 33% of these injuries require hospital admission.

Early deaths due to thoracic trauma which occur within 30 minutes to 3 hours after the injury are secondary to cardiac injury with/without tamponade, great vessels injury, airway obstruction and aspiration. Two thirds of these patients reach the hospital prior to die. Only 10-15% of blunt trauma require thoracic surgery, and 15-30% of the penetrating chest trauma require open thoracotomy. 85% of patients with thoracic trauma, can be managed by simple lifesaving maneuvers that do not require surgical treatment.
Optimal treatment requires a through knowledge of the pathophysiology of the thorax and expertise the therapeutic interventions. Improved prehospital care and rapid transportation have increased the survival, but the mortality remains high.

CLASSIFICATION
A. Blunt trauma Blunt trauma are closed thoracic trauma (there is no solution of continuity on the skin). Blunt chest trauma may affect any component of the chest wall and thoracic cavity (bony skeleton, lungs and pleurae, tracheobronchial tree, esophagus, heart, great vessels of the chest, and the diaphragm). Kinetic forces act in different ways or mechanism: Blast the pressure wave can produce: Tissue disruption Vascular lesions Disruption of alveolar tissue Disruption of tracheobronchial tree Traumatic diaphragm rupture

Direct impact by a blunt object A hard object that hit the thorax can produce bone fractures, especially ribs and through the fractured edges, lesions of the nearby anatomical structures (pleura, intercostal vessels, lungs, etc). Crush - compression The thorax is compressed between two hard surfaces. Direct injury of chest wall and internal structures occurs. It causes a marked increase in blood pressure within the veins of the upper thorax and may result in traumatic asphyxia. Anterior-posterior compression forces place indirect pressure on the ribs, causing lateral, mid-shaft fractures. Lateral compression forces applied to the shoulder are common causes of sternoclavicular joint dislocation and clavicle fractures.

Deceleration The body in motion strikes a fixed object. For example during frontal collision in car crashes (the sternum hits the steering wheel), or a fall from height. A blunt trauma to chest wall is produced, but after the contact with the hard surface the internal structures continue in their motion being crushed to the internal chest wall and also anatomical structures of fixation will be broken or even organs will be broken. The degree of external trauma may not fully predict the severity of internal injuries and clinical suspicion of cardiac and vascular trauma should be heightened.

Consequences of closed chest trauma are highly dependent on many factors. The first is the force intensity. Then the direction and site of action is also important. It should also be considered if injury occurred during inspiration or expiration. Last but not least should be considered patients age and existing co-morbidities. (The younger thorax is more flexible and better resist to deformation while in elderly fractures occur more easily). B. Penetrating Trauma there is a skin solution of continuity. Depth of penetration may be limited only to the soft tissues of the chest wall but penetration maybe deeper affecting the pleural cavity and internal organs. When the traumatic agent penetrates the whole thorax, being present an opening for entry and one of exit, we talk about transfixing trauma.

Low energy forces (arrows, knives, handguns) cause injury by direct contact and cavitation. 2. High energy forces (military guns, high powered hunting rifles) produce extensive cavitation injury due to high pressure. Tissue destruction is much higher due to bone fragments driven by traumatic agent. Penetrating wounds consequences depend primarily on penetration depth and the affected organs. If mediastinal organs as the heart or great vessels are affected, the chances of quickly death are very high. Affecting other organs (pleura, lungs, esophagus) are also life threatening but there is an interval of time when investigations could be performed and rescue measures can be taken.
1.

Classification according to pathophysiological criteria:

1. 2.

Without pathophysiological disorders With pathophysiological disorders:

1. 2. 3. 4.

Acute respiratory insufficiency Acute cardiocirculatory insufficiency Acute cardiorespiratory insufficiency With temporary stop of cardiorespiratory function

Classification according to pathogenesis

1. 2.

Closed chest trauma (blunt trauma) Open chest trauma (wounds)

1.
2. 3. 4.

Blind or transfixiant wounds Nonpenetrating or penetrating wounds With or without effusions Mixed

Classification based on anatomical criteria

Without anatomical lesions With anatomical lesions:

Parietal non-skeletal lesions Parietal skeletal lesions Diaphragmatic Endothoracic lesions

Single organ affected, multiple organ affected Associated with other trauma

Parietal lesions

Ribs fractures Sternum fractures Flail chest (free-floating segment of the chest wall) Simple pneumothorax Open pneumothorax Tension pneumothorax Hemothorax Contusions Lacerations

Pleural space

Pulmonary parenchyma Trachea and bronchi

Mediastinum Heart and great vessels Lesions of these organs Esophagus Diaphragm Diaphragmatic lesions

Potential physiological consequences in thoracic trauma:

1. 2. 3. 4. 5.

Hypoxia Hypercapnia Hypovolemic shock Obstructive" shock Acidosis

The 6 types of rapidly fatal chest injuries (found on primary examination):

1. 2.

3.
4. 5. 6.

Airway obstruction Suffocating pneumothorax Open pneumothorax Massive hemothorax Flail chest - free-floating segment of the chest wall Cardiac tamponade

The 6 types of potentially lethal chest trauma (found at secondary examination):

Rupture of the aorta (dissection) Myocardial contusion Tracheobronchial rupture Rupture (perforation) of esophagus Pulmonary contusion Diaphragmatic rupture (hernia)

The 8 types of thoracic injury free of fatal potential (identified at secondary examination):
Simple pneumothorax or reduced hemothorax Sternoclavicular joint dislocations Sternal fracture Clavicle fracture Scapular fracture Traumatic asphyxia Simple rib fractures Chest wall contusion

Some aspects of pathophysiology

1.

Chest trauma may affect vital functions: ventilation and circulation by several mechanisms manifested by the following syndromes: Compression syndrome (compression exerted on intrathoracic organs by pleural or pericardial effusions)

Air: Pneumothorax Fluid: blood = Hemothorax, lymphatic fluid = Chylothorax Mixed Fluidopneumothorax

2.

Chest wall instability - when the chest wall looses its rigidity as a consequence of multiple ribs fractures in two or more places (free-floating segment of the chest wall) the ventilatory dynamics is deeply affected, resulting in acute respiratory failure.

The following four disturbances of respiratory dynamics may appear:

Paradoxical respiration the floating area of the chest wall moves in during inhalation and out during exhalation causing poor ventilation of the lungs, oxygen depletion and severe and even fatal cardiovascular disturbances. Pendular motion of the mediastinum - still further hampers the heart and great vessels and reduces the already impaired oxygenating power of the lungs. The "pendulum air it appears when injury crushes only one side of the chest. On inhalation, the air is pulled out of the flailing side and exhalation pushes the healthy side's stale air back into the flailing lung. The paradoxical air "pendulum" only switches stale air from one lung to the other. Bronchial hypersecretion COURNAND - hypoxia pulmonary hypertension alveolar hypersecretion hypoxia POISVERT - paradoxical respiration hypoxia hyperventilation increased paradoxical respiration.

There are two important vicious circles:

 When several ribs are broken on the both sides and chest loses its rigidity and becomes soft (flail chest), the situation is more critical because the patient can not breathe. In this case the only solution is mechanical ventilation by orotracheal intubation .

3.

Obstructive syndrome - accumulation of fluids in tracheo-bronchial tree will occlude the lumen impairing ventilation, gas exchanges and promoting infection. Causes:

Bronchial hypersecretion Bleeding into the tracheobronchial tree Pulmonary hypertension Aspiration in the airway of saliva or gastric contents by vomiting Shock lung (wet lung) - insidious onset of rapid superficial breathing, dyspnea, and productive cough; rales and wheezes; refractory cyanosis. Xray appearance of enlarging interstitial and alveolar infiltrates which extend until the entire lung is enveloped in a diffuse haze.

4.

Fluid, electrolytes and acid-base imbalance: Loosing electrolytes can be caused by bleeding, sweating, tachypnea. Acidosis has a respiratory component and a metabolic component. Initially respiratory acidosis is followed by metabolic acidosis.

5.

Diaphragmatic syndrome:

Phrenic nerve injury will lead to paralysis of the diaphragm and so it will not participate in respiratory movements. Laceration of the diaphragm can cause the ascension into the chest of the abdominal organs.

6.
7.

8.

The infectious syndrome - although not the most important, must always be considered. Traumatic shock - refers to pulmonary shock or ARDS (Acute Respiratory Distress Syndrome) which is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. Pain is also an important element. Because of pain patients can not breathe well and that will lead to hypoventilation with bronchial hypersecretion and hypooxygenation and so oxygenation will decrease even more.

Hemorrhagic shock appears as a consequence of blood loss. The most severe and acute forms are due to cardiac and great vessels injury (hemomediastinum) but most often it is due to intercostal vessels lesions (produces by broken costal edges) and lung wounds. The blood accumulates into the pleural space (hemothorax) that may also dangerously reduce the vital capacity by compressing the lung on the involved side. In lung wounds the pleural space contains blood and also gas giving a characteristic image on thoracic X-ray (hemo-pneumothorax) with a horizontal line delimitation between fluid and gas.

Right Fluido-pneumothorax

Pneumothorax

Collapsed Lung

horizontal line delimitation between fluid and gas

The pathophysiological mechanisms (acting alone or in combination) can lead to two life threatening syndromes: acute posttraumatic respiratory failure and acute posttraumatic heart failure. The mechanism of acute respiratory failure in thoracic trauma: 1. Ventilation deficiency - may be caused by:

Disturbances of chest wall dynamics:

Flail chest Limitation of respiratory movements due to pain Pneumothorax

Cancellation of tightness of chest wall:

Disturbances of diaphragm movements:

Traumatic diaphragmatic rupture or phrenic nerves lesions

Compression by pleural effusions or herniated abdominal viscera Aspiration of foreign bodies, blood, tracheobronchial hypersecretion

Exclusion from ventilation of lung parenchyma areas:

Airway obstruction

2.

Impairment of air distribution in the lung parenchyma:

Paradoxical breathing Pendular mediastinal movements

3.

Alterations of gas diffusion:

Posttraumatic pulmonary edema Pulmonary shock

The mechanism of acute heart failure in thoracic trauma:

Compression and dislocation of the large venous trunks Mediastinum emphysema and hematoma Compression on atria (massive pleural effusions) Heart trauma Cardiac tamponade

Symptoms and signs of acute respiratory failure:

As a result of hematosis (venous blood oxygenation) deficiencies:

Polypnea or tachypnea (accelerated respiratory frequency) appears at the onset of the interstitial pulmonary edema and the frequency increases as respiratory failure progresses. Dyspnea is increasing progressively Cyanosis (due to hypoxemia) occurs when the de-oxygenated Hb reaches at least 5 g/dl. It is a late sign when anemia is associated.
Tachycardia, (bradycardia in end stages) Hypotension Impaired sensitivity Altered consciousness (dizziness, coma)

Cardiovascular signs (in advanced stages):

Neurological signs:

Signs of end stages:

Shallow breathing or agony breathing Cyanosis Sweating Hypotension, bradycardia Oliguria, anuria

Laboratory signs

Decreased oxygen saturation (SaO2) - normal 97.5% Respiratory acidosis - decreased PaO2 and increased PaCO2, decreased blood pH. Radiological signs - according to respiratory failure causes

Examination of patient with thoracic trauma

The evaluation of patient with chest trauma is performed in three stages: At site of accident (the primary evaluation) where vital function are assessed and also the first life-saving measures are taken. Then, at hospital level in the emergency receiving unit (the secondary evaluation) where further investigations (radiography, tomography, laboratory, etc.) are carried out and measures of stabilization and resuscitation are applied. In the department of surgery or intensive care unit if patient requires hospitalization for surgery or surveillance. If surgery is required the exploration and assessment of damages are continued intraoperatively.

1.

2.

3.

The initial management of the patient with thoracic trauma is frequently the responsibility of the emergency physician who is not a thoracic surgeon. It is therefore mandatory that the emergency physician should be able to recognise the thoracic injuries that are or will be dramatic if not treated properly.
Patients history - collect data from the patient (where possible) and/or environment (when patient can not communicate).

Circumstances of injury Traumatic agent nature Conditions which acted Injury time (time elapsed from the occurrence of trauma)

Patients co-morbidities and previous treatment Patient's symptoms (pain, dyspnea, bleeding, etc.)

In unstable and critical circumstances, quick decisions and adequate maneuvers based on recordings of vital signs and a right interpretation of clinical and diagnostic pattern are required. On inspection:
1. 2.

Patient examination

3.

4. 5. 6.

Parietal lesions (wounds, deformities, bruising, hematoma) Abnormal movements or limitation of thoracic respiratory movements (rib fractures with floating regions of the chest wall, paradoxical respiration - flail chest) Breathing disorders polypnea, dyspnea, tirage = inspiratory sinking of the intercostal spaces due to airway obstruction Signs of bleeding (pallor, hemoptysis, external bleeding) Disorders of hematosis (cyanosis, sweating) Other signs (ecchymotic mask a dusky discoloration of the head and neck occurring when the trunk has been subjected to sudden and extreme compression, mental disorders, other associated lesions, etc)

On palpation:

Pain Signs of rib or sternal fractures (focal pain, bone discontinuity, bone crepitations) Possible floating regions of chest wall Subcutaneous emphysema (subcutaneous crepitation accumulation of gas in the subcutaneous tissue)
Hypersonority in pneumothorax Dull sound in pleural effusions Enlargement of cardiac area Reduction or abolition of lungs vesicular murmur (pleural collection) Auscultatory asymmetry between the two hemithorax Pleural or pericardial friction rub sounds Blurred heart sounds (In the event of cardiac tamponade) Digestive sounds of intestinal movements (In case of traumatic diaphragmatic hernia)

On percussion:

On auscultation:

Primary evaluation
The evaluation of the patient's chest trauma is only a part of the total assessment. A general examination should also be performed to observe any associated lesions (abdominal, limb, head, spine). Because thoracic injuries are severe and potentially lethal, the diagnosis and therapy go hand in hand. In unstable and critical patients quick decisions based on check of the following vital signs are required: Airway patency: Ensuring a free airway is a major priority in emergency resuscitation, patients life depending largely on it. Foreign bodies must be removed from the month and specific maneuvers are applied to prevent backwards fall of the tongue. All the airway manipulations must be performed with respect to potential cervical spinal injuries.

Chin lift maneuver

Jaw trust maneuver

Head-tilt/chin-lift maneuver

Before starting any maneuver for airway patency some basic parameters should be assessed:
1.
2. 3. 4. 5.

6.

If patient is conscious or not Breathing is appropriate or not - check respiratory movement, and their extension Duration of hypoxia - cyanosis appears very late Airway patency Need for administration of neuromuscular blocking agents (muscle tension, teeth clenching, severe obstructive pulmonary disease or asthma) Stability of cervical spine

The circulation status is evaluated by assessing patient's pulses (radial, carotideal or femoral). In hypovolemic shock radial pulse becomes small and may be absent when blood pressure is below 60 mm/Hg. The neck veins are distended when there is cardiac tamponade, if it is associated with hypovolemic shock distension of the neck veins may be absent.

Airway Breathing Circulation

BLUNT THORACIC TRAUMA

Chest wall lesions

Contusions
1. Simple contusions

May be of variable severity, but often they are mild. Contusion is the effect of a direct or indirect, frontal or tangential action of the traumatic agent. Clinic picture is represented by: pain, respiratory discomfort, dyspnea associated with different chest wall lesions at the site of impact (abrasions, bruising, hematoma, effusions, etc..). Radiological examination is required but in most cases nothing pathological is found. Treatment is symptomatic with painkiller, myorelaxants, non-steroidal anti-inflammatories.

2. Muscular ruptures: Rarely due to the action of a blunt object, often as a result of accidents, sports, etc.. Clinically is manifested by violent pain with limitation of mobility. At the site of rupture initially a depression may be noticed followed by a hematoma. Chest X-Ray shows nothing special but ultrasound examination can highlight the muscular rupture and hematoma. Treatment is symptomatic with bed rest (immobilization), myorelaxants, non-steroidal anti-inflammatories and in rare cases surgical repair. 3. Chest compression: It occurs when the chest is compressed between two forces which leads to a sudden increase of pressure in the chest. The pressure exert a high force on the intra-thoracic organs (lungs, heart) which are squeezed and then transmitted then to vessels (veins, arteries).

MORESTIN - acute thoracic compression syndrome - is characterized by: cervico-facial cyanosis, petechiae and edema in the upper thoracic region and conjunctival and retinal hematic extravasation (ecchymotic mask) plus neurological signs of cerebral edema with CheyneStockes breathing type. In addition to symptomatic treatment, oxygen therapy is needed and/or assisted ventilation and also cardiac and renal treatment may be necessary.

Ecchymotic mask

Fractures
1.

Simple rib fractures: are the most common lesions in the thoracic contusion. They are produced either directly - at site of impact, or indirectly - by antero-posterior chest compression. Fractures may be complete or incomplete (Greenstick fractures). Rib fractures are not always simple. Depending on traumatic agent and its force, more than one rib may be fractured. There are many cases when rib fractures are complicated with lesions of the nearby tissues or organs due to the dislocation of the fractured edges.

The most frequent associated lesions are those of intercostal vessels and parietal pleura resulting in hemothorax. If the lung is also perforated hemothorax will be associated with pneumothorax too.

Rarely other intrathoracic organs (heart, aorta) are injured by fractured rib edges. In 20% of cases trauma and fractures of left ribs 9,10, and 11 are associated with spleen rupture and consecutive hemoperitoneum.

Even if rib fractures are not complicated, due to the intense pain exacerbated by every respiration, the respiratory function of the patient may be impaired especially in those with pulmonary co-morbidities. Pain prevents the patient to breathe deeply enough which will lead to alveolar hypooxygenation and bronchial hypersecretion. Because the patient can not cough effectively and expectorate, secretions accumulate and lead to airway obstruction, stasis and infection. Thats the reason why treating pain in rib fractures is very important. Diagnosis is based mainly on clinical criteria: pain at the site of fracture, bone crepitations, limitation of respiration, decreased breath sounds on the affected side.

Complications of rib fracture may include the following:

Hypoventilation Hypercapnia Hypoxia Atelectasis Pneumonia Damage to underlying visceral organs Pneumothorax (immediate or delayed) Hemothorax (immediate or delayed) Aortic injury (immediate or delayed) Pulmonary contusion Intra-abdominal organ injury First rib fractures have often been associated with serious head injury, cervical spine injury, delayed subclavian vessel thrombosis, aortic aneurysm, tracheobronchial fistula, thoracic outlet syndrome, and Horner's syndrome.

Chest X-ray in two incidences help much in diagnosis of rib fractures and associated complications (hemopneumothorax).
Multiple rib fractures

Cpllapsed lung

Rib fracture with right pneumothorax

Other useful investigations are: ultrasonography especially when spleen rupture is suspected, and CT scan which is not indicated for every simple case, just for those associated with complications or in polytrauma and unconscious patients.

Pneumo

Fracture
Lung

Heart

CT scan right pneumothorax

Costochondral disjunction may exist alone or in combination with the broken ribs. Without associated rib fracture the condition is not life-threatening and nothing special must be done, but in association with ribs fractures it causes a free-floating area of the chest wall (flail chest) which may be very dangerous impairing the ventilation.

Simple rib fractures without complications, may be managed on an outpatient basis. Pain killers, myorelaxants and anti-inflammatory drugs will be prescribed and a chest X-ray will be repeated at 24-48 hours. If pain is very intense, intercostal nerve block (first described by Braun in 1907) is indicated. It can be performed with Lidocain but it has a short effect, or with Lidocain associate with absolute alcohol (9/1) in which case the effect is longer. Respiratory parameters typically show impressive improvements upon removal of pain. Blockade of two dermatomes above and two below the level of fracture is required. Rib belts or binders do not control pain and are not recommended as they will limit the respiratory movements. When there are complications such as hemopneumothorax, the patient should be admitted in the hospital and properly monitored and treated. Also consider admission for elderly and patients with underlying lung disease or decreased pulmonary reserve.

The injection needle with bevel faced cephalad is inserted to the rib, then redirected until the point just clears the inferior margin of the same rib. It is then advanced 0.5 cm., and if aspiration is negative for blood, the anesthetic solution is injected.

2. Sternal fractures: Sternal fracture occurs as a consequence of a direct impact on the sternum such as the wheel steering during car accidents (deceleration mechanism). In most cases the fracture line is transversal but rarely it can be longitudinal. The fracture may be with or without displacement, with or without overlapping of fractured edges. In case of displacement there is a high risk of cardiac lesion or compression. The main symptom is the local pain. The pain must be differentiated from angina or cardiac infarction. On palpation there is a local tenderness, and a deformation as a step of scale when fractured parts are overlapping. The diagnosis is based on physical examination and imaging explorations.

The lateral radiograph is usually the most valuable view for detecting sternal fractures and for determining the degree of displacement. CT is particularly useful for assessing for associated injuries such as pulmonary contusion, pneumothorax, or retrosternal hematoma.
CT scan

lateral radiograph

Treatment as in rib fractures, treatment is aimed at achieving analgesia and optimization of respiration. In case of displacement with cardiac compression surgical reduction and fixation of the sternum may be considered.

3. Flail Chest represents a segment of the chest that is free-floating with the pressure changes of respiration. It appears when there are three or more adjacent rib fractures in two or more places or rib fractures are associated with costochondral disjunction or longitudinal fracture of the sternum. Variations include posterior flail segments, anterior flail segments, and flail including the sternum with ribs on both sides of the thoracic cage fractured, mixed forms and soft chest (totally crushed chest). Incidence: 20% of chest trauma in most cases representing a serious chest wall injury with underlying pulmonary injury. Effects of flail chest are:

Paradoxical respiration Pendulum air Pendulum mediastinum

Clinical picture. The major symptom is the pain caused by fractures. The degree of respiratory insufficiency is related to the underlying lung injury. The worst respiratory insufficiency is seen when the chest is totally crushed because the patient cannot breathe at all. In this case there are multiple bilateral rib fractures and the thorax looses it rigidity becoming soft. For saving patients life it must be intubated and ventilated with positive pressure (internal pneumatic stabilization). Tachypnea is present due to the pain. Paradoxical movements of the affected segment of the chest wall can be observed. Other symptoms and signs may be present depending on the associated lesions and the severity of respiratory insufficiency.

Diagnosis relies on physical examination (clinical observation), imaging studies and arterial blood gas measurements (helpful to assess the need for mechanical ventilation and to monitor the patient). Treatment Severity of respiratory insufficiency is less a result of the paradoxical motion of the chest wall but rather a result of pulmonary and other associated lesions. Priorities:

Airway patency remove the foreign bodies, blood cloths, secretions. If necessary orotracheal intubation or even tracheostomy may be performed. Oxygenation through mask or intubation. Remove pleural collections to ensure lungs expansion by thoracocentesis or thoracostomy (pleurostomy). Cardiocirculatory support fluid rebalancing, replace lost blood. Analgesia Stabilization of the chest wall or early intubation and mechanical ventilation for poor gas exchange

Stabilization of chest wall to eliminate the paradoxical respiration can be achieved by:
1. 2.

3.

Non surgical procedures. Surgical procedures which are most commonly performed in patients requiring a thoracotomy for other reasons. Internal pneumatic stabilization indicated in massive crash of the chest (soft chest wall).

For most patients with acceptable respiratory function the simple immobilization of the flail segment is sufficient. It can be done using bandages or better adhesive tapes applied only on the affected hemithorax not to impair the respiratory movements.

External fixation uses a metal plate whose ends lie on the rigid thoracic wall. Flail ribs are suspended by threads passed under the ribs and fixed to that plate.

Advantages of ribs fixation:

Decreased pain Improved mechanics Decreased need of mechanical ventilation Decreased hospital stay

Surgical fixation of fractures

OPEN CHEST TRAUMA

Penetrating trauma - presumes a solution of continuity in the skin with varying degrees of damage to the anatomical structures of the thoracic wall but without penetration into the chest cavity. The vast majority are due to weapons or accidents. Wounds are treated like any other wounds (decontamination, suture, etc..)

Penetrating trauma

Low Energy (arrows, knives, handguns) - Injury caused by direct contact and cavitation. High Energy (military, hunting rifles & high powered hand guns) extensive injury due to high pressure cavitation.

Shotguns - Injury severity based upon the distance between the victim and shotgun & caliber of shot:

Type I: >7 meters from the weapon - Soft tissue injury Type II: 3-7 meters from weapon - Penetration into deep fascia and some internal organs Type III: <3 meters from weapon - Massive tissue destruction

Penetrating chest wounds can cause damage to any intrathoracic organ but most frequently lungs and heart are affected. Extent of lesions depends on kinetic energy and type of the traumatic agent. Some injuries are simple perforations, others are so massive that are incompatible with life.

Intrathoracic organ injuries would cause accumulation of fluids (air, blood, lymph, digestive content) into the pleural cavity, mediastinum or pericardium. Most of these are life-threatening injury, surgical repair being mandatory for life rescue. Surgical gestures can be very simple but there are situations in which complex interventions are required.

Pneumothorax

It represents the presence of air into the pleural cavity which is an abnormal situation because the parietal and visceral pleura loose their intimate contact which is necessary for a good expansion of the lungs in inspiration. There are two possible sources from where the atmospheric air may enter the pleural cavity:

through an opening of the chest wall (wound), or through an opening in the lung or bronchial tree (wound or leak)
Spontaneous Usually on an emphysematous lung during an intense efforts or cough when emphysematous bubbles burst. Traumatic
1. 2.

Mechanisms:
1. 2.

Closed chest trauma due to lung, bronchial or tracheal rupture or tear Open chest trauma - penetrating wounds which may affect lungs

3.

Iatrogenic during subclavian vein catheter insertion or cardiac resuscitation maneuvers.

Simple post-traumatic pneumothorax

In most cases, is the consequence of lung perforation by fractured ribs edges during blunt trauma. More rarely the tracheobronchial tree lesions are the cause of pneumothorax in which case this is associated with pneumomediastinum. Simple pneumothorax may be also a consequence of penetrating chest trauma (wounds) with lesions of the lungs and/or thracheobronchial tree but, if the parietal wound is large enough, an open pneumothorax will develop. Accumulation of gas into the pleural space in most cases is associated with accumulation of blood resulting in hemo-pneumothorax. Depending on how much gas and fluid are accumulated into the pleural space, the lung will collapse more or less and respiratory function will be affected accordingly.

Lung

Left pneumothorax

If there are no adhesions between the two pleura: parietal and pulmonary, the lung will collapse entirely. If there are adhesions, gas and fluid will be trapped in some pleural spaces and lung wont collapse. In this last eventuality if there is a tear in the parietal pleura the air will spread between anatomical layers of the thoracic wall till the subcutaneous plane resulting in subcutaneous emphysema. The air will spread in all directions especially in the upper part of the body (chest, neck, face) but it may reach in the lower part also (abdomen, scrotum). Air can also spread in fatty tissue of the mediastinum (pneumomediastinum) and the irritation of recurrent laryngeal nerves will cause hoarseness.

A simple pneumothorax may progress to a tension pneumothorax. Symptoms may vary very much depending on pneumothorax extension and associated lesions. In small pneumothorax there are no symptoms except those caused by chest trauma (pain exacerbated by respiration). In larger pneumothorax associated with blood collection symptoms of respiratory insufficiency are intricated with those of anemia with tachycardia, pallor, hypotension, cold sweats. In subcutaneous emphysema swelling of the neck, chest, face, eyelids can be observed. This can induce pain, difficulty of swallowing, wheezing and difficulty of breathing.

Skin marks of thoracic trauma may be evident or not. On percussion of the affected side there is a tympanic sound and on auscultation vesicular murmur is diminished or absent. In hemopneumothorax, on percussion, two zones are found: the upper of sonority and a lower of dullness, separation line between them being horizontal. Diagnosis is based on clinical and imagistic investigations. On a postero-anterior chest X-ray the pneumothorax can be seen, the lung being collapsed more or less. In hemopneumothorax the superior level of fluid is highlighted by a horizontal line. In simple fluid collections without pneumothorax this line is not horizontal but convex downward. Subcutaneous emphysema has also a specific image on X-ray. CT scan is helpful in assessing associated lesions.

Treatment. All patients with pneumothorax should be admitted, investigated, treated and monitored. Small simple pneumothorax (not tension pneumothorax !) often resolve on their own by gas resorption. Gas reabsorbs from the pleural space at a rate of 1.25% of the trapped volume per day. Therefore, a pneumothorax occupying 30% of the hemithorax would require 24 days to resolve with the patient breathing room air. Additional oxygen administration increases the rate of resorption. Medication consists of painkillers, anti-inflammatory drugs, O2, myorelaxants, antibiotics, fluid rebalancing, administration of blood if necessary. Surgical therapy consists of thoracostomy with pleural drainage which in most cases is sufficient for lung reexpansion and blood evacuation. In certain cases when pneumthorax does not resolve with this procedure or bleeding is massive, thoracotomy and lesions treatment (aerostasis and hemostasis) becomes necessary.

If not massive, the subcutaneous emphysema is reabsorbed by itself in a few days. To remove the gas from subcutaneous layer there are several methods: insertion of large bore needles, small skin incisions or subcutaneous drainage tubes. Pleural drainage if performed will eliminate the source of the air entering the subcutaneous space.

Open pneumothorax with traumatopnea

Traumatopnea = passage of respiratory air in and out through a wound of the chest wall. Due to the gradient of pressure between the pleural space and atmosphere during respiration, the air passes through the open thoracic wound into the pleural cavity during inspiration and leaves it during expiration through the same opening (sucking chest wound). Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger.

Chest wound may be associated with pulmonary lesions so that air can enter the pleural space also from the lung.

The consequences are :

1.

Acute respiratory failure with reduced tidal volume and vital capacity caused by lung collapse and oscillation (pendulation) between the two lungs of the deoxygenated air. Circulatory failure by pendulation of mediastinum toward the healthy hemithorax during inspiration and toward affected hemithorax during expiration which affects the return of venous blood by vena cava compression.

2.

Tidal volume is the lung volume representing the normal volume of air displaced between normal inspiration and expiration when extra effort is not applied. Typical values are around 500ml Vital capacity is the maximum amount of air a person can expel from the lungs after a maximum inspiration. It is equal to the inspiratory reserve volume plus the tidal volume plus the expiratory reserve volume.

Symptoms are represented by dyspnea with cyanosis. On inspection the penetrating wound is found through which air enters and exits. On percussion of the affected side there is a tympanic sound and on auscultation vesicular murmur is absent being replaced by the sound produced by flowing air through the thoracic wound. Chest X-ray will show a total collapse of the lung.

Treatment of open pneumothorax. The first aid intention is to close (seal) the wound to prevent further pendulum air and mediastinum. It can be done by dressing the wound with an impermeable gauze (soaked with ointment) and the patient must be transported urgently to the hospital. High-flow oxygen will be administered and aggressive hemodynamic and respiratory resuscitation should be initiated. Patients with severe respiratory insufficiency should be intubated and ventilated. As long the thoracic wound is opened there is no risk of tension pneumothorax. In hospital a chest tube drainage will be applied through thoracostomy (or toracotomy if necessary) into the pleural cavity to evacuate collections and allow the lung reexpension. The thoracic wound will be closed. The patient will be monitored and lung reexpansion will be assessed by auscultation and chest X-ray.

Tension pneumothorax

Represents the progressive accumulation of air (with every inspiration) into the pleural cavity, air which remains trapped into the cavity and gradually compresses the lung and shifts the mediastinum to the opposite side. It is a high life-threatening condition but life can be saved by simple maneuvers. The mechanism is due to a lesion of the thoracic wall (external pneumothorax) or lung (internal pneumothorax) that acts like a one-way valve letting the air to enter the pleural cavity but not to exit. Major vessels such as the vena cava, pulmonary artery, and aorta become kinked or compressed, and severe hypoxemia ensues. Cardiovascular compromise develops because the return of venous blood to the right ventricle is severely impaired, as is the cardiac output. Circulatory collapse shortly follows. General condition is rapidly altered and the patient can die in few minutes.

Tension pneumothorax can be a progression of a simple or open pneumothorax. Sympyoms and signs: Dyspnea with tachypnea is the first symptom. As pulmonary atelectasis by compression progresses dyspnea becomes more and more intense with cyanosis. On inspection a thoracic wound may be noticed in external pneumothorax and the flow of air through the opening may be heard. The affected hemithorax is distended with intercostal spaces bloating. Other signs are: tachycardia, tachypnea, and diminished breath sounds, hyperresonance to percussion, and decreased tactile fremitus on the ipsilateral side. A significant volume of gas in the pleural space causes tracheal deviation and mediastinal shift toward the contralateral lung, hypotension, distended neck veins, and respiratory distress.

Tension pneumothorax is a major emergency - rarely there is enough time available to conduct investigations. The diagnosis relies on clinical symptoms and signs. When possible, anteroposterior chest radiography while the patient assumes a Fowler's or semi-Fowler's position shows:

Collapse of the lung Mediastinal shift to the healthy side Descend of the affected side diaphragm Widening of intercostal spaces

Treatment Pleural decompression is needed urgently before patient reaches the hospital. If this diagnosis is suspected, do not delay treatment in the interest of confirming the diagnosis. Immediately place the patient on 100% oxygen.

Decompression can be easily performed by inserting a 14-16-gauge needle into the 2nd intercostal space along the mid-clavicular line or into the 5th intercostal space along the mid axillary line. When the needle enters the pleural space, the sound of gas escaping is generally perceived. The needle should be placed just above the cephalad border of the rib to avoid the intercostal vessels.
A catheter can be introduced through the needle and then the needle may be withdrawn. This maneuver actually establishes a communication between the pleural space and atmosphere converting a tension penumothorax into an open pneumothorax. After needle decompression (if it is not performed in the hospital) the patient will be transported urgently to the hospital. All patients with pneumothorax will be admitted.

 If a patient is to be ventilated with positive pressure following needle aspiration, whether fluid, air or nothing was encountered, a chest drain should be inserted.
In hospital conditions treatment will be continued by inserting a pleural drainage, although this maneuver can be performed at site of accident by specialized rescue team. The site of insertion depends on coexisting of fluid accumulation (blood, effusions, lymph) into the pleural cavity. In case of pure pneumothorax the drain may be inserted into the 2nd intercostal space on mid-clavicular line. If there is fluid collection too, the drain should be inserted into the 5th-6th intercostal space on mid axillary line, or associated to that in the 2nd space.

Steps for a correct insertion of pleural drainage tube:

A. B. C. D. Incision Dissection Finger exploration Inserting the tube with the forceps E. Advancing the tube into the pleural cavity F. Fixation of tube

The chest tube will be attached to a Heimlich valve with drainage bag or sealed underwater (simple Bulau or Beclaire or aspiration drainage). Mild aspiration can be applied through the drainage tube in order to reexpand the lung but suction should be seen as the exception rather than the rule.

Heimlich valve

Most chest drains need no suction. An effective cough can generate a much higher pressure than can safely be produced with suction. Thoracic suction should only be used on wards where the staff are familiar with chest drain suction. A drain is safer with no suction than suction which is not working correctly.
Aggressive aspiration could maintain open an air leak, the better solution instead of aspiration being the surgically closure of the air fistula (aerostasis). After drainage obtain a follow-up chest x-ray to assess for lung reexpansion and thoracostomy tube positioning. Monitor the patient continuously for arterial oxygen saturation. In case of an external tension pneumothorax the cause can be very easily removed by suturing the wound chest.

In case of internal pneumothorax due to lung perforation, lung reexpansion against the internal chest wall and adhesions formation will seal the perforation in a few days.

Hemothorax

Represents the accumulation of blood into the pleural space. The source of blood may be any anatomical structure of the thorax but in most cases after trauma it comes from intercostal vessels injured by rib fracture and lung lesions. The quantity of blood into the pleural cavity may be small, medium or large. Blood loss can be sudden and massive like in large vessels injuries or slow and progressive.

Symptoms and hemodynamic changes vary depending on the amount of bleeding and the rapidity of blood loss.
1.

2.

3.

Blood loss of up to 750 mL should cause no significant hemodynamic change. Loss of 750-1500 mL will cause the early symptoms of shock (ie, tachycardia, tachypnea, and a decrease in pulse pressure). Significant signs of shock with signs of poor perfusion occur with loss of blood volume of 30% or more (1500-2000 mL).

Exsanguinating hemorrhage can occur without external evidence of blood loss. Dyspnea is often the predominant complaint associated to those caused by chest trauma and hypovolemia. On general examination pallor, tachycardia, cold sweats, and tachypnea can be noticed. On chest examination beside the traumatic lesions of the skin (bruising, hematoma, wounds, etc..) on percussion dull sound over the affected side may be noticed. The upper margin of the dull depends on blood quantity in the pleural cavity.

On auscultation breath sounds are diminished if there is a large hemothorax. In many traumatic cases hemothorax is associated with pneumothorax. The main imagistic investigation is the upright chest radiography. CT scan is a valuable method in assessing lungs and other intrathoracic organs.

Hemothorax

Hemopneumothorax

Possible evolution of hemothorax:

1.

Accumulation in large quantities endangering the patients life. Needs evacuation or thoracotomy and hemostasis and also blood replacement.

2.
3.

Lysis and resorbtion if small hemothorax.

It causes a pleural reaction with exudate and increases the volume of the pleural fluid. Infection with thoracic empyema.

4.

5.

Transformation in fibrothorax causing lung adhesions which prevent a good lung expansion reducing their capacity.

Differential diagnosis should be made with other pleural collections Hydrothorax, Pleurisy, Empyema, Chylothorax. In thoracic trauma context the chylothorax is more likely to be produced or blood can come from abdominal cavity through a diaphragmatic rupture.

Treatment depends on the size of hemothorax, its speed of developing and the source of bleeding. In most cases patients will be admitted for treatment and surveillance. Indications for thoracotomy after trauma:

A. >1500 mL blood from chest tube on insertion. B. >200 mL blood/hour from chest tube thereafter (for 2-4 hours). C. Massive air leak such that lung will not re-expand after a properly placed and functioning chest tube has been inserted.

The medical treatment will be common as for thoracic trauma plus blood replacement if necessary and antibiotherapy. In small hemothorax aspiration of blood by thoracocentesis can be performed. In medium and large hemothorax pleural drainage through thoracostomy is the method of choice. If bleeding continues or pleural drainage is not effective thoracotomy should be performed for hemostasis (intercostal vessels ligation, lung suture, etc).

Cardiac tamponade

It is a highly life threatening condition. Accumulation of fluid (blood in most traumatic cases) into the pericardial sac will lead to cardiac movements limitation with cardiocirculatory insufficiency and cardiac arrest. The pericardial space normally contains 20-50 mL of fluid. Pericardial effusions can be serous, serosanguineous, hemorrhagic, or chylous. In chest trauma intrapericardial fluid is represented by blood which may come from:
1.

2. 3.

A penetrating (stab, shot) wound which produces a lesion of the cardiac vessels (coronary vessels) or heart wall (heart perforation) A contusion of the heart with consecutive heart wall necrosis and rupture Contusion of the heart with rupture of its wall

The pathophysiologic mechanism is represented by diminished diastolic filling because ventricles cannot distend sufficiently to overcome the increased intrapericardial pressures. Tachycardia is the initial cardiac response to these changes to maintain the cardiac output. The rate of fluid accumulation into the pericardial sac is very important. Rapid accumulation of about 150 ml will develop an increased pressure that opposes filling the heart with blood. The rapid accumulation is more likely to occur during chest trauma. In other conditions, when accumulation produces over a long period of time, more than 1000 ml of fluid wont have significant effect due to adaptive stretching of the pericardium. Symptoms: tachycardia, tachypnea, palpitations, dyspnea, restless body movements, unusual facial expressions, sense of impending death, dizziness, drowsiness.

Signs: distended jugular veins, hepatomegaly, enlarged cardiac dullness on percussion, diminished heart sounds, pericardial friction rub, weak pulse, hypotension and also other signs related to chest trauma. The Beck triad:
1.
2. 3.

increased jugular venous pressure hypotension diminished heart sounds

Kussmauls sign: Decrease or absence of jugular vein dilatation during inspiration Imaging studies:
Chest X-Ray enlargement of the heart shadow as a tent, with disappearance of heart contours (plus other possible associated modifications due to trauma) Ultrasound reveals fluid accumulation in the pericardial sac limiting the amplitude of cardiac movements) CT scan may reveal fluid accumulation in pericardial sac and other lesions but in most cases there is not sufficient time to perform the examination

Cardiac tamponade

Shape of tent

Electrocardiogram will show: sinus tachycardia, lowvoltage QRS complexes and PR segment depression. Differential diagnosis in chest trauma should include:

Tension pneumothorax distended jugular veins is also present ! Cardiogenic shock Pulmonary embolism

Treatment Cardiac tamponade during chest trauma is a very serious condition with a high mortality. Life saving depend on rapid recognition of it and rapid pericardial decompression. After decompression the treatment must be continued for the underlying cause that means in majority of cases thoracotomy or sternotomy, opening the pericardial sac and hemostasis either by cardiac suture or vascular suture.


1.

2.

Pericardial puncture Epigastric approach Marfans point at the tip of xiphoid appendix. Chest approach - may be performed on the right or left side of the sternum
The left approach:

In the 4th or 5th intercostal space very close to the sternum to avoid the internal mammary artery. The needle is inserted perpendicularly. Dieulafoy point in the 5th intercostal space at 6 cm beyond the sternum Delormes point in the 6th intercostal space at the edge of sternum Rendus point - in the 6th intercostal space at 8 cm beyond the sternum Huchards point in the 7th intercostal space at 8 - 9 cm from sternal midline (below the Dieulafoy point) Roths point in the 6th intercostal space, very close to the sternum. The needle is inserted to the left and up.

The righ approach

The patient will be in a semi-seated position in a 45 degree inclination of the thorax. After the needle passes the skin it is driven cephalad and obliquely to the left, following the posterior face of the sternum. Then it passes the diaphragm and after a trajectory of 4 cm for patients younger than 5 years and 6 cm for those over 15 years it enters the pericardial sac in its lowest region. Advantages of this technique is that it avoids the pleura and the internal mammary vessels and may be used in small pericardial collections. The epigastric approach is contraindicated in sternum deformities.

 The possible complications of pericardial puncture: 1. Coronary artery damage 2. Laceration of the myocardium 3. Penetration in the lung Echocardiograpic guidance increases the success rate of pericardiocentesis by reducing these complications.

Lesions of the intrathoracic organs

Lungs
Pulmonary contusion is represented by an intraparenchymatous hematoma surrounded by atelectasis. It is manifested by pain, dyspnea, cough, hemoptysis. In case of extensive contusion hypooxygenation and low blood oxygen saturation may occur with cyanosis. The severity ranges from mild to very serious. Pulmonary contusion is the most common type of potentially lethal chest trauma. Estimated mortality rate ranges between 14% and 40%. It occurs in 3075% of severe chest injuries. On chest X-ray a zone of pulmonary condensation (characteristic white region) is seen. The presence of hemothorax or pneumothorax may obscure the contusion on a radiograph.

CT scanning is a more sensitive for pulmonary contusion. Contusion can be detected almost immediately after the injury. However, in both X-ray and CT a contusion may become more visible over the first 2448 hours after trauma. Differential diagnosis. If the consolidation lasts longer than 72 hours, consider:

Aspiration Pneumonia ARD

Treatment in most cases is just supportive. In severe extended pulmonary lesions with hypoxia mechanical ventilation with oxygen supplementation is needed. Mechanical ventilation with moderate positive pressure is indicated when:

Partial pressure of oxygen is less than 60 mm Hg at a concentration of 50% oxygen in the inspired air Respiratory rate> 24/minut Maximum vital capacity <10 ml / kg

Antibiotherapy is used to prevent pulmonary infection. Pulmonary contusion can progress to complete resorption in 5-10 days or with complications such as infection and abscess formation. It can also permanently reduce the compliance of the lungs. Pulmonary laceration Pulmonary laceration is produced in most cases by penetrating chest wounds (stab or shot) but also it can occur during very intense blunt thoracic trauma or as a consequence of rib fractures. The injury is more serious when is closer to the pulmonary hilum (in these cases large vessels and bronchi are damaged too). Symptoms and signs are the same as in thoracic contusions or penetrating wounds with hemothorax or hemopneumothorax plus hemoptysis.

Radiological images are similar to those of lung contusion + hemothorax or hemopneumothorax. Treatment - in patients with small lesions without respiratory failure thoracostomy and pleural cavity drainage with mild aspiration for lung reexpansion is sufficient. In case of important penumothorax or hemoptysis, bronchoscopy would be necessary for diagnosis of tracheobronchial tree lesions. Patients requiring mechanical ventilation may develop broncho-pleural fistulas, sometimes requiring two independent lung ventilation. In more serious lesions thoracotomy is necessary for saving the life of the patient. Lungs lesions are surgically resolved, aerostasis and hemostasis is checked and two drainage tubes are placed in the pleural cavity. In most cases this patients are monitored in the intensive care unit.

Tracheo-bronchial tree lesions

Lesions can be axial or circular, complete or incomplete. Symptoms are dependent on the size and permeability of the affected bronchus (fragments of lung parenchyma or blood clots can obstruct airways). Characteristic features on which diagnosis relies are hemoptysis accompanied by tension pneumothorax, pneumomediastinum or subcutaneous emphysema. Suspected bronchial rupture arises whenever in a pneumothorax the lung does not reexpand under proper suction drainage. Bronchoscopy should be carried out promptly since it is the most reliable means of establishing the diagnosis. Surgical treatment is represented by thoracotomy and suture of the ruptured bronchus or trachea under ventilatory support using double lumen tubes and selective bronchial intubation.

Cardiac lesions
Cardiac lesions may be a consequence of blunt thoracic trauma (most often in traffic accidents when the steering wheel hit the sternum) or penetrating trauma (stab, gunshot, puncture, etc). Types of lesions and their severity depend on traumatic agent type, its force and coexisting cardiac diseases. Survival depends much on the type of cardiac lesion and time elapsed between the accident and establishment of treatment. Blunt trauma are represented by myocardial contusion and myocardial rupture. The rupture may interest the walls or septum ( interventricular / interatrial) and valves. The right atrium and ventricle are the most frequently injured due to their anterior position followed by the left atrium and left ventricle. The survival rate with 1chamber rupture is about 40%. Two-chamber rupture has a mortality of 100%.

A sudden rise in blood pressure during compression of the chest may injure the cardiac valves or lacerate the ventricular wall or septum. Myocardial contusion is represented by patchy areas of muscle necrosis and hemorrhagic infiltrate. Les extended heart muscle contusion induces cardiac arrhythmias that usually improves with time but injury to a coronary artery can lead to myocardial infarction. Regurgitation and cardiac insufficiency due to traumatic lesions of valvular system tends to worsen with time within in few weeks or years. Diagnosis A patient with angina-like chest pain or progressive dyspnea after trauma must be suspected of having a cardiac injury. Arrhythmias are not very specific. Systemic hypotension and elevated venous pressure are important signs of cardiogenic shock or tamponade.

Paraclinical investigations comprise:

Thoracic X-ray reveals sternal and ribs fracture, hemothorax, enlarged cardiac shadow ,but cannot offer information about heart. CT scan offer more detailed aspects concerning the pleural spaces, lungs and mediastinum, but not very much about cardiac contusion. Ultrasound echocardiography is an important diagnostic tool that can be used to detect anatomical anomalies (pericardial effusion, areas of ventricular dyskinesia, and valvular dysfunction) and physiologic anomalies of the heart (abnormal blood-flow patterns). 12-lead EKG may show abnormalities. CPK (Creatine phosphokinase) values may be elevated, but also in skeletal and muscular trauma so they are not very specific. Troponins (a complex of three regulatory proteins: troponin C, troponin I and troponin T found in skeletal and cardiac muscle, but not smooth muscle) are more specific.

Treatment

In stable patients without evident lesions on echocardiography the evolution is good and only a close monitoring for several hours is required. If their condition remains stable and the ECG reveals no or only minor changes they can be admitted to a regular ward. A patient with angina-like chest pain, elevated enzyme levels or minor arrhythmias should be monitored in an intermediate care unit. A patient with progressive dyspnea, ischemic patterns on ECG, or complex arrhythmias should be treated in an intensive care unit, receive specific therapy, and be investigated further. A patient in cardiogenic shock due to cardiac tamponade will be quickly investigated and treated accordingly (see cardiac tamponade). In case of ventricular akinesia the patient may benefit from inotropic support or intraaortic balloon counterpulsation. More serious injuries of intracardiac septa and valves require surgery and extracorporeal circulation.

Most penetrating cardiac injuries are secondary to assaults or accidents (industrial, traffic). Penetration with sharp objects is associated in general with a better outcome than penetration resulting from gunshot. Iatrogenic causes are represented by lesions produced secondary to cardiopulmonary resuscitation (fractured sternum or ribs may penetrate the heart), central venous catheterization, or percutaneous cardiac procedures. Survival after such lesions is very low (6-17%), very few patients reaching the hospital alive but from those who reach alive almost can be saved. Patients with small wounds of the heart will develop cardiac tamponade but those with extensive lacerations die almost immediately, as a result of rapid and voluminous blood loss.

To prevent exsanguination, any stabbing weapons still present in the chest should not be removed before reaching the hospital.

If there are suspicions of penetrating cardiac lesion a pericardial window can be performed by subxiphoid approach. Penetrating cardiac trauma must be surgically resolved. The approach can be through a left thoracotomy or by sternotomy. The pericadial sac is opened, the blood and cloths removed and the cardiac wound is assessed. Digital compression direct on the wound is the procedure for temporary hemostasis. Cardiac suture can be performed with the finger still in place on the wound or using a balloon catheter introduced into the cardiac cavity for temporary hemostasis. Larger injured coronary arteries will require either direct repair or bypass.

Aortic injury

The two most common causes of this type of lesion are traffic accidents and stab or shot wounds. In the first case the mechanism is deceleration (heart displacement will put under tension the aorta) and in the second the direct action of the traumatic agent. Aortic rupture is very deadly, about 90% of patients die within minutes. Of those who arrive at the hospital alive, another 90% die. Many patients have little external evidence of serious chest trauma. Aortic injury should be suspected on chest radiographs when the mediastinum is enlarged more than 8 cm and aortic knuckle is disappeared. CT scan reveals mediastinal hematoma but not necessarily from aortic rupture.

When the diagnosis is suspected on basis of chest radiography or clinical findings it can be confirmed by means of contrast-enhanced aortography. Treatment is only surgical but unfortunately with a very high mortality rate.

Esophageal rupture

The esophagus is located in the posterior mediastinum being a well protected organ against traumatic agents. However, there are rare cases when esophagus may be injured during thoracic trauma especially during penetrating trauma caused by stab wounds or shot gun wounds. On the other hand, iatrogenic lesions are not very rare (85-90% of cases) occurring during endoscopic procedures, gastric tubing or during abdominal or thoracic operations. There are also self induced esophageal lesions caused by foreign bodies, corrosive or drug ingestion and postemetic trauma. Esophageal lesions are a potentially devastating condition. Rapid diagnosis and therapy provide the best chance for survival but delay in diagnosis is common, resulting in substantial morbidity and mortality.

Spontaneous esophageal rupture is a rare entity, which is known as Boerhaave syndrome (rupture of the esophageal wall due to vomiting).
The estimated mortality is approximately 35%, making it the most lethal perforation of the digestive tract. The best outcomes are associated with early diagnosis and definitive surgical management within 12 hours of rupture. If intervention is delayed longer than 24 hours, the mortality rate (even with surgical intervention) rises to higher than 50% and to nearly 90% after 48 hours. As a result of a tear or rupture of the esophagus, its content (saliva, food, air) will enter the mediastinum resulting in mediastinitis. Clinical picture is represented by retrosternal pain, dysphagia, hematemesis, subcutaneous emphysema, pleural effusion, fever, septic shock.

The Mackler triad:

1. 2. 3.

vomiting lower chest pain cervical subcutaneous emphysema

Chest radiography and CT scan may show: enlargement of the mediastinum, pneumomediastinum, pleural effusion especially on the left side, subcutaneous emphysema. A water-soluble contrast (Gastrografin) can be used to highlight the extravasation of contrast and location and extent of rupture/tear. Esophagogastroduodenoscopy is not recommended for acute esophageal rupture. Treatment.
Patients will be admitted to ICU Nothing by mouth Parenteral nutritional support Nasogastric suction Broad-spectrum antibiotics

Criteria for nonoperative treatment :

Recent iatrogenic or postemetic esophageal perforation with minimal symptoms and absence of sepsis. No malignancy, obstruction, or stricture in the region of the perforation Isolation of the leak within the mediastinum and drainage of perforation into the esophagus Medical contraindications to surgery (eg, severe emphysema, severe coronary artery disease) Prevent further mediastinal contamination Drainage of the medistinum and pleural cavity Ensure enteral nutrition Reestablish the esophageal integrity or replace a portion of it (esophagoplasty)

The aims of surgery for esophageal rupture are:

Surgical techniques include the following:

Tube thoracostomy (alone or associated to other techniques) Primary repair (suture plus reinforcement) of the rupture either by thoracic or abdominal approach or by thoracoscopic approach. Diversion (cervical esophagostomy) Diversion and exclusion (cervical esophagostomy + esophagus ligation above the cardia + feeding gastrostomy or jejunostomy)

Esophageal resection (+ cervical diversion + feeding jejunostomy)

Esophageal stent Endoscopic placement of fibrin sealant Esophagoplasty (using stomach or colon) in a second phase after mediastinitis resolution

Diaphragmatic rupture

It may be a consequence of blunt or penetrating thoracic and abdominal trauma. The diaphragm is the main respiratory muscle which separates the abdominal cavity from the thoracic cavity. Between those two cavities there is a gradient of pressure: the intra-abdominal pressure is higher then the intrathoracic, and this is the reason why abdominal organs tend to protrude into the thoracic cavity when there is a solution of continuity (rupture) of the diaphragm. The right diaphragm is better protected against rupture during blunt trauma by the liver while the left diaphragm ruptures more frequently (70-90%) especially at level of the central tendon. More frequently the rupture is the consequence of a sudden rise of the intra-abdominal pressure during blunt abdominal trauma then during thoracic trauma because the thoracic wall is more rigid.

On the other hand during blunt thoracic trauma, especially from lateral side, the diaphragm (and also the nearby organs spleen, liver) may be injured by fractured ribs.
Penetrating trauma, either thoracic or abdominal, may produce tears in the diaphragm and organs from both cavities. Even though they are not injured, abdominal organs can protrude into the pleural cavity resulting in diaphragmatic hernia with the possibility of strangulation and necrosis of herniated organs. Visceral herniation occurs in 30-50% of patients with diaphragmatic tears, and the stomach is the most common abdominal organ to become herniated, but there are not rare cases when the transverse colon, spleen or small intestines are involved in herniation.

In large diaphragmatic ruptures the herniated abdominal organs produce a dislocation of the lung and heart leading to ventilatory, respiratory and cardiocirculatory dysfunction with dyspnea, cyanosis and cardiac rhythm disturbances. Other symptoms may be: sharp shoulder pain, digestive symptoms (dysphagia, vomiting, intestinal obstruction) and associated symptoms depending on the associated traumatic lesions. The small diaphragmatic ruptures are frequently unrecognized in the first days as they do not give any specific symptoms and may be overlooked at chest x-ray investigation. Diagnosis may be delayed in as many as two thirds of all patients. The plain chest radiograph is abnormal in 77% of patients, but the findings are nonspecific and the diagnosis is initially missed in most cases.

On physical examination of the thorax the most important sign that rises the suspicion of diaphragmatic rupture is the bowel movements heard on auscultation. There are 3 clinical phases of diaphragmatic injuries (described by Grimes).

1. Acute phase - in the same day with the trauma. 2. The second or latent phase if the injury is not recognized in the early phase. It is an asymptomatic phase but intra-abdominal viscera evolve into gradual herniation. 3. The third phase is that of complications (obstruction, incarceration, strangulation, perforation, peritonitis, pleural effusions, etc).

Radiographic findings include apparent elevation of the hemidiaphragm, loss of the normal contour, distortion of the normal shape or mediastinal shift away from the injury. The pathognomonic findings are the intrathoracic intestinal fluid-air levels and bowel or gastric movements observed during fluoroscopy. Administered Gastrographin will fill the herniated stomach or intestines.

Left diaphragmatic rupture

Colon
Gastric gas bubble

CT findings of diaphragmatic rupture include the followings:

Discontinuity of the diaphragm Herniation of abdominal organs into the chest Pneumothorax and/or hemothorax and/or hemoperitoneum

The mortality rate in unrecognized cases is 30% as a result of delayed herniation of abdominal viscera and bowel strangulation. Early recognition and repair of diaphragmatic tears improves the prognosis. Most often the patients are polytraumatized and unconscious. The first taken measures are those for life support, but concomitant good clinical and paraclinical evaluation must be carried out.

Intrathoracic organs lesions are more life threatening than those intra-abdominal, and therefore the initial approach should be the thoracotomy in this cases. The abdominal organs can be assessed somewhat through the diaphragmatic rupture and if there are no intra abdominal lesions the diaphragm will be sutured without laparotomy. Some abdominal organs lesions can be managed through the thoracic approach (splenectomy). If necessary, laparotomy can be associated.