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ACS

Thoracic Trauma
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ACS

Objectives
Identify and treat injuries found during
the primary survey.
Identify and treat injuries found during
the secondary survey.
Demonstrate the ability to perform life
saving chest management.
Indications
Contraindications
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ACS

Thoracic Trauma

1 out of 4 deaths
Blunt : < 10% require operation
Penetrating : 15% - 30% require operation
Majority : require simple procedures
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ACS

Initial Assessment / Management

Primary Survey
Identifies most life-threatening injuries

Resuscitation
Airway control

Ensure oxygenation / ventilation

Needle / tube thoracostomy

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ACS

Initial Assessment / Management

Secondary Survey Definitive Care
Identifies most Airway control
potentially lethal Ensure oxygenation /
ventilation
injuries
Tube thoracostomy
Physical exam /
Hemodynamic
diagnostic tests
support
Operation
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ACS

Life threatening Chest Trauma

Primary Survey
Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade
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ACS

Airway Obstruction
Laryngeal injury
Rare occurrence
Hoarseness
Subcutaneous emphysema
Treatment
Intubation (caution)
Tracheostomy (by surgeon)
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ACS

Breathing

Tension pneumothorax : Etiology

Parenchymal and / or chest-wall injuries
Air enters pleural space with no exit
Positive pressure ventilation
Collapse of affected lung
Venous return
Ventilation of opposite lung
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ACS

Breathing
Tension Pneumothorax : Signs / Symptoms
Respiratory distress
Distended neck veins
Unilateral in breath sounds
Hyperresonance
Cyanosis, late
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ACS

Breathing
Tension
Pneumothorax
Immediate
decompression
Clinical diagnosis,

not by x-ray
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ACS

Breathing
Open Pneumothorax

Cover defect
Chest tube
Definitive operation
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ACS

Breathing
Flail chest
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ACS

Breathing
Flail Chest / pulmonary Contusion
Reexpand lung
Oxygen
Judicious fluid management
Intubation as indicated
Analgesia
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ACS

Circulation
Massive Hemothorax
1500 ml blood loss
Systemic / pulmonary vessel disruption
Flat vs distended neck veins
Shock with no breath sounds and /or
percussion dullness
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ACS

Circulation
Massive Hemothorax
Rapid volume restoration
Chest decompression and x-ray
Autotransfusion
Operative intervention
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ACS

Circulation
Cardiac Tamponade
Arterial pressure
Distended neck veins
Muffled heart sounds
PEA
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ACS

Circulation
Cardiac Tamponade
Patent airway
IV therapy
Pericardiocentesis
Pericardiotomy
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ACS

Resuscitative Thoracotomy
Qualified surgeon present on patients arrival
Indications

Penetrating thoracic injury

Pulseless with electrical activity
Contraindications

Blunt injury
Pulseless, without electrical activity
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ACS

Potentially- Lethal Chest Trauma

Identified by :
In depth examination

Upright chest x-ray, if possible

ABGs

Pulse oximetry

ECG
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ACS

Potentially- Lethal Chest Trauma

Simple pneumothorax
Hemothorax
Pulmonary contusion
Tracheobronchial tree injury
Blunt cardiac injury
Traumatic aortic disruption
Traumatic diaphragmatic injury
Mediastinal traversing wounds
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ACS

Secondary Survey
Pneumothorax
Penetrating / blunt
trauma
V / Q defect
Hyperresonance
Breath sounds
Tube thoracostomy
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ACS

Secondary Survey

Hemothorax

Chest wall injury

Lung / vessel
laceration
Tube thoracostomy
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ACS

Secondary Survey

Pulmonary Contusion
Most common
Oxygenate, ventilate
Selective intubation
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ACS

Secondary Survey
Tracheobronchial injury
Frequently missed Treatment

injury Airway
Blunt / penetrating ventilation
trauma Operation
Partial vs complete
Diagnostic aid : Endoscopy
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ACS

Secondary Survey
Blunt Cardiac Injury
Injury spectrum
Abnormal ECG : Monitor changes
Echocardiography
Treat : Dysrhythmias, Q, complications
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ACS
Secondary Survey
Traumatic Aortic
Rupture
Rapid acceleration/
deceleration
Ligamentum
arteriosum
Salvage : identify early
Surgical consult
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ACS

Secondary Survey
Diaphragmatic Rupture
Most diagnosed on left
Blunt large tears
Penetrating small
perforations
Misinterpreted x ray
Contrast radiography
Operation
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ACS

Mediastinal Traversing wounds

Hemodynamically Abnormal
Exsanguinating thoracic hemorrhage
Tension pneumothorax
Pericardial tamponade
Esophageal / tracheobronchial injury
Spinal cord injury
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ACS

Mediastinal Traversing Wounds

Hemodynamically Abnormal
Treatment
Bilateral tube thoracostomies
Emergent surgical consultation
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ACS

Mediastinal Traversing Wounds

Hemodynamically Normal
Vascular : Angiography
Tracheobronchial : Bronchoscopy
Esophageal Esophagography,
esophagoscopy
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ACS

Mediastinal Traversing Wounds

Hemodynamically Normal
Treatment
Mandatory surgical consultation
Repair identified injuries
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ACS

Secondary Survey
Subcutaneous
Emphysema
Airway injury
Pneumothorax
Blast injury
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ACS

Secondary Survey
Traumatic Asphyxia

Petechiae
Swelling

Plethora

Cerebral edema
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ACS

Secondary Survey

Sternal, Scapular, and Rib Fractures :

Pathophysiology
Pain Splinting Hemopneumothorax
Associated injuries Retained secretion
Impaired ventilation Atelectasis
Pulmonary contusion pneumonia
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ACS

Secondary Survey
Sternal, Scapular, and Rib Fractures
Ribs 1- 3
Severe force
Associated injuries High mortality
risk
Ribs 4 9
Pulmonary contusion
Pneumohemothorax
Ribs 10 12 : Suspect abdominal injury
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ACS

Secondary Survey
Sternal, Scapular, and Rib Fractures :
Management

Chest x ray Adequate pain

Chest tube as relief
necessary Treat associated
Selective injuries
ventilation No constrictive
devices
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ACS

Secondary Survey
Esophageal Trauma
Blunt vs penetrating
Severe epigastric blow
Pain, shock > injury
Pneumohemothorax without fracture
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ACS

Secondary Survey
Esophageal Trauma
Chest tube :
Particulate matter
Mediastinal air
Contrast swallow,
esophagoscopy
Operation
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ACS

Secondary Survey
Other indication for Tube Thoracostomy
Suspected, severe lung injury

Air or ground transfer

General anesthesia
Positive pressure ventilation
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ACS

Pitfalls
Simple pneumothorax tension
pneumothorax
Retained hemothorax
Diaphragmatic injury
Delayed diagnosis of aortic injury
Severity of rib fractures pulmonary
contusion
Elderly
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ACS

Questions
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ACS

Summary
Common in multiply injured
Life threatening injuries

Develop skills to treat

Monitoring