1. Thoracic Trauma
Hossam Hassan

2. Thoracic Trauma Anatomy Thorax is a hollow cylinder composed of
12 pairs of ribs,10articulate posteriorly with the thoracic spine and anteriorly with the sternum via costal cartilages,the lower 2 pairs are floating ribs
A nerve,an artery and a vein are located a long the under side of each rib
Intercostals muscles connect each rib to the one above these muscles with the diaphragm are the primary muscle of ventilation.

4. Anatomy
The pleurae are thin membranes that consist of 2 distinct layers:
The partial pleurae line the inner side of the thoracic cavity
The visceral pleurae cover the outer surface of each lung

5. Anatomy
The lungs occupy the right and the left halves of the thoracic cavity
An area called the mediastinum is located in the middle of the thoracic cavity within the mediastinum lie all the other organs and structures of the chest cavity:the heart,great vessels,trachea,mainstem bronchi and esophagus
Any or all of these structures can be injured by thoracic trauma.

7. General Assessment
The signs and symptoms of chest truma related to the chest wall and lungs are sob,tachypnea and chest pain
The initial 3 points in general assessment is :
1.Observation ex.bruises,lacerations,distended neck veins
2.Palpation ex.tenderness,bony crepitus
3.Auscultation ex.presence ,diminished or absence of breath sounds.

8. Thoracic injuries can be:
Rib Fractures
Flail chest
Pulmonary contusion
Pneumothorax(open and close)
Tension pneumothorx
Hemothorax
Blunt cardiac injuries
Pericardial tamponade
Tracheal and bronchial rupture
Aortic rupture
Diaphragmatic rupture

9. Chest Trauma History & PE ATLS protocol A,B,C,D,E’s
Contusions, diminished or absent breath sounds, SQ emphysema

10. AMPLE
A allergies
M Medications (Anticoagulants, insulin and cardiovascular medications especially)
Previous medical/surgical history
L Last meal (Time)
E Events /Environment surrounding the injury; ie. Exactly what happened

11. CXR-fast, easy, least expensive for initial evaluation
Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
CT Scan VS Angiography
EChO VS Transesophogeal Echocardiography

12. FAST

13. Normal CXR

14. Pneumothorax

15. Subcutaneous Emphysema

16. Hemothorax

17. Management of specific injuries.
Rib fracture
Assessment:
Simple rib fracture alone are rarely life threatening in adults
Signs and symptoms of fractured ribs include pain with movement,local tenderness and perhaps bony crepitus

18. Rib fracture Management
The initial management of patient with simple rib fracture is pain reduction
supplemental oxygen in case hypoxia
Bed rest
Fractured ribs should not be stabilized by taping or using any other firm bandaging such attempt can limit ventilation and lead to atelactasis (collapse of the alveoli or part of the lung)and pneumonia

19. Flail Chest
Flail chest is when 2 or more adjacent ribs are each fractured in at least 2 places
Assessment :
Tenderness
Bony crepitus
Hypoxia might happen then lead to increase in respiratory rate as well.

20. Flail chest Management:
The key management is BVM (for positive pressure ventilation)
All patient who have an obvious flail segment should supplied with supplemental O% if not respond then will require more aggressive ventilataroy support

21. Pulmonary contusion
A pulmonary contusion is an area of the lung that has been traumatized to the point where intertitial and leveolar bleeding occur
The amount of intertitial fluids increase in the area between the wall of the cappilaries and alveoli resulting in decreased O% transporst across the thickened membranes

22. Pulmonary contusion Managements
Patient should closely monitored with special attention to fluid administration
Ensuring adequate ventilation and enriched O% administration
In inadequate ventilations or altered LOC or other major injuries BVM and endotracheal intubation if required.

23. Pneumothorax
Simple pneumothorax
Open pneumothorax.

24. Simple pneumothorax
Simple pneumothorax is caused by the presence of air in the pleural space
Assessment:
Pleuratic chest pain
Difficult and rapid breathing
Decreased or absent breath sounds on the involved side are classic signs
Percussion is an excellent indicator

25. Simple pneumothorax Management:
High concentration of O% should be administrated to patients with pneumothorax
Assisted ventilation might be for those who display signs of hypoxia
Semi sitting position is preferred.

26. Open pneumothorax
Penetrating wounds to the chest can produce open chest wall injuries(open pneumothorax)
Assessment :
Pain at the injured side
SOB
The sings might included sucking out bubbling sound as air moves in and out of the pleural space through the chest wall defected

27. Open pneumothorax Management Close the hole in the chest
Closing the hole it could be with a Vaseline gauze by 3 sides taped .
Provide supplemental O%
If signs of increasing respiratory distress are observed the patient may be developing a tension pneumothorax and the dressing should be removed to assess in decompressing the affected side.

28. Tension pneumothorax It is a life threatening situation
The amount of air trapped in the pleural space continues to increase not only is the lung on the affected side collapsed but the mediastinum is also shifted into the opposite side
The intra thoracic pressure increase witch decrease the capillaries blood flow and kinks the vena cava.

29. Tension pneumothorax Assessment:
The presentation of patient with tension pneumothorax varies according to how much intrathoracic pressure has developed.
Signs and symptoms can be minimal or moderate
Anxiety
Cyanosis
Tachypnea
Diminished or absent breath sound on the injured side
JVD (jugular vein distension)note in case hypovolemic this sign might not present.

30. Tension pneumothorax Management:
The management of the patient with a tension pneumothorax involves reducing the pressure in the pleural space
Needle decompression in the field can be done by the expert people
Chest tube
Incase penetrating injury then dressing
Refer to the specialist area as soon as possible.

32. Hemothorax Blood in the pleural space constitutes a hemothorax
In adult the pleural space on each side of the thorax can hold 2500 to 3000 ml of blood

33. Hemothorax Assessment: The symptoms are related to the blood loss
Sings:
Sob
Tachypnea
Decreased breath sound
Clinical signs of shock
Management: transfer to surgical repair.

34. Myocardial Contusion
Occurs in 76% of patients with severe blunt chest trauma
–Right Atrium and Ventricle is commonly injured
–Injury may reduce strength of cardiac contractions Reduced cardiac output

35. Electrical Disturbances due to irritability of damaged myocardial cells
–Progressive Problems
Hematoma
Hemoperitoneum
Myocardial necrosis
Dysrhythmias
CHF & or Cardiogenic shock

36. Myocardial Contusion Signs & Symptoms
Bruising of chest wall
􀂄Tachycardia and/or irregular rhythm
􀂄Retrosternal pain similar to MI
􀂄Associated injuries Rib/ Sternal fractures

37. Chest pain unrelieved by oxygen May be relieved with rest
THIS IS TRAUMA-RELATED PAIN Similar signs and symptoms of medical chest pain

38. Blunt Cardiac Injury
EKG (for any blunt chest injury, persistent tachycardia, ST-T changes or ectopy)
􀂄Cardiac enzymes (CPK, CK-MB and Troponin I)
􀂄Echocardiography (TEE)

39. Pericardial Tamponade
Restriction to cardiac filling caused by blood or other fluid within the pericardium
–Occurs in <2% of all serious chest trauma However, very high mortality

40. –Results from tear in the coronary artery or penetration of myocardium
Blood seeps into pericardium and is unable to escape
200 ml of blood can restrict effectiveness of cardiac contrac

41. Pericardial Tamponade Signs & Symptoms
Dyspnea
Possible cyanosis
Beck’s Triad
JVD
Distant heart tones
Hypotension or narrowing pulse pressure
Weak, thready pulse
Shock

42. Kussmaul’s signDecrease or absence of JVD during inspiration
Pulsus ParadoxusDrop in SBP >10 during inspiration
Electrical AlteransP, QRS, & T amplitude changes in every other cardiac cycle
PEA

43. Traumatic Aortic injury
Aorta most commonly injured in severe blunt 85-95% mortality
Injury may be confined to areas of aorta attachment
Signs & Symptoms
Rapid and deterioration of vitals
Pulse deficit between right and left upper or lower extremities

44. Traumatic Esophageal Rupture
Rare complication of blunt thoracic trauma
–30% mortality
–Contents in esophagus/stomach may move into mediastinum
Serious infection occurs
Chemical irritation
Damage to mediastinal structures
Air enters mediastinum –

45. Subcutaneous emphysema and penetrating trauma present

46. Tracheo-bronchial Injury
Blunt trauma
Penetrating trauma
50% of patients with injury die within 1 hr of injury
Disruption can occur anywhere in tracheobronchial tree –

47. Signs & SymptomsDyspnea
Cyanosis
Hemoptysis
Massive subcutaneous emphysema
Suspect/ evaluate for other closed chest trauma

48. Treatment summary Observe Palpate Auscultation
Management always included to provide supplemental O% then aggressive method if required.
ATLS protocol: A,B,C,D,E’s

49. Treatment summary Emergency management Needle thoracentesis
Tube thoracostomy
Subxiphoid pericardotomy
Video assisted thoracic surgery (VATS)

50. THANK YOU

51. 3. Identification of which of the following is NOT an essential part of the primary survey?
A: Tension Pneumothorax
B: Open Pneumothorax
C: Flail Chest
D: Cardiac Tamponade
E: Rib Fractures

52. 4. Upon Identification of a Tension Pneumothorax, which is the correct management pathway?
A: A chest X-ray to confirm the clinical diagnosis.
B: Insertion of a chest drain in the 5th intercostals interspace in mid-axillary line.
C: Immediate decompression with a 14g 5cm needle in the 2nd intercostal interspace in mid-calvicular line.
D: An ECG to assess for concurrent cardiac contusion.
E: Completion of a secondary survey to exclude any concurrent injury.

53. In massive haemothorax, which of the following is an indication for emergency thoracotomy?
A: Production of 500ml of blood on immediate insertion of a chest drain.
B: Production of 50ml/hour of blood for two consecutive hours in the chest drain.
C: Production 1000ml of blood on immediate insertion of a chest drain.
D: Production of greater than 1500ml of blood on immediate insertion of a chest drain.
E: Evidence of greater than 5 rib fractures in conjunction with radiological evidence of haemothorax

54. A pulmonary contusion:
 A: Can cause immediate respiratory difficulties.
B: Results in increased lung compliance at 24 hours.
C: Does not occur without rib fractures in children.
D: Can cause ventilation/perfusion mismatch which evolves over 24 hours.
E: Is not associated with Adult Respiratory Distress Syndrome.

55. When evaluating the chest of a patient with a chest injury, you note a fine crackling sensation under the areas that you palpate. This is best described as:
  pulses paradoxus. subcutaneous emphysema. hemothorax. none of the above.

56. In which condition would you observe paradoxical movement of the chest wall?
  mediastinal shift tension pneumothorax flail chest Cheyne–Stokes breathing

57. Proper care for a patient with a sucking chest wound includes:
  pulling the wound open on inhalation to release trapped air. sealing the wound with an occlusive dressing. covering the wound with sterile gauze. decompression of the chest.

58. Which of the following statements correctly differentiates a simple pneumothorax from a tension pneumothorax?
  A tension pneumothorax requires decompression while a simple pneumothorax does not. A simple pneumothorax is caused by air in the pleural space while a tension pneumothorax is caused by blood in the pleural space. A simple pneumothorax is caused by damage to the lung from inside while a tension pneumothorax is caused by injury to the outside chest wall. There is no difference between a tension pneumothorax and simple pneumothorax.

59. After placing an occlusive dressing over a sucking chest wound to the right chest, you note that the patient has become extremely dyspneic and cyanotic with breath sounds absent on the right side. Your next action would be to:
  perform a needle cricothyroidotomy. remove the occlusive dressing and replace it with sterile gauze. insert an oropharyngeal airway. loosen a corner of the occlusive dressing.