1. Chest Trauma I For Undergraduate
Staff Members of Cardio-thoracic Surgery Departments
Egypt

2. Types of Thoracic Trauma
Accidental Trauma.
Iatrogenic Trauma.
Chemical Trauma.
Thermal Trauma.
Barotrauma and blast injuries.
Isolated thoracic trauma, Thoraco-abdominal, Associated with others.
About 20% to 25% of all trauma-related deaths, are related to chest injuries.

3. Accidental Trauma Caused by: RTA, Fall from a height, Blunt objects.
i) Blunt chest trauma
ii) Penetrating chest trauma
Caused by: RTA, Fall from a height, Blunt objects.
90% of blunt trauma can be managed without thoracotomy (i.e. with conservative management or with intercostal tube drainage)
Caused by: 1. Stab wounds by Knife, Sword, sharp objects. arme blanche السلاح الأبيض
2. Gunshot injuries by Bullet, Shot-gun or air-gun and by Shrapnel. arme à feu الطلق الناري
70% to 85% of penetrating trauma can be managed without thoracotomy ( i.e. with conservative management or with intercostal tube drainage).
Perforating injury has inlet and exit.

4. Blunt Trauma - RTA

5. Penetrating Trauma - Bullet Injury

6. Bullet Injury (PA&Lat)

7. Air-gun Injury

8. Shot-gun Injury

9. Shrapnel

10. Shrapnel

11. Effects or squeals Immediate or direct effects.
Delayed effects or complications.

12. Primary Survey Resuscitation phase:
ABCDE (Airway, Breathing, Circulation, Disability, and Exposure).
Rapid clinical assessment of:
- Life-threatening thoracic injuries.
- Associated injuries.

13. Resuscitation phase >>>>>ABCDE
Airway maintenance with cervical spine protection: Breathing and ventilation Circulation with hemorrhage control Disability/Neurologic assessment Exposure and environmental control

14. A-Airway Assess the airway. Airway obstruction cleared by:
Suction (oral, nasopharyngeal, Nasotracheal).
Oral or nasal Airway
Endotracheal or endobronchial tube
Cricothyroidotomy
Tracheostomy
Bronchoscopy

15. B-Breathing Oxygen inhalation. Close chest wall defects.
Chest must be examined by inspection, palpation, percussion & auscultation. Subcutaneous emphysema and tracheal deviation.
Identify and manage six life-threatening thoracic conditions as Airway Obstruction, Tension Pneumothorax, Massive Haemothorax, Open Pneumothorax, Flail chest segment  and Cardiac Tamponade. 
Oxygen inhalation.
Close chest wall defects.
Expand lung by ICTD.
Stabilize chest wall.
Blood gas analysis.
Mechanical Ventilation.

16. C-Circulation Hypovolemic shock is caused by significant blood loss.
Two large-bore intravenous lines.
CVP line.
Volume resuscitation by crystalloid solution >>>> does not respond >>>> type-specific blood, or O-negative group.
Stop bleeding (ICTD, Thoracotomy)
Exclude cardiac tamponade.

17. D- Disability/Neurologic assessment
Neurological assessment: known by the mnemonic AVPU (alert, verbal stimuli response, painful stimuli response, or unresponsive).
Glasgow Coma Scale.

18. Glasgow Coma Scale 1 2 3 4 5 6
Eye
Does not open eyes
Opens eyes in response to painful stimuli
Opens eyes in response to voice
Opens eyes spontaneously
N/A
Verbal
Makes no sounds
Incomprehensible sounds
Utters inappropriate words
Confused, disoriented
Oriented, converses normally
Motor
Makes no movements
Extension to painful stimuli (decerebrate response)
Abnormal flexion to painful stimuli (decorticate response)
Flexion / Withdrawal to painful stimuli
Localizes painful stimuli
Obeys commands
The scale is composed of three tests: eye, verbal and motor responses. The three values separately as well as their sum are considered. The lowest possible GCS (the sum) is 3 (deep coma or death), while the highest is 15 (fully awake person).

19. E- Exposure and environmental control
The patient is undressed & Covered with warm blankets to prevent hypothermia.

20. Immediate Life-threatening Injuries
Airway obstruction;
Tension pneumothorax.
Open pneumothorax.
Massive haemothorax.
Cardiac Tamponade.
Massive flail chest.

21. Secondary Survey More thorough examination + investigations
Laboratory Studies:
CBC count
Arterial blood gas & electrolyte status.
Coagulation profile:
Serum troponin levels & CK –MB in patients with possible blunt cardiac injuries.
Blood type and cross-match:

22. Imaging:
Chest X-ray.
CT scan.
MRI.
U/S: FAST & eFAST
ECG & ECHO (TTE & TEE).
Angiography as Aortography
Contrast esophagogram & Upper GIT Studies.

23. Instrumental
Flexible or rigid esophagoscopy in patients with possible esophageal injuries.
Fiberoptic or rigid bronchoscopy: in patients with possible tracheobronchial injuries.

24. Focused assessment with sonography for trauma (FAST)
Rapid bedside ultrasound examination performed as a screening test for blood around the heart (pericardial effusion) or abdominal organs (hemoperitoneum) after trauma.
Four classic areas examined for free fluid are the perihepatic space (also called Morison's pouch or the hepatorenal recess), perisplenic space, pericardium, and the pelvis.

25. Extended FAST (eFAST)
Examination of both lungs by adding bilateral anterior thoracic sonography to the FAST exam. For detection of a pneumothorax.
Advantages of FAST & eFAST:
Have high sensitivity.
Fast; can be performed in under a minute.
Less invasive
No exposure to radiation
Cheaper
Useful in trauma patients who are hemodynamically unstable or undergoing positive-pressure ventilation.

26. Potential life-threatening injuries
Cardiac contusion
Deceleration aortic injury
Tracheo-bronchial rupture
Diaphragmatic rupture
Oesophageal perforation
Pulmonary contusion
Pneumothorax
Haemothorax

27. Tertiary survey Serial assessments to help recognize missed injuries.
The rate of delayed diagnosis may be as high as 10%.

28. I- Thoracic Cage Injuries A-Surgical emphysema
Definition
Presence of air in subcutaneous tissue from surgical causes.
NB.: Infection with gas forming organisms may cause subcutaneous emphysema.

29. Surgical emphysema (cont.)
Aetiology
Fractured rib injuring underlying lung resulting in closed or tension pneumothorax.
Tracheobronchial tears.
Penetrating chest injury and open pneumothorax.
Mediastinal emphysema due to ruptured bronchioles or alveoli without disrupting the visceral pleura following blunt trauma or barotrauma of ventilators or even spontaneously esp in asthmatics.
Ruptured oesophagus.
After intercostal tube insertion for pneumothorax when the tube is blocked.
Rarely after dental surgery and laparoscopy.

30. Surgical emphysema (cont.)
Presentation:
Presence of air under the skin with characteristic crackling sensation (subcutaneous crepitation).
Localised or rapidly progressive; up to neck and face closing eyelids, or down to abdomenal wall and scrotum.
It causes patient’s discomfort and worry.
It is benign but may signify serious underlying problem.
It is evident in X-ray and CT chest.

31. Surgical emphysema face

32. Surgical emphysema scrotum

33. Surgical emphysema (cont.)
Treatment:
It will be absorbed spontaneously.
Find and manage its cause.
If extensive, evacuated with needles, skin incisions or subcutaneous catheters.

34. B-Fracture Ribs The most common chest injury.
Uncommon in children [pliable ribs].
The 4th to 9th ribs are the most commonly fractured [thin and poorly protected].
First Rib Fracture is Dangerous , may be associated with brachial plexus or subclavian vessels injury.
Fractures of the upper ribs (1, 2, and 3) indicate major trauma
Fractures of the lower ribs(8, 9, and 10) may be associated with renal, hepatic or splenic injuries.

35. Fracture Ribs (cont.) Aetiology: Effects:
Usually caused by blunt trauma
Direct violence.
Indirect violence.
Muscular violence.
Effects:
Fracture ribs → Severe pain → respiratory movements & ineffective coughing → Atelectasis & pneumonia.
Injury of underlying pleura and lung.
Injury of intercostal bundle.

36. Fracture Ribs (cont.) Clinical Picture:
Severe pain on inspiration or coughing .
Localized tenderness.
Bruising.
Spring test (Anteroposterior chest compresion causes pain laterally in the fractured site).
Crepitus.
Surgical emphysema.
Look for associated haemopneumothorax.,

37. Fracture Ribs (cont.) Investigations: Chest X-ray.
CT when suspected associated injuries.
Multi slice CT (Skeleton view).

38. Plain chest X-ray (Rib view).

39. Fracture Ribs (cont.) Treatment: Pain control, by:
i) Systemic analgesics oral or intravenous.
ii) Intercostal nerve block
iii) Epidural anesthesia.
2. Optimization of pulmonary toilet (e.g. incentive Spirometer, coughing & ambulation) >>>> prevention of atelectasis.
3. Treatment of complications e.g. hemothorax or pneumothorax.
N.B. : Chest strapping (by binders or adhesive tape, and rib belts) is not recommended as they cause reduction of ventilation of the affected side that promote atelectasis.

40. C- Flail Chest Definition:
Paradoxial movement of a segment of chest wall caused by fractures of three or more successive ribs broken in two or more places.
Serious, life-threatening chest injury often associated with underlying pulmonary injury.
Stove-in chest, the fractured ribs are drivin inwards without exhibiting paradoxical movements.
Aetiology:
Severe blunt trauma.

41. Types of flail Chest: Anterior Lateral. Posterior (least dangerous).
Flail sternum.

42. Pathophysiology
4 mechanisms contribute to the pathophysiology of the flail chest: 1- Paradoxical movement of the flail segment: It moves in with inspiration and out with expiration in paradox with the other parts of the thoracic cage. 2- Paradoxical respiration: The lung portion related to the flail segment: o During normal inspiration, will collapse instead of inflating. o During normal expiration, will inflate and the expired air from healthy lung (that contains more CO2) will be transmitted to it according to pressure changes. This will lead to gas exchange mismatch impairing the ABGs. 3- Pendular respiration: This result from the above mentioned paradoxical respiration as shown in figure, one lung will inflate while the other lung is collapsing. 4- Mediastinal flutter: Right and left movement of mediastinum this will lead to kinking of great veins of mediastinum causing decrease of venous return and subsequently decrease of cardiac output.

43. Pathophysiology: In flail chest, Hypoxaemia is due to:
Underlying pulmonary contusion with ventilation perfusion mismatch.
Pain of rib fractures → ↓ tidal volume, accumulate secretions →Atelectasis →↑ pulmonary shunting & ↓functional reserve capacity.
Associated haemopneumothorax or cardiac trauma.

44. Pathophysiology (cont.):
4. Hypoventilation of the underlying lung from paradoxical respiration.
5. Mediastinal flutter with kink of great vessels.
6. Pendulum-like movement of dead space air.

45. Paradoxical movement >>> Mediastinal flutter & Movement of dead space air

46. Pathophysiology (cont.): Pendulum-like movement of dead space air.

47. Presentation: Severe blunt trauma. Severe chest pain of rib fractures.
Dyspnoea, tachypnoea and cyanosis.
Hypotension and tachycardia.
Paradoxical movement of the flail segment.
Chest wall contusions ± surgical emphysema.
Diagnosis:
- Inspection of paradoxical movement which is confirmed by palpation.
X-ray: Fractured ribs seen and may show complication.
NB: Diagnosis of Flail chest is clinical rather than radiological.
Complication:
Pneumothorax, hemothorax, lung contusion, respiratory insufficiency.

48. Investigations Chest X-ray. CT scan chest.
Multislice CT (MSCT) scan chest wall.
Blood gas analysis.

49. Prevention Prognosis Safer Automobiles, seat belt, air bag design.
Safer roads.
Prognosis
5-10% mortality depending on severity of injury, age, bilaterality and number of ribs fractured.

50. Treatment Oxygen inhalation (Nasal or face mask).
Pain relief: - Systemic analgesics (avoid opiate), patient-controlled analgesia (PCA) machines. - Intercostal nerve block. - Epidural catheter.
Intercostal tube drainage of associated hemo or pneumothorax.
Pulmonary toilet: to clear secretions from the airways and prevent atelectasis. By suctioning of airways, nasotracheal suction, bronchoscopy, tracheostomy, chest physiotherapy, blow bottles, incentive spirometry, coughing, percussion and positioning in prone position.

51. Treatment (cont.):
External chest wall stabilization by compressive dressing strapping.
CPAP (Continuous Positive Airway Pressure) by mask.
Mechanical ventilation: IPPV (Intermittent Positive Pressure Ventilation) indicated for a respiratory rate over 40 breath / min, blood gases deteriorate >>> PaO2 < 60mmHg, PaCo2 > 60mmHg despite 60% face mask oxygen.

52. Treatment (cont.) Surgical fixation:
Indicated for cosmetic chest wall deformity, thoracotomy for other reasons (hemothorax) and failed weaning from ventilation.
By orthopaedic devices ( Judet struts, Kirschner [K-] wires).

53. . If ABGs are not improving and patient condition becomes more worse we shift to mechanical ventilation if the following criteria were found:
 PaO2< 50 mmHg and PaCO2 > 50 mmHg in absence of metabolic alkalosis.
o Internal surgical fixation: this is indicated in: 

54. D-Fracture Sternum
Transverse fractures generally in the body of the sternum near the manibriosternal junction.
Diagnosed by lateral X-ray chest. CT scan to exclude associated injuries. ECG & ECHO to exclude cardiac injury.

55. Fracture Sternum (cont.)
In most cases, analgesia & follow up.
In severe cases, IPPV &/or operative reduction.

56. II-Pleural space injuries A- Pneumothorax
Pneumothorax >>> Accumulation of air in the pleural cavity.
Types of Pneumothorax:
Etiology, Communication, Tension, Recurrence.
Etiology:
Traumatic: blunt, penetrating or iatrogenic (Lung biopsy, central line insertion, barotrauma during mechanical ventilation).
Spontaneous (Primary: without previous lung disease or Secondary: on top of a previous lung disease).

57. A- Pneumothorax Cont. Etiology: Cont. Spontaneous pneumothorax cont.
Primary: Ruptured apical bleb.
Secondary : Associated with :
Chronic obstructive lung disease (rupture of air-filled bulla within lung parenchyma).
Cystic fibrosis.
Infection: Cavitating nonspecific bacterial, tuberculous, mycotic and parasitic infections.
Tumors: Rupture of ischemic primary or metastatic lung carcinoma, lymphoma, and sarcoma.
Catamenial: Associated with menstruation (focal pleural endometriosis).
Miscellaneous: Associated with many connective tissue and autoimmune diseases.

58. Pneumothorax (cont.) 2. Communication:
Open pneunothorax: with communication through the chest wall to the exterior.
Closed pneumothorax: without communication.

59. Open Pneumothorax: Pleural cavity communicates with the atmosphere.
One of the life threatening complications.
Wide communication (more than the diameter of trachea) to the outside results in (as with tension pneumothprax):
Total lung collapse on the affected side.
Mediastinal flutter : The mediastinum is mobile, so with inspiration the mediastinum moves towards the healthy side and opposite on expiration. So, paradoxical respiration in the healthy side occurs
Impaired venous return

60. Closed Pneumothorax: No communication to the atmosphere.
Usually well tolerated.

61. Pneumothorax (cont.) 3. Tension:
Simple pneumothorax without tension (mild, moderate, massive).
Tension pneumothorax ( presence of one way valvular mechanism or on positive pressure ventilation).
4. Recurrence:
Primary.
Recurrent.

62. Tension Pneumothorax Life threatening condition.
Developed when an injury to the lung or chest wall allows air to continue to enter the pleural space with each inspiration without being able to exit during expiration 9one way valve mechanism).

63. Tension pneumothorax, cont.
Through this valvular mechanism, air will accumulate in the pleural cavity with increased positive pressure.
lung collapse on the affected side with shift of mediastinum to the other side
leads kinking of the caval veins resulting in impairment of venous return and low cardiac output.
Compression to the other lung leads to significant hypoxia.

64. Pathogenesis of pneumothorax
Penetration of chest wall.
Laceration of the lung.
Perforation of bronchus , trachea or oesophagus.
Tear of the lung by driven-in rib fragment.
Pulmonary interstitial emphysema → Mediastinal emphysema → Pneumothorax &/or surgical emphysema.

65. Pathogenesis of pneumothorax (cont.)

66. Traumatic Pneumothorax (cont.)
Clinical Picture:
Symptoms are related to the degree of lung collapse and underlying pulmonary function. Asymptomatic or symptomatic (dyspnea, chest pain, dry cough, severe respiratory distress with hypoxia, hypercarbia and acidosis).
Signs:
Decreased movement on the same side
Trachea may be central or shifted to the healthy side.
Hyper resonance & Tympanetic percussion note.
Diminished air entry on auscultation.

67. Tension pneumothorax, cont.
Classic signs: Shock (hypotension, tachycardia), Hypoxia, Distended neck veins. Tracheal deviation to contralateral side, Hyperresonant and reduced breath sounds, Hyperexpanded hemithorax with decreased expansion.

68. Traumatic Pneumothorax (cont.)
Investigations:
Chest X-ray (mild → one finger breadth, moderate → two fingers breadth, massive → total lung collapse or tension → mediastinal shift to the other side.) Expiratory film accentuates small pneumothorax.
CT scan (can diagnose the smallest amount of pneumothorax). Differentiates lung cysts and bullae in the presence of subcutaneous emphysema, and quantitates the degree of pneumothorax.

69. CXR Left Pneumothorax. 3 Radiologic Criteria of Pneumothorax : 1
CXR Left Pneumothorax. 3 Radiologic Criteria of Pneumothorax : 1. Jet black discoloration. 2. Absence of lung reticulations (markings). 3. Presence of lung border.

70. CXR with right Pneumothorax:
Jet black discoloration (air).
Absence of lung reticulations (bronchovascular markings).
Presence of lung border: The outline of the lung is seen in the pleural space (which is the visceral pleura).

71. Traumatic Pneumothorax (evidence of trauma present in CXR)
Notice right shrapnel
Notice associated left rib fracture

72. Tension pneumothorax, cont.
Tension pneumothorax is a clinical diagnosis with no time for investigation
Chest X-ray: Shows, collapse of entire lung, depression of diaphragm with flattening of it's dome, and mediastinal shift.

73. CXR left tension pneumothorax

74. CT scan of tension pneumothorax

75. Complications: Persistent air leak: denotes bronchopleural fistula.
Recurrence:
Tension pneumothorax:
Hemothorax: From tearing of vascular adhesion between the lung and chest wall.
Pneumomediastinum:

76. Treatment Simple mild cases → Observation.
Moderate and severe → Chest-tube drainage under water seal in the second space mid clavicular line.
Tension → Immediate decompression (live-saving) Emergency wide pore needle under water seal in the 2nd intercostal space midclavicular line to releif tension → ICTD. insertion once available.
Open → Close the external wound and insert ICT.

77. 5. For spontaneous pneumothorax → ICTD → Pleurodesis: using tetracycline or talc (Chemical pleurodesis).
6. Failure of lung expansion and continuous air leak → Surgery (Thoracotomy or VATS):
Close site of air leak, resect blebs or bullae, close bronchopleural fistula and repair major tracheobronchial tears.
Mechanical pleurodesis by pleurectomy or mechanical pleural abrasion.
7. Bronchoscopy: should be done to exclude endobronchial lesion that prevents re-expansion of the lung.

78. B-Hemothorax Etiology: Sources of blood: Definition :
Accumulation of blood in the pleural space.
Sources of blood:
1-Intercostal and internal mammary vessels. 2-Pulmonary vessels & bronchial arteries, 3-Heart and great vessels. 4-Mediastinal vessels. 5-Diaphragmatic vessels. 6- Infra diaphragmatic vessels through diaphragmatic tear.
Etiology:
Trauma (The most common cause):
Blunt or penetrating injury.
Iatrogenic:
Postoperative. Thoracocentesis. Needle lung biopsy.
Spontaneous pneumothorax: with tear of vascular adhesions.
Bloody effusion :
Pulmonary embolus. Neoplasm. Tuberculosis.

79. Traumatic Haemothorax (cont.)
Pathology:
Isolated hemothorax or hemopneumothorax.
Degree:
-Mild → ml
-Moderate → ml
-Severe → ml

80. Traumatic Hemothorax (cont.)
Clinical Picture:
General:
Pallor, tachycardia, tachypnoeia, hypotension and shock.
Local:
Decreased respiratory movement, Tracheal deviation to contralateral side in massive hemothorax, Dullness and Decreased air entry on affected side.

81. Traumatic Hemothorax (cont.)
Investigations:
Anaemia.
Diagnostic thoracocentesis → blood
CXR (PA and lateral) views:
< 300 ml of blood may be hidden by diaphragm on erect chest film.
Supine CXR can easily miss hemothorax.
Mild → obliterated costophrenic angle
Moderate → till the level of the hilum
Massive → above the level of the hilum

82. Traumatic Hemothorax:, cont
Fast Ultrasound.
CT scan.

83. Massive Left Hemothorax

84. Haemopneumothorax

85. Traumatic Hemothorax (cont.)
Complications:
-Clotting → clotted hemothorax.
-Organization → fibrothorax and frozen chest.
-Infection → empyema.

86. Traumatic Haemothorax (cont.)
Treatment:
General supportive measures → blood transfusion & oxygen inhalation.
Minimal→Conserve.
Mild to moderate→Aspiration.
Moderate to massive→ ICTD
Intercostal tube drainage: Using the 5th or 6th space in the mid-axillary line. Large bore (32-36 F) chest drain/s.

87. Treatment Cont.: Thoractomy: indicated in:
Massive Initial chest tube drainage ˃ 1500 cc with hemodynamic instability not responding to adequate resuscitation.
Continued bleeding through the tube ˃ ml/hour (3-5 ml/kg/hour) for 3 successive hours
Drainage is inadequate with persistent collection on CXR.
Manage associated intrathoracic injuries or pathology (bronchopulmonary injury with continued air leak, cardiac tamponade, traumatic aortic aneurysm,…) .
Evacuation of clotted hemothorax. After 4-6 weeks clot organization requires decortication.