1. Thoracic Trauma
Chapter 4

2. Objectives
Identify and treat life-threatening injuries found during the primary survey
Identify and treat injuries found during the secondary survey
This lecture focuses on the ABCDE approach to the initial assessment and management process of identifying and treating patients who sustain thoracic trauma.

3. Thoracic Trauma Significant cause of mortality
Blunt: <10% require operation
Penetrating: 15-30% require operation
Majority: require simple procedures
Most life-threatening injuries identified in primary survey
Chest injuries remain a significant cause of morbidity and mortality among trauma patients.

4. Key Questions
What life-threatening chest injuries should I recognize as causing major patho- physiologic events?
What are the significant pathophysiologic effects of chest injury that I should identify in the primary survey?
When and how do I correct the problem identified in the primary survey?
It is important to think in terms of ABCDE.

5. Life-threatening injuries?
Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade
These life-threatening injuries are treated as they are identified.

6. Major pathophysiologic events?
Hypoxia
Hypoventilation
Acidosis
Respiratory
Metabolic
Inadequate tissue perfusion
Treatment is directed at these events.
These are the important pathophysiologic events.

7. When do I correct the problem?
When the problem is identified in the Primary Survey
The problem should be corrected when the problem is identified in the Primary Survey.

8. Life-threatening chest injuries?
What life-threatening injuries might occur in the event below?
28 year-old male involved in high speed car wreck
Prolonged extrication from driver’s seat
Significant deformation to car and steering column
This scenario is used to stimulate the in-depth discussions of the various life-threatening chest injuries.

9. Life-threatening injuries
Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest
Massive hemothorax
Cardiac tamponade
The patient in the previous scenario could have sustained any one or various combinaitons of these life-threatening injuries.

10. Laryngeal Injury Causing airway obstruction Rare Hoarseness
Subcutaneous emphysema
Treatment: intubate cautiously, tracheostomy
Treatment is establishing a definitive airway.

11. Tension Pneumothorax Respiratory distress Distended neck veins
Unilateral decrease in breath sounds
Hyperresonance
Cyanosis (late)
Blunt injury is a more likely cause of tension pneumothroax. Cardiac tamponade occurs more often with penetrating trauma.

12. Tension pneumothorax Immediate decompression
Clinical diagnosis, not by X-ray
A tension pneumothorax must be immediately decompressed by inserting a needle, followed by insertion of a chest tube.

13. Open pneumothorax 3-sided cover over defect Chest tube
Definitive operation
The photo illustrates a chest tube.

14. Flail chest/pulmonary contusion
Reexpand lung
Oxygen
Judicious fluids
Intubate as indicated
Analgesia
The flail segment serves as a marker for pulmonary contusion. The treatment goal is to reexpand the lung, and avoid progressive atelectasis.

15. Massive hemothorax Systemic/pulmonary vessel disruption
>1500 mL blood loss
Flat vs distended neck veins
Shock with no breath sounds and/or percussion dullness
Treatment:
Restore volume
Chest decompression
X-ray
Operation
This injury results in a circulation problem.

16. Cardiac Tamponade
Most survivors of cardiac tamponade have an anterior or posterior penetrating wound to the chest
Decrease arterial pressure
Distended neck veins
Muffled heart sounds
PEA
Cardiac tamponade is suspected if the patient has a penetrating peristernal wound, is hypotensive and dyspneic, and may even verbalize that he/she senses she/she is dying.

17. Cardiac Tamponade Treatment: Surgery Airway
Breathing: ventilate/Oxygen
Pericardiocentesis/FAST
Surgery
Thoracoctomy
Not on PEA
Pericardiocentesis is performed to confirm the diagnosis.

18. Key Questions
What potentially lethal chest injuries should I recognize as causing patho-physiologic events?
What are the pathophysiologic effects of chest injury that I should identify in the secondary survey?
When and how do I correct the problem identified in the secondary survey?
It is important to think in terms of ABCDE.

19. Potentially lethal chest injuries
Simple pneumothorax
Hemothorax
Tracheobronchial tree injury
Blunt cardiac injury
Traumatic aortic disruption
Mediastinal traversing wound
These are injuries addressed during secondary survey.

20. Pathophysiologic events?
Hypoxia
Hypoventilation
Acidosis
Respiratory
Metabolic
Inadequate tissue perfusion
Treatment is directed at these events in the secondary survey.
These are the important pathophysiologic events.

21. Pneumothorax Penetrating/blunt trauma Ventilation/perfusion
Hyperresonance
Decreased breath sounds
Treatment:
Chest tube
Obtaining a chest X-ray as part of the initial assessment process can help identify this injury.

22. Hemothorax Chest wall injury Lung/vessel laceration Treatment:
Chest tube
Hemothorax is suspected by hypotension without obvious sources of blood loss or by decreased breath sounds and dullness to percussion over a hemithorax.

23. Pulmonary Contusion Common Treatment: Oxygenate and ventilate
Selective intubation
Late X-ray change
A pulmonary contusion can be mild to severe and may cause very little hypoxia to severe hypoxia.

24. Tracheobronchial Injury
Often missed
Blunt or penetrating
Persistent pneumothorax
Treatment:
Bronchoscopy
Airway/Ventilation
Chest tube
Operation
Strong suspicion of a tracheobronchial injury is raised if the lung does not properly inflate after insertion of a chest tube, or there is a persistent air leak after tube thoracocstomy.

25. Blunt Cardiac Injury Injury spectrum Abnormal ECG Treatment:
Echocardiography
Treat dysrhythmias
Perfusion
Complications
Blunt cardiac injury is rare. Patient usually presents with an abnormal ECG within the first 24 hours from injury.

26. Traumatic Aortic Disruption
Rapid acceleration/ deceleration mechanism
High index of suspicion
Rapid surgical consult
A patient involved in a rapid acceleration or deceleration situation is at risk for an aortic injury. The Xiray may show a widened mediastinum.

27. Diaphragmatic Rupture
Most diagnosed on left
Blunt: large tears
Penetrating: small perforations
Misinterpreted X-ray
Contrast radiography
Operation
An elevated diaphragm on the chest X-ray should raise suspicion for a ruptured diaphragm.

28. Mediastinal Traversing Wound
Hemodynamically abnormal
Multiple mediastinal injuries
Bilateral chest tubes
Emergent surgical consult
Hemodynamically normal
Diagnostic studies
Surgical consult
Penetrating wounds traversing the mediastinum present unique challenges to the doctor caring for the patient with this type of injury.

29. Subcutaneous Emphysema
Airway injury
Pneumothorax
Blast injury
Latrogenic
Such an appearance usually indicates an airway injury.

30. Traumatic Asphyxia
Acute, temporary compression of the superior vena cava
Brain edema
Petechiae
Traumatic asphyxia occurs when a powerful compressive force is applied to the thoracic cavity. This is most often seen in motor vehicle accidents, as well as industrial and farming accidents. However, it can present anytime a significant pressure is applied to the thorax. The sudden impact on the thorax causes an increase in intrathoracic pressure. In order for traumatic asphyxia to occur, a Valsalva maneuver is required when the traumatic force is applied. Exhalation against the closed glottis along with the traumatic event causes air that cannot escape from the thoracic cavity. Instead, the air causes increased venous back-pressure, which is transferred back to through the right atrium, to the superior vena cava and to the head and neck veins and capillaries.
Traumatic asphyxia is characterized by cyanosis in the upper extremities, neck, and head as well as petechiae in the conjunctiva. Patients can also display jugular venous distention and facial edema. Associated injuries include pulmonary contusion, myocardial contusion, hemo/pneumothorax, and broken ribs.

31. Fracture Pathophysiology
Sternum, scapular, and rib
Pain
Associated injuries
Complications
Atelectasis
Pneumonia
Patient tends to breath shallow due to pain
Need adequate pain relief.

32. Associated Injuries Ribs 1-3 = severe force
Ribs 4-9 = pulmonary contusion and pneumothorax
The location of the fracture can provide clues about other possible injuries.
Ribs = suspect abdominal injury

33. Esophageal injury Blunt/penetrating Severe blow
Pain/shock out of proportion of injury
Signs:
Chest tube discharging particulate matter
Mediastinal air
Treatment:
Contrast swallow
Operative intervention
Esophageal injury is more common with penetrating injuries.

34. Pitfalls?
Application of an occlusive dressing over a wound associated with a simple pneumothorax can produce a tension pneumothorax
Chest tube placement is important to clear pleural space and reduce iatrogenic injury
Adequate pain relief
Extremes of age
These are pitfalls to avoid.

35. Summary Common in multiple injured Life-threatening injuries
Potentially lethal injuries
Initial stabilzation by simple techniques in the majority of cases
Goal: restore normal gas exchange and perfusion
This is the summary.

36. Questions?