CHEST TRAUMA
CDR JOHN P WEI, USN MC MD
4
th
Medical Battallion, 4
th
MLG
BSRF-12
CHEST TRAUMA
Blunt versus penetrating trauma
Injury dependent on mechanism
Motor vehicle accident
Fall from height
Physical assault
Explosive blast
Gunshot wound
Stab wound
CHEST TRAUMA
Blunt force injuries from
assault or fall from height
Bony fractures
Lung injuries
Cardiac contusion
CHEST TRAUMA
Acceleration : Deceleration Injuries
CHEST TRAUMA
Penetrating injuries:
Gunshot wounds
Stabbing wounds
CHEST TRAUMA
Improved field diagnosis and treatment
of life threatening conditions
Rapid evacuation to higher level of care
High risk of death despite acute
intervention
Need for prompt diagnosis and
treatment
CHEST TRAUMA
Chest wall and ribs
Lungs and pleura
Great and thoracic
vessels
Heart and
mediastinal
structures
Diaphragm
CHEST TRAUMA
Common Injuries
Rib fractures
Sternal fractures
Open or Closed Pneumothorax
- unilateral / bilateral
Hemothorax
Hemopneumothorax
CHEST TRAUMA
Clinical consequences associated with:
Mechanism of injury
Location of injury
Associated injuries
Co-morbidities
CHEST TRAUMA
Blunt injuries managed non-operatively
Management of airway / oxygenation
Analgesia
Intubation and ventilator support if
needed
Chest tubes if needed for pneumothorax
or hemothorax
CHEST TRAUMA
PENETRATING INJURIES
Trajectory across chest
Mechanism due to knife or gunshot
Type of bullet
CHEST TRAUMA
INITIAL MANAGEMENT
Airway, Breathing, Circulation
PRIMARY SURVEY
Identify & treat immediately life threatening
conditions
CHEST TRAUMA
Early intervention directed toward
diagnosing and treating:
Tension pneumothorax
Massive hemothorax
Open pneumothorax
Cardiac tamponade
Flail chest
CHEST TRAUMA
RADIOLOGIC TESTS
Chest X-ray, usually portable
Abdominal KUB and FAST Ultrasound Exam
CAT scan, and CT Angiogram if needed
CHEST TRAUMA
Rib Fractures
Physical Diagnosis:
Deformity
Localized pain
Crepitus
Treatment:
Analgesia (PCA)
Pulmonary toilet
Observe for pneumothorax
CHEST TRAUMA
FLAIL CHEST
Segment of chest wall that does not have
continuity with rest of thoracic cage
Usually 2 fractures per rib in at least 2 ribs
Segment does not contribute to lung expansion
Disrupts normal pulmonary mechanics
Accompanied by pulmonary contusion in 50% of
patients
CHEST TRAUMA
Flail Chest Diagnosis:
Paradoxical chest wall movement
Poor air movement
Hypoxia
Therapy:
Pain control
Pulmonary & physical therapy
Intubation and ventilator support if needed
Fluid restriction if possible
CHEST TRAUMA
Pneumothorax or Hemothorax
most treated with simple tube
thoracostomy
CHEST TRAUMA
Decompression of Tension Pneumothorax
large bore needle
2nd intercostal space
midclavicular line
Chest tube as definitive treatment
PULMONARY CONTUSION
Common with blunt trauma
May be associated with laceration of
lung parenchyma
Leakage of blood and fluid into
interstitial spaces of lung
Significant inflammatory reaction to
blood components in the lung
PULMONARY CONTUSION
Parenchymal
infiltrate seen on
CXR adjacent to
injured chest wall
PULMONARY CONTUSION
Indications for intubation
Respiratory distress
Hypoxia
Other injuries which compromise
respiratory effort, such as abdominal
or neurologic
MYOCARDIAL CONTUSION
Physical bruising of
the cardiac muscle
Associated with
fractures of the
sternum
Any severe anterior
chest injury
MYOCARDIAL CONTUSION
DIAGNOSIS:
Ectopy
ST elevation
Tachycardia
Friction rub
CPK enzymes, Troponin
Monitor in ICU & treat dysrhythmias
Serial enzymes
Analgesia
MASSIVE HEMOTHORAX
From blunt or penetrating injuries
200cc 1L in chest cavity seen on CXR
Treat with chest tube, if immediate drainage is
1500 cc or if 250 cc/hr for 4 hours, then
immediate thoracotomy
Bleeding may be from ribs, lung, blood
vessels
AORTIC RUPTURE
Abrupt deceleration or compression injury
Sudden motion of heart / great vessels in chest
Great vessel injury may occur in 0.3 => 10%
penetrating trauma
Often rapidly fatal
10% survive to hospital
20% survive > 1 hour
90% who reach hospital will die
Early diagnosis and treatment
AORTIC RUPTURE
mechanism of injury
widened
mediastinum on
CXR
AORTIC RUPTURE
CT with contrast
angiogram
Contained injury
treat with BP control
Operative repair
CARDIAC INJURY AND
TAMPONADE
Fatality rates > 80%
Mostly ventricular, right > left
Blood in pericardial sac causes tamponade
Occurs with penetrating injuries
DIAPHRAGM RUPTURE
Associated with blunt
trauma or blast injury
Can be due to stab wounds
DIAPHRAGM RUPTURE
Surgical repair to replace herniated contents
back into abdomen
Close muscular diaphragm to restore
pulmonary function
Chest tube to treat pneumothorax
ESOPHAGEAL INJURY
Most due to penetrating trauma
Difficult to diagnosis
If delayed or missed, rapid sepsis & high
mortality
Radiography
Endoscopy
Thoracoscopy
Treatment: surgical repair via thoracotomy
EMERGENCY THORACOTOMY
ACUTE THORACOTOMY
Cardiac tamponade (relieved)
Vascular injury to thoracic outlet
Massive air leak
Endoscopic / radiographic evidence of
tracheal or bronchial injury
Esophageal injury
Chest tube output
immediate evacuation of 1500ml blood
or > 250cc/ hour
ER THORACOTOMY
survival rates < 8%
ER THORACOTOMY
BLUNT injury with arrest
Arriving without pulse/BP
Penetrating injury with arrest
High likelihood of isolated / correctable
intra-thoracic injury
ER THORACOTOMY in presence of :
pulse
blood pressure
organized cardiac activity
CHEST TUBE INSERTION
Insertion Site
mid or anterior axillary line behind pectoralis
major
above 5th rib avoid diaphragm
CHEST TUBE INSERTION
Connect tube to
underwater seal and
suture in place
Examine chest to
check effect
CXR to check
placement and
position
SUMMARY
Chest trauma may be due to blunt,
penetrating or combination of causes
Organs at risk include bony, hollow, as well
as cardiovascular structures
Immediate life threatening conditions need to
be treated
Maintenance of airway, oxygenation, and
control of hemorrhage are important goals
