THORACIC CARDIAC & VASCULAR
(Basic Knowledge)
Darmawan Ismail MD
Sub Department of CARDIO THORACIC & VASCULAR SURGERY
UNS Medical Faculty – Dr Moewardi Hospital
Surakarta
CASES
• Trauma
• Non Trauma
Introduction of Trauma
• Chest trauma is often sudden and dramatic
• Accounts for 25% of all trauma deaths
• 2/3 of deaths occur after reaching hospital
• Serious pathological consequnces:
– hypoxia,
– hypovolaemia,
– myocardial failure
Mechanism of Injury
Penetrating Trauma
– Low Energy
• Arrows, knives, handguns
• Injury caused by direct contact
– High Energy
• Military, hunting rifles & high powered hand guns
• Extensive injury due to high pressure
Blunt injuries
• Either:
– direct blow (e.g. rib fracture)
– deceleration injury
– compression injury
• Rib fracture is the most common sign of blunt thoracic
trauma
• Fracture of scapula, sternum, or first rib suggests
massive force of injury
• Age Factors
• Pediatric Thorax: More cartilage = Absorbs forces
• Geriatric Thorax: Calcification & osteoporosis = More fracture
Injuries Associated with
Cardio Thoracic Vascular Trauma
• Airway obstruction • Tracheobronchial tree
• Closed pneumothorax lacerations (rupture)
• Open pneumothorax • Esophageal lacerations
(sucking chest wound) • Penetrating cardiac injuries
• Tension pneumothorax • Pericardial tamponade
• Spinal cord injuries
• Pneumomediastinum
• Diaphragm trauma
• Hemothorax (massive)
• Intra-abdominal trauma
• Hemopneumothorax associated organ injury
• Rib fracture (flail chest) • Laceration of vascular
structures (central &
peripheral)
Basic management concept
in traumatic patient
Is
ABCDE
Sub Department of Cardio Thoracic & Vascular Surgery
responsible in ABC
Airway obstruction
• Clinical finding
– Shortness of breath (dyspnea)
– Stridor
– Apnea
• Management
– Chin lift
– Jaw thrust
– Triple finger manuever
– Evacuate foreign body
– ET insertion
– Cricothyroidostomy
– Tracheostomy
Tension Pneumothorax
– Ventile phenomenon
– Build up of air under
pressure in the thorax.
– Excessive pressure
reduces effectiveness
of respiration
– Air is unable to escape
from inside the pleural
space
– Progression of Simple
(closed) or Open
Pneumothorax
CXR image
Tension Pneumothorax (simplify)
• Anx: Progressive shortness of breath
• PE :
– Respiratory distress
– Tracheal deviation (away)
– Absence of breath sound & percusion: hypersonor
– Jugular Vein Distend
– Hypotension
• Treatment :
– Needle thoracocentesis
– Consult : chest tube insertion
Needle thoracocentesis
SUCKING CHEST WOUND
SUCKING CHEST WOUND
• Upon exhaling, air in
the chest escapes
through the flutter-type
valve created by taping
3 sides only
• With inhaling, the patch
should suck against the
skin, preventing air
entry
Hemothorax
• Hemothorax
– Accumulation of blood in the pleural space
– Serious hemorrhage may accumulate 1,500 mL of blood
• Mortality rate of 75%
• Each side of thorax may hold up to 3,000 mL
• MASSIVE (criteria)
– Blood loss in thorax causes a decrease in tidal volume
• Ventilation/Perfusion Mismatch & Shock
– Typically accompanies pneumothorax
• Hemopneumothorax
Hemothorax (simplify)
• Blunt or penetrating chest
trauma
• Shock
– Dyspnea
– Tachycardia
– Tachypnea
– Diaphoresis
– Hypotension massive
• Dull to percussion over injured
side
• Treatment
Chest tube insertion & consult
CXR Image
Trauma.org
Flail chest
• Multiple rib fractures produce a mobile
fragment which moves paradoxically with
respiration
• Significant force required
• Usually diagnosed clinically
• Treatment
– ABC
– Analgesia
– Fixation : internal &/ external
PARADOXICAL RESPIRATIONS
Flail Chest - detail
Tracheobronchial Injury
– MOI
• Blunt trauma
• Penetrating trauma
– 50% of patients with injury die within 1 hr of injury
– Disruption can occur anywhere in tracheobronchial tree
– Signs & Symptoms
• Dyspnea
• Cyanosis
• Hemoptysis
• Massive subcutaneous emphysema
• Suspect/Evaluate for other closed chest trauma
Tracheobronchial Injury
• Observe for development of
Subcutaneus emphysema & tension
pneumothorax (deadly)
• Treatment
• Keep airway clear
• Administer high flow O2
• Consider intubation if unable to
maintain patient airway
• If tension needle thoracocentesis
• Consult : tracheal repair or
tracheostomy
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
– Results from tear in the coronary artery or
penetration of myocardium
• Blood seeps into pericardium and is unable to escape
• 200-300 ml of blood can restrict effectiveness of
cardiac contractions
– Removing as little as 20 ml can provide relief
Pericardial Tamponade (simplify)
• Dyspnea • Kussmaul’s sign
• Possible cyanosis – Decrease or absence of
• Beck’s Triad JVD during inspiration
– JVD • Pulsus Paradoxus
– Distant heart tones – Drop in SBP >10 during
inspiration
– Hypotension or
– Due to increase in CO2
narrowing pulse during inspiration
pressure
• Electrical Alterans
• Weak, thready pulse
– P, QRS, & T amplitude
• Shock changes in every other
cardiac cycle
• PEA
Pericardial or Cardiac tamponade
Pericardial Tamponade (ilustrations)
Laceration of vascular structures
• General sign
– Shock Hypovolemia (co morbid cardiogenic)
– Penetrating trauma (mostly)
• Internal bleeding
– Thoracic Chest XR
– Abdominal FAST or CT
– Pelvicum CXR
– Femur expanding hematoma + XR
• External bleeding thorough examination &
suturing
Laceration of vascular structures
• Internal bleeding consult
• External bleeding
Introduction of Non Trauma
• Congenital
• Degenerative
• Infection
• Malignancy
• Cardio-respiratory serious pathological
consequnces:
– hypoxia,
– hypovolaemia,
– myocardial failure
congenital
• Cardiac
– ASD, VSD, PDA, TOF
• Thoracic
– PES EXCAVATUM
• Vascular
– MALFORMATION
AQUIRED
• Cardiac
– CORONARY HEART DISEASE
– VALVULAR HEART DISEASE
• Thoracic
– CHRONIC OBSTRUCTIVE PULMONARY DISEASE
• Vascular
– ANEURYSM AORTA
– DISSECTING ANEURYSM
– VARICES
– ETC
INFECTION
• Cardiac
– ENDOCARDITIS
– RHEUMATIC HEART DISEASE
• Thoracic
– FUNGUS BALL
– TUBERCULOMA
– EMPYEMA
• Vascular
– TROMBHOPHLEBITIS
– ARTERITIS
– ETC
MALIGNANCIES
• Cardiac
– MYXOMA LEFT ATRIAL
• Thoracic
– LUNG CANCER
CRYOSURGERY
– MEDIASTINAL CANCER
• Vascular
– HEMANGIOMA
– LYMPHANGIOMA
