Chest Trauma Leading to

Surgery : Surgeons Demand

Yan Efrata Sembiring, dr, Sp.B(K)TKV

Division of Thoracic, Cardiac and Vascular
Department of Surgery,
Faculty of Medicine Airlangga University/
Dr Soetomo Hospital
Surabaya, Indonesia
Chest Anatomy
Chest Anatomy
 Chest  trauma  

—  Lethality  due  to  an  Isolated  chest  traumas  -­‐  5%  to  8%.    

—  Of  all  deaths  caused  in  relation  to  chest  injuries-­‐  25%                                        
(2nd  leading  cause  of  death)  
 
—  Role  of  surgery  –  10%  -­‐15%  

—  Important  factor  -­‐    Total  morbidity  and  mortality  in  

traumatized  emergency  patients  

J  Emerg  Trauma  Shock.  2011  Apr-­‐Jun  

Incidence of Chest trauma and
associated injuries

- United State : 372 cases per year

27% Extremities injury
15% Brain Injury
24% Abdominal Injury
- Surabaya: 149 cases per year
19% extremities injury
14% brain injury
9% abdominal injury
Life threatening chest trauma
—  Tension Pneumothorax
—  Massive haemothorax
—  Open Pneumothorax
—  Cardiac Tamponade
—  Flail chest
Mechanism of Injury
—  Bluntchest trauma
—  Penetrating chest trauma
Tension Pneumothorax
—  Incidence
◦  Penetrating Trauma
◦  Blunt Trauma
—  Morbidity/Mortality
◦  Severe hypoventilation
◦  Immediate life-threat if not managed early

9
Tension  Pneumothorax
—  Amount  of  air  in  the  pleural  space  increases  and  the  loss  of  
air  is  impaired  or  impossible  due  to  a  valve  mechanism.  
   
—  Tension  Pneumothorax  is  purely  a  clinical  diagnosis  

—  Reducing  cardiac  output.    

•  Displacement  of  the  mediastinal  structures  and  the  lungs  
•  Reduction  of  venous  Plow  to  the  heart,
•  Shock will develop rapidly
•  True life-threatening emergency!

  J  Emerg  Trauma  Shock.  2011  Apr-­‐Jun  

Tension Pneumothorax
—  Assessment Findings - Most Likely
◦  Severe dyspnea ⇒ extreme resp distress
◦  Restlessness, anxiety, agitation
◦  Decreased/absent breath sounds
◦  Worsening or Severe Shock / Cardiovascular
collapse
–  Tachycardia
–  Weak pulse
–  Hypotension
–  Narrow pulse pressure

11
Tension Pneumothorax
—  Assessment Findings - Less Likely
◦  Jugular Vein Distension
–  absent if also hypovolemic
◦  Subcutaneous emphysema
◦  Tracheal shift away from injured side (late)
◦  Cyanosis (late)

12
TENSION  PNEUMOTHORAX  
SIGNS  AND  SYMPTOMS
 TENSION  PNEUMOTHORAX  
RADIOGRAPHIC  FINDINGS

Mediastinal
shift to the TENSION
right PNEUMOTHORAX

Tension pneumothorax is a clinical diagnosis.

Treatment should not be delayed to wait for radiologic confirmation.
Treated  with  immediate  decompression  of  the  pleural  space  -­‐  
Open  thoracostomy  alone  is  appropriate.  
 
Formal  tube  thoracostomy  can  then  be  performed  once  the  
patient  reaches  an  appropriate  setting  
 

J  Emerg  Trauma  Shock.  2011  Apr-­‐Jun  

 TENSION  PNEUMOTHORAX  
Management
1.  Ini'al  Management:  needle  thoracostomy  
 -­‐  convert  the  injury  to  simple  pneumothorax.  
 
2.  Defini've  management:  chest  tube  inser'on  
 
3.  Suppor've  management:  
 -­‐    Analgesia  
 -­‐    Ven'latory  support  
 -­‐    CXR  monitoring  
 -­‐  Chest  phyisotherapy  
   
 
   
Tension Pneumothorax
—  Management
◦  Needle Thoracostomy Review
–  Decompress with 14g (lg bore), 2-inch needle
–  Midclavicular line: 2nd intercostal space
–  Go over superior margin of rib to avoid blood
vessels
–  Be careful not to kink or bend needle or
catheter
–  If available, attach a one-way valve

19
NEEDLE THORACOSTOMY
MASSIVE HEMOTHORAX
 MASSIVE  HEMOTHORAX

Defined as presence of
>1.5 liter
of blood drained from
the pleural space upon
chest tube insertion

or >200cc/hour in
first 4 hours.
MASSIVE  HEMOTHORAX  
Clinical  Findings
 MASSIVE  HEMOTHORAX
Management

Volume Chest
replacement decompression

Large caliber IV lines Chest tube insertion

Crystalloid infusion Consider for thoracotomy
Blood transfusion
MASSIVE  HEMOTHORAX

Chest tube insertion

 MASSIVE  HEMOTHORAX

On admission 10 days after chest tube insertion

Kapan hematotoraks dilakukan
torakotomi?
—  Bila perdarahan > dari 800 cc
—  Perdarahan lebih dari 15cc/
kgBB dalam 1 jam
—  Perdarahan 3-5 cc/kgBB/jam
selama 3 jam berturut turut
OPEN PNEUMOTHORAX
OPEN  PNEUMOTHORAX:  
Pathophysiology
—  Known  as  “sucking  
chest  wound.”  
—  Air  allowed  to  enter  
pleural  space  from  
the  outside.  
—  Ineffec've  
ven'la'on  because  
air  goes  in  and  out  
from  the  chest  
wound,  rather  than  
from  trachea.  
—  Leading  to  hypoxia  
and  hypercarbia.  
 Open  Pneumothorax  
Clinical  Findings

—  A  defect  in  the  chest  wall  

with  air  coming  in  &  out  
—  A  sucking  sound  on  
inhala'on  
—  Tachycardia  &  tachypnea  
—  Respiratory  distress  
—  Subcutaneous  
emphysema  
—  Decreased  breath  sounds  
on  the  affected  side  
OPEN  PNEUMOTHORAX  
MANAGEMENT

1. Initial management:
•  3 sided sterile occlusive
dressing
•  Treat concurrent shock

2. Definitive
management
•  Chest tube insertion
3-sided occlusive dressing
 CARDIAC  TAMPONADE  /CARDIAC  
INJURY

—  Suspect  if  injury  

within  the  “box”.  
 
—  May  need  prompt  
involvement  of  
cardiothoracic  team  
Do  not  
take  out  the  
penetra'ng  
object  
 CARDIAC TAMPONADE

Pathophysiology

—  A  blunt  or  penetra'ng  trauma  may  cause  tears  

in  the  myocardial  walls,  allowing  blood  to  leak  
from  the  heart.  

If 150 to 200 mL of blood enters the pericardial space

acutely, pericardial tamponade can develops
 CARDIAC  TAMPONADE

Decrease Reduced
Blood in Hypotensio
stroke cardiac SHOCK
pericardium n
volume output
CARDIAC  TAMPONADE
Cardiac  Tamponade    
Management
—  Airway  and  ven'la'on    
—  Circula'on—IV  fluid  challenge  
—  Pericardiocentesis  
—  Prompt  involvement  of  cardiothoracic  team.  
—  Do  not  take  out  the  penetra'ng  object  
CARDIAC  TAMPONADE
CARDIAC  TAMPONADE

Pericardocentesis
Penjahitan luka pada jantung:
—  Menggunakan benang non absorbable monofilament
—  Jarum atraumatik
—  Jahitan jelujur bolak balik atau pledget secara matras
—  Luka pada atrium memerlukan partial clamp dan harus sgr di
jahit
—  Pericardium dibiarkan terbuka agar darah dapat keluar ke pleura
FLAIL CHEST
 FLAIL  CHEST

—   Described  as  the  

paradoxical  
movement  of  a  
segment  of  chest  wall  
caused  by  fractures  
of  3  or  more  ribs  in  2  
or  more  placed.    
 FLAIL  CHEST

Severe hypoxia resulting from:

•  The underlying lung injury à disturbance of ventilation & perfusion
•  Restricted chest wall movement associated with pain à impaired ventilation
 FLAIL  CHEST  
Clinical  findings

INSPECTION
-  Chest wall contusion
-  Paradoxical chest
wall movement
-  Respiratory distress

Palpation
-  Crepitation of rib
 FLAIL  CHEST

Investigation

•  CXR : multiple
ribs fracture

•  ABG:
respiratory
failure with
hypoxia
 FLAIL  CHEST  
Management  
1.  Ini9al  management:  
-­‐  adequate  ven'la'on  
fluid  resuscita'on    
 
In  absence  of  systemic  hypotension,  fluid  
resuscita'on  should  be  carefully  controlled  to  
prevent  overhydra'on.    
 FLAIL  CHEST  
Management  
2. Definitive management

Positive-pressure ventilation may be needed.

•  Reverses
the mechanism of paradoxical chest wall
movement
•  Restores the tidal volume

Adequate analgesic
•  Reduces the pain of chest wall movement

Assess for the development of a pneumothorax

•  May need chest tube insertion
 SHAPP
CLIP
(Setiono, Heru, Agung, Paul,
Puruhito)
 TAKE HOME MESSAGES
1.  Life threatening condition in thoracic injury are
•  Tension pneumothorax
•  Open pneumothorax
•  Massive hemothorax
•  Flail chest
•  Cardiac temponade.
2.  Tension pneumothorax required emergent needle thoracotomy
without waiting for CXR if highly suspected clinically
3.  Do not remove the object causing the penetrating thoracic
injury
4.  Open pneumothorax is managed with flutter-valve dressing or
three sided dressing
 TAKE HOME MESSAGES
5.  Flail chest is defined as segmental fractures in 2 or more
places of 3 or more consecutive ribs.
6.  Massive hemothorax happen when
•  more than 1.5 liters blood drained upon chest tube insertion
•  Or more than 200cc/hour in 4 hours
7.  All symptomatic traumatic pneumo/hemothorax require chest
tube insertion
8.  Cardiac tamponade is recognized by presence of Beck’s Triad
which are
•  Muffled heart sound
•  Hypotension
•  Distended neck veins
 TAKE HOME MESSAGES
9.  Key management in thoracic injury include
•  Identifying the life threatening condition
•  Resuscitation and oxygen therapy
•  Chest tube insertion
•  Adequate pain control and aggressive chest physiotherapy
•  Ventilation and early associate team referral
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