ACS

Thoracic Trauma
 ACS

Objectives

Indentify and treat injuries found during the

primary survey.

Indentify and treat injuries found during the

secondary survey.

Demonstrate the ability to perform life

saving chest management.
Indications
Contraindications
 ACS

Thoracic Trauma

1 out of 4 deaths

Blunt : < 10% require operation

Penetrating : 15% - 30% require operation

Majority : require simple procedures
 ACS

Initial Assessment/ Management

Primary Survey

Identifies most life -threatening injuries
Resuscitation

Airway control

Ensure oxygenation/ventilation

Needle / tube thoracostomy
 ACS
Initial Assessment/Management
Secondary Survey Definitive Care

Identifies most Airway control
potentially lethal
Ensure oxygenation
/ventilation
injuries
Tube thoracostomy

Physical exam/ Hemodynamic
diagnostic tests
support
Operation
 ACS

Life threatening Chest Trauma

Primary Survey

Airway obstruction

Tension pneumothorax

Open pneumothorax

Flail chest

Massive hemothorax

Cardiac tamponade
 ACS
Airway Obstruction
Laryngeal injury

Rare occurrence

Hoarseness

Subcutaneous emphysema

Treatment
Intubation (caution)
Tracheostomy (by surgeon)
 ACS

Breathing
Tension pneumothorax: Etiology

Parenchymal and / or chest-wall injuries

Air enters pleural space with no exit

Positive pressure ventilation
Collapse of affected lung
Venous return
Ventilation of opposite lung
 ACS

Breathing
Tension Pneumothorax : Signs / Symptoms
Respiratory distress
Distended neck veins
Unilateral in breath sounds
Hyperresonance
Cyanosis, late
 ACS
Breathing
Tension
Pneumothorax

Immediate
decompression

Clinical diagnosis,
not by x-ray
 ACS

Breathing
Open Pneumothorax
Cover defect
Chest tube
Definitive operation
 ACS

Breathing
Flail chest
 ACS

Breathing
Flail Chest/pulmonary Contusion

Reexpand lung

Oxygen

Judicious fluid management

Intubation as indicated

Analgesia
 ACS

Circulation
Massive Hemothorax

1500 ml blood loss

Systemic / pulmonary vessel disruption

Flat vs distended neck veins

Shock with no breath sounds and /or
percussion dullness
 ACS

Circulation
Massive Hemothorax
Rapid volume restoration

Chest decompression and x-ray

Autotransfusion

Operative intervention
 ACS

Circulation
Cardiac Tamponade
Arterial pressure
Distended neck veins
Muffled heart sounds
PEA
 ACS

Circulation
Cardiac Tamponade

Patent airway

IV therapy

Pericardiocentesis

Pericardiotomy
 ACS

Resuscitative Thoracotomy
Qualified surgeon present on patients arrival
Indications

Penetrating thoracic injury

Pulseless with electrical activity
Contraindications

Blunt injury
Pulseless without electrical activity
 ACS

Potentially- Lethal Chest Trauma

Identified by :

In depth examination

Upright chest x-ray, if possible

ABGs

Pulse oximetry

ECG
 ACS

Potentially- Lethal Chest Trauma

Simple pneumothorax

Hemothorax

Pulmonary contusion

Tracheobronchial tree injury

Blunt cardiac injury

Traumatic aortic disruption

Traumatic diagpramatic injury

Mediastinal traversing wounds
 ACS
Secondary Survey
Pneumothorax

Penetrating /blunt
trauma

V / Q defect

Hyperresonance

Breath sounds
Tube thoracostomy
 ACS

Secondary Survey
Hemothorax

Chest wall injury

Lung /vessel
laceration

Tube thoracostomy
 ACS

Secondary Survey
Pulmonary Contusion

Most common

Oxygenate , ventilate

Selective intubation
 ACS

Secondary Survey
Tracheobronchial injury
Frequently missed Treatment
injury
Blunt / penetrating
Airway
trauma ventilation
Partial vs complete
Operation
Diagnostic aid : Endoscopy
 ACS

Secondary Survey
Blunt Cardiac Injury

Injury spectrum

Abnormal ECG : Monitor changes

Echocardiography

Treat : Dysrhythmias, Q, complications
Secondary Survey ACS

Traumatic Aortic
Rupture

Rapid acceleration/
deceleration

Ligamentum
arteriosum

Salvage : identify early

Surgical consult
 ACS
Secondary Survey
Diaphragmatic Rupture

Most diagnosed on left

Blunt large tears

Penetrating small
perforations

Misinterpreted x ray

Contrast radiography

Operation
 ACS

Mediastinal Traversing wounds

Hemodynamically Abnormal

Exsanguinating thoracic hemorrhage

Tension pneumothorax

Pericardial tamponade

Esophageal / tracheobronchial injury

Spinal cord injury
 ACS

Mediastinal Traversing Wounds

Hemodynamically Abnormal
Treatment
Bilateral tube thoracostomies
Emergent surgical consultation
 ACS

Mediastinal Traversing Wounds

Hemodynamically Normal

Vascular : Angiography

Tracheobronchial : Bronchoscopy

Esophageal Esophagography,
esophagoscopy
 ACS

Mediastinal Traversing Wounds

Hemodynamically Normal

Treatment
Mandatory surgical consultation
Repair identified injuries
 ACS

Secondary Survey
Subcutaneous
Emphysema

Airway injury

Pneumothorax

Blast injury
 ACS

Secondary Survey
Traumatic Asphyxia
Petechiae
Swelling

Plethora

Cerebral edema
 ACS

Secondary Survey
Sternal, Scapular, and Rib Fracture:
Pathophysiology

Pain Splinting

Hemopneumothorax

Associated injuries

Retained secretion

Impaired ventilation

Atelectasis pneumonia

Pulmonary contusion
 ACS

Secondary Survey
Sternal, Scapular, and Rib Fractures
Ribs 1- 3

Severe force
Associated injuries High mortality risk
Ribs 4 9
Pulmonary contusion
Pneumohemothorax
Ribs 10 12 : Suspect abdominal injury
 ACS

Secondary Survey
Sternal, Scapular, and Rib Fractures :
Management

Chest x ray

Adequate pain
relief

Chest tube as
Treat associated injuries
necessary
No constrictive devices

Selective

ventilation
 ACS

Secondary Survey
Esophageal Trauma

Blunt vs penetrating

Severe epigastric blow

Pain, shock > injury

Pneumohemothorax without fracture
 ACS

Secondary Survey
Esophageal Trauma

Chest tube :
Particulate matter

Mediastinal air

Contrast swallow,
esophagoscopy

Operation
 ACS

Secondary Survey
Other indication for Tube Thoracostomy

Suspected, severe lung injury
Air or ground transfer
General anesthesia
Positive pressure ventilation
 ACS

Pitfalls
Simple pneumothorax tension
pneumothorax

Retained hemothorax
Diaphragmatic injury
Delayed diagnosis of aortic injury

Severity of rib fractures pulmonary
contusion
Elderly
 ACS

Questions

?
 ACS

Summary
Common in multiply injured

Life threatening injuries

Develop skills to treat

Monitoring