Dr Anil Kumar

Assistant Professor
Department of Surgical Disciplines
All India Institute of Medical Sciences

25-11-2015
Objective:
Burden of Chest Trauma.

Types of chest trauma.

Background & Consequences/effect of chest injury

Basic Principle to manage chest Trauma.

Life threatening chest injuries

Role of X-Ray & E-FAST in chest trauma

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Burden of chesttrauma:
Chest trauma : 10- 15%of all the cases .

Responsible for 25% of death

The rising burden of serious thoracic trauma

sustained by motorcyclist in road traffic crashes
(Bambach MR,Mitchell RJ 2014 Jan;. Epub 2013 Oct 19)

The high burden of injuries in South Africa

(WHO:Rosana Norman, Richard Matzopoulos, Pam
Groenewald, Debbie Bradshaw)
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Types of Chest Trauma:
Blunt

Penetrating

Explosion related
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Background:
Significant cause of mortality.

Immediate cause of death: Myocardial injury, Aortic

rupture

Can be preventable : Prompt Diagnosis & Treatment.

Thoracotomy : < 10 % of BTC & only 15-30 % ofPTC.

Majority of Chest Trauma patient can be managed:

simple intervention.
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Issues in chest Trauma:Hypoxia,
Hypercarbia & Acidosis
Hypoxia: Inadequate delivery of oxygen to the tissue.

(A)Hypovolemia(Blood Loss)

(B)- Pulmonary ventilation/Perfusion mismatch

e.g- Contusion, Hematoma & Alveolar collapse

(C)Change in ITP relationship

e.g - Tension Pneumothorax
- Open Pneumothorax

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Issues in chest Trauma : Hypoxia,
Hypercarbia & Acidosis
Hypercarbia: Inadequate ventilation.

(A) Change in ITP relationship

e.g - Tension Pneumothorax
- Open Pneumothorax

(B) Dec Level of consciousness

 Metabolic Acidosis: Hypo-perfusion of the tissu(Shock).

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Basic principle of Management:
Primary survey

Resuscitation of vital functions

Adjunct of primary survey including CXR & E-FAST

Detailed secondary survey

Definitive care.
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Primary Survey
Airway with cervical spine protection

Breathing and ventilation

Circulation with Hemorrhage control

Disability: GCS

Exposure(Undress)/Events with Hypothermia control

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Life threatening chest injuries:
Inspection Palpation Percussion Auscultation Diagnosis

Restricted CCT=+/- Hyper- B.S= Dec/ - Tension

Chest move resonan Pneumothorax
t .
Open wound CCT=+/- Hyper- B.S=Dec/- Open
resonan Pneumothora
t x

Restricted CCT=+/- Dullness B.S=Dec/- Massive

chest move Haemothorax

Paradoxica CCT=+ Dull/Hyper B.S=Dec/- Flail Chest with

l pulmonary
movement contusion
Asymetry
Tension Pneumothorax
One-way valve air leak

Air is forced to enter into the

thoracic cavity without any
means of escape

Completely collapsing the

affected lung

Mediastinal shift &

compressing the opposite
lung

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Tension Pneumothorax: Etiology
Mechanical Ventilation with PPV in patients with
visceral pleural injury.

CVP Insertion
Iatrogenic
Esophageal Endoscopy

Thoracic Spine #

Chest Trauma (15-50% of severe chest trauma)

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Tension Pneumothorax:
Dx –Absolutelyclinical
-Restricted Chest Movement
-Absent Breath Sound
-Hyper-resonant note on Percussion

Don't wait for radiological confirmation

Immediate do the needle thoracostomy/ICD

( Definitive t/t)
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T/t of TensionPneumothorax:

Needle
Thoracostomy in
2nd I.C.S in M.C.L.
Chest tube insertion in 5th
I.C.S in M.A.L.

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CXR- Pneumothorax.

JPNATC, AIIMS
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How to read CXR:ABCDEF
Airway- Trachea

Broncho alveolar Marking

Cardiac Shadow

Diaphragm

External cage i.e the Bony

Area

Foreign Bodies like

ET tube, Chest tube,
Central line, Nasogastric tube
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 Open Pneumothorax
(Sucking chest wound)

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 Open Pneumothorax
(Sucking chest wound)

Sucking wound

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T/t of openPneumothorax:
Apply Sterile Occlusive dressing over the defect

Taped securely on 3sides

Provide Flutter -TypeValve

effect.

Breath in- Dressing occlu-

des the wound & prevent
air to enter from out &
vice versa
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T/t of openPneumothorax:
Don’t put ICD through the defect

Site of ICD –Remote from the wound

Definitive surgical closure of the

defect after ICD insertion, when
pneumo subsides

Open wound

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Flail Chest & PulmonaryContusion:
If 2 or more ribs fractured in
2 or moreplaces.
Flail segment don't have
bony continuity.
Paradoxical movement of flail
segment with underlying
normal chest movement .
High association with Pulmonary
Contusion
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Flail Chest & PulmonaryContusion
Asymmetrical & uncoordinated chest movement

Pain , Tenderness & Crepitation.

CXR

ABG

CT

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Flail Chest & Pul. Contusion -M/n
Better to admit- ICU ( Intubation & Ventilation)

Administration of Humidified Oxygen.

Fluid Resuscitation judiciously

Analgesia- IV Narcotics/ Intercostals nerve block/

Epidural Anesthesia(Prefered)

ICD (If A/w Pneumo/Haemo)

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Massive Haemothorax:
Rapid accumulation of more than 1500 ml of blood in
the chest cavity

Mainly caused by Penetrating wound- Disruption of

systemic & hilar vessels.

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Massive Haemothorax: Dx
Restricted Chest Movement(Inspection)

Breath Sound = Absent

Dullness to Percussion

Chest X-Ray
ABG
CT.
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Massive Haemothorax: M/n
Follow the ABC.

ICD (In Safety Triangle )

IV Fluid – Infused 2 lit warmed RL very fast.

5-10 ml blood for grouping & cross matching to start Blood

Transfusion at earliest.

Auto transfusion from the ICD Bag.

Plan- Thoracotomy (If indicated)

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Indication of Thoracotomy
1500 ml blood collected immediately in ICD bag

Blood loss @200ml/hr for 2-4 hrs.

Persistent need of BT.

Penetrating Injury -medial to the nipple line ( Over

anterior chest wall ) & medial to the scapula(Over
posterior chest wall)

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Penetrating Chest Trauma:

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Operative finding: Lacerated Lung

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E-FAST
Lung USG is more sensitive than CXR for
Pneumothorax

Perform rapidly at bed side by Surgeon, don't wait for

radiologist.

Safe, fast & effective for detecting the pneumo

Very easy to learn

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To detectPneumothorax??
A Line

B Line

Seashore sign

Barcode sign

Lung Point.
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E-FASTin ChestTrauma

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Bat’s Sign: Normal Finding: BMode

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E-FAST in Chest Trauma: Bmode

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Seashore sign & Barcodesign
Barcode sign

Seashore sign

Pneumothorax- Find
Normal Lung
the lung point
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Lung Point: Pneumothorax

Lung Point

Barcode sign

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Chest Trauma- Follow ABC
Lung Sliding= Bat’s Sign, Pleural Line
Absent & Lung Sliding

Switch to M Mode Normal Lung

Seashore sign N
n

Bar Code Sign

Lung Point Put needle or Chest

Bar code
tube
Scan laterally &
Find the Lung
Point Pneumothorax
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Home Message!!!!!!!!!!!
Thoracic trauma is a significant cause of mortality.

Hypoxia, Hypercarbia & Acidosis- main concerned.

Basic principle of m/n is the primary survey ( ABCDE)

Life threatening injuries should be managed during

Primary survey.

> 90% of BTC & > 70 % of PTC - simple intervention.

E-FAST- Rapid, accurate & easily deployed and can be

lifesaving
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