Chest Trauma 2024 - Dr Joshua Tadayo.pdf

A quick and in-depth review on the surgical management of chest trauma

1. CHEST TRAUMA
Dr. Joshua Joseph Tadayo

2. OUTLINE
•INTRODUCTION
•MECHANISMS OF CHEST TRAUMA
•PATHOPHYSIOLOGY
•TYPES OF CHEST INJURIES
Rib Fracture vsFlail Chest
Pulmonary Contusion
Pneumothorax
Hemothorax
Cardiac Injuries
Esophageal Injuries
2KCMC -DEPT. GENERAL SURGERY

3. INTRODUCTION
Defn:
•Chest Injury is any form of physical injury to the chest
including the ribs, heart and lungs.
•Major chest injuries may occur alone or multiple other
injuries
•Chest injuries are potentially life threatening because of
immediate disturbances of cardiorespiratory
physiology and hemorrhageand later developments
of infection, damaged lungs and thoracic cage
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4. MECHANISMS
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1)Bluntchestinjury(Closed chestinjury)
•Mostlyby RTA,fall, sports
•Usuallyassociatedwithmultipleinjuries(head, limb,abdomen)
2)Penetratingchestinjury(Openchestinjury)
•Mostlybyassault
•High velocity (gun shot and missile fragments)
•Low velocity (stab injury)
•Associatedwithchestwalldamage,openpneumothorax, organinjuries

5. PATHOPHYSIOLOGY
5
Morbidity and mortality occurs because injuries interfere with respiration, circulation, or both.
Respirationcan be compromised by
Direct damage to the lungs or airways
Altered mechanics of breathing
•Injuries that directly damage the lung or airways include pulmonary contusion and
tracheobronchial disruption.
•Injuries that alter the mechanics of breathing include hemothorax, pneumothorax, and flail
chest.
Circulationcan be impaired by
Bleeding
Decreased venous return
Direct cardiac injury
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6. TYPES OF CHEST INJURIES
6
•Rib Fracture + Flail Chest
•Pulmonary Contusion
•Pneumothorax
•Hemothorax
•Cardiac Tamponade
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8. RIB FRACTURE
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•Break in the continuity of rib bone
•Simplerib fracturesare the most common injury sustained followingblunt chest
trauma, accounting for more than half of thoracic injuries from non-penetrating trauma.
•There are 12 pairs of ribs in the thoracic region:
First 7 attach anteriorly to the sternum and posteriorly to the spinal column;
8 through 10 attach similarly but connect to the costal cartilage of the sternum
anteriorly;
11 and 12 are considered floating; they only attach posteriorly, not anteriorly

9. RIB FRACTURE Cont…
9
•Physical Examination:
Chest wall deformity
Decreased chest expansion
Tenderness on palpation,
Crepitus
•Imaging:
Chest X ray
Chest CT
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10. RIB FRACTURE IMAGES…
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11. RIB FRACTURE Cont…
11
•Management:
For simple isolated rib fractures, conservative management which includes
analgesia, rest, ice
IncentiveSpirometerto prevent pulmonary atelectasis + splinting
Intercostal nerve block can be applied to aid in pain control
Surgical stabilization for more severe rib fractures
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12. RIB FRACTURE Cont…
12
•Management:
For simple isolated rib fractures, conservative management which includes
analgesia, rest, ice
Incentive Spirometer to prevent pulmonary atelectasis + splinting
Intercostal nerve block can be applied to aid in pain control
Surgical stabilization for more severe rib fractures
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13. PULMONARY CONTUSION
13
•A bruiseof the lung, caused by thoracic trauma, results into the leakage of blood and
tissue fluid into the pleural space.
•Can occur with or without rib fractures especially in children after blunt chest trauma
due to having more compliant chest walls
•Pulmonary contusion often progresses during the first 12 hours; the patient’s initial
chest radiograph often underestimates the extent of the pulmonary parenchymal
damage; close monitoring and frequent clinical re-evaluation are warranted.
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14. PULMONARY CONTUSION
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•Haemoptysis or blood in the endotracheal tube is a
sign of pulmonary contusion.
•In mild contusion, the treatment is oxygen
administration, aggressive pulmonary toilet and
adequate analgesia.
•In more severe cases, mechanical ventilation is
necessary.
•IV fluids should be given with caution to prevent fluid
overload

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16. FLAIL CHEST
16
•Flail chest occurs when three or more contiguous ribs are fractured in at
least twolocations.
•Paradoxical movement of this free-floating segment of chest wall is usually
evident in patients with spontaneous ventilation, due to the negative intra-
pleural pressure of inspiration.
•Canalsooccurwhenthesternumisfracturedlooseformits attachments
with the ribs
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17. FLAIL CHEST Cont…
17
Mechanics of Respiration
•Inspiration (chest wall expands outwards):
External intercoastalmuscles contract causing the chest wall to expand outwards
The diaphragm contracts and lowers
Anegative intrathoracicpressure is created
Air enters through the upper respiratory system
•Expiration:
Contraction of theinternal intercostalmuscles brings the rib cage back to its
normal position
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18. FLAIL CHEST Cont…
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19. FLAIL CHEST Cont…
19
Management:
•Analgesia
NSAIDS
Epidurals
•Chest Tube insertion
Hemo/Pneumothorax
•Intubation and mechanical ventilation
Rarely indicated in cases with Hypoxia secondary to pulmonary contusion
•Surgical Stabilization
Failure to wean off ventilation
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21. PNEUMOTHORAX
21
•Collection of air outside the lung but within the pleural cavity i.e:
between the parietal and visceral pleurae inside the chest.
•The air accumulation applies pressure on the lung making it collapse
•Types:
Spontaneous Pneumothorax
Traumatic Pneumothorax
Tension Pneumothorax
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22. PNEUMOTHORAX Cont…
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Spontaneous Pneumothorax
•Primary Spontaneous Pneumothorax
Occurs in people without underlying lung disease and in the absence of an inciting
event.However, many patients whose condition is labeled as primary spontaneous
pneumothorax have subclinical lung disease, such as pleural blebs, that can be
detected by CT scanning.
•Secondary Spontaneous Pneumothorax
Occurs in people with a wide variety of lung pathology e.g: COPD, Lung Ca, TB, Cystic
Fibrosis. Air enters the pleural space via distended, damaged, or compromised alveoli.

23. PNEUMOTHORAX Cont…
23
Traumatic Pneumothorax
Causes: GSW, Stab wounds, Iatrogenic i.e. : postoperative mechanical ventilation, Central
venous cannulation, thoracocentesis
•Open Pneumothorax (Sucking Chest Wound)
There is full thickness loss of chest wall, permitting free communication between
pleural space and the atmosphere
•Closed Pneumothorax
Air leaks from a ruptured bronchus. Potential of developing into a tension
pneumothorax
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24. PNEUMOTHORAX Cont…
24
Tension Pneumothorax
•Life threatening condition!
•Pleural pressure is more than the atmospheric pressure.
The diagnosis of tension pneumothorax is presumed in any patient
manifesting respiratorydistressand hypotensionin combination with
any of the following physical signs:
tracheal deviation away from the affected side,
lack of or decreased breath sounds on the affected side.
subcutaneous emphysema on the affected side
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25. PNEUMOTHORAX Cont…
25
Tension Pneumothorax
•Patients may have distended neck veins due to impedance of venous
return, but the neck veins may be flat due to concurrent systemic
hypovolemia.
•Tension pneumothorax and simple pneumothorax have similar signs,
symptoms, and examination findings, but hypotensionqualifies the
pneumothorax as a tension pneumothorax
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26. PNEUMOTHORAX Cont…
26
Tension Pneumothorax
•Parenchymal tear in the lung acts as a one-way valve, with each
inhalation allowing additional air to accumulate in the pleural space.
•The normally negative intrapleuralpressure becomes positive, which
depresses the ipsilateralhemidiaphragmand shifts the mediastinal
structures into the contralateral chest.
•Subsequently, the contralateral lung is compressed and the heart
rotates about the superior and inferior vena cava; this decreases venous
return and ultimately cardiac output, which culminates in cardiovascular
collapse.
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28. PNEUMOTHORAX Cont…
28
Clinical Features
•Pleuriticchest pain
•DIB
•Tachypnea
•Hyper resonant percussion
•Reduced air entry
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29. PNEUMOTHORAX Cont…
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30. PNEUMOTHORAX Cont…
30
Management
•Tube thoracostomy
•Needle thoracostomydecompression with a 14-gauge angiocatheter
2
nd
intercostal mid-clavicularline vs5
th
intercostal anterior
axillary line??
•Occlusive dressing for Open Pneumothorax
Occlusive dressing taped on three sides
Complete occlusion will covert it to tension pneumothorax
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31. PNEUMOTHORAX Cont…
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Occlusive Dressing for
Open Pneumothorax
This acts as a flutter
valve, permitting
effective ventilation on
inspiration while
allowing accumulated air
to escape from the
pleural space on the
untapedside, so that a
tension pneumothorax
is prevented.

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33. HEMOTHORAX Cont…
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•Collection of blood within the pleural cavity i.e. : between the parietal and
visceral pleurae inside the chest.
•Each side of the chest can hold 2500-3000mlof blood
•Can result from penetrating or blunt chest trauma
•A massivehemothoraxis defined as >1500 mL of blood or, in the
pediatric population, >25% of the patient’s blood volume in the pleural
space.

34. HEMOTHORAX Cont…
34
Clinical Features
•Hemorrhagic shock
•Absenceordiminutionofbreathsoundin
affectedside
•Dullnessonpercussioninaffectedside
•Flattenedneckveins
•CXRwillshowunilateral“white out”
(opacification)
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35. HEMOTHORAX Cont…
35
Management
•ABC + resuscitation
•Chest tube thoracostomy(large size 32Fr)
•Thoracotomy
Evacuation of more than 1000 –1500 mL of blood immediately after
tube thoracostomy.
Continued bleeding from the chest, defined as 150-200 mL/hrfor 2-4
hours
Repeated blood transfusion is required to maintain hemodynamic
stability
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36. HEMOTHORAX Cont…
36
Sequelae:
•Retained Clot
•Thoracic empyema
•Fibrothorax
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37. HEMOTHORAX Cont…
37
Sequelae:
•Retained Clot
•Thoracic empyema
•Fibrothorax
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38. CHEST TUBE THORACOSTOMY
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Indications:
•Pneumothorax
•Hemothorax
•Empyema
•Pleurodesis
Contraindications
•Coagulopathy
•Pulmonary bullae
•Pulmonary, pleural or thoracic adhesions
•Loculatedempyema or effusion
•Skin infection over chest tube insertion site
•Chylothorax
•Hydrothorax
•Hemopneumothorax

39. CHEST TUBE THORACOSTOMY
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•Position: Supineor at a 45°anglewith the arm on the affected side
abducted and externally rotated; the palm of the hand is behind the
patient's head.
•Elevating the patient lessens the risk of diaphragm elevation and
consequent misplacement of the chest tube into the abdominal space.

40. CHEST TUBE THORACOSTOMY
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41. CHEST TUBE THORACOSTOMY
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•Tube thoracostomyis performed in the midaxillaryline at the 4
th
or
5
th
intercostal space(inframammarycrease) to avoid iatrogenic injury
to the liver or spleen.
•Identify the intercostaland the midaxillaryline. The skin incision is
made in between the midaxillaryand anterior axillary lines over a rib that
is below the intercostal level selected for chest tube insertion.

42. CHEST TUBE THORACOSTOMY
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•Administer a systemic analgesic (unless contraindicated).
•Inject 5 mL of the local anesthetic solution into the skinoverlying the
initial skin incision. Infiltrate about 5 mL of the anesthetic solution to a
wide area of subcutaneoustissuesuperior to the expected initial
incision.
•Redirect the needle to the expected course of the chest tube (following
the upper border of the rib), and inject approximately 10 mL of the
anesthetic solution into the periosteum, intercostalmuscle, and the
pleura.

43. CHEST TUBE THORACOSTOMY
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•Make a skin incision approximately 4 cm long overlying the rib that is
below the desired intercostal level of entry. The skin incision should be in
the same direction as the rib itself.
•Use a kellyclamp to bluntly dissect a tract in the subcutaneous tissue by
intermittently advancing the closed instrument and opening it

44. CHEST TUBE THORACOSTOMY
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•Palpate the tract with a finger, and make sure that the tract ends at the
upper border of the rib above the skin incision.
•Insertion of the chest tube as close as possible to the upper border of
the rib will minimize the risks of injury to the nerve and blood vessels
that follow the lower border of each rib.

45. CHEST TUBE THORACOSTOMY
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•Adding more local anesthetic to the intercostal muscles and pleura at
this time is recommended.
•Use a closed large kellyclamp to pass through the intercostal muscles
and parietal pleura and enter into the pleural space.
•This maneuver requires some force and twisting motion of the tip of the
closed kellyclamp. This motion should be done in a controlled manner
so the instrument does not enter too far into the chest, which could
injure the lung or diaphragm. Upon entry into the pleural space, a rush of
air or fluid should occur.

46. CHEST TUBE THORACOSTOMY
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•The Kelly clamp should be opened (while still inside the pleural space)
and then withdrawn so that its jaws enlarge the dissected tract through
all layers of the chest wall as shown. This facilitates passage of the chest
tube when it is inserted.

47. CHEST TUBE THORACOSTOMY
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•Use a sterile, gloved finger to appreciate the size of the tract and to feel
for lung tissue and possible adhesions.
•Rotate the finger 360º to appreciate the presence of dense adhesions
that cannot be broken and require placement of the chest tube in a
different site.

48. CHEST TUBE THORACOSTOMY
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•Grasp the proximal (fenestrated) end of the chest tube with the large
clamp and introduce it through the tract and into the thoracic cavity.

49. CHEST TUBE THORACOSTOMY
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•Release the Kelly clamp and continue to advance the chest tube
posteriorly and superiorly. Make sure that all of the fenestrated holes in
the chest tube are inside the thoracic cavity.
•Connect the chest tube to the drainage device. Release the cross clamp
that is on the chest tube only after the chest tube is connected to the
drainage device.
•Before securing the tube with stitches, look for a respiration-related
swing in the fluid level of the water seal device to confirm correct
intrathoracicplacement.
•Secure the chest tube to the skin using 0 or 1 silk or nylon stitches.

50. CHEST TUBE THORACOSTOMY
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•Create an occlusive dressing to place over the chest tube. Make sure to
provide enough padding between the chest tube and the chest wall.
•Obtain a chest radiograph, to ensure correct placement of the chest
tube.

51. HEMOTHORAX Cont…
51
Sequelae:
•Retained Clot
•Thoracic empyema
•Fibrothorax
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52. CARDIAC INJURIES
52
•Blunt vsPenetrating
Penetrating Cardiac Injuries
Patients may present with pericardial tamponadeor bleeding into one of the
hemi-thoraces.
Blunt Cardiac Injuries
Most of these cases represent a contusion of the myocardium that results in
arrhythmias and are frequently self-limited. In rare cases, blunt cardiac injury
results in heart failure with cardiogenic shock.
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53. CARDIAC INJURIES Cont…
53
Cardiac Tamponade
Accumulation of excess fluid within the pericardial space resulting in
impaired cardiac filling, reduction in stroke volume, coronary artery
compression with resultant myocardial ischemia
Beck’s Triad
Muffled Heart sounds
Distended Neck veins
Hypotension
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54. CARDIAC INJURIES Cont…
54
Cardiac Tamponade
Diagnosis of hemopericardiumis best achieved by bedside
ultrasoundof the pericardium
Pericardiocentesisis successful in decompressing tamponadein
approximately 80% of cases; the majority of failures are due to
the presence of clotted blood within the pericardium
Ideal management is emergency left antero-lateral thoracotomytorelieve
the tamponade
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55. CARDIAC INJURIES Cont…
55
Cardiac Tamponade
Diagnosis of hemopericardiumis best achieved by bedside
ultrasoundof the pericardium
Pericardiocentesisis successful in decompressing tamponadein
approximately 80% of cases; the majority of failures are due to
the presence of clotted blood within the pericardium
Ideal management is emergency left antero-lateral thoracotomytorelieve
the tamponade
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56. CARDIAC INJURIES Cont…
56
Pericardiocentesis
•Pericardiocentesisisa procedure performed to removepericardial
fluidfrom the pericardial sac.
•It is often performed in the setting ofcardiac tamponadeto correct
hypotension due to decreased stroke volume from extrinsic compression
of the heart chambers.
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57. CARDIAC INJURIES Cont…
57
Pericardiocentesis
•Position: Semirecumbentposition at a 30 -45 degree angle. This position
brings the heart closer to the anterior chest wall. The supine position is an
acceptable alternative.
•Ensure that the patient has at least one established IV access line, is
receiving supplementaloxygen, and is connected to a cardiacmonitorand
continuous pulse oximetry.
•If time permits,placement of a nasogastric tubeto decompress the
stomach and decrease the risk of gastric perforation is strongly
recommended.
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58. CARDIAC INJURIES Cont…
58
Pericardiocentesis
•Anatomic landmarks: xiphoid process, 5
th
and 6
th
ribs, shown below and
select a site for needle insertion. The most commonly used sites are the
left sternocostalmargin or the subxiphoidapproach.
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59. CARDIAC INJURIES Cont…
59
Pericardiocentesis
•Infiltrate local anesthetic solution at the chosen site by first creating a skin
wheal and then infiltrating the subcutaneous and deeper tissues.
•Puncture the skin using a No. 11 blade scalpel at the chosen site (between
the xiphoid process and the left sternocostalmargin).
•Connect a 20-mL or 60-mL syringe to the spinal needle, and aspirate 5 mL
of normal saline into the syringe. While advancing the needle, the
occasional injection of up to 1 mL of normal saline may ensure that the
needle lumen remains patent.
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60. CARDIAC INJURIES Cont…
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Pericardiocentesis
•Insert the spinal needle through the skin incision and direct it toward the
left shoulder. Maintain the needle at a 45-degree angle to the abdominal
wall and 45 degrees off the midline sagittal plane as shown below. If time
permits, needle insertion should be performed under direct
ultrasonographicguidance.
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61. CARDIAC INJURIES Cont…
61
Pericardiocentesis
•Slowly advance the spinal needle up to a depth of 5 cm, while applying
negative pressure on the syringe until a return of fluid is visualized, cardiac
pulsations are felt, or an abrupt change in the ECG waveform is noted.
•If the ECG waveform shows an injury pattern (ST segment elevation), then
slowly withdraw the needle until the pattern returns to normal, as this
change in waveform suggests that the spinal needle is in direct contact with
the myocardium.
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62. CARDIAC INJURIES Cont…
62
Pericardiocentesis
•Withdraw as much fluid as possible; when the syringe is filled, stabilize the
needle against the patient’s torso, remove the filled syringe, and replace it
with another one.
•As pericardial fluid is aspirated, the needle may move closer to the heart,
and if an injury pattern appears on the ECG waveform, then the needle
should be slowly withdrawn.
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63. CARDIAC INJURIES Cont…
63
Cardiac Tamponade
Diagnosis of hemopericardiumis best achieved by bedside
ultrasoundof the pericardium
Pericardiocentesisis successful in decompressing tamponadein
approximately 80% of cases; the majority of failures are due to
the presence of clotted blood within the pericardium
Ideal management is emergency left antero-lateral thoracotomytorelieve
the tamponade
KCMC -DEPT. GENERAL SURGERY

64. ESOPHAGEAL INJURIES Cont…
64
•The esophagus lacks a serosa layer, making it vulnerable to perforate or
rupture.
•Once a perforation occurs, retained gastric contents, saliva, bile enter the
mediastinum resulting in mediastinitis
•The distribution by location:
Cervical 27%
Intrathoracic54%
Intra abdominal 19%
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65. ESOPHAGEAL INJURIES Cont…
65
Etiology
•Iatrogenic
Endoscopic procedures (diagnostic, biopsy, dilatation)
NGT insertion
•External trauma (blunt vspenetrating)
•Foreign body
Fish bones in Adults
Buttons, batteries, toys in Pediatric population
•Spontaneous (BoerhaavesSyndrome)
•Caustic substance ingestion
•Malignancy
•Infections (Candida,Herpes)
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66. ESOPHAGEAL INJURIES Cont…
66
Clinical Features
•Makcler’sTriad
Chest pain
Subcutaneous emphysema
Vomiting
•Dysphagia
•Chocking after swallowing
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67. ESOPHAGEAL INJURIES Cont…
67
Diagnosis
•Contrasted Radiological Studies
Chest X ray wihGastrografinswallow (Decubitus position)
CT scan with oral contrast
•Esophagoscopy
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68. ESOPHAGEAL INJURIES Cont…
68
Treatment
•Esophageal injuries with mediastinal contamination require immediate
identification and repair; delays are associated with worse outcomes.
•Esophageal injuries require operative repair to close the esophageal defect
and to provide adequate mediastinal drainage.
The upper and midthoracic esophagus:
right posterolateral thoracotomy (4
th
or 5
th
interspace)
The lower esophagus:
left 6
th
or 7
th
interspace.
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69. ESOPHAGEAL INJURIES Cont…
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71. REFERENCES
71
1.Schwartz’s Principles of Surgery (Chapter 7)
2.SabistonTexbookof Surgery (Chapter 16)
3.Medscape
•Pericardiocentesis-Gil Z Shlamovitz, MD
•Tube Thoracostomy-PranitChotai, MD
4.Radiopedia
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72. THANK
YOU!
72KCMC -DEPT. GENERAL SURGERY