chest trauma by dr. samir abdallah m.d prof. of cardio-thoracic surgery cairo university

Chest TraumaChest TraumaChest TraumaChest TraumaByBy

Dr. Samir Abdallah Dr. Samir Abdallah M.DM.D

Prof. of Cardio-Thoracic Surgery Prof. of Cardio-Thoracic Surgery

Cairo University Cairo University

Chest TraumaChest TraumaChest TraumaChest Trauma

The fact that it has become possible in recent The fact that it has become possible in recent

decades for millions of people to travel at high decades for millions of people to travel at high

speed had led to a phenomenal increase in blunt speed had led to a phenomenal increase in blunt

injury to the chest - injury to the chest - a most lethal type of injury. a most lethal type of injury.

EpidemiologyEpidemiology

All casualties, and particularly children who have All casualties, and particularly children who have

been exposed to blunt chest injury may have been exposed to blunt chest injury may have

sustained highly lethal internal lesions (rupture of sustained highly lethal internal lesions (rupture of

the heart, the aorta or the major airway, for the heart, the aorta or the major airway, for

example, or contusion of the heart although the example, or contusion of the heart although the

external stigmata of chest injury may be quite trivial external stigmata of chest injury may be quite trivial

or even absents altogether. or even absents altogether.

For this reason any causality who has sustained For this reason any causality who has sustained

blunt trauma to the chest should be considered blunt trauma to the chest should be considered

seriously injured until proved otherwise. seriously injured until proved otherwise.

Frequency of Various InjuriesFrequency of Various InjuriesIn Motor Vehicle AccidentsIn Motor Vehicle Accidents

Frequency of Various InjuriesFrequency of Various InjuriesIn Motor Vehicle AccidentsIn Motor Vehicle Accidents

ExtremitiesExtremities 34%34%

Head and neckHead and neck 32%32%

ChestChest 25%25%

AbdomenAbdomen 15%15%

Mechanism of Injury Mechanism of Injury in Chest Traumain Chest Trauma

Mechanism of Injury Mechanism of Injury in Chest Traumain Chest Trauma

Acceleration/deceleration (motor vehicle accident)Acceleration/deceleration (motor vehicle accident) Body compression (crush injury)Body compression (crush injury) High-speed impact (gunshot wound)High-speed impact (gunshot wound) MiscellaneousMiscellaneous

Low-velocity penetration (stab wound)Low-velocity penetration (stab wound)

Airway obstruction (suffocation)Airway obstruction (suffocation)

Caustic injury (poisoning)Caustic injury (poisoning)

BurnsBurns

ElectrocutionElectrocution

Blunt or Penetration Blunt or Penetration TraumaTrauma

Schematic diagram of the various forms of thoracic injuries showing how disturbed Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosiscardiopulmonary physiologic equilibrium results in tissue anoxia acidosis

Schematic diagram of the various forms of thoracic injuries showing how disturbed Schematic diagram of the various forms of thoracic injuries showing how disturbed cardiopulmonary physiologic equilibrium results in tissue anoxia acidosiscardiopulmonary physiologic equilibrium results in tissue anoxia acidosis

Chest wall injuryChest wall injury Airway ObstructionAirway Obstruction PneumothoraxPneumothorax Hemorrhage Hemorrhage Cardiac injuryCardiac injury

Pain, Restriction, Pain, Restriction, Retention of Retention of Secretions, Secretions, AtelectasisAtelectasis

Flail Chest Flail Chest HemothoraxHemothorax

HypovolemiaHypovolemia

TamponadeTamponade

Myocardial Myocardial dysfunctiondysfunction

Diminished Diminished

Cardiac OutputCardiac Output

Hypoventilation

Hypoxemia

Respiratory Acidosis

PulmonaryPulmonary

Shunting Shunting

Tissue HypoxiaTissue Hypoxia

Metabolic AcidosisMetabolic Acidosis

TRAUMA DEATHSTRAUMA DEATHSTRAUMA DEATHSTRAUMA DEATHS

EARLYEARLY

30%-35%

Within Hours (Golden Hour)

Thoracic Trauma

Liver/Spleen Injuries

Multiple Pelvic Fractures Others

Optimum Initial Care

IMMEDIATEIMMEDIATE

50%

Seconds or Minutes

Spinal Cord Injuries

Severe Brain Injuries

Lesions to Great Vessels

Prevention

Optimum Prehospital Care

LATE

15%-20%

2-3 Weeks

Sepsis

Multiple Organ Failure

Optimum Initial Care

(Future?)

Percentage of Specific Types of Percentage of Specific Types of Thoracic Organ Injury Thoracic Organ Injury

Percentage of Specific Types of Percentage of Specific Types of Thoracic Organ Injury Thoracic Organ Injury

Chest wallChest wall 5454

Flail chestFlail chest 1313

PneumothoraxPneumothorax 2020

HemothoraxHemothorax 2121

PulmonaryPulmonary 2121

MiscellaneousMiscellaneous 1818

The evaluation of thoracic injuries is only one The evaluation of thoracic injuries is only one

aspect of the total assessment of severely injured aspect of the total assessment of severely injured

patients. patients.

Both diagnosis and therapy go hand in hand. Both diagnosis and therapy go hand in hand.

The basic principle of elective surgery - The basic principle of elective surgery - ““First First

investigate and make the diagnosis, then treat the investigate and make the diagnosis, then treat the

illnessillness”” - is a dangerous illusion. - is a dangerous illusion.

Assessment of patient with Assessment of patient with Thoracic injuryThoracic injury


The first step is to make The first step is to make a a rough estimate of rough estimate of

the status of the circulatory and respiratory the status of the circulatory and respiratory

systems.systems. This provides the first diagnostic clues This provides the first diagnostic clues

and often determines which therapeutic action is to and often determines which therapeutic action is to

be taken. be taken. Specific questionsSpecific questions are then posed are then posed

pertaining to individual injuries or their pertaining to individual injuries or their

consequences.consequences.



Immediately life-threatening; diagnosis

and therapy before taking roentgenograms

TEN QUESTIONSTEN QUESTIONS to be asked in the initial to be asked in the initial assessment of severe blunt thoracic injuries assessment of severe blunt thoracic injuries TEN QUESTIONSTEN QUESTIONS to be asked in the initial to be asked in the initial assessment of severe blunt thoracic injuries assessment of severe blunt thoracic injuries

1.1. Hypovolemia?Hypovolemia?

2.2. Respiratory insufficiency?Respiratory insufficiency?

3.3. Tension pneumothorax?Tension pneumothorax?

4.4. Cardiac tamponade Cardiac tamponade

5.5. Multiple rib fractures? (Paradoxical respiration?)Multiple rib fractures? (Paradoxical respiration?)

6.6. Pneumothorax ? (subcutaneous emphysema? Pneumothorax ? (subcutaneous emphysema? mediastinal emphysema?)mediastinal emphysema?)

7.7. Hemothorax?Hemothorax?

8.8. Diaphragmatic rupture?Diaphragmatic rupture?

9.9. Aortic rupture?Aortic rupture?

10.10. Cardiac contusion? Cardiac contusion?

TEN QUESTIONSTEN QUESTIONS to be asked in the initial to be asked in the initial assessment of severe blunt thoracic injuries assessment of severe blunt thoracic injuries TEN QUESTIONSTEN QUESTIONS to be asked in the initial to be asked in the initial assessment of severe blunt thoracic injuries assessment of severe blunt thoracic injuries

Monitoring and evaluating the patient Monitoring and evaluating the patient with Thoracic traumawith Thoracic trauma

Monitoring and evaluating the patient Monitoring and evaluating the patient with Thoracic traumawith Thoracic trauma

Roentgenograms of the thorax (Chest wall Roentgenograms of the thorax (Chest wall i.e. ribs, sternum, vertebral, clavicles). i.e. ribs, sternum, vertebral, clavicles). Mediastmum (wide or normal) shifted Mediastmum (wide or normal) shifted

or not. or not. Lung parenchyma (Contusion). Lung parenchyma (Contusion). The heart (cardiac tamponade). The heart (cardiac tamponade). Diaphragm. Diaphragm. Pneumothorax, hemothorax. Pneumothorax, hemothorax.

ECGECG CVPCVP Arterial blood gases. Arterial blood gases. Urine output. Urine output. Lab. Investigations.Lab. Investigations. Others. Others.

The treatment of polytraumatized patient must follow a The treatment of polytraumatized patient must follow a certain protocol which includes. certain protocol which includes. Adequate oxygenation. Adequate oxygenation. Fluid replacement. Fluid replacement. Surgical intervention. Surgical intervention. Treatment of septic complications. Treatment of septic complications. Adequate caloric and substrate supplementation. Adequate caloric and substrate supplementation. Prevention of stress bleeding. Prevention of stress bleeding. Finally, be alert of possible complication (CNS, ARDS, Finally, be alert of possible complication (CNS, ARDS,

hepatic, renal, coagulation disorders, sepsis. hepatic, renal, coagulation disorders, sepsis.

Management of patients with Management of patients with Thoracic TraumaThoracic Trauma

Management of patients with Management of patients with Thoracic TraumaThoracic Trauma

Rib and Sternal Fracture Mechanism of Injury

Indirect violence

Direct Violence

Lung injuries are more common

Rib and Sternal fractures Rib and Sternal fractures Rib and Sternal fractures Rib and Sternal fractures

DiagnosisDiagnosis Patient complains of localized pain that is Patient complains of localized pain that is

aggravated by coughing deep breathing aggravated by coughing deep breathing ““Localised Localised tenderness. tenderness.

Subcutaneous emphysemaSubcutaneous emphysema False motion, paradoxical respiration False motion, paradoxical respiration Rib fractures must be diagnosed clinically many rib Rib fractures must be diagnosed clinically many rib

fractures are not visible on X-ray chest. fractures are not visible on X-ray chest.

Flail Chest Flail Chest

Therapy in multiple rib fractures Therapy in multiple rib fractures ((not taking companion injuries into considerationnot taking companion injuries into consideration))

Therapy in multiple rib fractures Therapy in multiple rib fractures ((not taking companion injuries into considerationnot taking companion injuries into consideration))

Stable thoracic wall Unstable thoracic wallUnstable thoracic wall

Paradoxical respirationParadoxical respiration

1. Controlling pain Analgesics (morphine derivatives) every 4h Analgesics (morphine derivatives) every 4h even if there are “no pains” even if there are “no pains”

If necessary, intercostal nerve block If necessary, intercostal nerve block

If necessary, epidural anesthesiaIf necessary, epidural anesthesia

2. Intensive breathing exercises Only in cases of respiratory insufficiency Only in cases of respiratory insufficiency Mechanical ventilation; prophylactic Mechanical ventilation; prophylactic insertion of a chest tubeinsertion of a chest tube

In exceptional cases, operative stabilization In exceptional cases, operative stabilization of the thoracic wallof the thoracic wall

Intercostal BlocksIntercostal Blocks(Sites)(Sites)

It is a tried and tested rule that a prophylactic chest It is a tried and tested rule that a prophylactic chest

tube should be inserted in every patient with tube should be inserted in every patient with

multiple rib fractures who is to undergo an operation multiple rib fractures who is to undergo an operation

under general anaesthesia even when there is under general anaesthesia even when there is

neither evidence of a hemothorax nor of a neither evidence of a hemothorax nor of a

pneumothorax. pneumothorax.

Pneumothorax and Pneumothorax and HemothoraxHemothoraxPneumothorax and Pneumothorax and HemothoraxHemothorax

Cases of pneumothorax and hemothorax can be Cases of pneumothorax and hemothorax can be

provided with extremely effective therapy for the provided with extremely effective therapy for the

most part with simple methods, in more than 80% of most part with simple methods, in more than 80% of

cases. cases.

It must, however, be given early, furthermore the It must, however, be given early, furthermore the

drainage of air and blood must be efficient. drainage of air and blood must be efficient.

Tension Pneumothorax Tension Pneumothorax ((Life ThreateningLife Threatening))

Tension Pneumothorax Tension Pneumothorax ((Life ThreateningLife Threatening))

Every traumatic pneumothorax can develop into Every traumatic pneumothorax can develop into

tension pneumothorax, however, this complication tension pneumothorax, however, this complication

is rare with spontaneous breathing. is rare with spontaneous breathing.

Very frequently, in a more dangerous form by for, a Very frequently, in a more dangerous form by for, a

tension pneumothorax occurs tension pneumothorax occurs during mechanical during mechanical

ventilation. ventilation.

Treatment consists of immediate relief of pressure. Treatment consists of immediate relief of pressure.

Open Pneumothorax Open Pneumothorax Open Pneumothorax Open Pneumothorax Diagnosis: Diagnosis: A penetrating thoracic wound with a sucking sound A penetrating thoracic wound with a sucking sound

of incoming and outgoing air of incoming and outgoing air ““sucking woundsucking wound”” adds adds to the clinical and radiological evidence of to the clinical and radiological evidence of pneumothorax pneumothorax

Therapy:Therapy: Immediate air tight closure of the thoracic wound. Immediate air tight closure of the thoracic wound. Immediate intubation and mechanical ventilation. Immediate intubation and mechanical ventilation.

HemothoraxHemothoraxHemothoraxHemothoraxDiagnosisDiagnosis

Diminished breath sound. Diminished breath sound.

Muffled sound on percussion. Muffled sound on percussion.

X-ray chest: Clouding of the affected half of the X-ray chest: Clouding of the affected half of the

thorax up to complete opacity. thorax up to complete opacity.

In the diagnosis of hemothorax formation of In the diagnosis of hemothorax formation of

atelectosis and rupture of the diaphragm should be atelectosis and rupture of the diaphragm should be

differentiated. differentiated.

Sources of blood accumulating in the chest Sources of blood accumulating in the chest following blunt or penetrating trauma: following blunt or penetrating trauma: Sources of blood accumulating in the chest Sources of blood accumulating in the chest following blunt or penetrating trauma: following blunt or penetrating trauma:

Pulmonary parenchymal laceration. Pulmonary parenchymal laceration. Rupture of pleural adhesions. Rupture of pleural adhesions. Mediastinal injury with or without vascular injury. Mediastinal injury with or without vascular injury. Cardiac injury with pericardio-pleural Cardiac injury with pericardio-pleural

communication. communication. Decompression of abdominal hemorrhage through a Decompression of abdominal hemorrhage through a

traumatic diaphragmatic injury. traumatic diaphragmatic injury.

HemothoraxHemothoraxHemothoraxHemothorax

TherapyTherapy

The key to successful management of acute The key to successful management of acute

hemothorax is early aggressive care in the form of hemothorax is early aggressive care in the form of

adequate pleural evacuation by thoracostomy or adequate pleural evacuation by thoracostomy or

thoracotomy in order to minimize the morbidity. thoracotomy in order to minimize the morbidity.

The rate and cessation of bleeding depends on the The rate and cessation of bleeding depends on the

site and size of the bleeding wound. site and size of the bleeding wound.


Thoracotomy is done if the bleeding is constant and Thoracotomy is done if the bleeding is constant and

more than 300 ml per hour during the first three to more than 300 ml per hour during the first three to

four hours. However, tube thoracotomy is all what is four hours. However, tube thoracotomy is all what is

needed if bleeding is less and decreasing without needed if bleeding is less and decreasing without

radiological evidence of clotted blood. radiological evidence of clotted blood.


Incision over Incision over intercostal spaceintercostal space

Development of subcutaneous tract

Penetration of parietal pleura

Insertion of Chest TubeInsertion of Chest Tube

Confirmation that lung is not adherent to chest wall at puncture site

Clinical significant Clinical significant TherapyTherapy

Lung laceration/Lung laceration/

lung rupturelung rupture

Mostly harmless Mostly harmless (exception: central (exception: central lung rupture)lung rupture)

Conservative Conservative

Thoracic drainage in pneumothorax and Thoracic drainage in pneumothorax and hemothoraxhemothorax

Operation only in exceptional cases because Operation only in exceptional cases because of bleeding or massive air lossof bleeding or massive air loss

Lung Parenchymal Injuries Lung Parenchymal Injuries Lung Parenchymal Injuries Lung Parenchymal Injuries


Intrapulmonary Intrapulmonary hematomahematoma

HarmlessHarmless NoneNone



Traumatic lung Traumatic lung pseudocystspseudocysts

HarmlessHarmless Mostly noneMostly none



Simple lung contusionSimple lung contusion Mostly harmless Mostly harmless

Can develop into lung Can develop into lung contusion with contusion with respiratory insufficiencyrespiratory insufficiency

Breathing exercisesBreathing exercises

Careful monitoring of Careful monitoring of progressprogress



Lung contusion with Lung contusion with respiratory insufficiencyrespiratory insufficiency

Progressive respiratory Progressive respiratory insufficiency: hypoxia, right-to-insufficiency: hypoxia, right-to-left shunt interstitial edema, left shunt interstitial edema, considerable mortality considerable mortality

Intubation and positive end-expiratory Intubation and positive end-expiratory pressure ventilation (PEEP)pressure ventilation (PEEP)

Maintenance of a normal oncotic Maintenance of a normal oncotic pressure (fluid infusion limited, human pressure (fluid infusion limited, human albumin 29%). albumin 29%).

SteroidsSteroids



Blast injury Blast injury Severest injurySeverest injury

Progressive respiratory insufficiency Progressive respiratory insufficiency

Danger of arterial air embolism Danger of arterial air embolism

Hemothorax, pneumothorax, abdominal Hemothorax, pneumothorax, abdominal injuries (colonl)injuries (colonl)

As in lung contusions with respiratory As in lung contusions with respiratory insufficiency insufficiency


Abnormalities following bronchial Abnormalities following bronchial rupture and methods of managementrupture and methods of managementAbnormalities following bronchial Abnormalities following bronchial

rupture and methods of managementrupture and methods of management

Acute respiratory

insufficiency

Acute

Infections

Early Bronchial

Obstruction

Tubes

Emergency Repair or Resection

Bronchial RuptureBronchial Rupture

ImmediateImmediate

Mediastinitis

EmpyemaAtelectasis

Pneumonia Abscess

DelayedDelayed

Pulmonary Infection Late bronchial obstruction

Fibrosis

Abnormalities following bronchial Abnormalities following bronchial rupture and methods of managementrupture and methods of managementAbnormalities following bronchial Abnormalities following bronchial

rupture and methods of managementrupture and methods of management

Bronchiectasis Pneumonitis Atelectasis

Fibrosis Abscess

Elective Pulmonary Resection

Pathologic courses following esophageal perforationPathologic courses following esophageal perforationPathologic courses following esophageal perforationPathologic courses following esophageal perforationEntry into cervical or

mediastinal fascial planes of:

AirAir Gastric juiceGastric juiceBacteria and SalivaBacteria and Saliva

MediastinitisMediastinitis EmphysemaEmphysema PneumothoraxPneumothorax BurnBurn

AbscessAbscess EmpyemaEmpyema

SepsisSepsis PneumoniaPneumonia

TensionTension Fluid and electrolyte Fluid and electrolyte disturbancedisturbance

CV CollapseCV Collapse

Essential components of and procedures used in Essential components of and procedures used in management of esophageal perforationmanagement of esophageal perforation

Essential components of and procedures used in Essential components of and procedures used in management of esophageal perforationmanagement of esophageal perforation

Fluid and Electrolytes Antibiotics Prevent further contamination

Therapy Therapy non-operativenon-operative

High-dose IV Topical, Luminal

Prox. Tube

Gast. Tube

Plus Operative

Drainage of

Mediastinal and/or

fascial planes

Closure

Or Exclusion

Or Re-section Only

With reconstruction

Injuries of the diaphragm Injuries of the diaphragm Injuries of the diaphragm Injuries of the diaphragm Diaphragmatic RuptureDiaphragmatic Rupture:: Incidence:Incidence: In 3% of all sever thoracic injuries. In 3% of all sever thoracic injuries. Mechanism: Mechanism: Broad surface blow. Broad surface blow. Location:Location: Left side in 85% of cases. Left side in 85% of cases. Clinical picture. Clinical picture.

Acute:Acute: symptoms of companion injury and shock. symptoms of companion injury and shock.

Chronic:Chronic: Intestinal obstruction or strangulation Intestinal obstruction or strangulation (usually)(usually)

Diaphragmatic ruptures Diaphragmatic ruptures (Cont.)(Cont.)Diaphragmatic ruptures Diaphragmatic ruptures (Cont.)(Cont.)

Radiological Ex.:Radiological Ex.: Rupture of the diaphragm are Rupture of the diaphragm are frequently overlooked. frequently overlooked.

Therapy:Therapy: Is indicated for increasing impairment to Is indicated for increasing impairment to respiration. respiration.

Operative approach from chest or abdomen. Operative approach from chest or abdomen.

Traumatic Traumatic Diaphragmatic Diaphragmatic RuptureRupture

Traumatic EmphysemaTraumatic EmphysemaTraumatic EmphysemaTraumatic Emphysema Subcutaneous. Subcutaneous. Mediastinal Emphysema. Mediastinal Emphysema.

““Present in about 27% of patients with blunt or Present in about 27% of patients with blunt or penetrating chest injurypenetrating chest injury””

Therapy:Therapy:

Despite its impressive appearance the treatment of Despite its impressive appearance the treatment of subcutaneous emphysema it self is mostly unnecessary. subcutaneous emphysema it self is mostly unnecessary.

Determite the site of origin. Determite the site of origin. Treat underlying pneumothorax if present by tube Treat underlying pneumothorax if present by tube

thoracostomy. thoracostomy. Treat tracheobronchial, or oesophageal rupture or tension Treat tracheobronchial, or oesophageal rupture or tension

pneumothorax in cases of mediastinal emphysema. pneumothorax in cases of mediastinal emphysema. Rarely, cervical mediastinotomy is needed for mediastinal Rarely, cervical mediastinotomy is needed for mediastinal

enphysema.enphysema.

Traumatic EmphysemaTraumatic EmphysemaTraumatic EmphysemaTraumatic Emphysema

Non-Non-penetrating penetrating wounds of wounds of HeartHeart

CardiacCardiacTamponadeTamponade

Algorithm for the diagnosis and management of Algorithm for the diagnosis and management of penetrating cardiac injuriespenetrating cardiac injuries

Precordial/Epigastric Wounds Precordial/Epigastric Wounds

HypotensionHypotension

Suspect Cardiac InjurySuspect Cardiac Injury

Airway Control Central Venous Lines Airway Control Central Venous Lines Volume Expansion Tube ThoracostomyVolume Expansion Tube Thoracostomy

Hemodymanic InstabilityHemodymanic InstabilityHemodymanic StabilityHemodymanic Stability

Operating Capability In E.R.Operating Capability In E.R.

YesYesNoNo

Immediate TRT Relief of Immediate TRT Relief of Tamponade Cardiorrhaphy Tamponade Cardiorrhaphy

Pericardiocentesis Intrapericardial Pericardiocentesis Intrapericardial Catheter Constinous Aspiration Catheter Constinous Aspiration

Operating Room Transfer Operating Room Transfer Subxiphoid Pericardial WindowSubxiphoid Pericardial Window

Diagnosis ConfirmedDiagnosis Confirmed

Operating Room Transfer Definitive Casrdiorrhaphy Operating Room Transfer Definitive Casrdiorrhaphy Control of Other Injuries Closure of Incision Control of Other Injuries Closure of Incision

Penetrating cardiac injuries (Therapy)Penetrating cardiac injuries (Therapy)

CARDIAC INJURYCARDIAC INJURYRepair Postoperative PeriodRepair Postoperative Period

AsymptomaticAsymptomatic SymptomaticSymptomatic

ElectrocardiogramElectrocardiogramChest X-rayChest X-ray

Physical examinationPhysical examination

NormalNormal AbnormalAbnormal 2-D Echocardiogram2-D Echocardiogram

Shunts Fistulae Equivocal Shunts Fistulae Equivocal

intracardiac Defectsintracardiac Defects

Foreign BodiesForeign Bodies

Cardiac CatheterizationCardiac Catheterization

NormalNormal AbnormalAbnormal Re-operationRe-operation

Follow-upFollow-up

Other Injury Patterns Other Injury Patterns in Thoracic Traumain Thoracic Trauma


I. Traumatic asphyxia: I. Traumatic asphyxia:

Due to a severe compression of thorax with sudden increase Due to a severe compression of thorax with sudden increase

of pressure in the venous system resulting in a characteristic of pressure in the venous system resulting in a characteristic

injury pattern where small hemorrhages in the conjunctiva, injury pattern where small hemorrhages in the conjunctiva,

the skin and the mucous membranes of the throat and head the skin and the mucous membranes of the throat and head

and reddish-blue discoloration in the latter region. and reddish-blue discoloration in the latter region.

Therapy:Therapy:

Is for the companion injuries and cerebral oedema if present. Is for the companion injuries and cerebral oedema if present.

II. Injuries of the thoracic duct: (Chylothorax) II. Injuries of the thoracic duct: (Chylothorax)

III. Cholothorax III. Cholothorax

IV. Traumatic induced hernia of the chest wall IV. Traumatic induced hernia of the chest wall

V. Arterial air embolism V. Arterial air embolism

VI. Blast injury VI. Blast injury



Indications for Thoracotomy:Indications for Thoracotomy:Decision to OperateDecision to Operate

Indications for Thoracotomy:Indications for Thoracotomy:Decision to OperateDecision to Operate

Excluding minor surgical procedures such as Excluding minor surgical procedures such as

tracheostomy pericardiocentesis, tube tracheostomy pericardiocentesis, tube

thoracostomy, and suture of chest wall lacerations, thoracostomy, and suture of chest wall lacerations,

formal operations are required in only formal operations are required in only 12 to 1512 to 15

percentpercent of patients with thoracic trauma. of patients with thoracic trauma.

Indications for thoracotomy: Indications for thoracotomy: ACUTEACUTE

Indications for thoracotomy: Indications for thoracotomy: ACUTEACUTE

Post-traumatic cardiovascular collapse Post-traumatic cardiovascular collapse

Pericardial tamponade Pericardial tamponade

Vascular injury to the thoracic outlet Vascular injury to the thoracic outlet

Traumatic thoracotomyTraumatic thoracotomy

Massive Air leak Massive Air leak

Proved tracheobronchial injury Proved tracheobronchial injury

Proved Esophageal injury Proved Esophageal injury

Great vessel injury Great vessel injury

Continuing Hemothorax Continuing Hemothorax

Mediastinal traversing injuryMediastinal traversing injury

Bullet Embolism Bullet Embolism

Air Embolism Air Embolism

Indications for thoracotomy: Indications for thoracotomy: CHRONICCHRONIC

Indications for thoracotomy: Indications for thoracotomy: CHRONICCHRONIC

Unevaluated clotted hemothorax Unevaluated clotted hemothorax Chronic traumatic Diaphragmic hernia Chronic traumatic Diaphragmic hernia Chronic cardiac septal or valvular lesions Chronic cardiac septal or valvular lesions Chronic false Aneurysms Chronic false Aneurysms Chronic non-closing thoracic duct fistulaChronic non-closing thoracic duct fistula Infected intrapulmonary hematoma Infected intrapulmonary hematoma Missed trachobronchial injury Missed trachobronchial injury Traumatic Arterio-venous fistula Traumatic Arterio-venous fistula

Suspected if there is Additional examination

required

Initial therapeutic measures

Tension pneum-

Othorax

Inflated hemithorax with reduced mobility of thorax

None Immediate thoracic

Hypersonorous auscultation

Weakened breath sounds

Venous congestion in creasing elevation of central venous pressure

Open pneumothorax

Thoracic wounds with sound of air rushing in and out (“sucking wound”)

None 1. Tight bandage +ICT or2. Intubation mechanical ventilation

Cardiac tamponade

Location of wound in the precordium or corresponding tract of the bullet or knife

None Pericardioeentesis Operation

Initial Assessment of the most important thoracic injuriesInitial Assessment of the most important thoracic injuries

Suspected if there isSuspected if there is Additional examination Additional examination

requiredrequired

Initial therapeutic Initial therapeutic measuresmeasures

Rib fracturesRib fractures Local tenderness Local tenderness Chest roentgenogramChest roentgenogram Relief of painRelief of pain

Compression painCompression pain Intubation and mechanical Intubation and mechanical ventilation when respiratory ventilation when respiratory insufficiency occursinsufficiency occurs

Possibly crepitation on Possibly crepitation on auscultationauscultation

Inspection: possibly Inspection: possibly

paradoxical respirationparadoxical respiration

PneumothoraxPneumothorax HyperresonanceHyperresonance Chest roentgenogramChest roentgenogram Thoracic drainageThoracic drainage

Diminished breath soundsDiminished breath sounds

HemothoraxHemothorax Dullness to percussionDullness to percussion Chest roentgenogramChest roentgenogram Thoracic drainageThoracic drainage

Subcutaneous Subcutaneous emphysemaemphysema


Suspected if there isSuspected if there is Additional Additional examination examination

requiredrequired


Rupture of Rupture of bronchusbronchus

Mediastinal emphysemaMediastinal emphysema BronchoscopyBronchoscopy OperationOperation

Pneumothorax or tension Pneumothorax or tension peneumothoraxpeneumothorax

No expansion of lung No expansion of lung during thoracic drainageduring thoracic drainage

Total atelectasisTotal atelectasis

Rupture of Rupture of esophagusesophagus

Mediastinal emphysemaMediastinal emphysema EsophagographyEsophagography OperationOperation



requiredrequired


Mediastinal Mediastinal emphysemaemphysema

Characteristic crunching Characteristic crunching sound above the heart, sound above the heart, synchronous with the synchronous with the heart beat (Hamman’s heart beat (Hamman’s sign)sign)

Chest roentgenogramChest roentgenogram Cervical mediastionotomy Cervical mediastionotomy only when there is only when there is significant venous significant venous congestion and no rupture congestion and no rupture of bronchus or esophagusof bronchus or esophagus

Central venous pressureCentral venous pressure

Determination of Determination of possible cause by possible cause by means of:means of:

Bronchoscopy Bronchoscopy

EsophagographyEsophagography

Diaphragmatic Diaphragmatic rupturerupture

Percussion: dampened or Percussion: dampened or hypersonorous hypersonorous percussionpercussion

Roentgenogram of Roentgenogram of thorax with possible use thorax with possible use of nasogastric tube of nasogastric tube and/or contrast mediaand/or contrast media

OperationOperation

Initial Assessment of the most important thoracic injuriesInitial Assessment of the most important thoracic injuriesInitial Assessment of the most important thoracic injuriesInitial Assessment of the most important thoracic injuries


requiredrequired


Rupture of aortaRupture of aorta Possibly pseudocoarctation syndromePossibly pseudocoarctation syndrome AortographyAortography OperationOperation

Possibly compression syndrome in the Possibly compression syndrome in the upper mediastinumupper mediastinum

Possibly systolic murmur Possibly systolic murmur

Roentgenorgram:Roentgenorgram:

Wide mediastinumWide mediastinum

Tracheal displacement to the rightTracheal displacement to the right

Displacement of the left bronchus Displacement of the left bronchus downwarddownward

Possible left-sided hemothoraxPossible left-sided hemothorax

Cardiac contusionCardiac contusion ECG:ECG:Irregularities in repolarizationIrregularities in repolarizationDisturbances in rhythm and Disturbances in rhythm and conductionconductionInfarct patternInfarct pattern

Cardiac enzymesCardiac enzymes ECG monitoringECG monitoring

Drug treatment of rhythm Drug treatment of rhythm irregularities and of irregularities and of possible cardiac possible cardiac insufficiencyinsufficiency


chest trauma by dr. samir abdallah m.d prof. of cardio-thoracic surgery cairo university

Documents

blunt chest injury

blunt injury

thoracic traumaroentgenograms

thoracic injurythe

chest traumabydr

mechanism of injury

assessment of patient

thorax chest wall