l 1thorax trauma

7/29/2019 L 1Thorax Trauma

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Thorax trauma

www.klymenko.ucoz.ru


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Frequency

Trauma is responsible for more than 100,000

deaths annually in the United States.1 Estimates

of thoracic trauma frequency indicate that

injuries occur in 12 persons per millionpopulation per day. Approximately 33% of these

injuries require hospital admission. Overall, blunt

thoracic injuries are directly responsible for 20-

25% of all deaths, and chest trauma is a majorcontributor in another 50% of deaths.


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Etiology

By far, the most important cause of

significant blunt chest trauma is motorvehicle accidents that account for 70-

80% of such injuries.


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Pathophysiology

The major pathophysiologies encountered in blunt

chest trauma involve derangements in the flow ofair, blood, or both in combination. Sepsis due to

leakage of alimentary tract contents, as in

esophageal perforations, also must be considered.Blunt trauma commonly results in chest wall injuries

(eg, rib fractures). The pain associated with these

injuries can make breathing difficult, and this may

compromise ventilation.Direct lung injuries, such as pulmonary contusions,are frequently associated with major chest traumaand may impair ventilation by a similar mechanism.


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Clinical

The clinical presentation of patients with

blunt chest trauma varies widely andranges from minor reports of pain to florid

shock. The presentation depends on themechanism of injury and the organ

systems injured.


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WorkupApproach Considerations

Initial emergency workup of a patient with multiple injuries should begin with the

ABCs of trauma, with appropriate intervention taken for each step.

Laboratory Studies

CBC count

Arterial blood gas

Serum chemistry profile

Coagulation profile

Serum troponin levels Serum myocardial muscle creatine kinase isoenzyme levels

Serum lactate levels

Blood type and crossmatch

Imaging Studies

Chest radiographs

Chest CT scan

Aortogram

Thoracic ultrasound

Contrast esophagogram

Focused Assessment for the Sonographic Examination of the Trauma Patient


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Workup

Diagnostic Tests and Procedures Twelve-lead electrocardiogram

Transesophageal echocardiography

Transthoracic echocardiography

Flexible esophagoscopy Fiberoptic bronchoscopy


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Indications

Operative intervention is rarely necessaryin blunt thoracic injuries. In one report,only 8% of cases with blunt thoracic

injuries required an operation. Most can betreated with supportive measures and

simple interventional procedures such as

tube thoracostomy.


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Chest wall fractures, dislocations, and barotrauma(including diaphragmatic injuries)

Indications for immediate surgery include (1) traumatic

disruption with loss of chest wall integrity and (2) blunt

diaphragmatic injuries.

Relatively immediate and long-term indications for

surgery include (1) delayed recognition of blunt

diaphragmatic injury and (2) the development of a

traumatic diaphragmatic hernia.


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Rib fractures

Rib fractures are the most common blunt thoracic injuries. Ribs 4-10 are

most frequently involved. Patients usually report inspiratory chest pain and

discomfort over the fractured rib or ribs. Physical findings include local

tenderness and crepitus over the site of the fracture. If a pneumothorax is

present, breath sounds may be decreased and resonance to percussion

may be increased. Rib fractures may also be a marker for other associatedsignificant injury, both intrathoracic and extrathoracic.

Effective pain control is the cornerstone of medical therapy for patients with

rib fractures. For most patients, this consists of oral or parenteral analgesic

agents. Intercostal nerve blocks may be feasible for those with severe pain

who do not have numerous rib fractures. A local anesthetic with a relatively

long duration of action (eg, bupivacaine) can be used. Patients with multiplerib fractures whose pain is difficult to control can be treated with epidural

analgesia.

Adjunctive measures in the care of these patients include early mobilization

and aggressive pulmonary toilet. Rib fractures do not require surgery. Pain

relief and the establishment of adequate ventilation are the therapeutic

goals for this injury.


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Flail chest A flail chest, by definition, involves 3 or more consecutive rib fractures

in 2 or more places, which produces a free-floating, unstable segment

of chest wall. Separation of the bony ribs from their cartilaginousattachments, termed costochondral separation, can also cause flail chest.Patients report pain at the fracture sites, pain upon inspiration, and,frequently, dyspnea. Physical examination reveals paradoxical motion ofthe flail segment. The chest wall moves inward with inspiration andoutward with expiration. Tenderness at the fracture sites is the rule.

Dyspnea, tachypnea, and tachycardia may be present. The clinician should specifically be aware of the high incidence of

associated thoracic injuries such as pulmonary contusions and closed head

injuries, which, in combination, significantly increase the mortalityassociated with flail chest.

In an attempt to stabilize the chest wall and to avoid endotracheal intubationand mechanical ventilation, various operations have been devised for

correcting flail chest. These include pericostal sutures, the application ofexternal fixation devices, or the placement of plates or pins for internalfixation.


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Blunt Injuries of the Pleurae, Lungs, and AerodigestiveTracts

Pneumothorax

Pneumothoraces in blunt thoracic trauma are most frequently caused when

a fractured rib penetrates the lung parenchyma.

Patients report inspiratory pain or dyspnea and pain at the sites of therib fractures. Physical examination demonstrates decreased breath soundsand hyperresonance to percussion over the affected hemithorax. In

practice, many patients with traumatic pneumothoraces also have someelement of hemorrhage, producing a hemopneumothorax.

Patients with pneumothoraces require pain control and pulmonary toilet. All

patients with pneumothoraces due to trauma need a tube thoracostomy.

The chest tube is connected to a collection system that is entrained to

suction at a pressure of approximately -20 cm water. The tube continues

suctioning until no air leak is detected. The tube is then disconnected fromsuction and placed to water seal. If the lung remains fully expanded, the

chest tube may be removed and another chest radiograph obtained to

ensure continued complete lung expansion.


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Hemothorax The accumulation of blood within the pleural space can be due to bleeding

from the chest wall (eg, lacerations of the intercostal or internal mammary

vessels attributable to fractures of chest wall elements) or to hemorrhagefrom the lung parenchyma or major thoracic vessels. Patients report pain

and dyspnea. Physical examination findings vary with the extent of the

hemothorax. Most hemothoraces are associated with a decrease in breath

sounds and dullness to percussion over the affected area. Massive

hemothoraces due to major vascular injuries manifest with the

aforementioned physical findings and varying degrees of hemodynamicinstability.

Hemothoraces are evacuated using tube thoracostomy. Multiple chest tubes

may be required. Pain control and aggressive pulmonary toilet are provided.

The chest tube output is monitored closely because indications for surgery

can be based on the initial and cumulative hourly chest tube drainage. Large, clotted hemothoraces may require an operation for evacuation to

allow full expansion of the lung and to avoid the development of other

complications such as fibrothorax and empyema. Thoracoscopic

approaches have been used successfully in the management of this

problem.15


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Frontal chest radiograph shows pleural effusion (asterisk)

opacifying entire left hemithorax (opacified hemithorax) with

contralateral mediastinal shift (arrows).


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42-year-old man with chronic empyema and opening in right chest wall.

Frontal chest radiograph shows right-sided pleural effusion (asterisk)

and chest wall defect (arrow)


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15-year-old girl with blunt injury to lower thorax. Frontal

chest radiograph shows pleural effusion (asterisk)

opacifying entire right hemithorax.


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Open pneumothorax

This injury is more commonly caused by penetrating mechanisms but may

rarely occur with blunt thoracic trauma. Patients are typically in respiratory

distress due to collapse of the lung on the affected side. Physical

examination should reveal a chest wall defect that is larger than the cross-

sectional area of the larynx. The affected hemithorax demonstrates a

significant-to-complete loss of breath sounds. The increased intrathoracicpressure can shift the contents of the mediastinum to the opposite side,

decreasing the return of blood to the heart, potentially leading to

hemodynamic instability.

Treatment for an open pneumothorax consists of placing a 3-way occlusive

dressing over the wound to preclude the continued ingress of air into the

hemithorax and to allow egress of air from the chest cavity. A tubethoracostomy is then performed. Pain control and pulmonary toilet

measures are applied.

Traumatic pulmonary herniation through the ribs, though uncommon, may

occur following chest trauma. Unless incarceration or infarction is evident,

immediate repair is not indicated.


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Pneumothorax


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Erect frontal chest radiograph shows left-sided pneumothorax ("visceral

pleural line" sign)


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Tension pneumothorax

The mechanisms that produce tension pneumothoraces are the

same as those that produce simple pneumothoraces. However, witha tension pneumothorax, air continues to leak from an underlying

pulmonary parenchymal injury, increasing pressure within the

affected hemithorax. Patients are typically in respiratory distress.

Breath sounds are severely diminished to absent, and the

hemithorax is hyperresonant to percussion. The trachea is deviatedaway from the side of the injury. The mediastinal contents are

shifted away from the affected side. This results in decreased

venous return of blood to the heart. The patient exhibits signs of

hemodynamic instability, such as hypotension, which can rapidly

progress to complete cardiovascular collapse.

Immediate therapy for this life-threatening condition includes

decompression of the affected hemithorax by needle thoracostomy.

A large-bore needle (ie, 14- to 16-gauge) is inserted through the

second intercostal space in the midclavicular line. A tube

thoracostomy is then performed. Pain control and pulmonary toilet

are instituted.


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Frontal chest radiograph shows complete right lung collapse (unilateral

hyperlucent lung) (asterisk) with ipsilateral hemidiaphragmatic depression,

widened intercostal spaces, and contralateral mediastinal shift (arrows)

indicative of tension pneumothorax.


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Pulmonary contusion and other parenchymal injuries

The forces associated with blunt thoracic trauma can be transmitted to the

lung parenchyma. This results in pulmonary contusion, as characterized bydevelopment of pulmonary infiltrates with hemorrhage into the lung tissue.

Clinical findings in pulmonary contusion depend on the extent of the injury.

Patients present with varying degrees of respiratory difficulty. Physical

examination demonstrates decreased breath sounds over the affected area.

Pain control, pulmonary toilet, and supplemental oxygen are the primary

therapies for pulmonary contusions and other parenchymal injuries. If theinjury involves a large amount of parenchyma, significant pulmonary

shunting and dead space ventilation may develop, necessitating

endotracheal intubation and mechanical ventilation. Laceration or avulsion

injuries that cause massive hemothoraces or prolonged high rates of bloody

chest tube output may require thoracotomy for surgical control of bleeding

vessels. If central bleeding is identified during thoracotomy, hilar control isgained first. Once the extent of injury is confirmed, it may become

necessary to perform a pneumonectomy, keeping in mind that trauma

pneumonectomy is generally associated with a high mortality rate (>50%).

Left pulmonary contusion following a motor


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Left pulmonary contusion following a motor

vehicle accident involving a pedestrian.


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Acute lung injury


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35-year-old woman 24 hours after motor vehicle collision.

Frontal chest radiograph shows diffuse patchy lung

opacities, suggesting acute respiratory distress syndrome.


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Pulmonary parenchymal injuries. 48-year-old woman 1 hour after motor

vehicle collision. Frontal chest radiograph shows diffuse bilateral

opacities, suggestive of pulmonary contusions.


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Pulmonary parenchymal injuries. 37-year-old man 1 week after blunt

chest trauma. Frontal chest radiograph shows diffuse bilateral opacities

and right-sided cavitary lung lesion (asterisk), reflecting sequela of prior

lung laceration.


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64-year-old man injured in motor vehicle collision. Frontal

chest radiograph shows left-sided lung herniation

(asterisk).


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Blunt bronchial injuries

Rapid deceleration is the most common mechanism causing major blunt

bronchial injuries. Many of these patients die of inadequate ventilation or

severe associated injuries before definitive therapy can be provided.

Patients are in respiratory distress and present with physical signs

consistent with a massive pneumothorax. Ipsilateral breath sounds are

severely diminished to absent, and the hemithorax is hyperresonant to

percussion. Subcutaneous emphysema may be present and may be

massive. Hemodynamic instability may be present and is caused by tensionpneumothorax or massive blood loss from associated injuries.

Laceration, tear, or disruption of a major bronchus is life threatening. These

injuries require surgical repair. As with tracheal injuries, establishment of a

secure and adequate airway is of primary importance. Patients with major

bronchial lacerations or avulsions have massive air leaks. The approach to

repair of these injuries is ipsilateral thoracotomy on the affected side aftersingle-lung ventilation is established on the uninjured side. Operative repair

consists of debridement of the injury and construction of a primary end-to-

end anastomosis.

Blunt injuries of the pleurae lungs and


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Blunt injuries of the pleurae, lungs, andaerodigestive tracts

Indications for immediate surgery include (1) a massive air leak

following chest tube insertion; (2) a massive hemothorax or

continued high rate of blood loss via the chest tube (ie, 1500 mL of

blood upon chest tube insertion or continued loss of 250 mL/h for 3

consecutive hours); (3) radiographically or endoscopically confirmed

tracheal, major bronchial, or esophageal injury; and (3) the recoveryof gastrointestinal tract contents via the chest tube.

Relatively immediate and long-term indications for surgery include

(1) a chronic clotted hemothorax or fibrothorax, especially when

associated with a trapped or nonexpanding lung; (2) empyema; (3)

traumatic lung abscess; (4) delayed recognition of tracheobronchialor esophageal injury; (5) tracheoesophageal fistula; and (6) a

persistent thoracic duct fistula/chylothorax.


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Contraindications

No distinct, absolute contraindications

exist for surgery in blunt thoracic trauma.


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Blunt esophageal injuries

Because of the relatively protected location of the esophagus in the posterior mediastinum, blunt

injuries of this organ are rare. Blunt esophageal injuries are usually caused by a sudden increase

in esophageal luminal pressure resulting from a forceful blow. Injury occurs predominantly in the

cervical region; rarely, intrathoracic and subdiaphragmatic ruptures are also encountered.

Associated injuries to other organs are common. Physical clues to the diagnosis may include

subcutaneous emphysema, pneumomediastinum, pneumothorax, or intra-abdominal free air.

Patients who present a significant time after the injury may manifest signs and symptoms of

systemic sepsis. General medical supportive measures are appropriate. Fluid resuscitation and broad-spectrum

intravenous antibiotics with activity against gram-positive organisms and anaerobic oral flora are

administered. Surgery is required.

Injuries identified within 24 hours of their occurrence are treated by debridement and primary

closure. Some surgeons choose to reinforce these repairs with autologous tissue. Wide

mediastinal drainage is established with multiple chest tubes. If more than 24 hours have passed

since injury, primary repair buttressed by well-vascularized autologous tissue is still the bestoption if technically feasible. Examples of tissues used to reinforce esophageal repairs include

parietal pleura and intercostal muscle. Very distal esophageal injuries can be covered with a

tongue of gastric fundus. This is called a Thal patch.

For patients in poor general condition and those with advanced mediastinitis or severe associated

injuries, esophageal exclusion and diversion is the most prudent choice. A cervical

esophagostomy is made, the distal esophagus is stapled, the stomach is decompressed via

gastrostomy, and a feeding jejunostomy tube is placed. Wide mediastinal drainage is establishedwith multiple chest tubes.

Pneumomediastinum 32-year-old woman with esophageal rupture


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Pneumomediastinum. 32-year-old woman with esophageal rupture

after blunt trauma. Frontal chest radiograph shows triangular

radiolucency in left cardiophrenic angle ("Naclerio's V" sign) (asterisk).


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Mediastinal bleeding and infection. 43-year-old man with penetrating injury to

chest. Frontal chest radiograph identifies mediastinal widening (double-headed

arrow), suggestive of vascular injury.

T h b hi l i j i 39 ld i j d i t hi l


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Tracheobronchial injuries. 39-year-old man injured in motor vehicle

crash. Frontal chest radiograph shows irregularity of left main bronchus

(arrow) and mediastinal widening (double-headed arrow), indicative of

paratracheal hematoma.


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Esophageal injuries. 31-year-old man with Boerhaave's syndrome.

Frontal chest radiograph shows bilateral pneumomediastinum (arrows).


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Esophageal injuries. 34-year-old woman with hiatal hernia. Frontal

chest radiograph shows large retrocardiac opacity (arrows).

Bl t di h ti i j i


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Blunt diaphragmatic injuries Diaphragmatic injuries are relatively uncommon. Blunt mechanisms,

usually a result of high-speed MVAs, cause approximately 33% of

diaphragmatic injuries. Most diaphragmatic injuries are diagnosed incidentally at the time of

laparotomy or thoracotomy for associated intra-abdominal or

intrathoracic injuries. Initial chest radiographs are normal. Findings

suggestive of diaphragmatic disruption on chest radiographs may

include abnormal location of the nasogastric tube in the chest,ipsilateral hemidiaphragm elevation, or abdominal visceral

herniation into the chest.

A confirmed diagnosis or the suggestion of blunt diaphragmatic

injury is an indication for surgery. Blunt diaphragmatic injuries

typically produce large tears measuring 5-10 cm or longer. Mostinjuries are best approached via laparotomy. Most injuries can be

repaired primarily with a continuous or interrupted braided suture (1-

0 or larger). Synthetic mesh made of polypropylene or Dacron is

occasionally needed to repair large defects.


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Blunt cardiac injuries


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Blunt cardiac injuries

MVAs are the most common cause of blunt cardiac injuries. Falls, crush injuries, acts of violence,

and sporting injuries are other causes. Blunt cardiac injuries range from mild trauma associated

only with transient arrhythmias to rupture of the valve mechanisms, interventricular septum, or

myocardium (cardiac chamber rupture). Therefore, patients can be asymptomatic or can manifestsigns and symptoms ranging from chest pain to cardiac tamponade (eg, muffled heart tones,

jugular venous distension, hypotension) to complete cardiovascular collapse and shock due to

rapid exsanguination.

Many patients with blunt cardiac injuries do not require specific therapy. Those who develop an

arrhythmia are treated with the appropriate antiarrhythmic drug

Patients with severe blunt cardiac injuries who survive to reach the hospital require surgery. Most

patients in this group have cardiac chamber rupture due to a high-speed MVA. The right sideinvolvement is most common, involving the right atrium and right ventricle. They present with

signs and symptoms of cardiac tamponade or exsanguinating hemorrhage. A few may be stable

initially, resulting in delayed diagnosis. Those with tamponade benefit from rapid

pericardiocentesis or surgical creation of a subxiphoid window. The next step is to repair the

cardiac chamber by cardiorrhaphy. Cardiopulmonary bypass techniques can facilitate this

procedure. Unstable patients may benefit from insertion of an intra-aortic counterpulsation balloon

pump.

Commotio cordis or sudden cardiac death in an otherwise healthy individual generally results from

participation in a sporting event or some form of recreational activity. It is a direct result of blow to

the heart just before the T-wave, resulting in ventricular fibrillation. Survival is not unheard of, if

resuscitation and defibrillation are started within minutes. Preventive strategies include chest

protective gear during sporting activities

Pericardial tears and ruptures. 24-year-old man injured in motor vehicle crash.


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Frontal chest radiograph shows leftward shift of heart silhouette (asterisk).

Pericardial tears and ruptures 36-year-old man injured in motor vehicle


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Pericardial tears and ruptures. 36-year-old man injured in motor vehicle

crash. Frontal chest radiograph shows complete rotation of heart

silhouette (asterisk) with apex pointing toward right.


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Pericardial effusion. 33-year-old woman with pericardial effusion. Frontal chest

radiograph shows globular bilateral enlargement of cardiac silhouette ("water-

bottle" sign) (asterisks).


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Pericardial effusion. 27-year-old man with pericardial effusion. Lateral

chest radiograph shows separation of retrosternal and epicardial fat

("epicardial fat-pad," "Oreo cookie," sandwich, or stripe sign) (arrows).

Pne mopericardi m 43 ear old oman ith


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Pneumopericardium. 43-year-old woman with

pneumopericardium. Frontal chest radiograph shows band

of air outlining heart (halo sign) inferiorly (arrows).

Pneumopericardium 34-year-old man with gunshot wound to chest


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Pneumopericardium. 34 year old man with gunshot wound to chest.

Frontal chest radiograph shows left-sided pneumothorax (asterisk) and

bilateral pneumopericardium compressing heart ("small heart" sign)

(arrows).

Blunt injuries of the thoracic aorta and major thoracic arteries


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j j

High-speed MVAs are the most common cause of blunt thoracic aortic injuries and blunt injuries of

the major thoracic arteries. The mechanisms of injury are rapid deceleration, production of

shearing forces, and direct luminal compression against points of fixation (especially at the

ligamentum arteriosum). Many of these patients die from vessel rupture and rapid exsanguination

at the scene of the injury or before reaching definitive care. Blunt aortic injuries follow closely

behind head injury as a cause of death after blunt trauma.

Physical clues include signs of significant chest wall trauma (eg, scapular fractures, first or second

rib fractures, sternal fractures, steering wheel imprint), hypotension, upper extremity blood

pressure differential, loss of upper or lower extremity pulses, and thoracic spine fractures. Signs of

cardiac tamponade may be present. Decreased breath sounds and dullness to percussion due to

massive hemothorax can also be found. Up to 50% of patients with these devastating, life-

threatening injuries have no overt external signs of injury. Therefore, a high index of suspicion is

warranted for earlier intervention.

Endovascular stent grafts are being developed to repair thoracic aortic injuries. While several

authors have reported success in treating such injuries with endo stents, the long-term durability

of the stents is yet unknown. Further experience with this technique will allow more victims with

concomitant severe injuries to become operative candidates. Techniques for repair of the

innominate artery and subclavian vessels vary depending on the type of injury. Many require only

lateral arteriorrhaphy. Large injuries of the innominate artery are managed first by placement of abypass graft from the ascending aorta to the distal innominate artery. The injury is then

approached directly and is oversewn or patched.21,22,23

Proximal pulmonary arterial injuries are relatively easy to repair when in an anterior location.

Posterior injuries frequently require cardiopulmonary bypass. Pulmonary hilar injuries present the

possibility of rapid exsanguination and are best treated with pneumonectomy. Peripheral

pulmonary arterial injuries are approached easily by thoracotomy on the affected side. They may

be repaired or the corresponding pulmonary lobe or segment may be resected.

Blunt injuries of the heart, great arteries,


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j , g ,veins, and lymphatics

Indications for immediate surgery include (1) cardiac

tamponade, (2) radiographic confirmation of a great

vessel injury, and (3) an embolism into the pulmonary

artery or heart.

Relatively immediate and long-term indications forsurgery include the late recognition of a great vessel

injury (eg, development of traumatic pseudoaneurysm).

Traumatic rupture of the aortic


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Traumatic rupture of the aortic

arch

Blunt aortic injury typically occurs in the proximal segment of the


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Blunt aortic injury typically occurs in the proximal segment of thedescending thoracic aorta, due in part to the sudden disruption of the

aortic isthmus. (B) Successful repair of a blunt aortic injury can be

accomplished using an endoluminal approach.

A wide aortic arch curvature is seen in a 65-year-old patient who sustained a


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A wide aortic arch curvature is seen in a 65 year old patient who sustained a

blunt aortic transaction injury. (B) Angiogram of a 17-year-old traffic accident

victim showing injury to the descending thoracic aorta. Note the acute sharp

curvature of the aortic arch.

(A) Aortogram revealing a blunt aortic injury in a 16-year-old male


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( ) g g j y y

(short arrow). (B) Placement of an oversized GORE TAG

endoprosthesis resulted in poor device apposition to the aorta in the

proximal landing zone (long arrow).

(A) Successful deployment of a GORE TAG thoracic device can be achievedwhen appropriate device selection is made, as evidenced by the full apposition


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when appropriate device selection is made, as evidenced by the full apposition

of the stent-graft in the aortic lumen. (B) When the device is inappropriately

oversized relative to the aortic diameter, it can lead to device collapse in its

leading segment (arrow). Image courtesy of Dr Michael Dake and WL Gore

Associates.


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Gore TAG thoracic


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Chest CT scan shows isthmic aorticrupture (asterisk) with massive left

hemothorax and contrast media


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Ruptureof thoracic aorta

Penetrating Chest Trauma


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Penetrating Chest Trauma

Thoracic injuries account for 20-25% of deaths due totrauma and contribute to 25-50% of the remaining

deaths. Approximately 16,000 deaths per year in the

United States alone are attributable to chest trauma.

oracotomy


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o acoto y Thoracotomy may be indicated for acute or chronic conditions.

Acute indications include the following:

Cardiac tamponade

Acute hemodynamic deterioration/cardiac arrest in the trauma

center

Penetrating truncal trauma (resuscitative thoracotomy)

Vascular injury at the thoracic outlet

Loss of chest wall substance (traumatic thoracotomy) Massive air leak

Endoscopic or radiographic evidence of significant tracheal or

bronchial injury

Endoscopic or radiographic evidence of esophageal injury

Radiographic evidence of great vessel injury

Mediastinal passage of a penetrating object

Significant missile embolism to the heart or pulmonary artery

Transcardiac placement of an inferior vena caval shunt for hepatic

vascular wounds

Chronic indications for thoracotomy


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Chronic indications for thoracotomyinclude the following:

Nonevacuated clotted hemothorax

Chronic traumatic diaphragmatic hernia

Traumatic cardiac septal or valvular lesion

Chronic traumatic thoracic aortic pseudoaneurysm

Nonclosing thoracic duct fistula

Chronic (or neglected) posttraumatic empyema

Infected intrapulmonary hematoma (eg, traumatic lung

abscess) Missed tracheal or bronchial injury

Tracheoesophageal fistula

Innominate artery/tracheal fistula

Traumatic arterial/venous fistula


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Thoracoscopy

The role of video-assisted thoracoscopic surgery in the

management of penetrating chest trauma is expanding

rapidly. Initially promoted for the management of

retained hemothoraces and the diagnosis ofdiaphragmatic injury, trauma and thoracic surgeons are

now using thoracoscopy for treatment of chest wall

bleeding, diagnosis of transmediastinal injuries,

pericardial window, and persistent pneumothoraces.

l 1thorax trauma

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