ANATOMY OF THORAIC CAVITY

THORACIC TRAUMA

Chest wall trauma is common and can range from an isolated rib fracture to flail

chest , hemopneumothorax, cardiac injury and is found to be responsible for 25% of all

deaths following road traffic accidents. Many of these deaths occur at the site of the

accident following serious chest injuries such as bilateral flail chest, severe lung

contusion with deep refrectory hypoxia, and great vessel distruption and

exsanguinations.

To approach to the treatment must be methodical to rule out the injuries to the

underlying viscera such as lung, heart, liver, and spleen as injuries to these are often

asscociated with chest wall trauma.

CHEST INJURIES

Blunt injury

- Blunt injury may lead to fracture ribs, sternum along with pulmonary and

cardiac contusion or rupture of airway, diaphragm and major vessel

depending upon low impact velocity(direct blow) or high velocity (deceleration

and crush injuries).

Penetrating injury

- Penetrating injury can be used by stab, impalement or gunshot and may lead

to pericardial tamponade, major vessel or intercostal hemorrhage,

hemopneumothorax or at times esophageal or airway perforation. A high

velocity bullet is always destructive because it creates an immense shock

wave with resultant cavitation.

PATHOPHYSIOLOGY

Most patient with chest injury can be managed by relatively simple measures

(intercostals drain insertion, adequate analgesia, careful fluid management and

physiotherapy) and do not require thoracotomy. If these injuries are not managed

appropriately, the consequences may be fatal. Immediate threats to life are massive

hemorrhage with consequent hypovolemia and low cardiac output. Hypoxia is the most

common pathophysiological process in thoracic trauma and it is therefore crucial to

ensure adequate oxygen delivery to viable sections of lung.

Hypoxia and acidosis may occur secondary

- Hypovolemia caused by blood loss

- Low cardiac output as a result of tamponade

- Pulmonary contusion or cpllapse

- Ventilatory failure

- Displacement of mediastinal structure

Respiratory acidosis results from inadequate ventilation, whereas metabolic

acidosis is causes by tissue hypoperfusion. Untreated chest injuries may cause

an increase in hypoxia and acidosis, which in turn will compound the adverse

effects of other injuries.

PRIMARY SURVEY

The basic principle in resuscitation is securing the airway and restoring the circulating

volume. The primary survey involves simultaneous assessment and treatment of life-

threatening injuries. It follows the ABC(airway,breathing,circulation) principle of

resuscitation, which may also include even emergency thoracotomy.

INJURIES ASSOCIATED WITH PENETRATING THORACIC TRAUMA

1. PNEUMOTHORAX

- Condition in which air can enter the pleural space, either through a breach in

the thin and delicate visceral pleura or through an injury to the chest wall

results in pneumothorax. It could be traumatic, spontaneous or iatrogenic.

-

2. TENSION PNEUMOTHORAX

- This occurs when air enters the pulmonary cavity during inspiration from

lungs, airway, or chest wall injury that seals or closes during expiration.

Excessive pressure reduces effectiveness of respiration and progression of

simple or open pneumothorax.

- The clinical signs of tension pneumothorax are :

Asphyxia

Tachycardia

Hypotension

Tracheal deviation to the contralateral side

Hyperresonance with loss of breath sounds on the affected side

- Tension pneumothorax is clinical diagnosis.

TREATMENT

Immediate decompression should be performed by insertion of a cannula into

the second intercostal space in the mid-clavicular line which should be

replaced later on with intercostals tube drain.

3. OPEN PNEUMOTHORAX

– Open pneumothorax is also known as sucking chest wound, because air

moves in and out through the chest wall injury with each breath. It also

free passage of air between atmosphere and pleural space.

– Sign and symptom

Penetrating chest trauma

Sucking chest wound

Frothy blood at wound site

Severe dyspnea

Hypovolemi

TREATMEANT

Initial management closure of the defect with a sterile occlusive dressing and

placement of intercostals drain should be away from the wound. Surgical closure

can be undertaken when the primary and secondary survey is complete.

4. TRAUMATIC PNEUMOTHORAX

(CLOSED PNEUMOTHORAX)

Pneumothorax due to trauma is usually closed. In this the chest wall is intact and

the visceral pleural damage is caused by a rib fracture. It can happen after a fall

against a hard edge or due to kick. At times, it can be a part of multiple injuries.

5. HEMOTHORAX

Massive hemothorax is defined as the loss of 1500 ml or more commonly caused

by a penetrating injury, it can be associated with blunt trauma of chest wall as

wall.

DIAGNOSIS

The signs are those of hypovolemic shock with absent breath sounds on the

affected side. The neck veins may be full secondary to the mechanical effects of

hemothorax or it may be empty in case the patient is hypovolumic.

Signs and Symptoms

Blunt or penetrating chest trauma

Shock

- Dyspnea

-Tachycardia

-Tachypnea

-Diaphoresis

-Hypotension

Dull to percussion over injured side

TREATMENT

It comprises of continued decompression of the chest and restoration of the

blood volume. A large bore chest drain(32F or larger) should be used. The rapid

infusion of fluid replacement is started through large caliber venous cannula until

type specific or cross-matched blood is available.

If there is continuing blood loss of more than 200ml/hour for more than three

hours, exploratory thoracotomy must be undertaken by an experienced surgeon.

Any penetrating wound medial to the nipple should heighten suspicion of damage

to the heart, great vessel or hilar structure.

6. INTERCOSTAL CHEST DRAINAGE

Underwater seal drainage successfully treats most cases of

hemopneumothorax. The modern chest drains are made up of clear plastic, are

available in varying diameter, have length markers, have multiple side roles and

have radiopaque stripe to allow confirmation of tube position on radiograph.

THORACOTOMY

Majority of chest injuries are managed conserve by underwater seal drainage.

Oxygen are physiotherapy are the mainstay in the management of blunt chest

trauma. However, some patient may require thoracotomy.

7. RIB FRACTURE

Single fracture of one or more ribs due to direct violence is a common

occurrence in the chest trauma. The degree of pain depends on the number of rib

invoved. Localized tenderness and crepitus are often elicited in examination. Sufficient

analgesia is the treatment of choice to encourage the normal repiratory pattern. At times

intercostal nerve block may be required for persistent pain.

Although the first rib is well protected an requires a considerable force for

fracture, the mortality is high because of its association with injury to major vessels.

Fracture of sternum results from decekeration or seat belt injury. It generally

leads to the injury of the underlying myocardium.

8. FLAIL CHEST

It occurs when several ribs are fractured at two places either on one side of the chest or

on either side of the sternum. The flail segment causes severe disruption of normal

chest wall function with paradoxical movement. It is usually accompanied by underlying

lung contusion and the combination of the two can cause serious hypoxia.

DIAGNOSIS

Careful observations of the respiratory movement which may be un-coordinated, and

the palpation of the chest wall for fracture crepitus are required so that the diagnosis is

not missed. The chest radiograph cannot always be relied onto reveal costochondral

separation or rib fracture.

TREATMENT

Resusciation of a patient with flail chest involves ensuring full expansion of the

lung with good oxygenation, which may require intubation and mechanical ventilation.

Any hemothorax must be drained by an intracostal drain. Adequate analgesia is

important because it allows the patient to self-ventilate completely as well as to clear

their own airway and cope with physiotherapy.

Thoracotomy with fracture fixation is occasionally appropriate when operative

procedure is required for an underlying injury.

9. CARDIAC TAMPONADE

In trauma patient it is usually caused by penetrating injury but disruption of the heart or

great vessels with bleeding into the pericardium may also result from a blunt injury as

well.

DIAGNOSIS

Sign of tamponade are hypotension, muffled sounds and an elevated jugular venous

pulse may be absent in the hypovolemia.

TREATMENT

Immediate pericardiocentesis should be under if tamponade is suspected. In 25% of

patients cardiac tamponade, clotting of blood within pericardium will prevent aspiration.

SECONDARY SURVEY

The aim of the secondary survey is to identify the potential life-threatening injuries and

this too should only begin when patient’s condition is fully stabilized.

Essential investigations during the secondary survey are:

Electrocardiograph

Chest radiograph

Arterial blood gas

POTENTIAL LIFE-THREATENING INJURIES

A) Pulmonary Contusion

The underlying lung often gets injured in thoracic trauma, which usually resolves

but laceration with persistent air leak, features of bleeding or failure of expansion

of the lung will require surgical intervention can be insidious and intubation and

ventilation may be required at any time.

Close monitoring is essential because the onset of an adult respiratory

distress syndrome like condition can be insidious and intubation and ventilation

may be required at any time.

B) Myocardial Contusion

The diagnosis of myocardial contusion is based on the electrocardiograph

abnormalities . Once the myocardial contusion is diagnosed, the patient should

be treated as if he had sustained myocardial infarction.

C) Aortic Disruption

It is usually occurs as a result of major deceleration injury. Clinical signs are

interscapular pain, murmur hoarseness, radio-femoral delay in arterial pulse.

Arteriography is diagnostic and computed tomography(CT) is of little help. If

complete, it is invariably fatal at the scene, but is the bleeding is slow it needs

early identification and management.

TREATMENT

Once the diagnosis is confirmed formal surgical repair is required and should not

be delayed. Urgent exploration by left thoracotomy through 4th intercostal space

is undertaken. Control above and below the transection is vital and the aorta is

repaired by direct suture or interposition graft.

D) Diaphragmatic Rupture

At times the blunt trauma produces large radial tears which lead to herniation of

abdominal viscera into the chest. This in turn may cause mediastinal

compression of thoracic organs with its consequent effects.

TREATMENT

Diaphragmatic tears should be repaired with non-absorbable sutures.

E) Tracheal Rupture

Tracheal is susceptive to blunt and penetrating trauma and the immediate

concern is the patency of the airway. Stridor indicates partial obstruction which

may became complete if not managed promptly.

DIAGNOSIS AND TREATMENT

Endoscopy and computed tomography(CT) scanning following stabilization of the

patient. Trachea if found injured should be repaired.

F) Esophageal Rupture

It usually follows a penetrating injury. The resulting mediastinitis often causes an

emphysema,If there is leakage into pleural cavity.

A radiograph is essential for diagnosis. This discloses the presence of air in the

mediastinum or pleural cavity or in the neck which may easily be palpable. Left

pneumothorax or hemothorax in the absence of rib fracture should raise a

suspicion for esophageal rupture. The diagnosis is confirmed by contrast studies

or esophagoscopy. Treatment is initially chest tube drainage followed by formal

repair.

ROLE OF ULTRASOUND AND STANDARD CITY IN THORACIC TRAUMA

Surgeons have found ultrasound to be useful in detection of post-traumatic

hemothorax. The sensitivity and specificity of ultrasound has found to be equivalent to

be portable chest radiograph. The only benefit is that ultrasound examination wan

significantly faster.

The standard thoracic computed tomography(CT) has been always an adjuvant to the

routine chest radiograph. The spiral computed tomography(CT) with contrast has been

found to be useful in detecting blunt rupture of the thoracic aorta.

THORACOSCOPY

The use of video-assisted thoracoscopy continues to increase in major trauma

centers. The indications for thoracoscopy in trauma include early evacuation of a clotted

hemothorax, evaluation of left thoraco-abdominal wounds and repair of pulmonary

lacerations or assistance with pulmonary lobectomy.

APPENDIX

HEMOTHORAX PNEUMOTHORAX

THORACOTOMY DIAPHRAGMATIC TEAR

CONCLUSION

At the end of this assignment, the student should be able to understand the

meaning of thoracic cavity and thoracic trauma. Thoracic cavity is

the space within the walls of the chest, bounded below the diaphragm and above by the

neck, and containing the heart and the lungs. The student also can describe the chest

injuries, pathophysiology, primary survey, and the others. Besides, the student can be

explain the injuries associated with penetrating thoracic trauma such as

pneumothorax,hemothorax and others with the treatment.Lastly, the student should be

describe the role of ultrasound and standard city in thoracic trauma and the example is

thoracoscopy.

REFERENCES

Bibliography

UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY.

NEW DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

Bibliography

TOY, S. (2010). CASE FILES EMERGENCY MEDICINE. UNITED STATES OF

AMERICA: LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA.

UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY.

NEW DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

Bibliography

BRENDA G.BARS, S. C. (2010). TEXTBOOK OF MEDICAL SURGICAL NURSING 1.

UNITED STATES OF AMERICA: LIBRARY OF CONGRESS CATALOGING IN

PUBLICATION DATA.

TOY, S. (2010). CASE FILES EMERGENCY MEDICINE. UNITED STATES OF

AMERICA: LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA.

UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY.

NEW DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

Bibliography

BASAVANTHAPPA, B. T. (2011). ESSENTIAL OF MEDICAL SURGICAL NURSING

(1ND EDITION ed.). NEW DELHI: TYPE BROTHERS MEDICAL PUBLISHER(P) LTD.

BRENDA G.BARS, S. C. (2010). TEXTBOOK OF MEDICAL SURGICAL NURSING 1.

UNITED STATES OF AMERICA: LIBRARY OF CONGRESS CATALOGING IN

PUBLICATION DATA.

TOY, S. (2010). CASE FILES EMERGENCY MEDICINE. UNITED STATES OF

AMERICA: LIBRARY OF CONGRESS CATALOGING IN PUBLICATION DATA.

UK SHRIVASTAVA, S. S. (2010). AN APPROACH TO SURGICAL EMERGENCY.

NEW DELHI INDIA: CBS PUBLISHER & DISTRIBUTORS.

BUDD, DC, COCHRAN , RC, FOUTY, WJ. CHOLECYSTECTOMY WITH AND

WITHOUT DRAINAGE. AM JSURG. 1982