CHEST TRAUMACHEST TRAUMA

Rodolfo Jose V. Abalos Jr. Rodolfo Jose V. Abalos Jr. FPCS FPATACSIFPCS FPATACSI

Thoracic TraumaThoracic Trauma

IncidenceIncidence 1 out of 4 trauma deaths; many of these deaths 1 out of 4 trauma deaths; many of these deaths

preventable – need prompt diagnosis and preventable – need prompt diagnosis and treatmenttreatment

Most can be managed with just chest tube Most can be managed with just chest tube insertion (80%); others will require thoracotomyinsertion (80%); others will require thoracotomy

Mechanism of injuryMechanism of injury Penetrating injury: stab wound, gun shot woundPenetrating injury: stab wound, gun shot wound Blunt injury: motor vehicle crash, fall from Blunt injury: motor vehicle crash, fall from

significant height, direct blow to the chest wallsignificant height, direct blow to the chest wall

Penetrating chest injury: Penetrating chest injury: stab woundstab wound

Chest lateralChest lateral

Penetrating chest trauma: Penetrating chest trauma: Gun shot woundGun shot wound

Motor Vehicle CrashMotor Vehicle Crash

Thoracic TraumaThoracic Trauma

Pathophysiology:Pathophysiology: Tissue hypoxia, hypercarbia and acidosisTissue hypoxia, hypercarbia and acidosis HypoxiaHypoxia

Inadequate oxygen delivery bec of blood loss, Inadequate oxygen delivery bec of blood loss, V/Q mismatch, changes in intrathoracic V/Q mismatch, changes in intrathoracic pressurepressure

HypercarbiaHypercarbia Inadequate ventilation, changes in Inadequate ventilation, changes in

intrathoracic pressure, depressed level of intrathoracic pressure, depressed level of consciousnessconsciousness

AcidosisAcidosis Hypoperfusion of tissues (shock)Hypoperfusion of tissues (shock)

Initial assessment in Initial assessment in TraumaTrauma

Primary survey (ABCs)Primary survey (ABCs) ResuscitationResuscitation Secondary survey (head to toe)Secondary survey (head to toe) Definitive careDefinitive care

ABCs of Trauma careABCs of Trauma care

Primary surveyPrimary survey A Airway maintenance with cervical A Airway maintenance with cervical

spine controlspine control B Breathing and ventilationB Breathing and ventilation C Circulation with hemorrhage controlC Circulation with hemorrhage control D Disability: neurologic statusD Disability: neurologic status E Exposure: completely undress the E Exposure: completely undress the

patient but prevent hypothermiapatient but prevent hypothermia

Primary survey: airway Primary survey: airway control control

Life threatening conditions are identified Life threatening conditions are identified and managed immediatelyand managed immediately

Airway with cervical spine controlAirway with cervical spine control Airway should be patent: inspect for FB, Airway should be patent: inspect for FB,

facial, mandibular or tracheal/laryngeal facial, mandibular or tracheal/laryngeal fractures that may result in airway obstructionfractures that may result in airway obstruction

Steps taken to minimize movement of the Steps taken to minimize movement of the cervical spine. Assume injury to cervical spine cervical spine. Assume injury to cervical spine in any patient with multisystem trauma esp in any patient with multisystem trauma esp one with altered level of consciousness or one with altered level of consciousness or blunt injury above the clavicleblunt injury above the clavicle

Patients requiring a Patients requiring a secured airwaysecured airway

ApneicApneic Glasgow coma score <9 or sustained Glasgow coma score <9 or sustained

seizure activityseizure activity Unstable with midface traumaUnstable with midface trauma Airway injuriesAirway injuries Large flail segment with respiratory Large flail segment with respiratory

failurefailure High aspiration riskHigh aspiration risk

Primary survey: Primary survey: Breathing/VentilationBreathing/Ventilation

Patent airway does not assure adequate Patent airway does not assure adequate ventilation ventilation

Auscultation to asses air exchange in the Auscultation to asses air exchange in the lungs, percussion to determine presence of lungs, percussion to determine presence of air or blood in the chest, inspection and air or blood in the chest, inspection and palpation to determine injuries to the chest palpation to determine injuries to the chest wall that may compromise ventilationwall that may compromise ventilation

Tension pneumothorax, flail chest with Tension pneumothorax, flail chest with pulmonary contusion, fractured ribs – pulmonary contusion, fractured ribs – contribute to impairment of ventilationcontribute to impairment of ventilation

Problems of ventilationProblems of ventilation

If breathing not improved by If breathing not improved by clearing the airway and a chest wall clearing the airway and a chest wall and lung pathology is ruled out, and lung pathology is ruled out, other etiologies must be soughtother etiologies must be sought Intracranial injury Intracranial injury abnormal patterns abnormal patterns

of breathingof breathing Cervical spine injury Cervical spine injury result in result in

respiratory paralysisrespiratory paralysis

Primary Survey: Circulation Primary Survey: Circulation with hemorrhage controlwith hemorrhage control

Hemorrhage is the predominant Hemorrhage is the predominant cause of postinjury deathscause of postinjury deaths

Hypotension following injury must Hypotension following injury must be considered to be hypovolemic in be considered to be hypovolemic in origin unless proved otherwiseorigin unless proved otherwise

Rapid and accurate assessment of Rapid and accurate assessment of the patient’s hemodynamic status is the patient’s hemodynamic status is importantimportant

Hemodynamic statusHemodynamic status

Level of consciousnessLevel of consciousness When blood volume is reduced, cerebral When blood volume is reduced, cerebral

perfusion may be impaired -> altered perfusion may be impaired -> altered levels of consciousness.levels of consciousness.

Skin colorSkin color Ashen gray skin of the face + white skin of Ashen gray skin of the face + white skin of

the extremities – hypovolemia (blood loss the extremities – hypovolemia (blood loss of 30%)of 30%)

Blood pressure/pulseBlood pressure/pulse Palpatory blood pressure, rapid thready Palpatory blood pressure, rapid thready

pulse - hypovolemiapulse - hypovolemia

Sources of Hypovolemia Sources of Hypovolemia

Intra abdominal or Intra abdominal or intra thoracic intra thoracic injuryinjury

Fractures of the femur and/or pelvisFractures of the femur and/or pelvis Penetrating injuries with arterial or Penetrating injuries with arterial or

venous involvementvenous involvement External hemorrhage from any External hemorrhage from any

sourcesource

Primary Survey: Disability Primary Survey: Disability (neurologic evaluation)(neurologic evaluation)

Done at the end of primary surveyDone at the end of primary survey Establishes the patient’s level of Establishes the patient’s level of

consciousness and pupillary size and consciousness and pupillary size and reactionreaction

GCSGCS Decrease in level of consciousnessDecrease in level of consciousness

Decrease cerebral oxygenation/perfusionDecrease cerebral oxygenation/perfusion Direct cerebral injuryDirect cerebral injury Alcohol and drugsAlcohol and drugs

Glasgow Coma ScoreGlasgow Coma Score Eye Opening ResponseEye Opening Response: : Spontaneous Spontaneous

opening 4 opening 4 Opens toOpens to verbal command, verbal command, speech, or shout 3speech, or shout 3 Opens to pain 2 None 1 Opens to pain 2 None 1

Verbal ResponseVerbal Response: : Oriented 5 Confused Oriented 5 Confused conversation, but able to answer questions 4 conversation, but able to answer questions 4 Inappropriate responses, words Inappropriate responses, words discerniblediscernible 33 Incomprehensible speech 2  Incomprehensible speech 2 None 1 None 1 

Motor ResponseMotor Response: : Obeys commands for Obeys commands for movement 6movement 6  Purposeful movement to painful Purposeful movement to painful stimulus 5 Withdraws from pain 4 Abnormal stimulus 5 Withdraws from pain 4 Abnormal (spastic) flexion, decorticate posture 3 (spastic) flexion, decorticate posture 3 Extensor (rigid) response, decerebrate Extensor (rigid) response, decerebrate posture 2 None 1posture 2 None 1

GCS InterpretationGCS Interpretation

Severe, with GCS ≤ 8 Severe, with GCS ≤ 8 Moderate, GCS 9 - 12 Moderate, GCS 9 - 12 Minor, GCS ≥ 13. Minor, GCS ≥ 13.

Primary Survey: Primary Survey: Exposure Exposure

Patient is undressed but covered and Patient is undressed but covered and protected from hypothermia while at protected from hypothermia while at the ERthe ER

Exposure: anterior chestExposure: anterior chest

Exposure: posterior chestExposure: posterior chest

Secondary surveySecondary survey

Does not begin until the primary survey Does not begin until the primary survey (ABCs) is completed, resuscitation (ABCs) is completed, resuscitation initiated and ABCs reassessedinitiated and ABCs reassessed

Head to toe evaluation of the trauma Head to toe evaluation of the trauma patientpatient

Each region of the body is completely Each region of the body is completely examinedexamined

Complete neurologic exam is done here Complete neurologic exam is done here if not done in the primary surveyif not done in the primary survey

Secondary surveySecondary survey

Special procedures done during this timeSpecial procedures done during this time DPL, radiologic evaluation, laboratory studiesDPL, radiologic evaluation, laboratory studies

History History from relatives/prehospital from relatives/prehospital

personnel/witnesses, AMPLEpersonnel/witnesses, AMPLE Physical examinationPhysical examination

Cervical spine and neckCervical spine and neck Cervical spine injury suspected in patients with Cervical spine injury suspected in patients with

head trauma and should be immobilizedhead trauma and should be immobilized

Secondary surveySecondary survey

Physical examinationPhysical examination Cervical spine and neckCervical spine and neck

Look for neck tenderness, SQ emphysema, Look for neck tenderness, SQ emphysema, tracheal deviation, laryngeal fracturetracheal deviation, laryngeal fracture

Palpate carotid arteriesPalpate carotid arteries Chest Chest

Inspect and palpate anterior and posterior Inspect and palpate anterior and posterior chestchest

Auscultate (sometimes difficult to do in a noisy Auscultate (sometimes difficult to do in a noisy ER setting), chest x-rayER setting), chest x-ray

Distant heart sounds – cardiac tamponadeDistant heart sounds – cardiac tamponade

Thoracic Injuries: Thoracic Injuries: Secondary SurverySecondary Survery

Inspection:Inspection:

Neck veins Neck veins distended/collapsed distended/collapsed

Chest wall Chest wall flail chest ? flail chest ?

Palpation:Palpation:

Crepitation Crepitation SQ emphysema SQ emphysema

Point tenderness Point tenderness rib fracture rib fracture

AuscultationAuscultation

Thoracic Injuries: Thoracic Injuries: Important PointsImportant Points

Location of penetrating wound noted Location of penetrating wound noted

NEVER probeNEVER probe

If wound below the 5th rib If wound below the 5th rib

Evaluate abdomenEvaluate abdomen

All critically injured patients All critically injured patients

Do chest x-rayDo chest x-ray

Thoracic TraumaThoracic Trauma

Immediately life threatening Immediately life threatening injuries:injuries:

Tension pneumothoraxTension pneumothorax Open pneumothoraxOpen pneumothorax Massive hemothoraxMassive hemothorax Flail chestFlail chest Cardiac tamponadeCardiac tamponade

Thoracic TraumaThoracic Trauma

Potentially life threatening injuries:Potentially life threatening injuries: Pulmonary contusionPulmonary contusion Myocardial contusionMyocardial contusion Aortic ruptureAortic rupture Tracheo-bronchial injuriesTracheo-bronchial injuries Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture Esophageal disruptionEsophageal disruption

Life threatening chest Life threatening chest injuries: Tension injuries: Tension pneumothoraxpneumothorax

Tension pneumothoraxTension pneumothorax Air forced into the thoracic cavity without Air forced into the thoracic cavity without

any means of escape completely any means of escape completely collapsing affected lung (parenchymal collapsing affected lung (parenchymal injury fails to seal)injury fails to seal)

Mediastinum and trachea displaced to the Mediastinum and trachea displaced to the opposite side compressing opposite lungopposite side compressing opposite lung

s/sx: respiratory distress, tachycardia, s/sx: respiratory distress, tachycardia, hypotension, absent breath sounds, NVEhypotension, absent breath sounds, NVE

Tx: immediate decompression Tx: immediate decompression needle/ needle/ chest tube insertionchest tube insertion

X-ray: X-ray: Tension PneumothoraxTension Pneumothorax

Tension PneumothoraxTension Pneumothorax

Needle decompression for Needle decompression for Tension PneumothoraxTension Pneumothorax

Life threatening chest Life threatening chest injuries: Open injuries: Open PneumothoraxPneumothorax

Open pneumothorax (sucking chest Open pneumothorax (sucking chest wound)wound) Open large defects of the chest wallOpen large defects of the chest wall If opening in the chest wall is 2/3 If opening in the chest wall is 2/3

diameter of the trachea, air passes thru diameter of the trachea, air passes thru the chest defect into the pleural space the chest defect into the pleural space with each respiratory effortwith each respiratory effort

Mgt: close defect with occlusive dressing Mgt: close defect with occlusive dressing taped securely on three sides taped securely on three sides chest chest tubetube

Open pneumothorax from Open pneumothorax from chest wall defectchest wall defect

Close up view of chest wall Close up view of chest wall defect defect open open pneumothoraxpneumothorax

Life threatening injuries: Life threatening injuries: Massive HemothoraxMassive Hemothorax

Massive hemothoraxMassive hemothorax rapid accumulation of 1500 cc of blood in rapid accumulation of 1500 cc of blood in

the chest cavitythe chest cavity Penetrating injury to the systemic and Penetrating injury to the systemic and

hilar vessels, blunt traumahilar vessels, blunt trauma Initially managed with volume restoration Initially managed with volume restoration

and decompression of chest cavityand decompression of chest cavity Thoracotomy may be needed: initial Thoracotomy may be needed: initial

drainage of > 1 liter or with continuous drainage of > 1 liter or with continuous bleeding from the chest tube (>100 cc/hr)bleeding from the chest tube (>100 cc/hr)

Massive HemothoraxMassive Hemothorax

Flail chestFlail chest Segment of chest wall does not have bony Segment of chest wall does not have bony

continuity with the rest of the thoracic continuity with the rest of the thoracic cagecage

Associated with 2 point fracture involving Associated with 2 point fracture involving 3 or more consecutive/adjacent ribs3 or more consecutive/adjacent ribs

Associated with injury to the underlying Associated with injury to the underlying lung lung pulmonary contusion pulmonary contusion hypoxia hypoxia

Mgt: intubation with assisted ventilation, Mgt: intubation with assisted ventilation, O2 administration, careful fluid O2 administration, careful fluid administration, provide adequate analgesiaadministration, provide adequate analgesia

Flail ChestFlail Chest

X-ray: Flail chestX-ray: Flail chest

Cardiac tamponadeCardiac tamponade

Results from penetrating injuries to Results from penetrating injuries to the heartthe heart

Beck’s triadBeck’s triad Neck vein engorgement (venous Neck vein engorgement (venous

pressure elevation)pressure elevation) HypotensionHypotension Muffled/distant heart soundsMuffled/distant heart sounds Its absence does not rule out presence Its absence does not rule out presence

of tamponadeof tamponade

Suspect Cardiac injurySuspect Cardiac injury

Penetrating injury: cardiac Penetrating injury: cardiac tamponadetamponade

X-ray: Penetrating X-ray: Penetrating Cardiac InjuryCardiac Injury

Potentially lethal: Potentially lethal: pulmonary contusionpulmonary contusion

Associated with or without flail chestAssociated with or without flail chest Result from blunt chest injury or gun shot Result from blunt chest injury or gun shot

woundwound Respiratory failure develops over time; Respiratory failure develops over time;

hemorrhage into the alveolar and interstitial hemorrhage into the alveolar and interstitial spacesspaces

Diagnosed by xray Diagnosed by xray radiodense area within radiodense area within the lung parenchymathe lung parenchyma

Stable patients Stable patients managed selectively managed selectively Unstable patients with significant hypoxia Unstable patients with significant hypoxia

intubated with assisted ventilationintubated with assisted ventilation

X-ray: Pulmonary X-ray: Pulmonary Contusion LeftContusion Left

Myocardial contusionMyocardial contusion

Difficult to diagnoseDifficult to diagnose Symptoms nonspecific: chest discomfortSymptoms nonspecific: chest discomfort Dx: abnormalities in the EKG or 2D echoDx: abnormalities in the EKG or 2D echo

Multiple PVC, unexplained sinus Multiple PVC, unexplained sinus tachycardia, AF, bundle branch block and tachycardia, AF, bundle branch block and ST segment changesST segment changes

Mgt: expectant, patients admitted at the Mgt: expectant, patients admitted at the ICU for observation and cardiac ICU for observation and cardiac monitoringmonitoring

Aortic ruptureAortic rupture

Common cause of sudden death after Common cause of sudden death after an automobile collision or fall from a an automobile collision or fall from a significant heightsignificant height

For survivors, salvage possible if For survivors, salvage possible if condition identified and treated earlycondition identified and treated early

Tear near the ligamentum arteriosum Tear near the ligamentum arteriosum of the aorta of the aorta intact adventitial layer intact adventitial layer prevents free rupture and immediate prevents free rupture and immediate deathdeath

Aortic ruptureAortic rupture Diagnosis is difficult; signs and symptoms Diagnosis is difficult; signs and symptoms

are absent; high index of suspicion based are absent; high index of suspicion based on history of decelerating force and x-ray on history of decelerating force and x-ray findings; angiography is gold standardfindings; angiography is gold standard

X-ray findings:X-ray findings: Widened mediastinum (most consistent finding)Widened mediastinum (most consistent finding) Fracture of the 1Fracture of the 1stst and 2 and 2ndnd ribs ribs Obliteration of aortic knobObliteration of aortic knob Tracheal deviation to the rightTracheal deviation to the right Depression of left main stem bronchusDepression of left main stem bronchus Deviation of the esophagus (NGT) to the rightDeviation of the esophagus (NGT) to the right

Traumatic diaphragmatic Traumatic diaphragmatic rupturerupture

Commonly diagnosed on the left sideCommonly diagnosed on the left side Blunt trauma Blunt trauma large radial tears large radial tears

that may lead to herniationthat may lead to herniation Penetrating trauma Penetrating trauma small small

lacerations that take some time to lacerations that take some time to develop into a diaphragmatic herniadevelop into a diaphragmatic hernia

May be missed initiallyMay be missed initially

Traumatic diaphragmatic Traumatic diaphragmatic rupturerupture

DiagnosisDiagnosis Chest xray/flouroscopy Chest xray/flouroscopy

Elevated left hemi-diaphragmElevated left hemi-diaphragm Blunted CP angleBlunted CP angle Air fluid levels in the mid to lower chest areaAir fluid levels in the mid to lower chest area NGT within the chest cavityNGT within the chest cavity

UltrasoundUltrasound Upper GI seriesUpper GI series CT scanCT scan Laparoscopy/thoracoscopyLaparoscopy/thoracoscopy

Treatment: surgicalTreatment: surgical

X-ray: diaphragmatic hernia X-ray: diaphragmatic hernia Left (air fluid level mid to Left (air fluid level mid to

lower lung field)lower lung field)

Upper GI series: Upper GI series: Diaphragmatic herniaDiaphragmatic hernia

Arrow points to the edge of Arrow points to the edge of the Diaphragmatic defectthe Diaphragmatic defect

Diaphragmatic Defect Diaphragmatic Defect mobilized and herniated mobilized and herniated

organs reducedorgans reduced

Repaired Diaphragmatic Repaired Diaphragmatic herniahernia

Tracheobronchial tree Tracheobronchial tree injuriesinjuries

LarynxLarynx Hoarseness, subcutaneous emphysema, Hoarseness, subcutaneous emphysema,

palpable fracture crepituspalpable fracture crepitus Severe distress Severe distress intubate, tracheostomy intubate, tracheostomy

TracheaTrachea SQ emphysema, dysphonia, hemoptysis, SQ emphysema, dysphonia, hemoptysis,

dyspneadyspnea BronchusBronchus

SQ emphysema,pneumomediastinum, air SQ emphysema,pneumomediastinum, air outlining a bronchus, persistent air leak, outlining a bronchus, persistent air leak, unexpanded lung despite tubeunexpanded lung despite tube

Esophageal injuriesEsophageal injuries

Commonly a result of penetrating Commonly a result of penetrating injuryinjury

Suspected:Suspected: Severe blow to the lower sternum or Severe blow to the lower sternum or

epigastrium and patient is in pain or epigastrium and patient is in pain or shock out of proportion to the apparent shock out of proportion to the apparent injuryinjury

Particulate matter in the chest tubeParticulate matter in the chest tube Mediastinal airMediastinal air

Other manifestations of Other manifestations of chest injurieschest injuries

Subcutaneous emphysemaSubcutaneous emphysema Simple pneumothoraxSimple pneumothorax HemothoraxHemothorax Scapular and rib fracturesScapular and rib fractures

Subcutaneous Subcutaneous emphysemaemphysema

Results from injury to the airway or Results from injury to the airway or to the lung parenchymato the lung parenchyma

No specific treatment if this is the No specific treatment if this is the sole findingsole finding

O2 administration in selected casesO2 administration in selected cases

Simple pneumothoraxSimple pneumothorax

Non expanding collection of air in the Non expanding collection of air in the pleural spacepleural space

Results from injury to the lung Results from injury to the lung parenchyma with air leakage, bronchial parenchyma with air leakage, bronchial injury, chest wall injuryinjury, chest wall injury

PE: dec breath sounds, hyperresonancePE: dec breath sounds, hyperresonance Dx: chest PADx: chest PA Mgt: chest tube insertion and Mgt: chest tube insertion and

observation in some selected casesobservation in some selected cases

Simple pneumothoraxSimple pneumothorax

X-ray: simple X-ray: simple pneumothorax (close up pneumothorax (close up

view)view)

HemothoraxHemothorax

Blood within the pleural cavityBlood within the pleural cavity Causes:Causes:

Lung parenchymaLung parenchyma Intercostal vesselsIntercostal vessels Pulmonary vesselsPulmonary vessels

Dx: chest x-ray, chest ultrasoundDx: chest x-ray, chest ultrasound 90%, bleeding will stop and can be 90%, bleeding will stop and can be

managed with CTT, remaining 10% managed with CTT, remaining 10% may need thoracotomymay need thoracotomy

X-ray: Hemothorax LeftX-ray: Hemothorax Left

PneumohemothoraxPneumohemothorax

Focus Assessment with Focus Assessment with Sonography for Trauma Sonography for Trauma

(FAST)(FAST)

FAST: Pericardial sub-FAST: Pericardial sub-xiphoid scanxiphoid scan

FAST: Areas examinedFAST: Areas examined

Pericardium (subxiphoid) Pericardium (subxiphoid) Peri-hepatic and hepato-renal space Peri-hepatic and hepato-renal space

(Right midaxillary line, between 11(Right midaxillary line, between 11thth and 12and 12thth ribs) ribs)

Peri-splenic space (Left posterior Peri-splenic space (Left posterior axillary line between the 9axillary line between the 9thth and 10 and 10thth ribs)ribs)

Pelvis (above symphysis pubis)Pelvis (above symphysis pubis)

Rib and scapular Rib and scapular fracturesfractures

Rib fractures: most common injury Rib fractures: most common injury involving the chest wallinvolving the chest wall

Blunt trauma to the chestBlunt trauma to the chest s/sx: chest pain, point tenderness, s/sx: chest pain, point tenderness,

crepitations over involved ribcrepitations over involved rib Fractures of the 1Fractures of the 1stst, 2, 2ndnd ribs and ribs and

scapula scapula may indicate major injury may indicate major injury to the head and neck, lungs and great to the head and neck, lungs and great vesselsvessels

Rib fracturesRib fractures

Fractures of the lower ribs (10-12) Fractures of the lower ribs (10-12) possible hepatosplenic injurypossible hepatosplenic injury

May be a serious problem in the elderlyMay be a serious problem in the elderly Diagnosis: chest PA, chest buckyDiagnosis: chest PA, chest bucky Treatment:Treatment:

pain control: oral analgesia, intercostal pain control: oral analgesia, intercostal nerve block, epidural analgesianerve block, epidural analgesia

Chest tube if with associated Chest tube if with associated pneumo/hemothoraxpneumo/hemothorax

Close Tube Close Tube ThoracostomyThoracostomy

Technique of Chest Tube Technique of Chest Tube InsertionInsertion

Technique of Chest Tube Technique of Chest Tube InsertionInsertion

Thank You for Thank You for your Attentionyour Attention