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,
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.
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 lifethreatening injuries. It follows the ABC(airway,breathing,circulation) principle of
resuscitation, which may also include even emergency thoracotomy.
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
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
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
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 patients condition is fully stabilized.
Essential investigations during the secondary survey are:
Electrocardiograph
Chest radiograph
Arterial blood gas
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 4 th 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
THORACOTOMY
PNEUMOTHORAX
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
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.