LIDIA IONESCU

The 3 rd. Surgical Unit

2009
The Thorax or Chest
Region of the body between the neck and the
abdomen
The framework of the wall- thoracic cage:
vertebral column, ribs, IC spaces, sternum,
costal cartilages
Communication with the neck- thotacic outlet
Separated from the abdomen by the
diaphragm
The thorax or Chest
The cavity of the thorax: mediastinum and
laterally, pleurae and lungs
The lungs are covered-thin membrane-
visceral pleura
The inner surface of the chest wall- parietal
pleura
Between lungs and thoracic wall- pleural
cavity
Physical examination

Detect the evidence of disease:

Inspection
Palpation
Percussion
Auscultation
EXAMINE THE CHEST
INSPECTION
CYANOSIS
RR AND RHYTHM
CHEST EXPANSION
PARADOXICAL MOVEMENT
DEFORMITIES
PECTUS EXCAVATUM
Pectum excavatum
Pectus carinatum
KYPHOSIS
SCOLIOSIS
Cyanosis

Bluish discoloration
Lack of O2 in the
blood
 Clubbing

 Exaggerated
anteroposterior and
longitudinal
curvature of the
nails
 Loss of angle
between nail and
nail bed
(demonstrated by
"Lovidond's
diamond sign")
 "Drumstick" or
"parrot beak"
appearance of the
nail
Thoracic cage
Surface landmarks
Surface landmarks
Surface landmarks
Thorax- anterior aspect
Suprasternal notch
Sternal angle
Xiphisternal joint
Subcostal angle
Costal margin
Clavicle
Ribs
Axillary folds
Lines of orientation
Midsternal line
Midclavicular line
Anterior axillary line
Posterior axillary line
Midaxillary line
Scapular line
Lines of orientation
Lines of orientation
Lines of orientation
Diaphragm
Surface landmarks
Thorax-posterior aspect

Spinous processes of the thoracic vertebrae

Scapula: superior angle, inferior angle
EXAMINE THE CHEST
PERCUSSION
RESONANT SOUND- NORMAL
HYPERRESONANCE- EXTRA AIR
DULNESS- PLEURAL FLUID
EXAMINE THE CHEST
PALPATION
TRACHEA
CHEST EXPANSION
APEX BEAT
AXILLAE
BREASTS
EXAMINE THE CHEST
AUSCULTATION
VESICULAR
BREATHING
WHEEZE
COARSE CRACKLES
FINE CRACKLES
PLEURAL RUB
CHEST EXPANSION
CHEST LANDMARKS
OF THE LUNGS
Surface landmarks
Surface landmarks
CHEST ASCULTATION
BREASTS
GYNECOMASTIA
AXILLARY PALPATION
LYMPHADENOPATHY
EXAMINE THE HEART AND
CIRCULATION

MEASURE BP
JUGULAR VEINS
NECK ARTERIES
TRACHEA
HEART
HEART LANDMARKS
POINT OF MAXIMUM IMPULSE
HEART INSIGHTS
Thoracic outlet syndrome
Compression of the neurovascular bundle
Causes: cervical rib or trauma arm/neck
Cervical rib- enlarged transverse process-C7:
 free anterior end or connected to rib 1
 fibrous band/joint
Pressure symptoms on lower trunk of BP- pain
forearm/hand , hand muscle wasting.
Arterial/venous involvement is less common
Thoracic outlet
obtruction

Diagnosis- history and physical examination

Ulnar nerve conduction studies- confirm dg.

Treatment- decompress the TO-resecting

cervical rib
Injuries to the thoracic
cage
Rib fractures

Sternal fractures

Flail chest
Rib fractures
The most common injuries- blunt chest
trauma
Old people- minor trauma- rib fracture
Fracture of the 1st rib- mark for severe lesions
Fracture of the lower ribs- hepatic and splenic
injury- hemoperitoneum
Treatment- IC nerve blocks/epidural
anesthesia
Complications: hemothorax, pneumothorax,
atelectasis, pneumonia.
Sternal fracture
Rare fracture- car steering wheel- abrupt
deceleration
Associated injuries: pseudoaneurism,
ruptured esophagus, myocardial contusion,
ruptured bronchus, flail chest
Diagnosis- mechanism of injury, physical
examination, CXR- lateral view
Treatment- pain killers
Flail chest
20% of pts. with severe blunt chest injury
Multiple segmental rib fractures
The stability of the chest is lost
The flail segment- sucked in – inspiration/
driven out-expiration= paradoxical respiratory
movements
Paradoxical respiration- movement of air
between the lungs- poor ventilation-poor
oxygenation
Treatment- pain relief, OTI with +p. if needed.
Chest trauma- case
report
 A 32-year-old female patient suffered an automobile accident
which resulted:
 in left hemopneumothorax,
 left pulmonary contusion and
 double fractures extending from the third to the eighth left costal
arches,
as seen on chest X-rays and computed tomography scans of the
chest.

 Tomography of the skull, cervical spine, abdomen, and pelvis, were

normal
 Electrocardiogram and echocardiogram-WNL,
 Tests for muscle enzymes and markers of myocardial necrosis-
WNL

 Water-sealed thoracic drainage was performed,

Case report
Mechanical ventilation- not needed

Chest deformation- surgical repair

Case report
Reduction of the fractures and fixation of the ribs
with steel wires, perforating the extremities of
the ribs with a drill, passing the steel wire from
one rib segment to another, and tying it.
 A chest tube was inserted and left in place until
the third day.
The patient evolved to excellent pain control and
improved respiratory dynamics.
Postoperative X rays and tomography scans
confirmed the favorable result of the surgical
treatment .
Fractures 2nd.and 6th left
rib with callus formation
Flail chest
Flail chest
Multiple rib fractures
Pneumothorax
Rib fractures, left hemo-
pneumothorax
Disorders of the pleural
space
Spontaneous pneumothorax
Iatrogenic pneumothorax
Traumatic pneumothorax
Tension pneumothorax
Sucking chest wound
Pneumothorax
Spontaneous pneumothorax
Iatrogenic pneumothorax
Traumatic pneumothorax
Tension pneumothorax
“Sucking chest wound”
Pleural effusion
Collection of pleural fluid
Etiology:
infection
secondary from intra abdo. sepsis
heart failure
cirrhosis
malignancy:
 primary mesothelial tumor,
 bronchogenic carcinoma,

 metastatic carcinoma
Pleural effusion
Symptoms: chest pain, cough, dyspnea

Signs: dullness on percussion, absent BS. on

auscultation

Diagnosis: CXR, thoracocentesis-

culture/Gram’s stain, Rivalta reaction,
cytology, biochemistry.
Hemothorax
Blood accumulating within pleural space
50%-70% of the pts. with blunt/penetrating
chest trauma
Minimal bleeding- observation
Extensive bleeding- prompt action
Diagnosis- mechanism of injury, symtoms,
signs, CXR/CT
Symtoms: chest pain, dyspnea/polipnea
cyanosis,
Signs: trauma mark, BS absent, BP, PR,
capillary refill
Hemothorax
Treatment:
Pleural drainage tube,
Oxygen
Pain killers
Exploratory thoracotomy
 massive initial drainage> 1000ml.
 bleeding> 200ml/h
Case report

 Horner’s syndrome - triad of symptoms (miosis, ptosis, and

anhydrosis) resulting from disruption of the cervical
sympathetic pathways .

 In blunt trauma, it is usually associated with carotid artery

dissection.

 A case of Horner’s syndrome in a 22-year-old man after

blunt trauma to the neck and head unrelated to carotid
artery dissection
Case report
A 22-year-old man was brought to the
emergency room after motorcycle fall, with
history of transitory loss of conscience.
At hospital, he was alert and orientated,
the carotid pulses were symmetric, regular
with no bruits.
The chest and the abdomen had no signs
of abnormalities.
Case report
The patient related moderate cervical pain
but no neurological deficits were noticed
except for the asymetric pupils that
measured 5 mm on the right and 2 mm on
the left side.
Foto motor reflexes normal
The left eyelid was 1–2 mm lower than the
right ,
The extraocular movements were intact
and the cranial nerve examination was
Assimetric pupils and left semiptosis
Case report
 The chest X-ray did not reveal any rib, sternal fractures or
mediastinal enlargement.
 Skull computed tomography (CT) showed no abnormality so
as the carotid ultrasonography Doppler and the angio-
tomography of the head and neck.
 Cervical spine CT showed a fracture of left C7 transverse
process
 Chest CT disclosed a mediastinal hematoma extending to
the left lung apex, exhibiting mass effect over surrounding
structures without signs of aortic dissection .
 A conservative management was adopted and the patient
left the hospital three days later but still with the neurologic
signs.
 Follow up four weeks after discharge revealed a normal
neurologic examination and no complaints.
Mediastinal hematoma extending to the
left apex
Case report
Horner,s syndrome is an uncommon occurrence in
all age groups (0.08% of blunt trauma patients).
Diagnosis is namely based on clinical findings,
and after careful history and examination, the
physician must decide whether further
investigation is necessary.
There is a wide variety of conditions that may
cause this syndrome, postsurgical and iatrogenic
causes comprise most of the cases.
Penetrating neck injuries, cervical spine
dislocation and birth trauma are the major factors
that lead to traumatic injury to the
Case report
 A history of trauma preceding these findings should prompt
the clinician to consider that the carotid artery, which lies
directly over the sympathetic chain in the neck, may have
been injured, particularly if signs of head or neck trauma are
present.
 The investigation of choice considered by some authors is a
magnetic resonance imaging and angiography scan of the
head and neck.
 Therefore, to exclude carotid injury the authors performed
an ultrasonography Doppler and an angio-tomography what
seems to be less invasive and with a high sensivitity.
 The carotid dissection diagnosis implies an emergent
condition that can lead, if misdiagnosed, to major
catastrophes including massive ischemic stroke, even in a
patient with minor symptoms at admission.
Case report
 In this case further investigation showed a mediastinal and
left lung apical hematoma which probably caused
compression of the sympathetic ganglia, as the clinical
findings appeared in first day of trauma.

 The fracture of the left C7 transverse process could explain

the cervical pain and hematoma

 Mediastinal hematoma due to trauma is associated with

sternal fracture, aortic dissection and extrapericardial
cardiac tamponade.
Case report
 In this case, the patient was
hemodynamically stable and no surgical
intervention was necessary.
This report illustrates a condition that can
be seen in the trauma emergency
department and shows that a meticulous
investigation with proper complementary
exams is necessary because such signs
can be just the "iceberg tip".
Conclusion
Horner’s syndrome is a very rare condition
after mild neck and chest trauma.

The understanding of this clinical entity

may help the surgeon to make a better
differential diagnosis in trauma patients in
whom correct and prompt diagnosis can be
lifesaving.
Case report 2
 41-year-old male developed a hemothorax after sustaining a
stab wound in the right chest.
 The patient was managed conservatively with thoracostomy
tube drainage for 3 days and was subsequently discharged
home.
 Two weeks later the patient returned to the hospital with
pleuritic chest pain and shortness of breath.
 Imaging studies revealed a right-sided pleural effusion and
an enlarged cardiac silhouette, which was consistent with
pericardial effusion as per ultrasonography.
 Thoracoscopic exploration revealed an enlarged heart, that
following pericardiotomy drained 400 mL of frank blood.
Subsequently, cardiac contractility improved, and no further
bleeding was evident.
Case report 2
 The majority of patients suffering penetrating wounds to the
heart do not survive long enough to receive any medical
assistance.
 However, among those who reach the hospital, most cardiac
injuries are discovered at admission and treated
accordingly, whether initially decompressed with a
subxiphoid pericardial window, or approached with an open
thoracotomy.
 Infrequently, a penetrating injury to the heart may be
missed on initial assessment, the patient returning to the
hospital a few weeks later with different degrees of
hemopericardium.
 Delayed hemopericardium after penetrating chest injury
has been described in the literature, with the therapeutic
approach invariably involving pericardiocentesis or open
Case report 2
Thoracoscopic pleuropericardial window
has been popularized as a way to drain
different types of pericardial effusion:
 with the advantage of better exposure than the
traditional subxiphoid pericardial window,
but without the morbidity associated with an
open thoracotomy..
Case rerport 2
A 41-year-old male was seen in the emergency
department after a stab wound to the right chest.
At admission the patient was in stable condition,
with a CXR positive for hemopneumothorax, and
without evidence of cardiac enlargement.
 A thoracostomy tube was placed in the right
hemithorax, and 3 days later the patient was
discharged after the chest tube was removed and
adequate lung expansion verified.
Case report 2
Two weeks later, the patient returned to the
emergency department complaining of increasing
right-sided pleuritic chest pain and shortness of
breath.
Initial assessment revealed bilateral pleural
effusions on CXR predominantly in the right side,
as well as an enlarged cardiac silhouette .
A thoracostomy tube was placed in the right chest
again and connected to wall suction, draining 300
mL of serosanguineous fluid upon insertion.
CXR- right pleural effusion, increased
cardiac size
Case report 2
Further imaging studies included a 2-D
echocardiogram, which was positive for
pericardial effusion.
A CT of the chest showed bilateral pleural
effusions and fluid around the pericardium .
 The patient was taken to the operating room for
thoracoscopic exploration, with the presumptive
diagnosis of bilateral loculated hematomas and
associated hemopericardium.
Pleural effusions, fluid around pericardium
Case report 2
It is worth mentioning that during the first
admission, pericardial ultrasound was not
performed on the patient, since at that point it
was not yet readily available in the emergency
department.

The operation was performed under general

anesthesia with double-lumen orotracheal
intubation.

The patient was placed in the right lateral position

and draped in the standard fashion as for a formal
Case report 2
After deflation of the left lung, a thoracoscope
was introduced one finger breadth below the tip of
the scapula, next to the posterior axillary line, in
the 6th. IC space.
Full assessment of the left hemithorax was
performed, and 200 mL of blood was drained.
During inspection, the heart was revealed to be
enlarged, suggesting a retained hemopericardium
after penetrating injury to the heart. After
identifying the phrenic nerve, a 4 cm. longitudinal
incision was made in the pericardial sac- 400 ml.
of frank blood was drained from the pericardial
cavity, with immediate evidence of improved
Case report 2
The camera was advanced and introduced
inside the sac, visualizing sparse clots and
no active bleeding evident at that time.

After complete inspection of the left

hemithorax, anterior and posterior chest
tubes were left in place for continuous
drainage.
Case report 2
The patient was then placed in the left lateral
position to approach the right hemithorax.
 Access was gained following the same landmarks
used for the left chest, and with selective
deflation of the left lung.
Full inspection of the right hemithorax revealed
sparse adhesions, and 400 mL of retained blood
was removed.
The adhesions were taken down, the chest cavity
irrigated, and a chest tube left in place.
Case report 2
The patient tolerated the procedure and
was extubated on the first postoperative
day.
With drainage progressively decreasing,
the thoracostomy tubes were removed four
days later.
Chest films revealed no reaccumulation of
pleural or pericardial effusions.
The patient was finally discharged with no
major complaints, and 8 months after
Case report 3
A 65 years old female was a driver
involved in a front-impact car versus tree
crash.
The impact occurred slightly to the left of
the car’s centerline, with a 15–20"
intrusion of the tree into the engine
compartment, displacing the front bumper,
grille and engine.
The steering wheel was bent, and because
neither door could be opened, a rescue
operation was conducted to remove the
Case report 3
Paramedics arrived within four minutes and found
the patient in the vehicle, complaining of severe
chest pain and dyspnea.
There was no chest wall asymmetry or
paradoxical movement, and equal bilateral breath
sounds were present.
The patient was conscious and alert, recalling
events and denying loss of consciousness.

 Initial vital signs: Pulse 124, respirations 24, BP

108/78
Case report 3
During the 14-minute extrication, the patient
continued to experience severe anterior chest
pain and increasing dypsnea.
She became pale and more tachycardic.
Hypotension developed, with palpable BP
dropping to 80 systolic at approximately minute
10 of the extrication.
Because the patient was becoming unstable,
rescuers expedited their efforts and decided to
perform a rapid extrication maneuver once the
door was removed.
Case report 3
 Approximately one minute prior to successful extrication,
the patient developed agonal breathing and her carotid
pulses were lost.
 Once the door was removed, the patient was moved onto a
long backboard, CPR was performed, and the patient was
intubated and transported to a Level 1 trauma center.
 On arrival at the trauma center, resuscitation proceeded
rapidly.
 A focused assessment sonogram for trauma showed a
pericardial tamponade.
 Surgeons performed an immediate thoracotomy and
pericardiotomy, which revealed a right atrial rupture .
 Resuscitative efforts failed to return organized heart
activity, and the patient died.
Blunt cardiac injuries
 (BCI) is a spectrum of injuries ranging from asymptomatic
myocardial contusion to cardiac chamber rupture and death.
 Mechanisms by which BCI may occur include motor vehicle
crashes, falls from heights, direct blows to the chest and
explosions.
 The most common mechanism of BCI is an MVC.
 Occasionally an isolated direct blow to the chest may cause
ventricular fibrillation and death, a condition termed 
commotio cordis.   
 Differential dg.: hemorrhage, tension pneumothotrax,
hypoxia.
Case report 3

Rupture of a cardiac chamber, coronary

artery or intrapericardial portion of a great
vessel leads to cardiogenic shock from
pericardial tamponade and rapid death.

Cardiac rupture is associated with a 60–

100% mortality rate in the literature.  
 
Large tear in the right atrium
BCI
BCI is difficult to diagnose without the aid of
echocardio.
Prehospital providers should inspect the scene of
the injury and surrounding circumstances, as well
as conduct a thorough physical exam.
Patients may complain of chest pain, shortness of
breath or palpitations.
Vital signs may be completely normal with minor
contusions, or demonstrate tachycardia,
arrhythmia or hypotension in more severe forms
of injury.
BCI
Although physical examination is non-
specific, sternal tenderness or ecchymoses
may be found.
On auscultation, the finding of a murmur,
rub or muffled heart sounds should raise
suspicion of BCI, but these findings aren’t
typically present.
 Because BCI is often associated with other
injuries to the thorax, subcutaneous
emphysema, flail chest and bony crepitus
secondary to rib fractures may be present.