Recognition & treatment of pneumothorax

hemothorax, flail chest, stove in chest

Objectives

Anatomy of Thorax
Main Causes of Chest Injuries
Different Types of Chest Injuries
S/S of Chest Injuries
Treatments of Chest Injuries

Anatomy of the Chest Cavity

Trachea

Left Lung

Right Lung

Mediastinum
Diaphragm
Pericardium
Intrapleural
space

Intrapleural
space

Intrapleural Space
Visceral
pleura

Chest
wall

Lung

Zoom

Parietal
pleura

Intrapleural space

The
The Lungs
Lungs
Passive organ (can not make any
movements by itself)
Needs to be expanded to work
Expansion of the lungs is achieved
by:
Negative intrapleural pressure
Lung surface tension
Air inlet/outlet into/from lungs is
achieved by:
Increase/Decrease of the volume of
the chest cavity (Boyles law)

Mechanism of air flow between

lungs and atmosphere
Stimulation of the phrenic nerve, and the
intercostal nerves contraction of
diaphragm & external intercostals.
Increasing the vertical & antero-posterior
diameter of the chest.. Increase in chest
volume . Decrease intra-pleural
pressure.. The lungs expands decrease
intra-alveolar pressure.the air flows into
the lungs
It is an active process (involving muscle
contraction)

Expiration
When inspiration ends, the muscles
relax. Decrease in the diameters of
the chest. The thoracic wall
recoils . The intra-pleural pressure
risesthe elastic lungs recoil
compressing the air rising of the
intra-alveolar pressure air is forced
out
It is a passive process (relaxation of
muscles & recoil of elastic fibers)

Accessory muscles of respiration

During quiet breathing, only 1/10 of the
external intercostal muscles & diaphragm
are active & expiration is a passive process
With more powerful respiration, all fibers of
intercostal & diaphragm are active, this
increases the pulmonary ventilation 10 folds
More forced respiration, there is accessory
ms of inspiration (sternomastoid, serratus
anterior, scaleni) & expiration (internal
intercostal, abdominal recti ms), these make
respiration more deep & decrease airway
resistance

Main Causes of Chest

Trauma
Blunt Trauma- Blunt
force to chest.

Chest injuries
may result from:

Penetrating TraumaProjectile that enters

chest causing small or
large hole.

Vehicle
accidents
Falls

Compression InjuryChest is caught between

two objects and chest is
compressed.

Gunshot wounds
Crush injuries
Stab wounds

Injuries Associated with Penetrating

Thoracic Trauma
Chest wall lacerations

Ribs/ stermal
fractures

Pulmonary: contusion,
hemothorax,
pneumothorax
Pneumomediastinum
Laceration of vascular
structures
Flail Chest

Tracheobronchial tree
lacerations
Esophageal
lacerations
Penetrating cardiac
injuries
Pericardial tamponade
Spinal cord injuries
Diaphragm trauma
Intra-abdominal
penetration with
associated organ
injury

Abnormal Conditions

Violation of the closed system of the thoracic cav

Loss of the negative intrapleural pressure
Accumulation of air in the intrapleural space
Accumulation of fluid in the intrapleural space

PARTIAL OR FULL LUNG COLLAPSE

DIMINISHED RESPIRATION

TREATMENT NEEDED

Terminology
Pneumothorax
accumulation of air in the pleural space
Haemothorax
accumulation of blood in the pleural space
Haemopneumothorax
accumulation of air and blood in the pleural
space
Hydrothorax
accumulation of any other fluid (matter) in
pleural space
Haemo/ pneumo mediastinum

EXAMINATION
LOOK
FEEL
LISTEN
PERCUSS

Assess the casualty

Identify signs and
symptoms

Airway
Breathing
Circulation
Rapid trauma
survey / focused
exam

Shock
Cyanosis
Hemoptysis
Chest wall contusion
Flail chest
Open wounds
Distended neck veins
Tracheal deviation
Subcutaneous
emphysema

Assess the Chest

Assess Vital Signs

Pulse
Blood pressure
Hypotension
Respiratory rate and
effort
Tachypenia
Bradypenia
Labored
Retractions
Heart sounds--Muffled
(cardiac tamponade),
Distant

Contusions
Tenderness
Asymmetry
Open wounds or impaled
objects
Crepitation
Paradoxical movement
Percussion
Hyperresonance
Hyporesonance (hemothorax)
Lung sounds
Absent or decreased
Unilateral
Bilateral
Location
Bowel sounds in chest

Examination

Assessing The Chest

Compare both sides of
the chest at the same
time when assessing for
asymmetry.

Combat Trauma Treatment

Feel carefully and listen closely

for subcutaneous emphysema

Chest Injury

18

Dont forget to examine the back??

Management of the Chest Injury Patient-

General

Management

Ensure ABCs
High flow O2 via NRB
Intubate if indicated
Consider overdrive ventilation
If tidal volume less than 6,000 mL
BVM at a rate of 12-16
May be beneficial for chest contusion and rib
fractures
Promotes oxygen perfusion of alveoli and
prevents atelectasis
Anticipate Myocardial Compromise
Shock Management
Consider PASG
Only in blunt chest trauma with SP <60 mm Hg
Fluid Bolus: 20 mL/kg
AUSCULTATE! AUSCULATE! AUSCULATE

DIAGNOSTIC IMIGING

DIAGNOSTIC IMIGING

Secondary survey
Further diagnostic study :
Chest CT
Broncoscopy
Angiogram
Oesophagoscopy / oesophagram

Patients with rib fractures should be

admitted

Rib fractures cause severe pain, delayed morbidity and

mortality that leads to pneumonia
Chest wall injury; have pulmonary complications
concurrent 2 extra-thoracic injuries mortality
Blunt chest injury treatment;
pain control (epidural analgesia better outcome, esp if > 4
rib# and > 65yo)
chest physio
mobilisation
Unnecessary IV fluid administration should be meticulously
avoided

S/S of Open Pneumothorax

Dyspnea
Sudden sharp pain
Subcutaneous Emphysema (Feels like rice crispies or
bubble wrap)
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound ( Sucking
chest wound)

Pneumothorax

Opening in chest w
Trauma, operation

Opening in the chest

wall

AIR

Open
communicatio

Loss of the negative intrapleural pressure

Collapse of the lungs

managements
Oxygenation and possible intubations
if in distress
Occlusive dressing to the wound
Immediate CT insertion
If no CT available , bandage may be
applied over the wound and taped on
3 sides
OR for closure of the defect

neumothorax, Haemothora
Objectives of treatment
Removal of air
Removal of fluid
Re-building of negative intrapleural pressure

Lung re-expansion

Tension Pneumothorax

Trauma

One way (valve

Opening in lung

Opening in the lung

Loss of the negative
intrapleural pressure
Collapse of the lungs
Risk of building of
positive
intrapleural presure !!

AIR

S/S of Tension
Pneumothorax
Anxiety/Restlessne
ss
Severe Dyspnea
Absent Breath
sounds on affected
side
Tachypnea
Tachycardia
Poor Color

Accessory Muscle
Use
JVP
Narrowing Pulse
Pressures
Hypotension
Tracheal Deviation
(late if seen at all)

Needle Decompression
Locate 2-3 Intercostal
space midclavicular line
Cleanse area using
aseptic technique
Insert catheter ( 14g or
larger) at least 3 in
length over the top of the
3rd rib
Remove Stylette and
listen for rush of air
Place Flutter valve over
catheter
Reassess for
Improvement

stabbin
g

Most are clinically stable on arrival

15% require operative management
normal CXR require repeat in 6 hrs
Less than 25% make it to hospital; of which
41% present haemodynamically stable
CXR; 59% widened mediastinum
27% haemothorax
CT; replacing angiogram, shows trajectory
S/S of Hemothorax
Tachypnea
Signs of Shock
Frothy, Bloody Sputum
Diminished Breath Sounds on Affected Side
Tachycardia
Flat Neck Veins

Hemothorax

May put pressure on the heart

Treatment for Hemothorax

ABCs with c-spine control as indicated

Secure Airway assist ventilation if necessary
General Shock Care due to Blood loss
Consider Left Lateral Recumbent position if not
contraindicated
RAPID TRANSPORT
Contact Hospital and ALS Unit as soon as possible
CT insertion first
Thoracotomy indicated if immediate drainage of 1-1.5
lit. Or 200ml of blood for 4 hours
However the initial volume of blood drained is not as
important as the amount of on-going bleeding

Pneumothorax, Haemothor
Method of treatment

UNDERWATER SEAL
THORACIC DRAINAG

Underwater Seal
Chest drainage
Provides means for
air and fluid to
To the drainage escape the chest
system
cavity
Prevents air from reentering the pleural
space
Re-establishes
intrapleural negative
pressure

Tube
Thoracostomy

Principles of Chest Tube

Functioning
The idea is to create a one way mechanism that will let air
out of the pleural space and prevent outside air from coming
in.why would this be a problem?
This is accomplished by the use of an underwater seal. The
distal end of the drainage tube is submerged in 2cm of H2O.
Types of Drainage Systems
Glass Bottle System:
1 bottle
2 bottle
3 bottle
Plastic System:
Thoraseal
Pleuravac

One bottle
system
Air out

From patient

For small pneumothorax

use only !
Risk of progressive resistance building by
haemothorax.
Water seal

No control of the situation

in the chest cavity.

Two bottle system

From patient

Collection
bottle

Separation of water seal

Air outand collection in 2 bottles
elliminates the risk of
progressive resistance
building.
No active suction conection recommended.
Limited information about
the situation in the chest
cavity

Water seal

Three bottle
system
Separated collection, underwater seal and suction
control bottle
No risk of progressive resistance building
Exact active suction control
Limited information about the situation inside the
chest cavity

Patient

3Ch.CDU system

Active
suction

Suction
control
chamber
Collectio
n
chamber

Underwater seal chamb

Thoracic catheters

For open chest application (peroperative)

Made from thermosensitive PVC or clear silicone

Sentinel Line and Eye for X-ray possition verificat
Smooth finish on tip and eyes
Integral bubble connector for easy connection
Rigid pack container

Nursing Responsibilities/Care
of Patient with Chest Tube
Keep drainage system 2-3 feet below
patients chest
Keep tubing patent; make sure no
kinks or clots present
Observe and record amount of
drainage. >100cc/hr is heavynotify
physician.
Encourage ambulation as ordered.

Amount, Color, and Consistency

Consistency changes from thin, clear fluid
to milky could be evidence of evolving
infection
Changes in drainage from pure liquid to red
could indicate hemorrhage
Decreased drainage may be a sign of tube
displacement, kinked tubing, or a clot may
be obstructing the lumen of the tube
Sudden drainage increases could be
indicative of hemorrhage

Common Complications of Chest Tube Insertion

Allergic reaction
Bronchopleural fistula
Cardiac injury
Hemorrhage
Hepatic injury
Infection
Intercostal
neurovascular injury
Lung laceration
Re-expansion
pulmonary edema
Splenic injury
Subcutaneous
emphysema

When to remove ICD

When lung expansion is satisfied
both clinically & radiologically
No e/o air leak
No e/o bleeding or pus drainage
Clinically patient should be
comfortable even after clamping the
the ICD.

Flail ChestThe breaking of 2

or more ribs in 2 or more places

Stove-in chest- entire hemithorax

indrawn into pleural cavity

Flail chest

most severe form of blunt chest trauma; mortality 10-20%

Poor outcome is due to the underlying pulmonary contusion
S/S of Flail Chest
Shortness of Breath
Paradoxical Movement
Bruising/Swelling
Crepitus( Grinding of bone ends on palpation)
Causes long term chest wall pain and exertional dyspnea
Management
Unnecessary IVF infusion should be avoided
Obligatory mechanical ventilation should be avoided
(intubate to improve gas exchange and not for mechanical
correction)
Optimal analgesia (epidural)
Chest physio
CPAP works
Surgical fixation not always required.

Treatment of Flail Chest

ABCs with c-spine
control as indicated
High Flow oxygen that
may include Bipap vent.
Monitor Patient for signs
of Pneumothorax
Use Gloved hand as
splint till bulky dressing
can be put on patient
Contact hospital and
ALS Unit as soon as
possible

managements
Operative Fixation
by wires or plates
indicated in
Patient going for
thoracotomy
Fixed thoracic
impaction
Failure to wean
from ventilator

Operative
fixation(Judet plates )

Operative
fixation(Sanchez plates )

Tracheo-broncheal
injury
Its rare( 0.2 to 4%)
Most victims die prior to ER
80% within 2.5 from carina
Main stem 86% -More common in right side

Signs and symptoms :

Strider
Hoarseness
Hemoptysis
Pneumothorax with major air leak
Bronchoscopy is the most reliable test
CT scan also helps in diagnosis of level of injury

Tracheo-broncheal injury
Intraoperative airway management :
Coordinate with anesthesiologist
Sterile anesthesia circuit
Double lumen tube

Tracheostomy if needed 2-3 rings above the injured

segment
Surgical approach :

Extrathoracic consider collar incision

RT thoracotomy for RT bronchial and proximal left
LT thoracotomy for distal LT bronchial injury
Debriment , mucosa to mucosa, absorbable suture
Reinforce suture line with pericardium, pleura,..

Postoperative airway management :

Maintained low airway pressure
Allows immediate extubation

Outcome:
>90 of patient reach hospital alive, have good outcome

Tension gastrothorax
May be confused with a
tension pneumothorax
There is
haemodynamic
compromise, tracheal &
mediastinal deviation,
and decreased air entry
in the affected
hemithorax
Treatment: surgical
correction through
thoracotomy

Thoracoscopy for trauma patients

DIAGNOSTIC APPLICATIONS :
DIAGNOSIS OF DIAPHRAGMATIC INJURIES
DIAGNOSIS OF PERSISTENT HEMORRHAGE
DIAGNOSIS OF BRONCHOPLEURAL
FISTULAS
ASSESSMENT OF CARDIAC AND
MEDIASTINAL STRUCTURES

THERAPEUTIC APPLICATIONS
MANAGEMENT OF RETAINED THORACIC
COLLECTIONS
REPAIR OF DIAPHRAGMATIC INJURIES

Emergency Department Thoracotomy

Accepted Indications :
Penetrating thoracic injury :
Traumatic arrest with previously witnessed cardiac activity
Unresponsive hypotension (BP < 70mmHg)
Blunt thoracic injury
Unresponsive hypotension (BP < 70mmHg)
Rapid exsanguination from chest tube (>1500ml)

Relative Indications :
Penetrating non-thoracic injury :
Traumatic arrest with previously witnessed cardiac activity
Blunt thoracic injuries: Traumatic arrest with previously
witnessed cardiac activity

Contraindications :
Blunt injuries:
Blunt thoracic injuries with no witnessed cardiac activity
Multiple blunt trauma
Severe head injury

Emergency Department Thoracotomy

Operative Technique
The primary aims of emergency thoractomy are:
Release of cardiac tamponade
Control of haemorrhage

Allow access for internal cardiac massage Approach :

A supine anterolateral thoracotomy
left sided approach is used in all patients and with injuries
to the left chest
Patients who are not arrested but with profound hypotension
and right sided injuries have their right chest opened first.
Clamshell incision for bilateral thoracotomy approach.

Secondary manoeuvers
cross-clamping of the descending thoracic aorta.

Thank you