CHEST TRAUMA

Traumatic asphyxia due to blunt

chest trauma
A 44-year-old Caucasian man was working under a car
when the vehicles transmission system fell on his
chest, squeezing his torso between the heavy item and
the ground.
After an unknown time, he was found in an unconscious
state by a relative, who called for medical aid. It was
estimated that at least one hour elapsed before our
patient received medical care.

http://www.jmedicalcasereports.com/content/6/1/25

 On arrival to our emergency department, our patient had a

gasping breath without foreign bodies in his oronasal
cavities, palpable regular pulses with a rate of 130 beats
per minute and an arterial pressure of 80/40mmHg.
On pulse oxymetry he had a saturation of 80% on room air.
His GCS score was 8 (absent eye opening, unintelligible
voice responses and limp withdrawal to painful stimuli), his
papillae were isochoric and light reflexes were bilaterally
present.
Because of his altered consciousness and impending
respiratory failure, our patient was urgently intubated and
put under controlled mechanical ventilation

 The rest of the physical examination revealed that his face,

the front part of his neck and the upper part of his chest were
congested, edematous and covered with numerous petechiae,
especially on the conjunctivae and the periorbital skin.
In a later bedside ophthalmologic examination, mild bilateral
periorbital swelling, severe bilateral subconjunctival
hemorrhages, chemosis, mild exophthalmos and mild optic
disc edema were observed.
Ecchymotic bruises were also noted on the back part of his
neck and the upper part of both shoulders.
His tympanic membranes were clear and there were no
mucosal hemorrhages of his upper airways.

 Absence of breathing sounds over both lung apices in

combination with palpable subcutaneous emphysema
over his neck pointed towards the existence of bilateral
pneumothorax.
Moreover, bloody fluid was drained through the
endotracheal tube, indicating possible lung contusions.
The physical examination of his heart and abdomen was
unremarkable and electrocardiogram was normal.

 Thoracic X-ray examination

revealed bilateral
pneumothorax and multiple
rib fractures
Chest X-ray taken after
tube thoracostomies were
inserted. Note: multiple rib
fractures, subcutaneous
emphysema, multiple lung
opacities, particularly on the
right, corresponding to sites
of lung contusion and
residual pneumothorax on
the left side.

 In this respect, bilateral tube thoracostomies were

inserted, draining air and blood and eliciting major
improvement in his hemodynamic parameters.
In subsequent X-rays, bilateral lung opacities were
evident, which were consistent with the clinical
suspicion of lung contusions.
Fiberoptic bronchoscopy was not performed due to the
bilateral pneumothorax.
Subsequently, our patient was transferred to our
intensive care unit (ICU).

Pulmonary artery laceration

after blunt chest trauma
A 69-year-old male unrestrained driver was involved in a
motor vehicle collision where he collided with the back of a
bus.
The patient was hemodynamically unstable both at the
scene and upon arrival in the trauma bay.
Examination in the trauma bay revealed a pulse of
115/min, systolic blood pressure of 80 mm Hg, and a
respiratory rate of 10/min with no gross neurologic deficits.
He had a Glasgow coma scale score of 11 and the
remainder of the assessment was unremarkable.
The Annals of Thoracic Surgery
Volume 70, Issue 3, Pages 955-957

 Examination of the chest revealed a well-healed median

sternotomy scar (the result of coronary artery bypass
grafting performed approximately one year previously),
multiple rib fractures bilaterally, and decreased air entry
in the left hemithorax.
Diagnostic peritoneal lavage was negative.

 A portable chest roentgenogram

revealed a wide mediastinum with a
left pleural effusion.
A left chest tube was inserted and
drained 300 ml of blood.
The patient was subsequently
transported to the radiography
department to evaluate his
abnormal chest findings.
A chest computed tomographic
scan revealed a large mediastinal
hematoma with active extravasation
from the main pulmonary artery.
A computed tomography (CT) scan of the chest
reveals tear in the main pulmonary artery (small
black arrow), extravasation of CT contrast dye
(solid white arrow), and a large mediastinal

 The image also revealed persistence of hemothorax, in

spite of the presence of a functioning chest tube, which
by the end of the procedure had drained a total of 1200
ml of blood.
The patient was emergently taken to the operating
room. A left thoracotomy showed an expanding
hematoma with a laceration involving half of the
circumference of the main extrapericardial pulmonary
artery.

Flail chest from blunt thoracic

trauma
A 56-year-old male smoker sustained non-penetrating
left-sided chest trauma, following a 2-m fall onto a flattopped wooden post.
He was in severe pain and respiratory distress in the
Emergency Department, with a dramatic degree of flail
and marked subcutaneous emphysema.

BMJ Case Reports 2011; doi:10.1136/bcr.04.2011.4068

 A left side tube

thoracostomy was
inserted urgently with
marked improvement in
respiratory parameters.
Subsequent CT thorax
confirmed left-sided
haemopneumothorax,
subcutaneous
emphysema, multiple
rib fractures and
adequate chest tube
position

CT thorax showing leftsided

haemopneumothorax,
subcutaneous
emphysema and tube
thoracostomy.

CT thorax showing
marked left sided
subcutaneous
emphysema.

 Analgesia was provided by

thoracic epidural infusion of local
anaesthetic and fentanyl.
This allowed early chest
physiotherapy and mobilisation,
and helped prevent
hypoventilation and sputum
retention which may have led to
respiratory infection and delayed
recovery.
The chest tube was removed on
day 3 and the patient was
discharged home on day 5. He
has since made a full recovery.
Chest radiograph at 2 months.

Chest radiograph showing

complete resolution 2 months
postinjury.