RESUSCITATION

& THORACIC
TRAUMA

OUTLINE

INTRODUCTION

LIFE

THREATENING THORACIC INJURY

COMMON

INJURY

CONDITION OF THORACIC

TAKE HOME MESSAGES

INTRODUCTION

Trauma causes 100,000 deaths and more than 9 million

disability injury annually in worldwide (6 th leading cause of
death).

Chest injuries are responsible for 20-25% of all trauma

death.

The

World Health Ranking 2011 has ranked Malaysia at

number 20 with the most deaths caused by road accidents.

An

average of 18 people were killed on Malaysian roads daily.

* Malaysian Institute of Road Safety (MIROS)

CLASIFICATION
Anatomy
Lungs,

pleura and ribs

Cardiac injury
Trachea , oesophagus & major vessels
Diaphragm

Mechanism
Blunt

of injury

Penetrating
Shearing

Cause
MVA

/ acceleration-decelaration injury

/ Aetiology

/ trauma
Fall from height
Gunshot / sharp or blunt object

LIFE THREATENING
CONDITION

TENSION
PNEUMOTHORAX

TENSION PNEUMOTHORAX
Develops when air leak
occurs from the lung or
through chest wall.
Air is forced into thoracic
cavity without means of
escape
Creating a one-way
valve.
Affected

lung collapsed

Displaced

mediastinum
to opposite site
Decrease

venous return

Compressing

opposite lung

the

TENSION PNEUMOTHORAX
SIGNS AND SYMPTOMS

TENSION
PNEUMOTHORAX

RADIOGRAPHIC FINDINGS
Mediastinal
shift to the
right

TENSION
PNEUMOTHORAX

Tension pneumothorax is a clinical diagnosis.

Treatment should not be delayed to wait for radiologic confirmation.

TENSION
PNEUMOTHORAX
Management

1. Initial Management: needle thoracostomy

- convert the injury to simple pneumothorax.

2. Definitive management: chest tube insertion
3. Supportive management:
- Analgesia
- Ventilatory support
- CXR monitoring
- Chest phyisotherapy

NEEDLE THORACOSTOMY

OPEN
PNEUMOTHORAX

OPEN PNEUMOTHORAX:
Pathophysiology
Known

as sucking
chest wound.

Air

allowed to enter
pleural space from
the outside.

Ineffective

ventilation because
air goes in and out
from the chest
wound, rather than
from trachea.

Leading

to hypoxia
and hypercarbia.

Open Pneumothorax
Clinical Findings

defect in the chest

wall with air coming in &
out

sucking sound on
inhalation

Tachycardia

& tachypnea
Respiratory distress
Subcutaneous

emphysema

Decreased

breath
sounds on the affected
side

OPEN PNEUMOTHORAX
MANAGEMENT
1. Initial
management:
3 sided sterile
occlusive dressing
Treat concurrent shock
2. Definitive
management
Chest tube insertion

3-sided occlusive dressing

FLAIL CHEST
& PULMONARY
CONTUSION

FLAIL CHEST
Described

as the
paradoxical
movement of a
segment of chest
wall caused by
fractures of 3 or
more ribs in 2 or
more placed.

FLAIL CHEST

Severe hypoxia resulting from:

The underlying lung injury disturbance of ventilation & perfusion
Restricted chest wall movement associated with pain impaired
ventilation

FLAIL CHEST
Clinical findings

INSPECTION
-Chest

wall contusion
-Paradoxical chest
wall movement
-Respiratory distress

Palpation
-Crepitation

of rib

FLAIL CHEST
Investigation
CXR : multiple
ribs fracture
ABG: respiratory
failure with
hypoxia

FLAIL CHEST
Management
1. Initial management:
- adequate ventilation
fluid resuscitation
In absence of systemic hypotension, fluid
resuscitation should be carefully
controlled to prevent overhydration.

FLAIL CHEST
Management
2. Definitive management
Positive-pressure ventilation may be
needed.
Reverses

the mechanism of paradoxical chest

wall movement
Restores

the tidal volume

Adequate analgesic
Reduces

the pain of chest wall movement

Assess for the development of a

pneumothorax

MASSIVE
HEMOTHORAX

MASSIVE HEMOTHORAX
Defined as
presence of >1.5
liter
of blood drained
from the pleural
space upon chest
tube insertion
or >200cc/hour
in first 4 hours.

MASSIVE HEMOTHORAX
Clinical Findings

MASSIVE HEMOTHORAX
Management

Large caliber IV lines

Crystalloid infusion
Blood transfusion

Chest tube insertion

Consider for thoracotomy

MASSIVE HEMOTHORAX

Chest tube insertion

MASSIVE HEMOTHORAX

On admission

10 days after chest tube insertion

CARDIAC
TAMPONADE

CARDIAC TAMPONADE
Suspect

if injury
within the box.

May

need prompt
involvement of
cardiothoracic
team

CARDIAC TAMPONADE
Pathophysiology
A

blunt or penetrating trauma may

cause tears in the myocardial walls,
allowing blood to leak from the heart.
If 150 to 200 mL of blood enters the pericardial
space acutely, pericardial tamponade can develops

CARDIAC TAMPONADE

CARDIAC TAMPONADE

CARDIAC TAMPONADE

Cardiac Tamponade
Management
Airway

and ventilation
CirculationIV fluid challenge
Pericardiocentesis
Prompt involvement of cardiothoracic
team.
Do not take out the penetrating object

CARDIAC TAMPONADE

Pericardocentesis

OTHER CHEST INJURIES

1.
2.
3.
4.
5.
6.
7.
8.

RIB FRACTURE
SIMPLE PNEUMOTHORAX
HEMOTHORAX
PULMONARY CONTUSION
TRACHEOBRONCHIAL TREE INJURIES
CARDIAC CONTUSION
TRAUMATIC MAJOR VESSEL DISRUPTION
DIAPHRAGMATIC INJURIES

*Hemorrhage should be excluded in all patients who are in shock after

major trauma
Neck vein distention may be absent in patients with hypovolemic shock.

GENERAL MANAGEMENT
Primary

& secondary survey

Serial clinical assessment & SPO2 monitoring
Adequate analgesia (pain control CPG)
Oxygen therapy tailored to oxygenation status
Chest tube insertion
Intensive & vigorous chest physiotherapy, deep
breathing exercise & incentive spirometry
Mucolytic & nebulizer
Early referral to appropriate team (i.e. anaest,
CTC)
Assisted ventilation or intubation
Thoracotomy / thorachoscopy and proceed

TAKE HOME MESSAGES

1.

Life threatening condition in thoracic injury are

Tension pneumothorax

Open pneumothorax

Massive hemothorax

Flail chest

Cardiac temponade.

2.

Tension pneumothorax required emergent needle

thoracotomy without waiting for CXR if highly suspected
clinically

3.

Do not remove the object causing the penetrating thoracic

injury

4.

Open pneumothorax is managed with flutter-valve dressing or

three sided dressing

TAKE HOME MESSAGES

5. Flail chest is defined as segmental fractures in 2 or more
places of 3 or more consecutive ribs.
6. Massive hemothorax happen when
more than 1.5 liters blood drained upon chest tube insertion
Or more than 200cc/hour in 4 hours
7. All symptomatic traumatic pneumo/hemothorax require chest
tube insertion
8. Cardiac tamponade is recognized by presence of Becks Triad
which are
Muffled heart sound
Hypotension
Distended neck veins

TAKE HOME MESSAGES

9. Key management in thoracic injury include
Identifying the life threatening condition
Resuscitation and oxygen therapy
Chest tube insertion
Adequate pain control and aggressive chest physiotherapy
Ventilation and early associate team referral

REFERENCES
ATLS for Doctors, 8th Edition
Bailey & Love Short Practice of Surgery, 25th
Editions
Emergency Medicine Clinics of North America
- Volume 30, Issue 2 (May 2012)
SRBs Manual of Surgery 4th edition