CHEST TRAUMA

Majid Pourfahraji
ANATOMY
 TRAUMA

Trauma, or injury, is defined as cellular disruption caused by an exchange

with environmental energy that is beyond the body's resilience.

Trauma remains the most common cause of death for all individuals
between the ages of 1 and 44 years and is the third most common cause
of death regardless of age.
 PRIMARY SURVEY

The initial management of seriously injured patients consists of

performing the primary survey (the "ABCs"Airway with cervical spine
protection, Breathing, and Circulation); the goals of the primary survey
are to identify and treat conditions that constitute an immediate threat to
life.
 MAIN CAUSES OF CHEST TRAUMA

Blunt Trauma: Blunt force to chest.

Penetrating Trauma: Projectile that enters chest causing small or

large hole.

Compression Injury: Chest is caught between two objects and chest

is compressed.
 TRAUMA TO THE CHEST

Chest wall Hemothorax

* Rib fracture Flail Chest and Pulmonary
* Flail chest Contusion
Airway obstruction Cardiac Tamponade
Pneumothorax Traumatic Aortic Rupture
* Simple/Closed Diaphragmatic Rupture
* Open Pneumothorax
* Tension Pneumothorax
 RIB FRACTURE

Blunt And Penetrating

PAIN
Shallow breathing
Atelectasis
Shunt: lack of ventilation
respiratory and metabolic acidosis
ANATOMY
Intercostal nerve block
 SIMPLE PNEUMOTHORAX

Opening in lung tissue that leaks air into chest cavity

Blunt trauma is main cause
May be spontaneous : Cough
Usually self correcting

S/S
Chest Pain
Dyspnea
Tachycardia
Tachypnea
Decreased Breath Sounds on Affected Side
 TREATMENT FOR SIMPLE/CLOSED

ABCs with C-spine control

Airway Assistance as needed
If not contraindicated transport in semi-sitting position
Provide supportive care
Contact Hospital and/or ALS unit as soon as possible
 TREATMENT FOR
SIMPLE/CLOSED

Thoracocentesis

Chest Tube or throcostomy

CHEST TUBE !!
 OPEN PNEUMOTHORAX

An open pneumothorax or "sucking chest wound" occurs with full-

thickness loss of the chest wall
Causes the lung to collapse due to increased pressure in pleural cavity
Can be life threatening and can deteriorate rapidly
Results in hypoxia and hypercarbia

Complete occlusion of the chest wall defect without

a tube thoracostomy may convert an open
pneumothorax to a tension pneumothorax
Temporary management of this injury includes covering the wound
with an occlusive dressing that is taped on three sides.
Definitive treatment requires closure of the chest wall defect and tube
thoracostomy remote from the wound.
OCCLUSIVE DRESSING
ASHERMAN CHEST SEAL
S/S OF OPEN PNEUMOTHORAX

Dyspnea
Sudden sharp pain
Subcutaneous Emphysema
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound

 TENSION PNEOMOTHORAX

Respiratory distress
Tachypnea
Tachycardia
Poor Color
Anxiety/Restlessness
Accessory Muscle Use
*Hypotension* But JVP +
Tracheal deviation away from the affected side
Lack of or decreased breath sounds on the affected side
Subcutaneous emphysema on the affected side
Hypotension qualifies the pneumothorax
Needle thoracostomy with a 14-gauge angiocatheter in the second intercostal
space in the midclavicular line
Tube thoracostomy should be performed immediately
 TENSION PNEOMOTHORAX

The normally negative intrapleural pressure becomes positive, which

depresses the ipsilateral hemidiaphragm and shifts the mediastinal structures
into the contralateral chest

the contralateral lung is compressed and the heart rotates about the
superior and inferior vena cava; this decreases venous return and ultimately
cardiac output, which results in cardiovascular collapse
TENSION PNEOMOTHORAX
NEEDLE TORACOSTOMY
NEEDLE DECOMPRESSION
NEEDLE THORACOSTOMY
 FLAIL CHEST

* Flail chest occurs when TWO or more contiguous ribs are fractured in at
least two location
* additional work of breathing and chest wall pain caused by the flail segment
is sufficient to compromise ventilation
* it is the decreased compliance and increased shunt fraction caused by the
associated pulmonary contusion that is typically the source of post injury
pulmonary dysfunction
* Treatment is intubation and mechanical ventilation (PEEP mode)
The patient's initial chest radiograph often underestimates the extent of the
pulmonary parenchymal damage
Must chest tube if bleeding!
FLAIL CHEST
FLAIL CHEST
 HEMOTHORAX

life-threatening injury number one

A massive hemothorax is defined as >1500 mL of blood or, in the pediatric
population, one third of the patient's blood volume in the pleural space
tube thoracostomy is the only reliable means to quantify the amount of
hemothorax
After blunt trauma, a hemothorax usually is due to multiple rib fractures
occasionally bleeding is from lacerated lung parenchyma
a massive hemothorax is an indication for operative intervention
Indication of emergency toracotomy
HEMOTHORAX
HEMOTHORAX PHYSICAL
FINDINGS
RIB FRACTURE WITH
HEMOTHORAX
RIB FRACTURE WITH
HEMOTHORAX
 CARDIAC TAMPONADE

life-threatening injury number two

Acutely, <100 mL of pericardial blood may cause pericardial tamponade
The classic diagnostic Beck's triaddilated neck veins, muffled heart tones,
and a decline in arterial pressureoften is not observed in the trauma
Increased intrapericardial pressure also impedes myocardial blood flow, which
leads to subendocardial ischemia
Best way to diagnose is ultrasound of the pericardium
Early in the course of tamponade fluid administration
a pericardial drain is placed using ultrasound guidance
Pericardiocentesis is successful in decompressing tamponade in
approximately 80% of cases : 15 to 20 cc
CARDIAC TAMPONADE
BECKS TRIAD
PERICARDIAL TAMPONADE
PHYSICAL FINDINGS
PERICARDIOCENTESIS