Chest Trauma

CHEST TRAUMA
BY
DR ALLAH NAWAZ
MBBS(K.E),FCPS(PAK)
Consultant general & laparoscopic surgeon

Assistant Professor surgery
S-II DHQ Hospital (UOS)
• Chest trauma accounts for 20 – 25% of
all trauma related deaths
• Early deaths caused hypoxaemia,

hypovolemia & temponade
PRIMARY SURVEY
• Primary survey of patient with thoracic trauma

begins with airway
• major problems should be

corrected as they are identified
AIRWAY
• Positioning of head
• Removal of blood / secretions
• Oropharyngeal airway / intubation

BREATHING
• INSPECTION: dyspnoea, engorged
neck veins, external evidence of trauma
• PALPATION: trachea, tenderness,
crepitus, decreased respiratory
movements
• PERCUSSION: dull / hyper-resonant
• AUSCULTATION: decreased / absent
breath sounds
•
TENSION
PNEUMOTHORAX
CLINICAL FEATURES
• Dyspnoea, engorged neck veins
• Tachycardia, hypotension, tracheal shift
• Hyper-resonant percussion
• Absent breath sound

MANAGEMENT
SUCKING CHEST
WOUNDS
CLINICAL FEATURES
• Tachypnoea, open wound on chest
• reduced respiratory movements
• hyper-resonant percussion
• reduced breath sounds

MANAGEMENT
• Sterile occlusive dressing
• Chest tube insertion

FLAIL CHEST
CLINICAL FEATURES
• Tachypnoea, paradoxical respiratory

movements

MANAGEMENT
• If hemodynamically stable - adequate
analgesia, humidified oxygen inhalation &
adequate fluid resuscitation
• If hemodynamically unstable - intubation

with PEEV
• Rarely open reduction, internal fixation

CIRCULATION
• Monitor quality, rate & regularity of pulse
• B.P & pulse pressure should be measured

MASSIVE
HEMOTHORAX
• Rapid accumulation of > 1500ml on chest
tube insertion
• Accumulation of 200 – 300ml/hr for 3 hrs

CLINICAL FEATURES
• Dyspnoea, distended neck veins may
be present.
• tachycardia, hypotension, cold clammy
skin, mediastinal shift may be present
• Dull percussion note
MANAGEMENT
• Large caliber IV lines & rapid crystalloid

fluids, blood transfusion,
• Single chest tube insertion
• Thoracotomy
CARDIAC
TEMPONADE
CLINICAL FEATURES
• Classic diagnostic Beck’s triad consists of

venous pressure elevation, decline in
arterial pressure& muffled heart sounds.
• Pulsus paradoxus on inspiration.
MANAGEMENT
• Pericardiocentesis
• Subxyphoid pericardial window /

thoracotomy with pericardiotomy
SECONDARY SURVEY
• Secondary survey requires further in-

depth physical examination
INJURIES TO CHEST
WALL
RIB FRACTURE
• Most commonly 4th - 10th rib are fractured
• Pain on breathing, local tenderness,

crepitus, x-rays for diagnosis
• Pain control with analgesics/ intercostal

nerve block / epidural analgesia
• Effective breathing exercises

STERNAL FRACTURE
• Indicates singnificant trauma to anterior chest
• Pain over sternum, local tenderness, crepitus,
hematoma
• If stable –manage conservatively & monitoring

with ECG, serial cardiac enzymes
• In instable – open reduction, internal fixation

PULMONARY
PARENCHYMAL INJUIES
PULMONARY LACERATION
• Simple lacerations are common after

penetrating trauma
• Patient present with pneumo /

hemothorax
• Chest tube intubation

PULMONARY CONTUSION
• Follows blunt trauma / sometimes

penetrating injuries
• Diagnosis: low Po2, x-rays
• i/v fluids, O2 inhalation, pain control,

intubation & mechanical ventilation
INJURIES TO MEDIASTINAL
STRUCTURES
TRACHEOBRONCHIAL
INJURY
• Unusual but fatal injuries
• Patient presents with hemoptysis,
subcutaneous emphysema, tension
pneumothorax, mediastinal shift
• Chest intubation, opposite main stem
intubation
• If < 1/3rd circumference involved – observe
• If > 1/3rd - repair
BLUNT CARDIAC INJURY
• Results in myocardial contusion/
chamber / valvular disruption
• If myocardial contusion – chest pain,
conduction defects on ECG
• If chamber disruption – cardiac
temponade
AORTIC DISRUPTION
• Common cause of death in automobile
collision
• X-Ray show wide mediastinum, indistinct
aortic knob, left pleural effusion, deviation
of NG tube to right
• Treatment – primray repair / resection of
injured area & grafting
ESOPHAGEAL INJURY
• Mostly caused by penetrating injuries
• Suspected if 1) left hemo /

pneumothorax without rib fracrure. 2)
blow to lower sternum & patient in
shock out of proportion. 3) particulate
matter in chest tube after blood begins
to clear
• Wide drainage of pleural space &
mediastinum with direct repair of injury
after thoracotomy (within few hours)
DIAPHRAGMATIC INURY
• Common on left side

• Lead to diaphragmatic hernia if large
enough
• Treatment is repair of defect
TRANSMEDIASTINAL GUNSHOT
WOUND
• Hemodynamically unstable – exploratory

thoracotomy
• Hemodynamically stable – evaluation by

different modalities

Chest Trauma

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CHEST TRAUMA

Consultant general & laparoscopic surgeon

• Early deaths caused hypoxaemia,

• Primary survey of patient with thoracic trauma

• major problems should be

• Removal of blood / secretions

• Oropharyngeal airway / intubation

• Dyspnoea, engorged neck veins

• Tachycardia, hypotension, tracheal shift

• Absent breath sound

• Tachypnoea, open wound on chest

• reduced respiratory movements

• reduced breath sounds

• Sterile occlusive dressing

• Chest tube insertion

• Tachypnoea, paradoxical respiratory

• reduced breath sounds

• If hemodynamically unstable - intubation

• Rarely open reduction, internal fixation

• B.P & pulse pressure should be measured

• Accumulation of 200 – 300ml/hr for 3 hrs

• Large caliber IV lines & rapid crystalloid

• Single chest tube insertion

• Classic diagnostic Beck’s triad consists of

• Subxyphoid pericardial window /

• Secondary survey requires further in-

• Pain on breathing, local tenderness,

• Pain control with analgesics/ intercostal

• Effective breathing exercises

• If stable –manage conservatively & monitoring

• In instable – open reduction, internal fixation

• Simple lacerations are common after

• Patient present with pneumo /

• Chest tube intubation

• Follows blunt trauma / sometimes

• Diagnosis: low Po2, x-rays

• i/v fluids, O2 inhalation, pain control,

• Mostly caused by penetrating injuries

• Suspected if 1) left hemo /

• Common on left side

• Hemodynamically unstable – exploratory

• Hemodynamically stable – evaluation by

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