Download Chest Injuries

Thoracic injuries
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Incidence:
10%mortality (25% of traumatic deaths)
<10% of blunt and 15-30% of penetrating require
thoracotomy
mediastinal penetrating trauma:
mortality 20%,
50% are hemodynamically unstable  40%mortality
additional 30% positive diagnostic evaluation
Patophysiology:
hypoxia, hypercarbia, acidosis (hypovolemia,
ventilation/perfusion mismatch, changes in intrathoracic
pressures)
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Thoracic injuries
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Chest wall
lacerations, l.communicating with pleural spaceopen
pneumothorax,
rib frs with possible: pain, splinting, atelectasis,
hypoxemiaanalgesia, pulmonary toilet, flail chest,
indicative of possible internal inj.
Sternal fractures (consider myocardial contusion)
Tracheobronchial (respiratory distress, large air leak
with subcutaneous emphysema)
Esophageal (penetrating trauma, delayed recognotion
→↑mortality – 3fold if over 24h, esophagoscopy with
contrast studies – Gastrografin, butressed repair)
Pulmonary: contusion, hemothorax, pneumothorax
Great vessel
Cardiac
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Rib fractures 25% of chest inj.
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May be undetectable on CXR (excludes other
intrathoracic injuries, present in 40% of symptomatic
patients), US (unreliable)
 Majority IV-IX
 Anteroposterior compression  midshaft fr. (outward
bowing), direct blow  fracture ends face inwards 
potential vessel or lung parenchymal injury
 X-XII  suspect hepatosplenic injury
 I-III  suspect great vessel injury
 Taping, rib belts – contraindicated
 Relief of pain (intercostal block, intrapleural analgesia,
systemic analgetics), pulmonary toilet
 Flail chest – bony discontinuity of a chest fragment (>3):
serious underlying lung inj., paradoxical chest wall
motion, pain, splinting (muscle spasm)  hypoxia
fluid restriction (if no hypovolemia), adequate ventilation
with chest wall splinting  mechanical ventilation
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US in rib frs. Time 13min.
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Flail chest complication
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Stove-in chest
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Pulmonary contusion
Blunt (blast shock wawes, falls from heights) or penetrating trauma
(high velocity GSW)
“Spalling effect” – shearing or bursting effect occurring at the gas/liquid
interface (large differences in density)
“Inertial effect” – low-density alveolar tissue is stripped from heavier
hilar structures as they accelerate at different rates.
“Implosion effect” - rebound or overexpansion of gas bubbles after a
pressure wave passes
 Interstitial and/or alveolar inj. without laceration– edema, alveolar
haemorrhage, parenchymal destruction
 Adequate perfusion, inadequate ventilation (mismatch →
hypoxemia) - ↑airway resistance, ↓compliance
 Initial CXR diagnostic (irregular patchy infiltrates) – progress in
density over 48h (CXR 4-6 hours /CT earlier/, resolves in 5-7 days)
ABGs, pulse oximetry,
 Dyspnea, hemoptysis, chest pain, cough, tachypnea, rales,
decreased breath sounds, tachycardia
 Respiratory support with intubation and mechanical ventilation
(often unusual ventilation modes), aggressive pulmonary toilet,
positioning on uninvolved side, fluid restriction, no steroids or
prophylactic antibiotics.
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Pulmonary contusion – X-ray
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Pulmonary contusion – X-ray
5h later: subcutaneous emphysema, pneumomediastinum
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Pulmonary contusion – CT GSW
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Pneumothorax
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Blunt or penetrating inj.
Decreased breath sounds (>25% of the lung collapsed)
Sucking chest wound – communicating ptrx (over 2/3 of
tracheal diameter)  preferential air flow (lung collapses
on inspiration and slighly expands on expiration) 
occlusive dressing + chest tube
CXR diagnostic
Tension ptrx is a clinical diagnosis
In significant chest inj. + p.p. mechanical ventilation 
prophylactic tube thoracostomy (prevention of tension P.)
Chest tube into II or IIIrd intercostal space in
midclavicular line
Chest tube ineffictive  tracheobronchial disruption 
diagnosis + thoracotomy
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Pneumothorax
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Tension pneumothorax
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L main stem bronchus
disruption
3% autopsies in trauma
victims
MVA
late diagnosis in 25-70%
tachypnoea, sc.
emphysema, pthx
possible no air leak
(incompleate inj.,
possible granulation with
airway obstruction 2-6w)
brochoscopy
posterolateral
thoracotomy V ics.
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Subcutaneous
emphysema
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Tracheobronchial disruption
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Tension pneumothorax
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Tension gastrothorax
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Hemothorax
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Opacification on CXR (intercostal a., internal mammary, Th spine fr.,
lung laceration, mediastinal vessels)
Chest tube usually sufficient (IV or Vtdh intercostal space in anterior
or midaxillary line)  bleeding self-limiting
Thoracotomy guidelines individualized: severe haemodynamic
instability (ERT), initial drainage exceding 1,5L, ongoing drainage of
100ml/h over 6h
Coagulation, ligation, pulmonary tractotomy, pulmonary resection
(hilar injury) – significant mortality
Air embolism in significant parenchymal injury (esp. on positive
pressure ventillation): sudden cardiovascular collapse – steep
Trendelenburg position, aspirate air from R ventricle, cardiovascular
support
Great vessel injury (profound shock, sometimes pericardiac
tamponade, retrosternal chest pain, dyspnea, new systolic murmur,
pseudocoarctation s., on CXR – blunt inj.: widend mediastinum,
obscured aortic knob, deviation of L stem brochus, opacification of
aortopulmonary window, R deviation of nasogastric tube, I or IInd rib
frs.)
no diagnostic investigations in unstable patient
aortography, contrast enhanced CT, echocardiography
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fluid restriction (blunt), thoracotomy
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Hemothorax
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Hemothorax
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Hemothorax
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Hemothorax
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Hemopneumothorax
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Chest tube drainage thoracostomy
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Widend mediastinum
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Mediastinal pseudoaneurysm
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Flail chest - traction
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Flail chest
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Empyema
 Stages
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(not separated – continuum):
exsudative
fibropurulent
organizing
 CXR,
US, CT
 Control of infection with appropriate
antibiotics, drainage (ev.streptokinaze),
obliteration of pleural space, thoracotomy
with decortication and pleurodesis
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Cardiac injury
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usually penetrating inj. between midclavicular
lines
 pericardiac tamponade: shock, JVD (JVD ↑ with
inspiration - Kussmaul`s sign), diminished
(muffled) heart sounds (Beck`s triad), electrical
alterans (varying amplitude of the R wave) 
warrants operation (often ERT)
 blunt c.inj.: history, inappropriate cardiovascular
response to injury (EKG – normal excludes,
abnormal  cardiac monitoring,
echocardiography)
advanced cardiac life support protocols
operation for myocardial or valvular rupture,
ventricular aneurysm
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Commotio cordis
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fatality (SCD) due to blunt thoracic injury (usually
caused by a hard projectile, such as a hockey
puck or baseball) without gross structural
damage to the heart or other intrathoracic
organs, results in ventricular fibrillation
aggravated by traumatic apnea.
 trauma occurs during the vulnerable period of
cardiac repolarization triggering the arrhythmia
(VF). Most vulnerable phase of the cardiac
cycle: T – wave  heart partially depolarized
and then repolarized (electrically unstable)
 more common in young athletes and children
because they have more compliant chest walls,
thus transmitting the energy from the projectile
to the heart.
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Thoracotomy
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Pitfalls
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Simple hemothorax  retained, clotted hemothorax with
lung entrapement or empyema (if infected)
Diaphragmatic inj. are often overlooked  respiratory
compromise, early or late entrapement and strangulation
of abd. Contents
Evaluation of widend mediastinum requires
cardiothoracic surgical capabilities
Underestimation of severe pathophysiology of rib frs.
esp. in the elderly (aggressive pain control with no resp.
depression)
underestimation of blunt pulmonary injury severety
(pulmonary contusion is not always correlated with X-ray
findings)
Klinika Chirurgii Urazowej
Paweł Grala
Klinika Chirurgii Urazowej
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