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عليكم ألسالم

TRAUMA TO THE CHESTTRAUMA TO THE CHEST(CHEST TRAUMA)(CHEST TRAUMA)

Dr.Ahmed Al-AzzawiDr.Ahmed Al-AzzawiM.B.Ch.B,F.I.C.M.SM.B.Ch.B,F.I.C.M.S

Cardiothoracic&Vascular Cardiothoracic&Vascular SurgeonSurgeon

University of SulaimaniUniversity of Sulaimani

College of MedicineCollege of Medicine

Thoracic traumaThoracic trauma The rate of thoracic trauma in The rate of thoracic trauma in

united states is 12 per million united states is 12 per million population per aday population per aday

20_25% of deaths due to trauma 20_25% of deaths due to trauma are attributed to thoracic injury.are attributed to thoracic injury.

The incidence has increased The incidence has increased rapidly in this century of high-rapidly in this century of high-speed vehicular travel. speed vehicular travel.

Historical AspectsHistorical Aspects In the fourth century B.C.,Hippocrates ,aware In the fourth century B.C.,Hippocrates ,aware

that rib fractures can be associated with that rib fractures can be associated with hemoptysis .hemoptysis .

The Greeks and Romans considered penetrating The Greeks and Romans considered penetrating injuries of the chest almost uniformly fatal.injuries of the chest almost uniformly fatal.

Aristotle writing in the third century B.C.,felt Aristotle writing in the third century B.C.,felt that "The heart alone of all the viscera cannot that "The heart alone of all the viscera cannot withstand injury.withstand injury.

In the 16th century ,Ambroise pare described In the 16th century ,Ambroise pare described surgical emphysema associated with chest wall surgical emphysema associated with chest wall injury and advocated debriding segment of injury and advocated debriding segment of broken ribs.broken ribs.

The use of water seal to drain the pleural cavity The use of water seal to drain the pleural cavity was first practiced in the rudimentary form in was first practiced in the rudimentary form in the 19th century.the 19th century.

Thoracentesis was associated with ahigh Thoracentesis was associated with ahigh mortality rate ,probably because of lack of mortality rate ,probably because of lack of antibiotics and aneasthesia.antibiotics and aneasthesia.

There was debate about the treatment of There was debate about the treatment of injuries to the heart ,Billroth stated that In injuries to the heart ,Billroth stated that In 1885 "the surgeon who should attempt to sutre 1885 "the surgeon who should attempt to sutre awound of the heart would lose the respect of awound of the heart would lose the respect of his colleagues".Despite such sentiments ,the his colleagues".Despite such sentiments ,the first repair of apenitrating cardiac wound in first repair of apenitrating cardiac wound in ahuman being was performed in 1896.ahuman being was performed in 1896.

The development of antibiotics and widespread The development of antibiotics and widespread acceptance of the impotance of drainage of the acceptance of the impotance of drainage of the pleural cavity for haemothorax and pleural cavity for haemothorax and pneumothorax markedly improve the pneumothorax markedly improve the prognosis for both penetrating and blunt prognosis for both penetrating and blunt trauma.trauma.

Truama to the Chest(Chest Truama to the Chest(Chest truama)truama)

Ausefull division of trauma is into :Ausefull division of trauma is into : 1.Blunt trauma.1.Blunt trauma. 2.Penetrating trauma.2.Penetrating trauma.This division is according to the mechanism of This division is according to the mechanism of

injury.Motor vehicle accidents are the most common injury.Motor vehicle accidents are the most common blunt mechanism .Others include motor cycle blunt mechanism .Others include motor cycle accidents ,predestrains hit by cars ,bicycle accidents accidents ,predestrains hit by cars ,bicycle accidents and assaults with blunt objects such as fists or and assaults with blunt objects such as fists or baseball bats .baseball bats .

Gunshot and stab wounds are the most common Gunshot and stab wounds are the most common penetrating mechanism of injury to the penetrating mechanism of injury to the chest .Widespread availability of high –velocity and chest .Widespread availability of high –velocity and large caliber guns has increased the frequency of large caliber guns has increased the frequency of high energy missile wounds of the chest.high energy missile wounds of the chest.

1. Blunt trauma(injuries):1. Blunt trauma(injuries):caused by blunt forces applied to the chest wall causing caused by blunt forces applied to the chest wall causing

injury, these forces are:injury, these forces are:• Rapid deceleationRapid deceleation :is the usual force involved in high :is the usual force involved in high

speed motor vehicle accidents&FFH.speed motor vehicle accidents&FFH.

• Direct impact by ablunt object can cause localized Direct impact by ablunt object can cause localized fracture of the ribs,sternum,scapula with underlying fracture of the ribs,sternum,scapula with underlying lung parenchymal injury ,cardiac contusion or lung parenchymal injury ,cardiac contusion or pneumothorax.pneumothorax.

• Compression of the chest by avery heavy object which Compression of the chest by avery heavy object which prevents respiration &causes marked increase in prevents respiration &causes marked increase in blood pressure within veins of the upper thorax may blood pressure within veins of the upper thorax may results in traumatic asphyxia.results in traumatic asphyxia.

ClassificationClassification Chest trauma (injury) Chest trauma (injury) either:either:

Compression forces are either:• Anterior –posterior compression forces

place indirect pressure on the ribs causing lateral ,midshaft fractures.

• Lateral compression forces applied to the shoulder are common causes of sterno-clavicular joint dislocation and clavicle fracture.

2.Penetrating trauma 2.Penetrating trauma (injuries)(injuries)

Penetrating wounds of the chest (gun shot or Penetrating wounds of the chest (gun shot or stab wound) may cause comminuted stab wound) may cause comminuted fractures of rib with bone fragments driven fractures of rib with bone fragments driven into the lung substance the most common into the lung substance the most common manifestation of penitrating trauma to the manifestation of penitrating trauma to the visceral and parietal pleura is disruption of visceral and parietal pleura is disruption of normal negative intrapleural pressure normal negative intrapleural pressure resulting in pneumothorax.resulting in pneumothorax.

Penetrating injuries cause both direct injury Penetrating injuries cause both direct injury to structures encountered by the weapon & to structures encountered by the weapon & indirect injury.indirect injury.

The extent of internal injuries can not be The extent of internal injuries can not be judge by the appearance of askin wound.judge by the appearance of askin wound.

Thoracic injury occurs in the chest Thoracic injury occurs in the chest wall ,lungs&pleura,great wall ,lungs&pleura,great vessels,diaphragm, vessels,diaphragm, heart,trachea,bronchus&oesophagus.heart,trachea,bronchus&oesophagus.

Magnitude of these problems and the Magnitude of these problems and the significance of the associated injuries significance of the associated injuries serve to underscore the importance serve to underscore the importance of complete evaluation and timely of complete evaluation and timely intervention in the management of intervention in the management of thoracic trauma.thoracic trauma.

Fate of patient sustaning thoracic trauma

Immediate deaths are usualy due to major disruption of the heart or of the great vessels .

Early deaths due to thoracic trauma occuring within 30 minutes to 3 hours after the injury are secondary to cardiac tamponade ,airway obstruction and aspiration.

Two thirds of these patients reach the hospital prior to die. Only 10-15% of blunt trauma require thoracic surgery ,and 15-

30%of the penitrating chest trauma require open thoracotomy ,85% of patients with thoracic trauma can be managed by simple lifesaving manoeuvre that do not require surgical treatment.

Optimal treatment of chest trauma Optimal treatment of chest trauma requires athorough knowledge of the requires athorough knowledge of the etiology and pathophysiology of the etiology and pathophysiology of the thorax and expertise the theraputic thorax and expertise the theraputic interventions.interventions.

Improved prehospital care and rapid Improved prehospital care and rapid transportation have increased the transportation have increased the survival ,but the lethality remain survival ,but the lethality remain high.high.

PathophysiologyPathophysiology

Thoracic trauma can induce two serious Thoracic trauma can induce two serious derangement:derangement:

1.Respiratory insufficiency due to :1.Respiratory insufficiency due to :

Pneumothorax ,tension Pneumothorax ,tension pneumothorax,open pneumothorax,open pneumothorax,flail chest,pulmonary pneumothorax,flail chest,pulmonary contusion,aspiration.contusion,aspiration.

2.Haemorrhagic shock due to:2.Haemorrhagic shock due to:

Haemothorax ,haemomediastinumHaemothorax ,haemomediastinum

Priorities :thoracic Priorities :thoracic injuriesinjuries

Because the thoracic injuries are severe and Because the thoracic injuries are severe and potentially lethal,the diagnosis and therapy go hand potentially lethal,the diagnosis and therapy go hand by hand.by hand.

In unstable &critical patients quick decisions based In unstable &critical patients quick decisions based on check of the following vital signs are required: on check of the following vital signs are required:

1.1. Air way patency:the air way can be occluded by Air way patency:the air way can be occluded by foreign bodies in mouth or by fall of the tongue foreign bodies in mouth or by fall of the tongue backwards as occurs in unconscious patients.backwards as occurs in unconscious patients.

2.2. Breathing:in order to know if patient is breathing it Breathing:in order to know if patient is breathing it is necessary to check respiratory movement,their is necessary to check respiratory movement,their extension.extension.

3.3. Circulation:it is evaluated by ossessing patients Circulation:it is evaluated by ossessing patients pulse(radial,carotideal or femoral)&pressurepulse(radial,carotideal or femoral)&pressure

INITIAL RESUSITATIONINITIAL RESUSITATION The initial resuscitation of patient with thoracic trauma follows the The initial resuscitation of patient with thoracic trauma follows the

same principles as for the resuscitation of any trauma patient:these same principles as for the resuscitation of any trauma patient:these have dubbed the "ABCs"as an acronym for airway ,breathing ,and have dubbed the "ABCs"as an acronym for airway ,breathing ,and circulation.Some elements of the ABCs have particular significance circulation.Some elements of the ABCs have particular significance for thoracic injury.for thoracic injury.

1.The first priority is to ensure an adequate airway ,in some patient.this 1.The first priority is to ensure an adequate airway ,in some patient.this requires endotracheal intubation.requires endotracheal intubation.

When intubation is difficult due to presence of injury to larynx or When intubation is difficult due to presence of injury to larynx or trachea ,emergent cricothyrotomy should be performed to ensure trachea ,emergent cricothyrotomy should be performed to ensure areliable airway.areliable airway.

If the tracheal injury is large ,the simplest and most expedient If the tracheal injury is large ,the simplest and most expedient means of management is to place an endotracheal tube through the means of management is to place an endotracheal tube through the defect.defect.

2.The second priority is to assure adequate ventilation ,some patient 2.The second priority is to assure adequate ventilation ,some patient are able to spontaneously ventilate,most patient require mechanical are able to spontaneously ventilate,most patient require mechanical ventilation .ventilation .

3.The third priority in trauma management is circulation .3.The third priority in trauma management is circulation . Intavenous catheter should be placed ,and several litters of fluid Intavenous catheter should be placed ,and several litters of fluid

should be infused rapidly .should be infused rapidly . Catheter should be placed at peripheral sites ,the saphenous vein at Catheter should be placed at peripheral sites ,the saphenous vein at

the ankle will admit avery large intravenous line,the ankle will admit avery large intravenous line,

Intrapleural haemorrhage usually can be Intrapleural haemorrhage usually can be suspected on physical examination and suspected on physical examination and confirmed with achest film ,most patient with confirmed with achest film ,most patient with chest trauma (blunt and penetrating)should chest trauma (blunt and penetrating)should undergo chest radiography early in initial undergo chest radiography early in initial management if at all possible .management if at all possible .

Blood should be drawn while the ABCs of Blood should be drawn while the ABCs of resuscitation are performed.resuscitation are performed.

Essential initial tests are arterial blood gases Essential initial tests are arterial blood gases ,haematocrit,and asample for typing and ,haematocrit,and asample for typing and cross-maching .cross-maching .

Urinary ccatheter is valuable in many Urinary ccatheter is valuable in many patient,the urine should be checked for gross patient,the urine should be checked for gross haematuriahaematuria..

CHEST WALL INJURIESCHEST WALL INJURIES

blunt chest wall injury is the most common form blunt chest wall injury is the most common form of thoracic trauma ,the chest wall consisting of thoracic trauma ,the chest wall consisting of the ribs,sternum ,clavicles ,and scapula,is of the ribs,sternum ,clavicles ,and scapula,is designed to protect the underlying viscera,but designed to protect the underlying viscera,but in some patient serious intrathoracic injuries in some patient serious intrathoracic injuries are present even in the absence of obvious are present even in the absence of obvious chest wall injury.This is particularly lickely in chest wall injury.This is particularly lickely in children and young adults ,because they have children and young adults ,because they have very pliable and compressible chest walls that very pliable and compressible chest walls that can deform significantly without inducing can deform significantly without inducing breaks in any of the bony elements. breaks in any of the bony elements.

AA. Rib fracture. Rib fracture is the most common thoracic is the most common thoracic injury ,the diagnosis of rib fractures is injury ,the diagnosis of rib fractures is aclinical rather than aradiographic,and the aclinical rather than aradiographic,and the important diagnostic findings are pain with important diagnostic findings are pain with respiration,and tenderness on respiration,and tenderness on palpation,presence of crepitus and deformity palpation,presence of crepitus and deformity at the fracture site.at the fracture site.

Blood loss also occurs from rib Blood loss also occurs from rib fructures ,amount can be as much as 100 fructures ,amount can be as much as 100 to150 cc collected within the pleural cavity as to150 cc collected within the pleural cavity as ahaemothorax or between the chet wall and ahaemothorax or between the chet wall and the parietal pleura if the pleura remain intact. the parietal pleura if the pleura remain intact.

Narcotics and intercostal nerve blocks are Narcotics and intercostal nerve blocks are sufficient for simple rib fractures sufficient for simple rib fractures

B.Sternal fracture :are most common in B.Sternal fracture :are most common in drivers of motor viehcles in whom the drivers of motor viehcles in whom the anterior chest wall hits the steering anterior chest wall hits the steering wheel during sudden deceleration,the wheel during sudden deceleration,the diagnosis is clinical ,there is ecchymosis diagnosis is clinical ,there is ecchymosis overlying the sternum .overlying the sternum .

D.Fructure of the clavicle:are relatively D.Fructure of the clavicle:are relatively common and treated with temporary common and treated with temporary immobilization of the arm and immobilization of the arm and observation ,most of these injuries heal observation ,most of these injuries heal with time,although on occasion there is with time,although on occasion there is acosmetic deformity at the site of acosmetic deformity at the site of fracture fracture

E.Flail chest :occurs when free floating E.Flail chest :occurs when free floating segment of chest wall moves segment of chest wall moves paradoxically with spontaneous paradoxically with spontaneous respiration ,flail segment can occur respiration ,flail segment can occur either laterally or anteriorly ,asegment of either laterally or anteriorly ,asegment of chest wall does not have continuity with chest wall does not have continuity with the rest of thoracic cage because the rest of thoracic cage because multiple rib fractures causing serious multiple rib fractures causing serious respiratory distress.respiratory distress.In flail chest injury, the unstable segment In flail chest injury, the unstable segment wall moves separately and in an opposite wall moves separately and in an opposite direction from the rest of the thoracic direction from the rest of the thoracic cage during the respiration cycle. cage during the respiration cycle.

F. First rib fracture indicates F. First rib fracture indicates significant force, and aortography is significant force, and aortography is indicated if the patient also has indicated if the patient also has brachial plexus deficit, absent radial brachial plexus deficit, absent radial pulse, pulsating supraclavicular pulse, pulsating supraclavicular mass, or mass, or widened widened mediastinummediastinum

22..Pulmonary InjuriesPulmonary Injuries

A. Pulmonary contusion probably occurs to a A. Pulmonary contusion probably occurs to a varying degree in all thoracic injuries and is varying degree in all thoracic injuries and is a major component of flail chest a major component of flail chest

B. Significant hypoventilation and shunting B. Significant hypoventilation and shunting from contusion requires judicious fluid from contusion requires judicious fluid management and ventilatory support, if management and ventilatory support, if indicated indicated

C. Partial, complete, and C. Partial, complete, and tension tension pneumothoraxpneumothorax should all be managed should all be managed promptly with chest tube insertion promptly with chest tube insertion

D. Subcutaneous emphysema should prompt D. Subcutaneous emphysema should prompt investigation for pneumothorax but is not in investigation for pneumothorax but is not in itself an indication for chest tube placement itself an indication for chest tube placement

E.Hemothorax should be managed with E.Hemothorax should be managed with early chest tube drainage to prevent clot early chest tube drainage to prevent clot formation and incomplete evacuation formation and incomplete evacuation

F. Surgical exploration is recommended if F. Surgical exploration is recommended if initial output is more than 1000 ml or initial output is more than 1000 ml or chest tube drainage is more than 100 chest tube drainage is more than 100 ml/hr for 4 hours ml/hr for 4 hours

G. A clotted hemothorax should be G. A clotted hemothorax should be evacuated early by thoracotomy to evacuated early by thoracotomy to improve pulmonary function and prevent improve pulmonary function and prevent late fibrothorax late fibrothorax

33 . .Tracheal/Bronchial Tracheal/Bronchial InjuriesInjuries

A. Most tracheal injuries are range from A. Most tracheal injuries are range from crush injuries to complete tracheal crush injuries to complete tracheal separation separation

B. If endotracheal intubation is not possible, B. If endotracheal intubation is not possible, a surgical airway should be obtained a surgical airway should be obtained

C. Primary repair of tracheal lacerations or C. Primary repair of tracheal lacerations or separation should be performed, if separation should be performed, if possible possible

D. Blunt trauma typically causes a D. Blunt trauma typically causes a circumferential laceration of either main circumferential laceration of either main bronchus with complete separation bronchus with complete separation

E. Only 50% of patients will have a E. Only 50% of patients will have a pneumothorax with this injury, and pneumothorax with this injury, and hemothorax is uncommon hemothorax is uncommon

F. Only 1/3 of patients are diagnosed in the first F. Only 1/3 of patients are diagnosed in the first 24 hours, and only 1/2 within the first month 24 hours, and only 1/2 within the first month

G. Early repair is the preferred treatment if the G. Early repair is the preferred treatment if the diagnosis is made, and requires thoracotomy diagnosis is made, and requires thoracotomy with intubation of the uninjured bronchus with intubation of the uninjured bronchus

H. Late strictures from incomplete tears or H. Late strictures from incomplete tears or parenchymal isolation from complete tears parenchymal isolation from complete tears can be repaired with bronchoplastic can be repaired with bronchoplastic procedures, but may require pulmonary procedures, but may require pulmonary resection resection

44 . .Cardiac/Great Vessel Cardiac/Great Vessel InjuriesInjuries

A. Myocardial contusion is the most common injury and A. Myocardial contusion is the most common injury and is suspected with ECG changes and serial enzyme is suspected with ECG changes and serial enzyme elevations elevations

B. Coronary artery injury can result in thrombosis and B. Coronary artery injury can result in thrombosis and myocardial infarction myocardial infarction

C. Atrial or ventricular rupture is usually fatal, although C. Atrial or ventricular rupture is usually fatal, although the pericardium may restrict bleeding enough to the pericardium may restrict bleeding enough to allow survival to the ER(emergency room). allow survival to the ER(emergency room).

D. The patient should be monitored in the ICU and may D. The patient should be monitored in the ICU and may require heparinization for coronary thrombosis and require heparinization for coronary thrombosis and anti-arrhythmic therapy anti-arrhythmic therapy

E. Echocardiography and angiography are indicated for E. Echocardiography and angiography are indicated for tamponade and post-injury murmurs, which suggest tamponade and post-injury murmurs, which suggest valvular insufficiency or septal defect valvular insufficiency or septal defect

F. Aortic rupture is also usually fatal, but can F. Aortic rupture is also usually fatal, but can result in formation of a false aneurysm, result in formation of a false aneurysm, typically at the aortic isthmus , rupture of typically at the aortic isthmus , rupture of the thoracic aorta is a common cause of the thoracic aorta is a common cause of sudden death in roctures of unrestrained sudden death in roctures of unrestrained frontal collision and in a fall from a great frontal collision and in a fall from a great height.height.Laceration of the thoracic aorta supervenes Laceration of the thoracic aorta supervenes near the aortic legamentum arteriosum.near the aortic legamentum arteriosum.

55 . .Diaphragm RuptureDiaphragm Rupture

A. Most lacerations occur on the left hemidiaphragm A. Most lacerations occur on the left hemidiaphragm and result from automobile accidents and result from automobile accidents

B. Usually, the B. Usually, the stomach stomach herniatesherniates and undergoes and undergoes volvulus, massively dilates, and causes left lung volvulus, massively dilates, and causes left lung collapse and mediastinal shift to the right collapse and mediastinal shift to the right

C. Gastric distension can also result in perforation and C. Gastric distension can also result in perforation and should be prevented by NG tube placement should be prevented by NG tube placement

D. Splenic and liver injury is also common in this D. Splenic and liver injury is also common in this setting setting

E. The diaphragm can be repaired either through the E. The diaphragm can be repaired either through the chest or abdomen, and all tears should be closed in chest or abdomen, and all tears should be closed in double-layer fashion double-layer fashion

F. Diaphragmatic injury is suspected F. Diaphragmatic injury is suspected in any penetrating thoracic wound in any penetrating thoracic wound (gunshot, stab or accidental (gunshot, stab or accidental perforation) at or below 4th perforation) at or below 4th intercostal space anteriorly, 6th intercostal space anteriorly, 6th interspace laterally, or 8th interspace laterally, or 8th interspace posteriorly interspace posteriorly

6.Trauma to oesophagus 6.Trauma to oesophagus In trauma patients rupture of oesophagus is very In trauma patients rupture of oesophagus is very

rare .rare . More frequent is the perforation of oesophagus More frequent is the perforation of oesophagus

for penitrating trauma.for penitrating trauma. Oesophageal trauma is lethal if unrecognised Oesophageal trauma is lethal if unrecognised

because mediastenitis due to contamination of because mediastenitis due to contamination of mediastinal space by oesophageal contents with mediastinal space by oesophageal contents with very high concentration of necrosis bacteria.very high concentration of necrosis bacteria.

Emphysema and pneumo-or hydropneumothorax Emphysema and pneumo-or hydropneumothorax especialy in the left mediastinum develop and especialy in the left mediastinum develop and become visible radiologically.become visible radiologically.

Esophagogram may be performed when the Esophagogram may be performed when the patient is stable.patient is stable.

In thoracic trauma patients the In thoracic trauma patients the following following life-threatening life-threatening lesions that must lesions that must immediately identified and immediately identified and treatedtreated . .

Tension pneumothoraxTension pneumothorax Developes when air enter the pleural Developes when air enter the pleural

space but can not exit .The consequence space but can not exit .The consequence is progressively increasing intrathoracic is progressively increasing intrathoracic pressure in the affected hemithorax pressure in the affected hemithorax resulting in impaired central venous resulting in impaired central venous return and mediastinal shift. In which return and mediastinal shift. In which the heart, trachea, esophagus, and great the heart, trachea, esophagus, and great vessels are pushed towards the vessels are pushed towards the unaffected side of the chest. The shift unaffected side of the chest. The shift may cause compression of the opposite may cause compression of the opposite lung and may affect the flow of blood lung and may affect the flow of blood returning to the heart. returning to the heart.

Massive haemothoraxMassive haemothorax is common in both penitrating & blunt chest is common in both penitrating & blunt chest

injuries.Sources of haemothorax injuries.Sources of haemothorax are :lung,intercostal vessels,I.M.A,mediastinal are :lung,intercostal vessels,I.M.A,mediastinal great vessels,heart,abdominal structures great vessels,heart,abdominal structures when there is diaphragmatic injury.Treatment when there is diaphragmatic injury.Treatment by placement of alarge chest tube(36 by placement of alarge chest tube(36 french),amoderate size haemothorax(500-french),amoderate size haemothorax(500-1500ml)that stops after thoracostomy can be 1500ml)that stops after thoracostomy can be treated by closed drainage treated by closed drainage alone.Ahaemothorax of greater than 1500-alone.Ahaemothorax of greater than 1500-2000ml as with continued bleeding of more 2000ml as with continued bleeding of more than 100-200ml per hr is an indication for than 100-200ml per hr is an indication for emergency thoracotomy or thoracoscopy .emergency thoracotomy or thoracoscopy .

The following lesions are life-The following lesions are life-threatening but give to the threatening but give to the

physician more time to diagnose physician more time to diagnose and treat themand treat them

RIB FRACTURESRIB FRACTURES::

The most common type of chest The most common type of chest trauma usually involving the fifth trauma usually involving the fifth through the ninth ribs.through the ninth ribs.

Occurs in over 60% of patients Occurs in over 60% of patients admitted with chest trauma.  Most rib admitted with chest trauma.  Most rib fractures are benign and are treated fractures are benign and are treated conservatively. conservatively.

Injuries to the great vesselsInjuries to the great vessels It may be result of penitrating or blunt trauma.It may be result of penitrating or blunt trauma. An initial rush of alarge volume of blood after tube An initial rush of alarge volume of blood after tube

thoracostomy may indicate great vessels injury.thoracostomy may indicate great vessels injury. Usualy present with shock or pericardial Usualy present with shock or pericardial

tamponade.tamponade.CXR finding :CXR finding :1.1. Widening of the mediastinum to greater than 8cm.Widening of the mediastinum to greater than 8cm.2.2. Depression of the left main bronchus to greater Depression of the left main bronchus to greater

than 140 degrees.than 140 degrees.3.3. Haematoma in the left apical area.Haematoma in the left apical area.4.4. Massive left haemothorax.Massive left haemothorax.5.5. Deviation of the oesophagus to te right.Deviation of the oesophagus to te right.6.6. Loss of aortic knob contour .Loss of aortic knob contour .

Aortography should be performed in the Aortography should be performed in the patient with moderate to severe injuries patient with moderate to severe injuries that is stable haemodynamics.CAT and that is stable haemodynamics.CAT and MR have not been shown to be as MR have not been shown to be as diagnostic as aortography.diagnostic as aortography.

Requires emergency thoracotomy or Requires emergency thoracotomy or sternotomy.sternotomy.

Injuries to desending thoracic aorta Injuries to desending thoracic aorta require left anterior thoracotomy.require left anterior thoracotomy.

Injuries to proximal aorta and proximal Injuries to proximal aorta and proximal carotid arteries require median carotid arteries require median sternotomy.sternotomy.

Indications for emergency Indications for emergency room thoracotomyroom thoracotomy Acute pericardial tamponade Acute pericardial tamponade

unresponsive to cardiac massage.unresponsive to cardiac massage. Exanguinating intra-thoracic Exanguinating intra-thoracic

haemorrhage.haemorrhage. Intraabdominal haemrrhage Intraabdominal haemrrhage

requiring aortic cross clamping.requiring aortic cross clamping. Need for internal cardiac massage.Need for internal cardiac massage.

Indications for urgent Indications for urgent thoracotomythoracotomy Chest drainage >1500ml or 200ml per hr.Chest drainage >1500ml or 200ml per hr. Large unevacuated clotted haemothorax.Large unevacuated clotted haemothorax. Developing cardiac tamponade.Developing cardiac tamponade. Chest wall defect.Chest wall defect. Massive air leak despite adequate Massive air leak despite adequate

drainage.drainage. Proven great vessel injury on angiography.Proven great vessel injury on angiography. Proven oesophageal injury.Proven oesophageal injury. Proven diaphragmatic injury.Proven diaphragmatic injury.

Most blunt injuries are managed Most blunt injuries are managed with relatively simple with relatively simple interventions like intubation and interventions like intubation and mechanical ventilation and chest mechanical ventilation and chest tube insertion.tube insertion.

Diagnosis of blunt injuries may be Diagnosis of blunt injuries may be more difficult and require more difficult and require additional investigations such as additional investigations such as CT scanning .CT scanning .

Specific chest injuriesSpecific chest injuries Chest wall contusion/haematomaChest wall contusion/haematoma Rib #Rib # Flail chestFlail chest Pneumothorax,haemothorax,haemopneumothPneumothorax,haemothorax,haemopneumoth

orax.orax. Pericardial tamponadePericardial tamponade Myocardial contusionMyocardial contusion Sternal#,#0f clavicle&shoulder girdleSternal#,#0f clavicle&shoulder girdle Traumatic aortic rupture,thoracic aorta Traumatic aortic rupture,thoracic aorta

injury.injury. Diaphragm injury,oesophageal injury.Diaphragm injury,oesophageal injury. Tracheobroncheal tear.Tracheobroncheal tear.

Penitrating chest traumaPenitrating chest trauma

Victims of penetrating trauma are not Victims of penetrating trauma are not

always injured while in the anatomic always injured while in the anatomic position position

no assumption can be made about the no assumption can be made about the direction of the knife, bullet,also ,it cannot direction of the knife, bullet,also ,it cannot be assumed that only the structures be assumed that only the structures immediately underlying the skin wound immediately underlying the skin wound have been wounded .have been wounded .

It is easy to miss small puncture or gunshot It is easy to miss small puncture or gunshot wounds if the skin is not closely inspectedwounds if the skin is not closely inspected

Mechanism of injuryMechanism of injury

The mechanism of injury may be categorized as low, The mechanism of injury may be categorized as low,

medium, or high velocitymedium, or high velocity.. LowLow--velocity injuries include impalement velocity injuries include impalement ((eg, knife eg, knife

woundswounds)), which disrupts only the structures , which disrupts only the structures penetratedpenetrated..

MediumMedium--velocity injuries include bullet wounds from velocity injuries include bullet wounds from most types of handguns and airmost types of handguns and air--powered pellet guns powered pellet guns and are characterized by much less primary tissue and are characterized by much less primary tissue destruction than wounds caused by highdestruction than wounds caused by high--velocity velocity forcesforces. .

HighHigh--velocity injuries include bullet wounds caused velocity injuries include bullet wounds caused by rifles and wounds resulting from military weaponsby rifles and wounds resulting from military weapons. .

PathophysiologyPathophysiology penetrating chest trauma penetrating chest trauma ((PCTPCT) ) comprises comprises

a broad spectrum of injuries and severitya broad spectrum of injuries and severity. . The injuries of patients The injuries of patients ((some with >1 some with >1 injuryinjury) ) is listed as followsis listed as follows: :

Hemothorax . Hemothorax . Hemopneumothorax.Hemopneumothorax. Pneumothorax . Pneumothorax . Diaphragmatic rupture . Diaphragmatic rupture . Open hemopneumothorax . Open hemopneumothorax . Pulmonary contusion .Pulmonary contusion . Open pneumothorax . Open pneumothorax . Rib fracture Rib fracture

Fewer than 2 fractures . Fewer than 2 fractures . More than 2 fractures .More than 2 fractures .

Subcutaneous emphysema . Subcutaneous emphysema . Bilateral pneumothorax .Bilateral pneumothorax . Open bilateral hemopneumothorax . Open bilateral hemopneumothorax . Pneumomediastinum .Pneumomediastinum . Thoracic wall lacerations . Thoracic wall lacerations . Bilateral hemopneumothorax . Bilateral hemopneumothorax . Open bilateral pneumothorax . Open bilateral pneumothorax . Sternal fracture .Sternal fracture . Bilateral diaphragmatic ruptureBilateral diaphragmatic rupture

Specific organ injuriesSpecific organ injuries

Any organ within the chest is potentially Any organ within the chest is potentially susceptible to penetrating trauma, and each susceptible to penetrating trauma, and each should be considered when evaluating a should be considered when evaluating a patient with thoracic injurypatient with thoracic injury..

These organs include the chest wall; the These organs include the chest wall; the lung and pleura; the tracheobronchial lung and pleura; the tracheobronchial system, including the esophagus, diaphragm, system, including the esophagus, diaphragm, thoracic blood vessels, and thoracic duct; thoracic blood vessels, and thoracic duct; and the heart and mediastinal structuresand the heart and mediastinal structures. .

Chest wall injuryChest wall injury Most penetrating chest injuries are relatively Most penetrating chest injuries are relatively

innocuous ,morbidity usually relates to underlying visceral innocuous ,morbidity usually relates to underlying visceral injury,shotgun injuries to the chest wall,especially when delivered injury,shotgun injuries to the chest wall,especially when delivered at close range can be highly destructive,and chest wall integrity at close range can be highly destructive,and chest wall integrity can be desrupted.can be desrupted.

Both gunshot and stab wounds to the chest wall can injure an Both gunshot and stab wounds to the chest wall can injure an intercostal or internal mammary artery,When this intercostal or internal mammary artery,When this occurs,bleeding into the pleural cavity is more common than occurs,bleeding into the pleural cavity is more common than external bleeding because these arteries are adjascent to the external bleeding because these arteries are adjascent to the parietal pleura.massive intrapleural bleeding after penetrating parietal pleura.massive intrapleural bleeding after penetrating trauma is more commonly derived from the chest wall rather than trauma is more commonly derived from the chest wall rather than from the lungs .from the lungs .

Indications for urgent thoracotomy for haemothrax are drainage Indications for urgent thoracotomy for haemothrax are drainage of 1000 –1500 ml with initial tube thoracostomy with>100ml/hr of 1000 –1500 ml with initial tube thoracostomy with>100ml/hr for 4 hours after tube thoracostomy placement,these numerical for 4 hours after tube thoracostomy placement,these numerical guidelines are usefull but should always be combined with the guidelines are usefull but should always be combined with the clinical status of the patient and the appearance of the repeated clinical status of the patient and the appearance of the repeated chest films ,for example if the tube is placed for haemothorax and chest films ,for example if the tube is placed for haemothorax and drained 800ml,the patient should still undergo thoracotomy if drained 800ml,the patient should still undergo thoracotomy if there is alarge undrained hemothorax on follow up chest films or there is alarge undrained hemothorax on follow up chest films or if the patient remain haemodynamically unstable and other if the patient remain haemodynamically unstable and other sources of bleeding are unlikely.sources of bleeding are unlikely.

Air embolism and bullets embolism are unique to Air embolism and bullets embolism are unique to penetrating trauma.penetrating trauma.

Air embolism occurs when air moves from the airway Air embolism occurs when air moves from the airway into the pulmonary venous system through into the pulmonary venous system through atruamatic fistula ,although this is uncommon,the atruamatic fistula ,although this is uncommon,the consequences can be devastating .consequences can be devastating .

Air emboli delivered to the systemic circulation can Air emboli delivered to the systemic circulation can cause mortality or major morbidity if delivered to cause mortality or major morbidity if delivered to critical arteries such as those in the cerebral or critical arteries such as those in the cerebral or coronary circulation.coronary circulation.

Treatment of air embolus begins with control of the Treatment of air embolus begins with control of the bronchopulmonary venous fistula,this done via bronchopulmonary venous fistula,this done via thoracotomy and placement of ahilar crossthoracotomy and placement of ahilar cross--clampclamp..

Bullet embolus is also unique to penetrating Bullet embolus is also unique to penetrating trauma ,abullet or abullet fragments enter the venous trauma ,abullet or abullet fragments enter the venous system via an iliac vein,inferior vena cava,or another system via an iliac vein,inferior vena cava,or another large veinslarge veins. .

Lung injury .Lung injury .

Tracheobronchial injury.Tracheobronchial injury.

Esophageal injury.Esophageal injury.

Diaphragmatic injury.Diaphragmatic injury.

Great vessels injury.Great vessels injury.

Cardiac injuriesCardiac injuries

Traumatic cardiac penetration is highly lethal, Traumatic cardiac penetration is highly lethal, with case fatality rates of 70-80%with case fatality rates of 70-80%. . The degree of The degree of anatomic injury and occurrence of cardiac anatomic injury and occurrence of cardiac standstill, both related to the mechanism of standstill, both related to the mechanism of injury, determine survival probabilityinjury, determine survival probability. . Patients Patients who reach the hospital before cardiac arrest who reach the hospital before cardiac arrest occurs usually surviveoccurs usually survive. .

Ventricular injuries are more common than atrial Ventricular injuries are more common than atrial injuries, and the right side is involved more often injuries, and the right side is involved more often than the left sidethan the left side: :

Right ventricle - 43% Right ventricle - 43% Left ventricle - 34% Left ventricle - 34% Right atrium - 16% Right atrium - 16% Left atrium - 7%Left atrium - 7%

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