Chest trauma

Chest Trauma

The torso is generally regarded as the area between the neck and the groin, made up of the thorax and abdomen. This is the largest area of the body and is commonly injured following both blunt and penetrating trauma. Because injury does not respect anatomical boundaries, division of the body into abdomen and thorax is artificial, and injury to the torso, with its associated physiological
consequences, is more appropriate.
Thoracic injury accounts for 25% of all injuries, and is responsible for over 70% of all deaths following road traffic accidents. Early deaths after thoracic trauma are caused by hypoxaemia, hypovolaemia and tamponade. Early management and resuscitation of such patients should follow the ATLS guidelines which includes:
Early assessment and primary survey
Simultaneous aggressive resuscitation
A careful secondary survey with full examination
Transfer to a definitive site of care

Approach to a patient presented with chest trauma:

ATLS support (ABC)
Clinical examination including assessing lung expansion, auscultation of back and front, assessing position of trachea and heart apex.
Chest X-ray: provided that it does not interfere with resuscitation. Preferably in erect position but even in supine will be helpful.
Ultrasound: mainly to differentiate between hemothorax and lung contusion (since both give white opacity on X-ray)
A chest tube which can be both diagnostic and therapeutic.
CT scan of the chest if indicated and can be afforded.

Management of a patient with chest trauma:

About 80% of patients with chest injury can be managed non-operatively with
Appropriate resuscitation following ATLS guidelines:
The airway must be controlled
Breathing assessed and established immediately if necessary.
Circulation must be supported through rapid establishment of reliable, large-bore venous access and the initiation of fluid resuscitation.
The patient’s neurological disabilities are quickly assessed,
The entire body is exposed to note significant deformities or penetrating injuries
Adequate drainage of the pleural cavity using a wide bore chest tube.
This will usually be sufficient to stabilize the patient followed by
Pain relief to ensure normal breathing and gas exchange and allow physiotherapy
Attending all wounds, by removal of all foreign material, debridement, with or without primary closure.
Early physiotherapy.
This is applicable for most patients with simple rib fracture, simple sternal fracture, mild to moderate hemothorax, traumatic pneumothorax, and those with a small lung contusion
An appropriate size chest tube will evacuate most of the blood and air within the pleural cavity and this will allow the lung to expand and tamponade most bleeders so bleeding ceases. Failure of such scenario may necessitate thoracotomy to stop the bleeding.
If a sucking chest wound is present, this should not be fully closed (until adequate size chest drain inserted) but should be covered with a piece of plastic, closed on three sides, to form a one-way valve, and then an underwater drain should be placed. No attempt should be made to close a sucking chest wound until controlled chest drainage has been achieved.
Causes of early death following chest trauma and their management:
Life-threatening injuries can be remembered as the deadly dozen. Six are immediately life-threatening and should be sought during the primary survey and six are potentially life-threatening and should be detected during the secondary survey.
Immediately life threatening conditions: Efficient initial assessment (1ry survey) should focus on identifying and correcting the immediate threats to life and these include:


Airway obstruction: due to dentures, teeth, secretions, blood, fracture mandible, neck hematoma…etc.
Treatment: early control of airway by,
Positioning, e.g.; head to the side or putting the patient in left lateral position
Removal of foreign bodies,
Oropharyngeal airway,
Endotracheal tube which should be considered early in patients with fractured mandible, neck hematomas, laryngeal injury,…etc. or
Tracheostomy.

Tension pneumothorax: develops when a ‘one-way valve’ air leak occurs either from the lung or through the chest wall. Air is forced into the thoracic cavity without any means of escape, completely collapsing the affected lung. The mediastinum is displaced to the opposite side, decreasing venous return and cardiac output and compressing the opposite lung.
Clinical presentation: patient shocked, dyspneic, tachypniec with distended neck veins. On examination: tracheal deviation, hyperresonance and absent breath sounds on affected hemithorax. Tension pneumothorax is a clinical diagnosis and treatment should not be delayed by waiting for radiological confirmation
Treatment: large-bore needle into the second intercostal space in the mid-clavicular line of the affected hemithorax followed by chest tube insertion.

Pericardial tamponade: (due to penetrating cardiac injury) Accumulation of a relatively small amount of blood into the non-distensible pericardial sac can produce physiological obstruction of the heart
Clinical presentation: hypotension, tachycardia, distended neck veins, elevated venous pressure (cardiogenic shock) and muffled heart sounds.
Chest X-ray showing an enlarged globular heart,
ECG showing low voltage QRS,
FAST, echocardiography or pericardiocenthesis can help in the diagnosis.
Treatment: early operative treatment through a sternotomy incision is indicated. Pericardiocenthesis for removal of small amount of blood from the pericardium to allow better patient transport to the O.R. is controversial as this itself may add insult to injury

Open pneumothorax: due to large chest wall defect (>3 cm) resulting in a sucking wound. So air moves into and out of the defect with each inspiration and expiration (rather than through the normal airway) leading to ineffective ventillation with hypoxia and hypercapnia.
Initial treatment: closing the defect with a sterile dressing taped on three sides to act as a flutter-type valve (one way valve) followed by chest tube insertion.
Definitive treatment: operative wound debridement and closure (sometimes even with muscle flaps to close the pleural cavity).


Massive hemothorax: most commonly due to trauma to intercostal vessels or internal mammary artery. The blood accumulates in the pleural cavity therefore compressing the lung and interfering with normal respiration.
Clinical presentation: haemorrhagic shock with flat neck veins, unilateral absence of breath sounds and dullness to percussion
Treatment: correcting the hypovolaemic shock, and insertion of a wide bore intercostal drain. Blood in the pleural space should be removed as completely and rapidly as possible to prevent on-going bleeding, empyema or a late fibrothorax. This treatment is sufficient in most patients as expansion of the lung will tamponade the bleeders and prevent further loss.
Emergency thoracotomy is indicated when:
Initial drainage of more than 1500 ml of blood or
On-going haemorrhage of more than 200 ml/h over 3 hours or
Evidence of retained clot inside the chest
Continued shock despite adequate resuscitation, and proper size chest tube
Thoracotomy here is done through a conventional postero-lateral incision or through an antero-lateral incision for hemodynamically unstable patients. Mechanical ventilation is preferably done with the use of a double lumen endotracheal tube. A general rule in thoracic trauma surgery is to spare as much lung as possible and avoid anatomical resection.

Flial chest: this usually results from blunt trauma associated with multiple rib fractures i.e., three or more ribs fractured in two or more places.
It results in paradoxical movement of the chest wall with inspiration (so that on inspiration; the negative pressure in the chest pulls the unstable segment inwards and on expiration it pushes it outwards in a paradoxical motion). The patient may be unable to develop sufficient intratracheal negative pressure to maintain adequate ventilation. And this leads to atelectasis, hypoxia and hypercapnia. The blunt force required to disrupt the integrity of the thoracic cage typically produces an underlying pulmonary contusion as well. Also these patients are at high risk for developing pneumothorax and hemothorax.
Diagnosis:
Patient dyspneic
Chest wall movement asymmetrical and paradoxical (this can be seen when the chest wall is observed for several respiratory cycles and during coughing).
Palpation of abnormal respiratory motion and crepitus of rib fracture.
CXR: multiple rib fractures
Arterial blood gas: hypoxia and hypercapnia.
Treatment:
Chest tube insertion (wide bore).
Oxygen administration, adequate analgesia (including opiates) and physiotherapy.
All patients should be observed in a high dependency unit with hourly blood gas monitoring
Administrate fluid judiciously: fluid intake reduced to 2/3 of requirement.
Patients who develop respiratory failure despite above treatment, require stabilization of the flial segment by:
Muscle relaxant, and mechanical ventilation to splint the chest till fusion of the broken ribs has occured, or
Surgical stabilization of the fractured segment, either by traction of the fractured ribs or by internal fixation.
Potentially life threatening conditions: A high index of suspicion must be maintained to diagnose the potential threats to life as their symptoms and signs can be very subtle
Aortic rupture: is a common cause of sudden death and usually due to blunt trauma (more specifically deceleration injury). The aortic arch is relatively mobile while the descending aorta is fixed (just distal to the left subclavian artery and ligamentum arteriosum). This is the most common site of aortic rupture. The clinical presentation and degree of shock depends on the size of the rupture and whether all the layers of the aortic wall have been disrupted or not. So clinical presentation may range from sudden death following a road traffic accident due to complete aortic disruption to a patient presented long time after with a pseudoaneurysm due to an intimal tear.
It should be clinically suspected in patients with asymmetry of upper or upper and lower extremity blood pressure, widened pulse pressure and chest wall contusion.
Investigations: CXR show a widened mediastinum. The diagnosis is confirmed by aortography or a contrast spiral CT scan of the mediastinum and to a lesser extent by transoesophageal echocardiography.
Treatment: Initially, management consists of control of the systolic arterial blood pressure (to less than 100 mmHg).
Definite treatment consist of endovascular intra-aortic stenting or left sided thoracotomy with repair of the aortic tear.


Tracheo-bronchial injuries: these patients are presented with pneumothorax, severe subcutaneous emphysema and respiratory compromise. A wide bore chest tube will reveal a massive air leak with failure of the lung to inflate. If after insertion of two drains the lung still fails to re-expand, tracheal or major bronchial injury should be suspected.
Investigations: Bronchoscopy is diagnostic although not needed.
Treatment involves intubation of the unaffected bronchus (with the aim to bypass the lesion) followed by operative repair.
Tracheobroncheal injury may be due to blunt trauma or penetrating trauma

Myocardial contusion: (due to blunt trauma) Significant blunt cardiac injury that causes haemodynamic instability is rare. Blunt myocardial injury should be suspected in any patient sustaining blunt trauma who develops ECG abnormalities in the resuscitation room. All patients with myocardial contusion are at risk of developing sudden arrhythmias and should be monitored for the first 24 hours. After this interval the risk for sudden onset of arrhythmias decreases substantially
Clinically, there are few signs and symptoms that are specific for blunt cardiac injuries. Sternal or rib injuries may or may not be present. Chest pain is common, and usually related to external injuries.
Investigation: there is no gold standard test and a high index of suspicion is required. The most reliable sign of significant injury to the myocardium is an abnormal ECG, echocardiography and cardiac enzymes may also be helpful.
Treatment: conservative treatment is all that is required in most cases.

Rupture diaphragm: Any penetrating injury to or below the fifth intercostal space should raise the suspicion of diaphragmatic penetration and, therefore, injury to abdominal contents. Blunt trauma tend to cause large diaphragmatic injuries with herniation of the abdominal contents into the chest while penetrating injury cause smaller tears. Most diaphragmatic injuries are silent and the presenting features are those of injury to the surrounding organs.
Investigations: There is no single standard investigation CXR with or without contrast, and CT may be helpful. The most accurate evaluation is by thoracoscopy (VATS) or laparoscopy.
Treatment: Operative repair is recommended in all cases. All acute diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out abdominal viscus injury.

Esophageal injuries: (mostly due to penetrating trauma) The esophagus is more commonly injured in the neck, where it is most exposed. However, thoracic esophageal injuries carry high morbidity and mortality rates A high index of suspicion is required if the diagnosis is to be made in a timely manner.
Presentation: The patient can present with odynophagia, subcutaneous or mediastinal emphysema, pleural effusion, and unexplained fever within 24 hours of injury. The mortality rate rises exponentially if treatment is delayed for more than 12–24 hours.
Investigations: A combination of oesophagogram in the decubitus position and oesophagoscopy confirm the diagnosis in the great majority of cases.
Treatment: The treatment is operative repair and drainage.

Pulmonary contusions: Pulmonary contusion is caused by haemorrhage into the lung parenchyma, usually underneath a flail segment or fractured ribs. This is a very common, potentially lethal chest injury and the major cause of hypoxaemia after blunt trauma. It is a risk factor for developing pneumonia and adult respiratory distress syndrome (ARDS).
Clinical presentation: Classic symptoms include dyspnea, tachypnea, hemoptysis, cyanosis, and hypotension
Physical examination can demonstrate inspiratory rales and decreased breath sounds on the affected side
The natural progression of pulmonary contusion is worsening hypoxemia for the first 24–48 hours.
Investigations: The chest radiography findings are typically delayed. If abnormalities are seen on the admission chest radiograph, the pulmonary contusion is severe. CT scan is the study of choice.
Treatment:
All patients should be observed on supplementary oxygen in a hospital setting because their ventilatory status tends to deteriorate rapidly
In mild contusion the treatment is oxygen administration, aggressive pulmonary toilet and adequate analgesia.
Patients with significant hypoxia with PaO2 <65 mmHg and SaO2 <90% should be intubated and mechanically ventilated


Emergency thoracotomy:
Thoracotomy can be broadly divided into the following:
Emergency (resuscitative) thoracotomy for control of life threatening bleeding;
Planned thoracotomy for repair of specific injury.
It is far better to perform a thoracotomy in the operating room, with good light and assistance, than it is to attempt heroic emergency surgery in the resuscitation suite. However, if the patient is in extremis with a falling systolic blood pressure, despite volume resuscitation, there is no choice but to proceed immediately with a left anterolateral thoracotomy in an attempt to relieve the situation. Emergency room thoracotomy (ERT) should be reserved for those patients suffering penetrating injury in whom signs of life are still present.