Thoracic Surgery
Lce : 9
Thoracic Injuries :-
Account for 25% of all injuries,
usually they life-threatening and occur due to bleeding
but fourtunately 80% can be manged conservatively by
proper Dx and resuscitation.
Immediate Life Threatening Injuries :-
1. Air Way Obstruction :- Early preventable trauma
deaths are usually dueto lack of or delay in air way
control.
Air way obstruction in trauma usuallycaused by :- 1.
Dentures , teeth , secreation and blood 2.Bilateral
mandibular fracture. 3.expanding neck hematoma cause
compression and deviation of trachea. 4.Laryngeal or
Tracheal injuries.
Mx :- Early endotracheal intubationis important
especially in case of neck hematoma or air-way edema
with protection of cervical spine if their injury is
suspected to prevent damage to cervical cord.
2. Cardiac Temponade :- Lec 4
3. 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 mean of escape, completely collapsing the affected
lung, the Mediastinum is displaced to the opposite side ,
decreasing the venous return and compressing the
opposite lung.
Etiology :- 1. Penterating chest trauma 2. Blunt chest
trauma with parenchymal lung injury and air leak that did
not close spontenously 3. Iatrogenic lung
puncture e.g from Subclavian central venous insertion.
4. mechanical positive pressure ventilation.
C.F :- 1. The Pt. is panicky with dypnea , tachypnea and
distended neck veins with cyanosis.
O/E :- tracheal deviation , hyperresonant and absent
breath sounds over the affected hemithorax
Tension Pneumothorax is a clinical Dx. And Rx
must not be delayed waiting for Radiological
confirmation.
nd
of large bore needle into 2
. Rapid insertion
1
-
Rx :
intercostal space in the Mid-clavicular line of the
affected hemithorax
.
ICS between
th
through 5
.insertion of chest tube
2
anterior and mid axillary line and direct it to apex of
hemithorax.
4. Open Pneumothorax :- is dueto large defect in the
chest wall > 3 cm leading to equilibration between
intrathoracic and atmospheric pressure , air accumulate
in hemithorax with each inspiration leading to profound
hypoventilation on the affected side and hypoxia.
Mx :- 1. close the defect with a sterile occlusive plastic
dressing taped on three sides act as a flatter-type valve.
2.a large bore chest tube is inserted in a site away from
the site of injury , if the lung doesnot expand the drain
must be connected to low pressure suction , a2nd drain is
sometimes necessary
3. debridement and closure of chest wall defect usually
done in the operative room.
5. Massive Heamothorax :- in blunt trauma is caused by
continous bleeding from torn intercostal or internal
mammary artery.
Accumulationof blood in the hemithorax compress the
lung and prevent adequate ventilation.
C.Fs :- pt. present with signs of heamorrhagic shock
(tachycardia and hypotension) with flat neck veins ,
unilateral absence of breath sounds and dullness to
percussion.
Rx :- 1. insertion of chest tube to remove the blood
completely
2. correct hypovolemic state by using central venous line
and replacement by crystalloid and colloids , sometimes
Endotracheal intubation may be necessary.
3. initial drain > 1500ml or continous bleeding > 200ml
/hr.for 3 hr.s indicates urgent Thoracotomy
6. Flial chest :- usually result from blunt trauma when 3
or more ribs fractured at 2 or more places producing a
loose segment of chest wall moves paradoxically with
respiration i.e moves inwards during inspiration this
together with lung contusion and pain result in hypoxia ,
a heamo and /or pneumothorax may be associated.
Mx 1. Oxygen administration 2.Adequate
analgesia and physiotherapy 3. chest tube insertion
when necessary.
Potenially Life Threatening injuries :-
1. Thoracic Aortic disruption :- Traumatic aortic rupture
is common cause of sudden death after Blunt trauma e.g
automobile collision or fall from height ,with
deceleration the aortic arch moves anteriorly while the
descending aorta is relatively fixed distal to ligamentum
arteriosum just distal to origin of subclavian A. this will
produce a shearing forces from the sudden impact will
disrupt the intima and media, if the adventetia is intact
the Pt. may remain stable but require Urgent Rx.
Dx :- Pt. with blunt chest trauma + Asymmetry of upper
and Lower limb Pressure + widen Pulse pressure , We
must suspect the injury , CXR in erect position shows
Widen Mediastinum
Dx is confirmed by Arch Aortography OR CT
angiography
Mx :- 1. control systolic BP < 100 mm Hg.
2. Use of Endovascular intra-Aortic Stent can be placed
or by surgery either repair OR Excision and grafting
using a Dacron graft.
2. Tracheobronchial injuries :- Pt. present with severe
subcutaneous emphysema withrespiratory compromise ,
chest tube shows massive air leak and lung fail to expand
, Bronchoscopy is diagnostic
Rx :- ETI of unaffected side followed by operative repair
of the injury.
3. Blunt Myocardial injury :-
ny penetrating injury below
a
-
4. Diaphragmatic injury :
ICS suspect it and Dxic Laproscope m.b required.
th
5
Blunt chest trauma can cause diaphragm rupture which
may be missed , it occurs mostly on left side.
Dx :- CXR after placement of Nasogastric tube can show
the stomach herniated to chest
Rx :- Diaphragm rupture when Dxed Acutely must be
repaired through laprotomy this will help toexamin
abdominal structures to exclude injury , but when Dx is
missed initially and injury discovered later it must be
repaired by thoracotomy.
5. Esophageal injury :- mostly caused by penetrating
trauma , it must be kept in mind , Pt. presnt with
odynophagia (pain on swallowing of food or fluids ) ,
subcutaneous or mediastinal emphysema , pleural
effusion , air in retroesophageal space and unexplained
fever with in 24 hours of onset of injury.
Dx:- Esophagogram in supine position + Esophagoscopy
Rx :- Operative repair and drainage.
6. Pulmonary contusion :- caused by bleeding into lung
parenchyma secondary to blunt trauma , Pt. present with
hypoxemia with in 24 – 48 hours of injury , sometimes
with hemoptasis.
Dx by CXR which shows opacified lung.
Rx O2 adminstration + analgesia + chest physiotherapy ,
in severe casesmechanical ventilation is required.