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Chest trauma

Primary survey chest injuries

  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • Massive haemothorax
  • Pericardial tamponade

Secondary survey chest injuries

  • Pulmonary contusion
  • Myocardial contusion
  • Aortic disruption
  • Traumatic diaphragmatic hernia
  • Tracheobronchial disruption
  • Oesophageal disruption

aortic rupture

Picture provided by Luis Pinheiro, Hospital Saint Teotonio, Viseu, Portugal

Traumatic left diaphragmatic hernia

Picture provided by Louis Alarcon, University of Pittsburgh Medical Centre, Pittsburgh, USA

Management of the unstable patient

Indications for emergency room thoracotomy

  • Acute pericardial tamponade unresponsive to cardiac massage
  • Exsanguinating intra-thoracic haemorrhage
  • Intra-abdominal haemorrhage requiring aortic cross clamping
  • Need for internal cardiac massage

Indications for urgent thoracotomy

  • Chest drainage >1500 ml or >200 ml per hour
  • Large unevacuated clotted haemothorax
  • Developing cardiac tamponade
  • Chest wall defect
  • Massive air leak despite adequate drainage
  • Proven great vessel injury on angiography
  • Proven oesophageal injury
  • Proven diaphragmatic laceration
  • Traumatic sepal or valvular injury of the heart

Haemothorax

  • Common after both penetrating and blunt trauma
  • Pleural cavity can hold up to 3 litres of blood
  • One litre may accumulate before apparent on chest x-ray
  • 90% due to injury to internal mammary or intercostal vessels
  • 10% from pulmonary vasculature
  • Bleeding usually stops when lung re-expanded
  • Most require no more than simple chest drainage

CT of haemopneumothorax assosciated with rib fractures

Picture provided by Rogerio Gonzaga,  Universidade de Porto, Portugal

Pericardial tamponade

  • Major complication of penetrating chest trauma
  • Haemopericardium prevents diastolic filling of the heart
  • Classic signs are Beck's triad
    • Hypotension
    • Venous distension
    • Muffled heart sounds
  • May be associated with pulsus paradoxus
  • Chest x-ray shows a globular heart
  • Unstable patient requires urgent thoracotomy
  • In stable patient diagnosis can be confirmed by
    • Echocardiography
    • Pericardiocentesis
  • Subxiphoid pericardiotomy is both a diagnostic and therapeutic procedure

Cardiac stab wounds

  • Right side of the heart is more commonly injured
  • Patients with right ventricular wound is more like to survive than with left sided injury
  • Atria, inflow and outflow tracts may also be damaged
  • Patients usually presents with pericardial tamponade
  • Treatment consists of resuscitation and pericardiocentesis
  • Stab wounds can be accessed via a median sternotomy
  • Can be directly repaired without cardiopulmonary bypass
  • Teflon-pledgeted prolene sutures are generally used

Injuries to the great vessels

  • Suspect possibility of injury from the mechanism or site of penetrating injury
  • Usually present with shock or pericardial tamponade
  • Chest x-ray may show:
    • Widening of the mediastinum to greater than 8 cm
    • Depression of the left main bronchus to greater than 140 degrees
    • Haematoma in the left apical area
    • Massive left haemothorax
    • Deviation of oesophagus ton the right
    • Loss of aortic knob contour
    • Loss of paraspinal pleural stripe
  • Requires emergency thoracotomy or sternotomy
  • Injuries to descending thoracic aorta require left anterior thoracotomy
  • Injuries to proximal aorta and proximal carotid arteries require median sternotomy

Flail chest

  • Flail chest is associated with multiple rib fractures on the same side
  • Flail segment does not have continuity with remainder of thoracic cage
  • Results in paradoxical chest wall movement with respiration
  • Often associated with underlying pulmonary contusion
  • Paradoxical movement results in impaired ventilation
  • The work of breathing is increased
  • Ventilation perfusion mismatch and arterio-venous shunting occurs
  • Chest x-ray will show
    • Multiple rib fractures
    • Underlying lung contusion
    • Haemopneumothorax
    • Other associated injuries
  • Treatment requires
    • Adequate ventilation
    • Humidified oxygen
    • Adequate analgesia
  • Consider intubation and ventilation if
    • Significant other injuries (ISS >50)
    • Respiratory rate more than 35 per min
    • Partial pressure oxygen less than 8.0 kPa
    • Partial pressure carbon dioxide greater than 6.6 kPa
    • Vital capacity less than 12 ml / kg
    • Right to left shunt of more than 15%
  • Operative fixation is not normally required

Multiple right rib fractures with flail segment

Bibliography

Asensio J A,  Soto S N,  Forno W et al.  Penetrating cardiac injuries:  a complex challenge.  Injury 2001;  32:  533-543.

Easter A.  Management of patients with multiple rib fractures. Am J Crit Care 2001; 10:  320-327.

Salehian O,  Teoh K,  Mulji A.  Blunt and penetrating cardiac trauma:  a review.  Can J Cardiol 2003;  19:  1054-1059.

Wall M J,  Hirschberg A, LeMaire S A et al.  Thoracic aortic and thoracic vascular injuries.  Surg Clin North Am 2001;  81:  1375-1393

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