Chest Trauma

Chest Trauma
by:Kent J. Blanke, D.O., FACOS
Introduction
Thoracic Trauma
Penetrating Chest Injuries
* Majority are stab wounds or gunshot wounds (GSW)
* Lower mortality rates--less likely to include multiorgan injury
* 85% of penetrating chest wounds can be treated with tube thoracostomy and supportive measures
Penetrating Chest Trauma
* Wounds that enter or exit inferior to the nipple or the posterior tip of scapula may perforate the dome of the diaphragm.
* Any penetrating wound such as this should be considered to have an abdominal component until proven otherwise.

Penetrating Chest Trauma: Treatment
* ATLS protocol: A,B,C,D,E’s
* Emergency management
o Needle thoracentesis
o Tube thoracostomy
o Subxiphoid pericardotomy
o Video assisted thoracic surgery (VATS)

Work-up of Penetrating Chest Trauma
* Physical examination
o Look, Listen, Feel
o Contusions, diminished or absent breath sounds, SQ emphysema can readily be found
* CXR- best, least expensive and fastest initial evaluation
* Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
* Angiography- to look for great vessel injuries
* CT Scan: for better evaluation of chest wall and parenchyma
* Transesophogeal Echocardiography

Penetrating Chest Injuries
* Operative intervention required for:
o Massive or persistent bleeding
o Massive air leak
o Tracheobronchial injuries
o Esophageal perforation
o Cardiac or great vessel injuries
o Post-traumatic empyema
* Wounds that enter or exit inferior to the nipple or the posterior tip of scapula may perforate the dome or the diaphragm.
* Any penetrating wound such as this should be considered to have an abdominal component until proven otherwise.

Penetrating Chest Trauma:Indications for Mechanical Ventilation
Intrapulmonary Foreign Bodies
* Bullets, fragments: indications for removal
Intrapulmonary Foreign Bodies
Pulmonary Parenchymal Laceration
High Velocity Missile Injuries
Blunt Chest Trauma
Categories of chest wall injuries
* Open pneumothorax
* Contusion and Hematoma
* Sternal fractures
* Scapular fractures
* Flail chest
* Intercostal vessel injury
Categories of Intra-thoracic Injuries
* Pulmonary
o Pneumothorax, hemothorax
o Pulmonary contusion
o Pulmonary laceration
* Vascular
o Great vessel disruption (Ao dissection, pulmonary vasculature)
* Cardiac
o Blunt Cardiac Injury, Penetrating injury

Work-up of Blunt Chest Trauma
* Physical examination
o Look, Listen, Feel
o Contusions, diminished or absent breath sounds, SQ emphysema can readily be found
* CXR- best, least expensive and fastest initial evaluation
* Ultrasound-may soon replace CXR as initial radiographic study in chest trauma
* Angiography- to look for great vessel injuries
* CT Scan: for better evaluation of chest wall and parenchyma
* Transesophogeal Echocardiography

Categories of chest wall injuries
* Contusion and hematoma

Categories of chest wall injuries
* Open pneumothorax
* Pneumothorax
Operative Intervention for Hemothorax
* As noted previously
* Hemothorax: massive = initial drainage more than 1,000 cc or
* Continuous bleeding of 200 cc/hr for 2 hrs

Fractured Ribs: Chest Wall Trauma
Blunt Cardiac Injury
Categories of chest wall injuries
* Sternal fractures
Categories of chest wall injuries
* Scapular fractures
* Flail chest
Pulmonary Contusion
Intra-thoracic Trauma: Pulmonary Contusion
Intra-thoracic Trauma: Great Vessel and Mediastinal Trauma
* Aorta
* Pulmonary vessels
* Tracheobronchial lacerations
* Esophageal lacerations

Intra-thoracic Trauma: Great Vessel and Mediastinal Trauma—Work-up
* Plain CXR to identify thoracic aorta injuries
* Look for air in the mediastinum
* Persistent airleak should cue into:
o Bronchopulmonary or tracheobronchial injury
* Mediastinitis, tube feedings in chest tube or saliva in chest tube should cue into:
o Esophageal injury
* Bronchoscopy
* Esophagoscopy
* CT
* Serial CXR

Initial CXR of Concern

Indications for Angiography
* Lateral deviation of the NGT in esophagus
* Widened mediastinum (>8cm)
* Loss of visualization of the aortic knob
* Hematoma of the Left cervical pleura (pleural cap)
* Depressed left main stem bronchus
* Rt lateral deviation of the trachea
* Widened mediastinum (>8cm)
* Forward displacement of the trachea on the lateral CXR
* Fx of the 1st or 2nd rib
* Massive chest trauma w/ multiple rib fx
* Fx or dislocation of the thoracic spine
* Major deceleration injury
Complete Aortogram

Chest Trauma.ppt