Thoracic Trauma

Thoracic Trauma

NO.1 Clinical Medicine School of Zheng Zhou University Thoracic Surgery Department

General Concept 1.

Anatomic and physiologic features

Anatomic and physiologic features

Characteristics of trauma

About

High morbidity

½ of trunk occupied

Respiratory

center

& circulatory

Bony

thorax: supporting, protection breathing

High mortality Higher violence tolerance Handicap in respiration

Balanced

bilateral negative Lung compression & pressure of the pleural cavity mediastinal shift

Blood

vessel: artery---large diameter, high pressure

Fatal bleeding

Anatomic and physiologic features

Characteristics of trauma

vein---

large diameter, Severe bleeding, negative obstacle to blood return pressure gradient redounds Traumatic Asphyxia to blood return, no venous valve Pericardium

Two

& Heart

cavities with different pressure are divided by the

Cardiac tamponade, rupture Thoracoabdominal injury, Diaphragmatic

2. Violence and trauma

Violence Fire-arm

Stab

Characteristics of trauma injury

wounds

Decelerative

Acute violence, labyrinthian trajectory, close relationship with posture, perforating wounds mainly Short straight wound tract, blindgut wounds mainly

injury Traffic accident, falling

Crush

injury

Earthquake, disturbance in public

Crash

injury

Collision, the part been hit

Blast

injury

Respiratory tract, body surface

3.

Classification 3.1 Logic of classification





According to variety of violence Penetrating chest injury Blunt chest injury According to whether there is any communication between pleural cavity and atmosphere Open chest injury Closed chest injury

3.2 Comparison of different thoracic trauma Penetrating chest injury

Blunt chest injury

Simple

Complex mechanism, prone to misdiagnosis or diagnosis missed

mechanism, easy diagnosis

Close

relationship with wound Hard to evaluate, rib fracture is common tract

Combined Visceral

injury rare

disruption common

Combined injury common Contused wound common

Bleeding

Edema

Rapid

Slow progress (measured by days)

hours)

progress (measured by

Penetrating chest injury

Blunt chest injury

Surgical

treatment often Surgical requirement not so often needed

Early

death, mainly from Late death, mainly from circulatory respiratory hemorrhagic shock insufficiency

4. Principle of diagnosis and treatment

4.1 Concept of time-effect

Time-effect: 

Time and outcome of trauma progress



Time and effect of diagnosis and management



Golden hour

4.2 

Diagnosis

Variety of trauma, mechanism of damage, time course after injury, vital signs

Evaluation of trauma

Physical Exam

Hypotension: bleeding, jugular vein collapse, CVP, cardiac sound, trachea Respiratory distress: Dyspnea, asthma, paradoxical movement of chest wall,

Appendix findings: X-ray, Ultrasound, diagnostic puncture, etc.

4.3 principle of treatment in early stage of chest injury



Keep airway



Analgesia



Close sucking chest wound



Prevent and treat shock



Improve respiratory function



Prevent infection

4.4 Indications of thoracotomy 

Progressing intrathoracic bleeding



Massive pulmonary laceration or bronchial rupture



Lesions of heart or great arteries



Thoracoabdominal injury



Esophageal rupture



Large defect of chest wall



Foreign body remained in thoracic cavity

4.5 Indications for Emergency Room Thoracotomy 

Profound shock as a result of penetrating chest injury



The one on the brink of death after penetrating chest injury, and high suspicion of pericardial tamponade

Rib Fracture

1. Costal anatomy and trauma rib Characteristics of trauma 1-3rd rib

Hard to be broken, comorbidity of clavicular and scapular fracture, cervical and axillary neuro-vascular lesions are common

4-7th rib

Easy to be broken, leading to pulmonary and intercostal vessel lesion

8-12th rib

Hard to be broken, often accompanied by abdominal and diaphragmatic injury

Multi“Flail chest”, floating chest wall, rib/segment paradoxical respiration, ARDS fracture

2. Pathophysiology and manifestation Rib Fracture ： Intercostal nerve—pain— ventilation , secretion atelectasis Floating wall —paradox. Resp. —ventilation , lung compression, mediastinal pendelluft Intercostal vessel —Hemothorax ——ventilation , lung compression, blood loss Lung tissue —Pneumothorax —ventilation , lung compression Visceral lesion —blood loss

Chest pain And tenderness

Closed single RF

Chest Complica tion

X-RAY of Closed single RF

Closed multi-rib/segment RF Floating wall

3. Diagnosis 

Distinguishing chest pain



Distinguishing tenderness and bony crepitus (thoracic crushing test)



X-ray

4.

Treatment

Principle: 

Analgesia



Airway secretions clearance



Chest cage fixation



Complication prevention and treatment

Local management: 

Closed single RF-----broad adhesive tape, elastic chest bandage



Closed multi-rib/segment RF-----same as above, fixation by traction, fixation by surgery, mechanical ventilation



Open RF-----debridement and fixation

Severe complications: 

Pulmonary contusion often present in severe chest wall injury



Severe pulmonary contusion often results in acute respiratory insuffeciency



ARDS

Pneumothorax

1. Anatomic and physiologic features 

Alteration of thoracic pressure is closely relative to the severity of Pneumothorax



Pneumothorax does harm to circulatory function as well as respiratory function



Mediastinum is fixed at the two ends and flexible at the middle, which could be shift aside as a result of unbalanced thoracic pressure



Location of gas in pleural cavity and fibrothorax

2. Principles of classification According to the thoracic pressure

3. Origin of intrathoracic air

Lung, Tracheobronchial, Esophagus, Out side, etc.

4.

Closed Pneumothorax



Intrathoracic pressure < atmosphere



Lung compression, Mediastinal shift, Trachea deviation



Asymtomatic  dyspnea, measured by the amount and leaking speed of the air



PE: Trachea deviation, percussion/auscultation, X-ray, diagnostic puncture



Loculated Pneumothorax----pleural synechia, a special type



Same principle as above, thoracentesis needed in > 30% cases

Closed Pneumothorax

5.

Open Pneumothorax



Intrathoracic pressure = atmosphere



Dyspnea, Sucking wounds



Lung collape, Mediastinal shift/pendelluft, circulatory disturbance



Obvious Trachea deviation, percussion /auscultation, X-ray

Lung collape

Cavity vein contortion

Mediastinal shift

circulatory disturbance

Principle of treatment: 

Take open pneumothorax into closed one Thoracostomy: Mechanism and method

6. Tension Pneumothorax  

 

Intrathoracic pressure > atmosphere one-way valve Lung collapse in the injured side, lung compression in the opposite side, severe mediastinal shift, circulatory & respiratory insufficiency Respiratory distress, subcutaneous emphysema Marked deviated trachea, evidence of positive intrapleural pressure suggested by palpation/percussion/ auscultation and thoracentesis

Intrathoracic pressure > atmosphere

Lung collapse

lung compression

Severe mediastinal hift

circulatory & respiratory insufficiency

one-way valve

spiratory distress, subcutaneous emphysema

Emergency management: 

Thoracentesis



Tube thoracostomy, suction



Thoracotomy if necessary

Hemothorax

1.

Source of hemothorax



Pulmonary parenchymal laceration



Intercostal vessel injury



Major cardiac and vascular injury



Injury of phrenic vessel

2.  

Pathophysiology of hemothorax

Lung compression Mediastinal shift



Blood loss Coagulation



Infection



Respiratory & circuLatory dysfunction

Progressive hemothorax Clotted hemothorax Organized hemothorax Infective hemothorax Empyema

3. Diagnosis 

Small amount (  0.5l for adult )



Middle amount (0.5-1l )



Large amount ( >1l )



History and PE: Vital signs, inspection/ palpation/percussion/auscultation



X-ray: pleural effusion, location



Thoracentesis

4.

management



Hemothorax------Thoracostomy



Progressive hemothorax-----Thoracotomy



Clotted hemothorax-----Thoracotomy



Infective hemothorax-----Thoracotomy

Traumatic Asphyxia

1. Pathophysiology and mechanism  





Sharp rise in intrathoracic pressure Marked increased pressure in Sup. Vena. Cava results in capillary rupture No venous valve in SVC, pressure conducts to head and neck Impairment of cerabral venous outflow increases intracranial pressure

2. Clinical presentation 

 

 

Edema and cyanosis of the head and neck, petechiae, subconjunctival hemorrhage Epistaxis Perforation of tympanic membrane, Tinnitus and deafness Mucosal bleeding Depressed level of consciousness, seizures, temporary or permanent blindness

3. Treatment and prognosis 

Relief of symptoms



Neurologic status been monitored



Venous drainage promotion



Elimination and management of other intrathoracic injuries

Prognosis: Excellent

Cardiac injury

1. Pathophysiology and mechanism 

Blunt injury------Myocardial contusion, cardiac rupture



Penatrating injury----stab (cardiac laceration) fire-arm (laceration or/ and foreign bodies)

2. 

Cardiac contusion

Be precautious of the incidence: Anterior chest wall crush, sternal fracture, falling, etc.



Lack of diagnostic means with high sensitivity and specificity: ECG, UCG, CK, CK-MB, LDH, LDH1.2 Cardiac Troponin I ( CTnI )



Complication: Cardiac Arrhythmia, Heart failure



Management: Symptom relief, complication prevention and treatment

3. Cardiac laceration 



Classification according to clinical features: Subclinical type, Tamponade type, hemorrhagic shock type Diagnosis: Wound around the body surface of the cardiac projection Time after damage, Beck’s triad Hemorrhagic shock



Management: Surgery as soon as possible !

Thoracoabdomin al injury

Denomination 2. Clinical presentation and diagnosis  Incidence: left >right  Symptom & signs: thoracic +abdominal  X-ray 3. Treatment  Surgical procedure  Surgical incision 1.