Mechanisms of injury

• blunt injuries
• crush injuries
• penetrating injuries
• inhalation burns
• aspiration of foreign bodies

2 major forces within chest which lead to injury: compression and distraction.
Compression results in destruction of vascular components, haemorrhage, oedema and
impairment of function. Distraction injuries usually result in shearing forces which
destroy integrity of intrathoracic viscera

Blunt trauma

- mode of injury important

- where there has been massive deformity of a car or a history of a fall of 5 metres or
more major intrathoracic injuries should always be suspected. The physical nature of
chest wall allows for considerable elastic recoil, especially in young patients and
therefore degree of injury within chest may need to be judged initially by deformity to
car rather than appearance of patient
- blunt injuries occur in 3 major directions: AP, lateral and transdiaphragmatic
- AP deformity results in relative backward motion of heart. This may result in disruption
of aorta at level of ligamentum arteriosum just below left subclavian. As heart swings
back and up it may cause so-called wishbone # of a proximal bronchus
- injuries to heart occur in up to 1/2 of patients after deceleration injuries
- deceleration with impact to back causes relatively few intrathoracic injuries
- lateral compression of chest during deceleration causes fractures typically of lower ribs
with risk of injury to liver, spleen and kidneys
- when lateral compression results in flail segments damage to thoracic cavity is usually
relatively small and most frequently limited to contusion and laceration of lung
parenchyma
- lap belt of seat belts leads to rise in intrabdominal pressure in massive deceleration
and this, combined with shearing and twisting of upper trunk may result in
diaphragmatic rupture

Penetrating injuries

• result in parenchymal damage related to track of missile or stabbing implement

and velocity
• more solid structures (eg heart and major vessels) suffer greater injury where
high-velocity missiles are penetrating weapon
• most lethal complication is haemorrhage
• often associated with abdominal trauma

Crush injury

• occurs where elastic limits of chest and its contents have been exceeded
• patients usually have AP deformity
• majority have flail chests with multiple fractures, pneumothorax or haemothorax
• most have pulmonary contusion
 • injuries of heart, aorta, diaphragm, liver , kidney and spleen are common
• another group of patients with crush injuries are those with "traumatic asphyxia"
syndrome, where constrictive forces are applied over a wide area for as little as 2-
5 mins. Profound venous hypertension associated with relative stasis is mechanism
of injury. There is widespread capillary dilatation and rupture, subconjunctival
haemorrhage and retinal haemorrhage. Simultaneous injuries (eg intracranial
haemorrhage) must be suspected
• severe crush injuries have a high mortality

Chest trauma haemodynamics

• hypovolaemia most important mechanism

• cardiac tamponade
• myocardial contusion
• valve injury
• intracardiac shunt

Chest trauma hypoxia

Due to:

• reduced blood volume

• ventilatory failure
• contusion
• displacement of mediastinum
• pneumothorax

Clinical features:

Initial history and examination are often abbreviated

Examination

• air hunger; use of accessory muscles; tracheal deviation; cyanosis or distended

neck veins; (evidence of tension pneumothorax, or tamponade);
• tracheal deviation (evidence of tension pneumothorax)
• major defects in the chest (sucking chest wounds);
• unilaterally diminished breath sounds or hyperresonance to percussion (evidence
of closed pneumothorax or tension pneumothorax);
• decreased heart sounds (pericardial tamponade);
• location of foreign bodies;
• location of entry and exit wounds.

Investigations

CXR
- CXR most useful screening investigation
- Look for subcutaneous air, foreign bodies, bony fractures, widening of mediastinum,
pneumothorax, pneumomediastinum, pleural fluid, pulmonary parenchymal
abnormalities(infiltrates, atelectasis etc)
- Check ETT, and other hardware.
- Inspiratory/expiratory films for checking for pneumothorax.
- supine AP film Þ some conditions have different radiological features. Look in particular
for the following:
- pneumothorax: (NB up to 30% of pneumothoraces missed on supine CXR) air collects in
anterior-inferior pleural space producing:

• "deep" costophrenic sulcus

• "double-diaphragm" contour +/- depression of hemidiaphragm
• hyperlucency in lower thorax and upper abdomen
• sharp demarcation of cardiac apex
• visceral pleura at base of lung may be outlined

- pneumomediastinum:

• parietal pleura visible along left mediastinal border. NB pleura descends below
mid-hemidiaphragm
• sharply defined edge to descending aorta which can often be followed into upper
abdomen
• "continuous diaphragm" sign under cardiac shadow
• subcutaneous, retroperitoneal or intraperitoneal emphysema

- pneumopericardium

• air around heart that does not rise above level of pericardial reflection at root of
great vessels
• air shifts with position of patient (unlike pneumomediastinum)

- pleural effusion:

• uniform increase in density over hemithorax

• pleural cap

- pulmonary contusion:

• homogenous infiltrates that tend to be peripheral and non-segmental

• may be associated with adjacent rib fractures
• air bronchograms are rare due to blood in small airways

- ruptured hemidiaphragm:- more commonly left sided

• non-specific signs include: apparent elevation of hemidiaphragm, obliteration or

distortion of contour of hemidiaphragm, contralateral displacement of
mediastinum, pleural effusion
• presence of gas containing viscera in thorax, particularly with a focal constriction
across gas-containing bowel is pathognomonic
 • haemopneumothorax may be misdiagnosed when dilated stomach gives horizontal
air-fluid interface on erect CXR
• in absence of right rib #s a small right haemothorax with a "high R diaphragm"
suggestive of ruptured diaphragm
• findings may be absent in 25-50% initially

- chest wall injuries:

• may give clues to associated injuries

• fractures of first 3 ribs in particular indicates significant trauma
• thoracic outlet fractures associated with brachial plexus or vascular injuries
• subclavian vascular injury should be suspected in patients with fractures of first 3
ribs, clavicle and scapula, particularly when associated with significant fracture
displacement, extrapleural haematoma, brachial plexus neuropathy or radiological
evidence of mediastinal haemorrhage
• fractures of sternum are rare and require both lateral and oblique views of thorax
for diagnosis. The presence of a fractured sternum and an abnormal mediastinal
contour should prompt a search for injury to great vessels

- haemopericardium:

• NB rapid accumulation of blood in pericardial space often causes cardiac

tamponade wthout altering appearance of cardiac silhouette

CT Scan

• Valuable tool
• Aids in diagnosis and precise location of numerous lesions.
• Contrast is useful particularly when looking for mediastinal haemorrhage and
periaortic haematomas.

Echocardiography

Cardiac wall motion abnormalities and valve function and presence of pericardial fluid or
blood.

ECG

Most common abnormality in thoracic trauma are S-T and T wave changes and findings
indicative of bundle branch block

Angiography

Remains the gold standard for defining thoracic vascular injuries

Bronchoscopy

Indications include evaluation of airway injury, haemoptysis, segmental or lobar collapse,

and removal of aspirated foreign bodies.
Management

Immediate management

- assure patent airway, oxygenation and ventilation

- exclude or treat:

• pneumothorax
• haemothorax
• cardiac tamponade

- assess for extrathoracic injuries

- decompress stomach
- provide pain relief
- reconsider endotracheal intubation, ventilation. In particular take into account gross
obesity, significant pre-existing lung disease, severe pulmonary contusion or aspiration,
need for surgery for thoracic or extrathoracic injuries

General management

Treatment of specific injuries

Monitoring

Should include follow-up CXRs. Common for patients with pulmonary contusion to
deteriorate in first 24-48 hrs following injury. Not necessarily due to progression of
contusion but is more often due to development of pneumothorax, haemothorax,
atelectasis or pulmonary oedema. For this reason serial CXRs are necessary in first 24
hrs
Following are danger signs requiring full reassessment:

• resp rate > 20/min

• heart rate > 100/min
• systolic BP < 100 mmHg
• reduced breath sounds on affected side
• Pao2 < 9 kPa on room air
• Paco2 > 8 kPa
• increased size of pneumothorax, haemothorax or increased width of mediastinum
on CXR

Deterioration in any of these signs must be followed by a search for evidence of blood
loss, tension pneumothorax, head injury, sepsis or fat embolism. Chest drains should be
checked for patency

Chest drains

Indications for insertion of chest drains in stable patients:

• pneumothorax > 10% in non-ventilated patient (ie >1 intercostal space)

• haemothorax > 500 ml (ie above neck of 7th rib)
• surgical emphysema
 • confluent opacity of lung field in a supine CXR suggesting haemothorax

There are arguments both for and against the insertion of prophylactic chest drains in
patients with rib fractures who are to be ventilated for a GA. However without air or fluid
draining the drain is likely to become blocked at an early stage. In a series of patients
with blunt chest trauma one pneumothorax occurred per 79 days of ventilation when
prophylactic drains were used as opposed to one per 62 days when they were not.
Complication rate associated with insertion 6-9%

Theoretically, all that is required to drain pneumothorax is a small-bore tube but this is
more likely to become blocked. When blood or pus is to be drained in an adult a 32 FG
tube is recommended

Antibiotics

• use of prophylactic antibiotics controversial. Some recommend them for patients

treated conservatively in whom a chest drain is inserted
• cefuroxime and metronidazole for patients with perforated viscus (in addition to
exploration and drainage)

Clearance of secretions and prevention of atelectasis

General measures:

• pain relief (eg pleural block)

• physio
• humidification
• bronchodilators (especially smokers or those exposed to smoke, irritant chemicals
or those with tracheobronchial burns)
• consider cricothyroidotomy or "minitracheostomy" for those in whom general
measures insufficient

Bronchoscopy

Indications for flexible bronchoscopy:

• massive air leak

• failure of lung to re-expand
• lobar collapse
• diagnosis and assessment of tracheal burns
• bronchial toilet

Rigid bronchoscopy has less of a role in the trauma patient but may be used in cases of
persistent lobar collapse to aspirate a blood clot or plug of sputum

Mechanical ventilation

- most centres use PCV or PSV to reduce incidence of barotrauma

- PCV and PSV also provide some compensation for air leaks
Analgesia

Of extreme importance in determining whether deep breathing and coughing possible.

Options:

• IV opioids in frequent small doses or by continuous infusion

• Entonox inhalation during physiotherapy
• intercostal nerve block:

• multiple individual nerve blocks (rptd as necessary)

• single large volume (eg 20 ml 0.5% bupivicaine) into 1 intercostal space. Spreads
to block nerves above and below
• intrapleural bupivicaine via intercostal catheters using intermittent injections or
continuous infusions

• epidural LA/opioids
• NSAIDs: fully resuscitated patients with normal renal function

Post-operative intensive care

• following tracheobronchial, lung or diaphragmatic repair high inflation pressures

should be avoided
• tracheal suction must be minimal where there is a tracheobronchial suture line
• avoid fluid overload
• prevent gastric distension

Specific injuries

Classification

• Require immediate intervention

• Tension pneumothorax
• Open pneumothorax
• Disruption of major airway
• Cardiac tamponade
• Massive haemothorax
• Traumatic air embolism
• Flail chest

• Injuries with potential for threatening survival

• Lung contusion
• Other pulmonary parenchymal injuries
• Myocardial contusion
• Aortic rupture
• Oesophageal disruption
• Diaphragmatic rupture
• Rib fractures
• Simple haemopneumothorax
• Traumatic asphyxia
 • Long term sequelae

• Clotted haemothorax
• Empyema
• Phrenic nerve palsy
• Pericardial complications
• Fistulae
• Diaphragmatic hernia
• Chylothorax

• Others

• Sternal, clavicular, scapular injuries

• Subcutaneous emphysema

Tension pneumothorax

• respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral

absence of breath sounds, distended neck veins. Cyanosis is a late manifestation
• may be confused with cardiac tamponade but tension pneumothorax is more
common. Differentiation may be made by unilateral hyper-resonance
• treat by immediate decompression: insert needle into 2nd intercostal space in MCL.
Ability to easily aspirate air confirms diagnosis. In event of failure to aspirate air,
withdraw needle but remember possibility of iatrogenic pneumothorax now exists

Open pneumothorax

• "sucking chest wound"

• if opening in chest wall is approximately 2/3 the diameter of trachea air passes
preferentially through chest defect
• promptly close defect with sterile occlusive dressing, large enough to overlap the
wound’s edges and taped securely on 3 sides to provide a flutter-type valve effect.
As patient breathes in the dressing is sucked over wound while the open end of the
wound allows air to escape during expiration
• place a chest drain in an area remote from the open wound

Disruption of major airway

• clinical features vary with level of rupture but usual picture is one of respiratory
distress, subcutaneous emphysema, haemoptysis
• pneumothorax invariable with ruptured bronchus. Suspect bronchial rupture if
pneumothorax associated with a persistent large air leak after placement of chest
drain. Rupture usually occurs within 2.5 cm of carina
• mediastinal emphysema common
• treatment of tracheal injuries: immediate intubation with cuff positioned distal to
tear. Drain pneumothorax.

Cardiac tamponade

• most commonly results from penetrating injuries but may follow blunt trauma
 • relatively small amounts of blood (approx. 100 ml) required to restrict cardiac
activity and interfere with cardiac filling. Removal of small amounts of blood or
fluid (often as little as 15-20 ml) by pericardiocentesis may have enormous
beneficial effects
• diagnosis is often difficult:
o volume of heart sounds difficult to assess in noisy environment
o distended neck veins may be absent because of hypovolaemia
o pulsus paradoxus may be absent and tension pneumothorax may mimic
tamponade
o consider possibility in patients who do not respond to usual resuscitation and
have a mechanism of injury compatible with tamponade
• pericardiocentesis
o blind pericardiocentesis
 only if ultrasound/echo not available
 use sub-xiphoid route and preferably a plastic sheathed needle for
pericardiocentesis. ECG monitoring is necessary to detect needle
induced arrhythmias
o pericardial aspiration may not be diagnostic or therapeutic if blood has
clotted, which may be the case after rapid bleeding. Open pericardiotomy
may be life-saving but is indicated only when an experienced surgeon is
available
o even if pericardial tamponade is strongly suspected volume resuscitation
should continue while preparations are made for pericardiocentesis
o aspiration of blood alone may temporarily relieve symptoms because of the
self sealing qualities of the myocardium but all patients with positive
pericardiocentesis following trauma require open thoracotomy and
inspection of the heart

Massive haemothorax

• incidence of haemothorax and haemopneumothorax ~50-60% in penetrating

trauma and 60-70% in blunt trauma. Majority are not massive
• massive haemothorax defined as >1500 ml of blood in chest cavity
• clinical signs:
o unilateral dullness to percussion
o shock
o unilateral absence of breath sounds
o deviation of trachea
o neck veins may be flat due to severe hypovolaemia or distended because of
the mechanical effects of intrathoracic blood
• blood loss complicated by hypoxia

Management

• manage initially by simultaneous restoration of volume deficits and decompression

of chest cavity. If auto-transfusion device is available it should be used
• emergency thoracotomy for massive haemothorax or haemothorax with ongoing
loss of >200 ml of blood per hour for 3-4 h

Systemic air embolism

 • more common in penetrating injuries
• immediately life-threatening
• usually due to broncho-pulmonary vein fistula
• suspect if:
o focal neurological signs exist in the absence of head injury
o circulatory collapse occurs on initiation of IPPV in absence of tension
pneumothorax
o froth is obtained in arterial blood gas sample from a collapsed patient

Management

If suspected:

• 100% O2
• minimise ventilation volumes and pressures
• emergency thoracotomy to clamp ascending aorta, remove air source (by
clamping pulmonary hilum) and aspirate air from LV and ascending aorta

Flail segment

• major physiological insult is contusion of underlying lung and decreased vital

capacity
• occurs when 3 or more consecutive ribs or costal cartilages are fractured bifocally.
• these circumscribed segments, having lost continuity with the rigid thorax, move
inwards with inspiration and push outward with exhalation, thus moving
paradoxically.
• presenting symptoms of pain, tachypnoea, dyspnoea, and thoracic splinting, along
with chest wall contusions, tenderness, crepitance, and palpable rib fractures are
suggestive, but paradoxical chest wall motion is the diagnostic sine qua non.
• may be difficult to diagnose if patient is already mechanically ventilated, in pain,
obese, or has large breasts or subcutaneous emphysema.
• CXR is helpful in identifying multiple fractured ribs, but will not reveal cartilaginous
disruptions. Major value of the CXR is in detecting associated injures (more than
90% will have associated injuries-and 3 out of 4 require tube thoracostomy for
haemopneumothorax; extrathoracic injuries are common: head injury in ~40%;
major fractures in 40%, and intraabdominal injuries in 30%.

Distribution of flail

Anterior: typically secondary to blows to the sternum, eg motor vehicle accident, CPR

Lateral: due to T-bone impacts or AP crush mechanisms

Posterior: result from direct blow to the back and are characterized by simultaneous
fractures along the midaxillary line and the rib neck. Splinting, plus a supine position
effectively limit paradoxical motion.

Management

• ~50% of cases can be managed without ventilation

• others require ventilation for 1-3 weeks
 • chest wall usually stabilises in 1-2 weeks
• operative fixation is suggested by some authors. Main benefit is to prevent
deformity.
• weaning should not wait till paradoxical movement improves, rather should be
initiated when gas exchange is adequate.
• in absence of systemic hypotension control administration of IV fluids to prevent
overhydration

Lung contusion

• essentially a bruise of the lung. Aetiology controversial: probably a combination of

shear stress (tearing tissue) and bursting forces (popping the balloons)
• direct injury causes pulmonary vascular damage with secondary alveolar
haemorrhage
• initially not much shunt as these alveoli are poorly perfused
• subsequently tissue inflammation develops. Resultant surrounding pulmonary
oedema produces regional alterations in compliance and airways resistance,
leading to localised V/Q mismatch
• atelectasis
• diagnosis is radiological.
o classically see nonsegmental pulmonary infiltrates-progress in first 12-24
hours of injury. Note that CXR undestimates degree of contusion. CT more
sensitive and better method of assessing severity
o may be irregular nodular densities that are discrete or confluent
o homogeneous consolidation
o diffuse patchy pattern
o early CXR changes suggest more severe contusion. Early pulmonary
contusion infiltrates are due to alveolar haemorrhage
o radiological differential diagnosis includes:
 Aspiration
 Re-expansion of collapsed RUL following right endobronchial intubation
o in most cases infiltrates associated with pulmonary contusion are not visible
till after fluid resuscitation.
• contusions tend to worsen over 24-48 hours and then slowly resolve unless
complicated by infection, ARDS or cavitation

Management

• supplemental oxygen
• only about 25% of patients require invasive ventilation
• good analgesia
• physiotherapy

Other pulmonary parenchymal injuries

Pulmonary Laceration

• Commonly associated with haemopneumothorax and haemoptysis

• Usually managed with simple tube drainage

Pulmonary Haematoma
Uncomplicated cases usually resolve in 3-4 weeks

Posttraumatic Pulmonary Cavitary Lesions

• Posttraumatic cysts, pseudocysts, or pneumatoceles are cavitary lesions within the

lung parenchyma filled with fluid, blood, of air.
• CT is useful in diagnosis
• Most resolve spontaneously
• Some can become infected requiring antibiotics, CT guided aspiration, and in some
cases surgical resection

AV fistulas

• diagnosis by pulmonary angiography

Torsion of the lung

XR signs:

• Opacification of affected hemithorax

• Mediastinal shift toward the contralateral side
• Reversal of bronchoalveolar markings of the affected side, with the major
pulmonary vessels coursing cephalad instead of caudad.

ARDS

Myocardial contusion

Definition and epidemiology

• direct traumatic myocardial damage without traumatic involvement of coronary

arteries
• common in blunt trauma but difficult to diagnose
• tends to occur in acceleration/deceleration and crush/compression injuries

Clinical features

• consider possibility in any patient with a mechanism of injury that suggests

likelihood of cardiac contusion
• patients who are conscious may complain of dyspnoea or chest pain
• may lead to significant physiological dysfunction and even death but massive
contusion leading to cardiogenic shock is rare. In patients with chest trauma
cardiogenic shock is usually due to cardiac tamponade or ventricular akinesia
• with compression in diastole valvular dysfunction may occur; usually aortic valve in
older patients and mitral in younger
• pericardial rub, S3 gallop, cardiac failure
• serious damage to virtually every cardiac structure has been reported
• most common presentation is with asymptomatic ECG abnormalities although
severe contusion will produce cardiac failure.
• LAD damage may occur with resulting anteroapical infarction
Investigations

• enzyme elevations, specifically CKMB correlate poorly with contusion

• ECG changes: range from non-specific T wave changes to pathological Qs. Multiple
VPBs, unexplained sinus tachycardia, AF, BBB (usually R) and ST segment changes
are most common ECG findings. Normal ECG at admission makes cardiac
contusion unlikely.
• TOE: +/- cardiac wall motion abnormalities. Exclude lesions that will benefit from
revascularization or other cardiac surgery
• sternal # associated with low incidence of cardiac contusion & arrhythmias

Management

• all patients with myocardial contusion should be admitted to ICU for observation
and cardiac monitoring (This view is being challenged). Admit patients with
arrhythmias or heart failure to level 3 ICU
• non-urgent surgery should be postponed where possible because of life
threatening operative complications. Consider invasive haemodynamic monitoring
for patients who have to undergo urgent surgery
• treat arrhythmias if life-threatening or associated with cardiac failure; treat specific
valve abnormalities surgically.
• treat cardiogenic shock along usual lines with optimization of preload, inotropes ±
IABP. Exclude tamponade.

Prognosis

• resolution of wall motion abnormalities in ~25% only (NB based on only 14

patients)

Ruptured aorta

• traumatic aortic injuries are the second most frequent causes of death in patients
with chest injuries

Mechanism and types of injury

Deceleration and traction-are the classic wounding mechanisms of the thoracic arteries

• Horizontal deceleration creates shearing forces at the aortic isthmus, the junction
between the relatively mobile aortic arch and the fixed descending aorta. 90-98%
of traumatic injuries of the thoracic aorta occur at the isthmus
• Vertical deceleration displaces the heart caudally and into the left pleural cavity
and acutely strains the ascending aorta or the innominate artery.
• Sudden extension of the neck or traction on the shoulder can overstrech the arch
vessels and produce tears of the intima, or complete rupture of the arterial wall®
dissection, thrombosis, pseudoaneurysm or haemorrhage.

Diagnosis

• circumstances may be only clue: head-on collision at high speed, ejection from a
vehicle, fall from great height
 • one characteristic shared by all survivors is that blood that leaks from aorta is in a
contained haematoma. Other than initial pressure drop associated with loss of 500-
1000 ml of blood, hypotension responds to intravascular infusion. Persistent or
recurrent hypotension is usually due to another source of bleeding. Free rupture
does occur but it is usually fatal unless patient is operated on within minutes
• CXR essential - always suspect ruptured aorta if mediastinum wide especially if
associated with any of following:
o L haemothorax
o depressed L main bronchus
o blurred outline of arch or descending aorta
o (?) # 1st rib or L apical haematoma
o displacement of mid-oesophagus to R
• other suspicious CXR features: loss of aorticopulmonary window, ant or lat
deviation of trachea, loss of paraspinal "stripe", calcium "layering" in aortic arch
• signs such as apical pleural cap, mediastinal width > 8 cm, 1st & 2nd rib #s no
value in indicating major arterial injury
• further investigations depend on CXR findings:
o further investigation not indicated if CXR normal
o if CXR technically unsatisfactory or mediastinal contour equivocally abnormal
then perform thoracic CT first to look for mediastinal haemorrhage. This
often also demonstrates aortic pseudoaneurysm if present. If mediastinal
haemorrhage is present and aortic pseudoaneurysm is not demonstrated
then proceed to aortogram
o if mediastinal contour on CXR clearly abnormal proceed directly to
aortography
• aortography is gold standard investigation although TOE may supercede it. TOE
may miss lesions of distal ascending aorta or of arch vessels
• typical aortographic finding in patients with an aortic tear is an irregular
outpouching of aorta just distal to left subclavian artery. Outpouching may be
circumferential with appearance of a "sleeve" around aorta or may be localized,
with abnormal area present only along medial or lateral aspect of aorta
NB there is frequently a convexity or a bulge in region of embryonic ductus
arteriosus. This is usually smooth and symmetrical

Treatment

• prompt surgery. Often requires cardiopulmonary bypass

Injuries to aortic arch vessels

• Bleeding from an arch vessel is usually contained, but in rare instances, the
avulsion of the origin of an arch artery causes massive bleeding into pericardial or
pleural cavity.
• Acute occlusion of the innominate or subclavian may cause ischaemic symptoms of
hand or arm (acute ischaemia of the common carotid may lead to brain ischaemia)
• Clinical features include cervical or supraclavicular haematomas, bruits, diminished
peripheral pulses

Oesophageal perforation

• usually due to penetrating injury but occasionally follows blunt trauma

 • +/- retrosternal pain, difficulty in swallowing, haematemesis, cervical emphysema
• CXR: +/- pneumomediastinum, widened mediastinum, pneumothorax, hydrothorax
• consider diagnosis in any patient:
o with L pneumothorax or haemothorax without a rib #
o who has received severe blow to lower sternum or epigastrium and is in pain
or shock out of proportion to the apparent injury
o who has particulate matter appearing in the chest tube drainage after the
blood begins to clear
• definitive investigation: gastrograffin swallow or endoscopy
• immediate surgical repair with gastrostomy or feeding jejunostomy

Ruptured diaphragm

- usually due to gross abdominal compression causing large radial tears. Penetrating
trauma tends to produce small perforations that take some time to develop into
diaphragmatic hernias
- rupture of L hemidiaphragm more common
- ± deterioration in respiratory status if MAST trousers are inflated
- CXR features listed above
- if rupture of L hemidiaphragm is suspected a NG tube should be inserted. If this
appears in thoracic cavity no further investigations are required. Occasionally it is
necessary to inject contrast down NG tube to confirm diagnosis
- if CT non-diagnostic consider MRI in stable patients
- significant risk of gut strangulation with L rupture
- 75% of patient with ruptured diaphragm have associated intra-abdominal injury
- surgery should follow basic resuscitation

Rib fractures

• Most common injury

• Extent of trauma and mortality correlates directly with the number of ribs fractured
• First three ribs fractured means a large amount of force caused the injury ?recent
study challenges this concept
• Ribs 10, 11, and 12 are associated with blunt injuries involving the spleen, liver,
kidneys and diaphragm.
• Fractures or three or more ribs are commonly associated with pulmonary
contusions

Simple haemopneumothorax

- usually diagnosed by a combination of physical examination and CXR

- generally insert a chest tube if it follows trauma regardless of size

- allows decompression of the pleural space, monitoring of drainage, and safer in view of
possibility of mechanical ventilation.

Traumatic Asphyxia
 • Prolonged compression of the thorax results in increased SVC pressure and
obstruction of flow through the valveless veins of the innominate and jugular
system
• Clinical findings are craniocervical cyanosis and oedema, subconjunctival
haemorrhage or petechiae, and distension of the cervical neck veins.
• Commonly associated injuries include pulmonary contusion and haemothorax
• Treatment is directed at the associated injuries

Sternal, clavicular and scapular injuries

Sternal fractures

Think of ie myocardial contusion or rupture of the great vessels

Clavicular fractures and dislocations

• Fractured clavicle can injure subclavian vein or brachial plexus

• Rarer posterior displacement of the medial clavicle can cause serious injury to the
trachea or innominate vessels.

Scapular Fractures

• Isolated fractures are rare

• More than 50% are associated with rib fractures and pulmonary contusion
• 10-20% are associated with pneumothorax
• >10% are associated with brachial plexus or major arterial injuries

Clotted haemothorax

- result of blood clotting in pleural cavity

- liquidizes after few days and may be evacuated if drain suitably positioned
- large clot encased in fibrin will not drain and lung fails to re-expand
- if clot small it can be well tolerated but a larger haemothorax will leave patient
chronically unwell, SOB and easily fatigued. Ribs on that side will be cramped together,
muscles will atrophy and a scoliosis may develop. Treatment is thoracotomy, evacuation
of clot and decortication of lung allowing re-expansion. This is a major procedure and
depending on timing may be exceedingly dangerous

Empyema

- infection frequently introduced at time of penetrating trauma, by insertion or

manipulation of a chest drain or misplaced CVP line or by leakage of gastrointestinal
contents into pleura
- prophylactic broad-spectrum antibiotics should be given before insertion of chest drain

Phrenic nerve palsy

- injury often only noticed as a difficulty in weaning off assisted ventilation. In these
circumstances thoracotomy and pliation of diaphragm may provide a better platform
against which opposite hemidiaphragm, intercostal muscles and accessory muscles can
act
Pericardial complications

- post-pericardiotomy syndrome
- infective pericarditis
- pericardial effusion (non-traumatic, non-infective and unrelated to post-pericardiotomy
syndrome)
- delayed haemopericardium; may be due to inflammatory or infected processes, but
may be due to secondary haemorrhage from an unsuspected cardiac wound. Latter may
nto be an acute event because inflammed pericardium from previous insult is adherent
to wound

Fistulae

- tend to occur where there has been injury to adjacent blood vessels or viscera
- viscerovascular fistulae are often fatal although there may be warning bleeds
- treatment of large arteriovenous fistulae should be considered because of risk of heart
failure, cerebral abscess or paradoxical systemic emboli

Diaphragmatic hernia

- may track in any plane of chest wall. Beware of any pointing subcutaneous "abscess"
following an injury which could have caused an abdominal wall or diaphragmatic breach

Chylothorax

- often diagnosed as a prolonged leak via a chest drain of clear, turbid or milky fluid
- many cases respond to conservative treatment of low-fat diet combined with TPN and
chest drainage
- surgical treatment is ligation of lymphatic at thoracotomy

Prognosis

- mortality rates vary widely reflecting varied severity of chest and other injuries
- one series of patients with chest and other injuries: overall mortality 5.3%. Commonest
causes of death: respiratory sepsis, severe head injury, exsanguination. Mortality 37.5%
for patients >60yrs with resp failure and 22.8% for patients requiring mechanical
ventilation (22.8%)
- in another series: 16% mortality in patients with isolated pulmonary contusion. When
associated with flail chest: 42%

Indications for urgent surgery

Major thoracic surgical intervention can be broadly divided into 3 categories:

- emergency thoracotomy (to resuscitate patient)
- urgent thoracotomy (performed once patient has been stabilized by resuscitation)
- thoracotomy for complications

Emergency thoracotomy
 • indications:patients who have sustained truncal trauma and remains unstable or
moribund despite adequate resuscitation by way of infusion, chest drainage and
ventilation
• lack of pupillary response is not a contraindication to operation, though is is an
indication for thoracotomy in casaulty rather than transfer to theatre
• patients who have shown no respiratory effort and no cardiac output since pick-up
will not survive
• criteria for discontinuation of resuscitation:
o irretrievable anatomic injury (eg ruptured heart)
o failure of volume resuscitation within 15 mins of starting
o failure to sustain spontaneous cardiac rhythm and maintain mean systemic
blood pressure > 50 mmHg, with or without inotropic support, within 30 mins
• in general those who survive with reasonable cerebral function are young,
previously fit and have only a short period of circulatory arrest
• patients with blunt trauma have a poor outcome and it may be deemed unwise
even to consider further measures if standard resuscitation fails
• overall only 5% of those undergoing emergency thoracotomy survive and many of
these have prolonged convalescence and cerebral damage

Urgent surgery

- purpose is to repair structures that will not heal optimally without surgery and to
prevent late complications
- indications for early (or emergency) surgery:

Absolute indications:

• cardiac arrest due to tamponade or exsanguination

• significant and continued haemorrhage: immediate blood loss from chest drain
> 1500 ml of total blood volume - immediate surgery. Loss > 500 ml in first hr. or
200 ml/hr thereafter is also an indication for thoracotomy. Decision to operate
should be made early before occurrence of a dilutional coagulopathy
• dangerous predicted track/mediastinal traversing
• massive air leak
• certain specific injuries

Relative indications:

• thoracoabdominal injury
• bullet embolism
• high-velocity gunshot wound
• missile retrieval. In general missiles should only be removed if they pose a risk of
embolization from heart or pulmonary artery, erosion of adjacent structures due to
repetitive cardiorespiratory movements or infection due to non-metallic pieces
• certain specific injuries

Relative contraindications:

• cardiac contusion
• pulmonary parenchymal contusion
• pneumomediastinum (without other injury). Exclude tracheobronchial tear,
pneumothorax, oesophageal perforation or gas forming organisms within
pericardium