144 Gopinath IJTCVS

Invited
Thoracic article
trauma 2004; 20: 144–148

Thoracic trauma*
Nagarur Gopinath

Introduction respiratory distress syndrome not usually recognized

early at locations where the patient is first received.
Thoracic trauma forms about 10% of all trauma cases
Aim of treatment in chest trauma cases is restoration
and may be associated with injuries to other organs.
of cardio respiratory function to normal, control of
Associated orthopedic injuries and head injuries are
bleeding and prevention of sepsis. This statement is
common in major vehicular traffic and in construction
simple but requires several steps to be taken.
work accidents. Injuries can be described broadly as due
Unfortunately deaths are due in many cases to airway
to blunt trauma and those due to penetrating (gunshot
obstruction, disturbances in physiology due to
or stab) wounds. These reflect the state or society and
haemothorax, pneumothorax with or without flail chest.
the state of development. Stab and gun shot injuries are
About 15% of patients need surgical intervention,
more common with communal disturbances. In this
whereas measures to relieve hemopneumothorax offer
situation the injuries are more likely to involve the vital
life saving benefits. Recognition of the need for
organs. If there is police firing to quell the mob, then
ventilatory support in such patients is delayed in the
there are likely to be gun shot injuries to legs because as
receiving centres where it is vitally required. A tube
a rule firing is directed to immobilize the crowd. This
thoracostomy and Ambu bag breathing kit may save
happens in many parts of our country. Casualties are
many patients.
many with instant fatalities and little chance of survival.
Flail chest means paradoxical movement of chest
In the developed urban areas fatalities are more due
wall, usually associated with multiple rib fractures and/
to blunt trauma from the traffic accidents on roads and
or fracture of the sternum. It may be associated with
at construction sites, coupled as this is with fascination
clinically recognizable signs such as cyanosis, rapid
for speed, alcohol, drugs, and guns.
breathing and consequent low cardiac output (fast pulse
In most accidents, the patient is caught unawares.
rate, drop in blood pressure with narrow pulse
Medical relief is rarely available. Even if it is available,
pressure).
it may not be any more than just first aid. Also the centre
where the patient is first taken is usually not equipped
Blunt trauma
to handle profuse bleeding and respiratory failure etc.
Usually affects middle aged men as they are more
Only recently trauma management is gaining
mobile and are involved in construction sites or other
recognition in India. Trauma care centres are associated
hazardous occupations. In these disasters, victims are
with other major hospitals in an urban area and are not
usually in groups, with rescue efforts being unavailable.
close to highways as in the United Kindgdom. At
These patients may have multiple organ injuries in the
present, communication between these centers and the
abdomen, limbs or skull adding to morbidity and
accident site is not satisfactory. Chest trauma patients
mortality. Transport of these patients to hospitals
are likely to deteriorate due to effects on respiratory
requires immediate communication to reach the victims
function with secondary associated cardiac dysfunction.
for timely and life saving measures. Males predominate
Victims of non-chest injuries are known to develop adult
in these injuries but increasingly women are also
involved.
Address for correspondence: Assault is also a major cause of blunt trauma and
Dr. N. Gopinath majority are in 20-50 years of age. Automobile accidents
Emeritus Professor, AIIMS
form the third major cause of chest trauma. Blunt trauma
Plot No. 374/375
14th Main, Shanti Niketan Layout accounts for nearly 75-80% of cases. Fifty percent
Near Arikeri, of patients have associated other organ injuries.
Bannerghatta Road Proper assessment of injuries and their consequences
Bangalore – 560 076
is therefore essential. Success of conservative
Tel : 080-2658226
management depends on early recognition and prompt
intra thoracic drainage for hemo/pneumo or
* Invited article, based on lecture delivered at Guwahati Neurological Research
Centre and Heart Inst., Guwahati, Assam on 8 Jan. 2004. hemopneumo thorax.

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 IJTCVS Gopinath 145
2004; 20: 144–148 Thoracic trauma

Penetrating injuries Table 1. PGIMER*, Chandigarh

Stab injuries, penetrating injuries and injuries caused 1994 – 1995
by gunfire are due to enmity and attempts to murder. Type of injuries No. of cases
Blood loss is a major contributor and fear of the
Blunt injuries 102
assailants prevents first aid. In Tirupati, 4 bull gore
Penetrating injuries
injuries accounted for sizeable proportion of penetrating Gunshot 30
injuries. Stab 17
Others 51
Prevention
Preventive measures that can be taken in highway 200
Management
traffic accidents include mobile telephones for all drivers
Conservative 160 (80%)
to call for emergency police assistance and to contact Operative 40 (20%)
nearby clinics/hospitals. Telephone numbers of these
can be placed on telephone poles or even on trunks of Mortality 15 (7%)
trees with luminous figures. Trucks and buses should Causes of death
carry first aid boxes with sterile dressing material and Respiratory insufficiency 06
splints. Clear information is to be made in newspaper Head injuries 03
Shock with abdominal injury 02
radio and local television stations to make public aware Cardiac surgery 01
that the injured must receive fist aid before a report is Shock with orthopedic injury 01
filed in police stations. Fear of medicolegal problems
15
results in delay in transport and medical attention to
the victims. A recent supreme court decision that *Post Graduate Institute of Medical Education and Research
immediate medical aid be provided by a doctor protects
Table 2. SVIMS* Tirupati
him from legal consequences.
1993–1998
Management
Management of chest injury begins at the site of Chest injury N = 91
injury. The victim’s identity should be obtained from Single rib fracture 11 (12.2%)
Multiple/rib fracture 46 (51.1%)
his clothes or from any identification card found on his Hemo pneumio thorax 32 (35.6%)
person. It may provide vital information. If the injured Pneumothorax 12 (13.3%)
patient is spitting blood, it is advisable that he be placed Hemothorax 07 (7.8%)
face down. If there is associated limb fracture then limb Flail chest 11 (12.2%)
on both sides of fracture should be splinted. If open Heart 07 (7.8%)
wound is present, it must be covered with sterile Lung 12 (13.3%)
Diaphragm 02 (2.2%)
dressing. At all clinics and local hospitals a quick
preliminary examination should be done. Blood 91 (100%)
pressure should be taken in both upper limbs to exclude Surgical management 22 cases
Emergency 18 (81.8%)
injury to ascending aorta and its branches. Breath
Lung injury 05 (22.7%)
sounds when diminished or absent, denote lung injury, Cardiac injury 04 (18.2%)
penumothorax or hemothorax. Bowel sounds, if heard, Vascular 03 (13.6%)
generally excludes intestinal injury. Bruises over left Hemothorax 04 (18.2%)
upper part of abdomen, if present, denotes splenic Hemothorax foreign body removal 02 (9.1%)
injury. For central nervous system examine site of injury, Delayed surgery
Clotted hemothorax 01 (4.5%)
bleeding from ears, unequal pupils, inability to move
Diaphragm injury 02 (9.3%)
limbs, consciousness etc. Check the spine for injury. If Empyema 01 (4.5%)
abdomen is distended insert a Ryle's tube.
22
X-ray chest should be taken (Figs 1-5) to check for
Mortality in 6 patients
fractured ribs, hemothorax, pneumothorax. (Air level Respiratory insufficiency 03
in subdiaphragmatic area indicates rupture of stomach Head injury 01
or bowel and needs exploration without delay). Start Shock with associated
intravenous fluid therapy. In case of pneumo or abdominal trauma 01
hemothorax it is life saving to insert an intercostal Infection 01
drainage tube. It can be done using a tube of any size *Sri Venkateshwara Institute of Medical Sciences

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 146 Gopinath IJTCVS
Thoracic trauma 2004; 20: 144–148

Fig. 1. Blunt injury chest with haemothorax

(a)

Fig. 2. Large right pnemothorax

and can be connected to any bottle with under water

level. One can use an IV set also. One can measure blood
loss, at hourly intervals and replace with appropriate
blood transfusion. This may not be possible at all times,
and facilities may not exist at short notice. Best option
is to transfer him to the nearest hospital. If blood loss is
large, measure every half hour, the amount drained
provides information for further steps to be taken.
Surgical intervention is indicated to control bleeding. If
the patient is having persistent haemoptysis leading to
flooding of lungs, ventilatory support may have to be
provided.
(b)
Fig. 3. (a) Plain X ray chest (PA view) shows rupture left dome of
diaphragm with herniation of stomach, (b) A contrast study shows
the stomach in the chest cavity
Flail chest – Generally in a minority of cases of flail
chest ventilatory support may be required.
Flail chest is usually evident if there is :

Fracture of 4 or more ribs anteriory and
posteriorly

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 IJTCVS Gopinath 147
2004; 20: 144–148 Thoracic trauma

(a)
Fig. 5. Gunshot injury, showing the bullet in the vicinity of the heart

Internal fixation with wires/plates

Positive pressure ventilation

General measures in all forms of chest injuries include:

Analgesics and antibiotics

Oxygen by mask; if patient is hypoxic, consider
manual ventilation

Appropriate intercostal drainage tubes

Arterial blood gas measurements

Intercostal block/ epidural block

Chest physiotherapy

Repeated bronchoscopic suction

Mini tracheostomy
Indications for ventilatory support are :
(b)

tachypnoea
Fig. 4 . A penetrating injury with multiple pellets in the chest
Shock
(a) PA view, (b) lat view
Cyanosis

PAO2 < 60mm Hg

Bilateral anterior rib fractures
PCO2 > 50mm Hg

Sternal and rib fractures Ventillatory supporty is indicated in patients with

Fracture of 7 to 8 ribs antero laterally Lung contusion, Hemo or pneumothorax, Flail chest,

Costochondral fracture of 4-5 ribs falling blood pressure, increasing pulse rate, low PO2
The effect of flail chest are immediate or delayed and rising PCO2. Manual ventilation is sometimes

Paradoxical movement beneficial in such patients.

Hypotension Morbidity and mortality depend on (1) severity of

Retained secretions the chest injury (2) condition of the underlying lung (3)

Atelectasis associated head injury (4) associated abdominal injury

Mediastinal flutter (5) long bone fracture/fat embolism. Mortality rate varies
from 20-80% mostly as a result of associated injury (<7% in
Flail chest management should include Indian hospitals tables 1 and 2).

Strapping/sand bag support Complications of prolonged ventilation include

External fixation with towel clips, pulley and
Infection/bed sores/Deep vein thrombosis
traction
Baro trauma/persistent pneumothorax

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 148 Gopinath
Thoracic trauma

Ventilator dependency and need for
tracheostomy

Tracheal stenosis

Rare complications include Tracheo – innominate
fistula and Tracheo oesophageal fistula
If chest injury is the only injury present - one must
look for cardiac tamponade (indicates myocardial
injury) (2) injury to great vessels (3) injury to bronchi
and oesophagus
Cardiac tamponade

More common in penetrating injury

Beck’s triad (low BP, increasing JVP, muffled
heart sound) is noticed in <30% of cases.

X-ray chest may show enlarged cardiac shadow.

Clinical suspicion/Echocardiography and/
pericardiocentesis are useful.

It is better to explore if there is a suspicion.

Median sternotomy and left Anterolateral
Thoracotomy are the preferred approaches.

Suture closure of tear in myocardium without
cardiopulmonary bypass is usually sufficient.
Penetrating chest injuries involve (1) 100% chest wall
(2) 55% hemo/hemopneumo/pneumothorax (3) 65-90%
involve the lungs (4) 30% diaphragm (5) 20% liver
(6) 8% stomach (7) 6% colon (8) 6% kidneys (9) 10%
major vessels.
There was 49% injury to the heart, 27% lung, 17%
intercostals arteries in one series where patients
underwent thoracotomy.
Surgical intervention/exploration is required if the
penetrating injury is close to the heart, great vessels,
with persistent bleeding and suspicion of cardiac
tamponade. Look for site of entry, weapons used,
direction of knife, resistance/movement by victim etc.
Delayed surgical intervention is required for
removing clotted blood from pleural cavity or clotted
hemothorax and empyema.
Usually (in about 70% of patients) conservative
management is sufficient to save life.
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IJTCVS
2004; 20: 144–148
Emergency surgery may be required in blunt trauma if
Initial drainage >1500 ml, Continuous bleed 200 ml/hr
for 4 hours, Suspected tracheo bronchial tear, Suspected
great vessel injury/oesophageal rupture.
Chest trauma, though a major entity, can be managed
if altered physiology consequent to the injury is
understood. As in all trauma cases, interval from time
of injury to reaching medical aid is vital. Oxygen supply
to lung and intercostal drainage are of vital importance.
Comprehensive examination of injured person for
physical status and associated organ injuries is vital.
Stabilisation of chest wall is essential.
Medical personnel, police, voluntary organizations
must be trained to treat chest trauma cases with first-
aid measures. Emergency kits should be at hand. With
mobile phones, quick communication can be established
with police, nearby hospitals, for help and
transportation.
Acknowledgement
My thanks to Prof. R.S. Dhaliwal, Prof. & Head Dept.
of Cardio Vascular and Thoracic Surgery, Postgraduate
Inst. Of Medical Education and Research, Chandigarh
and to Dr. D. Dilip, Senior consultant and Head, Dept.
of Cardio Vascular and Thoracic Surgery.
Sri Venkateswara Inst. Of Medical Sciences, Tirupati,
A.P. for permitting me to utilize their data and to
Dr. Nityananda Shetty, Senior Consultnat,
Cardiovascular and Thoracic Surgery Bangalore for the
excellent illustrative material. Also my thanks to
Dr. S. Buggi, Superitendent, S.D.S. Sanatorium
Bangalore for the X-rays. I have liberally used their
material.
References
1. Suri RK, et al. Spectrum of thoracic trauma in PGIMER
Chandigarh. I J Progress Cardiovasc 1996; 3: 70–74.
2. Raju S Iyer, Padmanabhan Manoj, Rajnish Jain, et al. Profile of
chest trauma in a referral hospital – a five year experiment. Asian
Cardiovascular and Thoracic Annals 1999; 79: 124–27.
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