Thoracic Thoracic TraumaTrauma

Yingkang Shi, M.D.Yingkang Shi, M.D.

WestChina Hospital, SiChuan UniversityWestChina Hospital, SiChuan University

General General ConceptConcept

1.1. Anatomic and Anatomic and

physiologic featuresphysiologic features

Anatomic and physiologic features

Characteristics of trauma

•About ½ of trunk occupied High morbidity

•Respiratory & circulatory center

High mortality

•Bony thorax: supporting, protection costal breathing

Higher violence toleranceHandicap in respiration

•Balanced bilateral negative pressure of the pleural cavity

Lung compression & mediastinal shift

•Blood vessel: artery---large diameter, high pressure

Fatal bleeding

Anatomic and physiologic

features

Characteristics of trauma

vein--- large diameter, negative

pressure gradient redounds to

blood return, no venous valve

Severe bleeding, obstacle

to blood return

Traumatic Asphyxia

•Pericardium & Heart Cardiac tamponade, ruptu

re

•Two cavities with different

pressure are divided by the

diaphragm

Thoracoabdominal injury,

Diaphragmatic Hernia

2. Violence and trauma2. Violence and trauma

Violence Characteristics of trauma

•Fire-arm injury Acute violence, labyrinthian trajectory, close relationship with posture, perforating wounds mainly

•Stab wounds Short straight wound tract, blindgut wounds mainly

•Decelerative injury Traffic accident, falling

•Crush injury Earthquake, disturbance in public

•Crash injury Collision, the part been hit

•Blast injury Respiratory tract, body surface

3. Classification3. Classification

3.1 Logic of classification3.1 Logic of classification

• According to varietyAccording to variety of violenceof violence

Penetrating chest injuryPenetrating chest injury

Blunt chest injuryBlunt chest injury

• According to whether there isAccording to whether there is any communication between any communication between pleural cavity and atmospherepleural cavity and atmosphere

Open chest injuryOpen chest injury

Closed chest injuryClosed chest injury

3.2 Comparison of different thoracic trauma3.2 Comparison of different thoracic trauma

Penetrating chest injury Blunt chest injury

• Simple mechanism, easy

diagnosis

Complex mechanism, prone to misdiagnosis or diagnosis missed

• Close relationship with wound

tract

Hard to evaluate, rib fracture is common

• Combined injury rare Combined injury common

• Visceral disruption common Contused wound common

• Bleeding Edema

• Rapid progress (measured by

hours)

Slow progress (measured by days)

Penetrating chest injury Blunt chest injury

• Surgical treatment often

needed

Surgical requirement not so often

• Early death, mainly from

hemorrhagic shock

Late death, mainly from circulatory respiratory insufficiency

4.4. Principle of diagnosis Principle of diagnosis

and treatmentand treatment

4.1 Concept of time-effect4.1 Concept of time-effect

Time-effect:Time-effect:

• Time and outcome of trauma progressTime and outcome of trauma progress

• Time and effect of diagnosis and managementTime and effect of diagnosis and management

• Golden hourGolden hour

4.2 Diagnosis4.2 Diagnosis

Variety of trauma, mechanism Variety of trauma, mechanism

of damage, time course after of damage, time course after

injury, vital signsinjury, vital signs

Evaluation of traumaEvaluation of trauma

Physical ExamPhysical Exam

Hypotension:

bleeding, jugular vein collapse,

CVP, cardiac sound, trachea

Respiratory distress:

Dyspnea, asthma, paradoxical

movement of chest wall,

“sucking injury”

Appendix findings:

X-ray, Ultrasound, diagnostic

puncture, etc.

4.3 principle of treatment in 4.3 principle of treatment in

early stage of chest injury 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 thoracotomy4.4 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 FractureRib Fracture

1. Costal anatomy and trauma1. 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-rib/segment fracture

“Flail chest”, floating chest wall, paradoxical respiration, ARDS

2. Pathophysiology and manifestation2. Pathophysiology and manifestation

Rib

Fracture

Intercostal nerve—pain— ventilation, secretion

atelectasis

Floating wall —paradox. Resp. —ventilation,

lung compression,

mediastinal pendelluft Interc

ostal vessel —Hemothorax ——ventilation,

lung compression, blood loss

Lung tissue —Pneumothorax —ventilation, lung

compression

Visceral lesion —blood loss

3. Diagnosis3. Diagnosis

• Distinguishing chest pain

• Distinguishing tenderness and

bony crepitus (thoracic crushing test)

• X-ray

4. Treatment4. Treatment

• Analgesia

• Airway secretions clearance

• Chest cage fixation

Principle:

• Complication prevention and treatment

Local managementLocal 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:Severe complications:

• Pulmonary contusion often present in severe

chest wall injury

• Severe pulmonary contusion often results in

acute respiratory insuffeciency

• ARDS

PneumothoraxPneumothorax

1. Anatomic and physiologic features1. Anatomic and physiologic features

• Pneumothorax does harm to circulatory function

as well as respiratory function

• Alteration of thoracic pressure is closely relative

to the severity of Pneumothorax

• Mediastinum is fixed at the two ends and flexibl

e

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 classification2. Principles of classification

According to the thoracic pressure

3. Origin of intrathoracic air3. Origin of intrathoracic air

Lung, Tracheobronchial, Esophagus,

Out side, etc.

4. Closed Pneumothorax4. 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

5. Open Pneumothorax5. Open Pneumothorax

• Intrathoracic pressure = atmosphere

• Dyspnea, Sucking wounds

• Lung collape, Mediastinal shift/pendelluft,

circulatory disturbance

• Obvious Trachea deviation, percussion

/auscultation, X-ray

• Principle of treatment:

Take open pneumothorax into closed one

Thoracostomy: Mechanism and method

6. Tension Pneumothorax6. 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 intra- pleural pressure suggested by palpation/percussion/ auscultation and thoracentesis

Emergency management:

•Thoracentesis

•Tube thoracostomy, suction

•Thoracotomy if necessary

HemothoraxHemothorax

1. Source of hemothorax

•Pulmonary parenchymal laceration

•Intercostal vessel injury

•Major cardiac and vascular injury

•Injury of phrenic vessel

2. Pathophysiology of hemothorax

hemothorax

Lung compression

Mediastinal shift

Respiratory & circu-

Latory dysfunction

Blood loss Progressive hemothorax

Coagulation Clotted hemothorax

Organized hemothoraxInfection

Infective hemothorax

Empyema

3. Diagnosis3. 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. management4. management

• Hemothorax------Thoracostomy

• Progressive hemothorax-----Thoracotomy

• Clotted hemothorax-----Thoracotomy

Video-Assisted

Thoracoscopy

• Infective hemothorax-----Thoracotomy

Traumatic Traumatic AsphyxiaAsphyxia

1. Pathophysiology and mechanism1. Pathophysiology and mechanism

• Sharp rise in intrathoracic pressure

• No venous valve in SVC, pressure conducts to head and neck

• Impairment of cerabral venous outflow increases intracranial pressure

• Marked increased pressure in Sup. Vena.

Cava results in capillary rupture

2. Clinical presentation2. Clinical presentation

• Epistaxis

• Perforation of tympanic membrane, Tinnitus and deafness

• Mucosal bleeding

• Depressed level of consciousness, seizures, temporary or permanent blindness

• Edema and cyanosis of the head and neck,

petechiae, subconjunctival hemorrhage

3. Treatment and prognosis3. Treatment and prognosis

• Relief of symptoms

• Neurologic status been monitored

• Venous drainage promotion

• Elimination and management of other

intrathoracic injuries

Prognosis: Excellent

Cardiac Cardiac injuryinjury

1. Pathophysiology and mechanism1. Pathophysiology and mechanism

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

• Blunt injury------Myocardial contusion,

cardiac rupture

2. Cardiac contusion2. Cardiac contusion

• Lack of diagnostic means with high sensitivity

and specificity:

ECG, UCG, CK, CK-MB, LDH, LDH1.2

Cardiac Troponin I ( CTnI )

• Be precautious of the incidence:

Anterior chest wall crush, sternal

fracture, falling, etc.

• Complication:

Cardiac Arrhythmia, Heart failure

• Management:

Symptom relief, complication prevention

and treatment

3. Cardiac laceration3. Cardiac laceration

• Diagnosis:

Wound around the body surface of

the cardiac projection

Time after damage, Beck’s triad

Hemorrhagic shock

• Classification according to clinical features:

Subclinical type, Tamponade type,

hemorrhagic shock type

• Management:

Surgery as soon as possible

Thoracoabdominal iThoracoabdominal injurynjury

1. Denomination1. Denomination

2. Clinical presentation and diagnosis2. Clinical presentation and diagnosis

• Incidence: left >right• Symptom & signs: thoracic +abdominal• X-ray

3. Treatment3. Treatment

• Surgical procedure• Surgical incision

Key ReferencesKey References

1. The mechanisms of injury. Chapt 1.

2. 石应康等，开放性胸腹联合伤的诊断与治疗。中华外科杂志， 1989； 27（ 8）： 466

3. 石应康等，闭合性胸腹多发性损伤等诊断与治疗。中华胸心血管外科杂志， 1991； 7： 93

4. Pearson et al. Thoracic Surgery. Trauma. Churchill Livingstone Inc. 1995, 1582

5. 石应康等，穿透性心脏损伤等临床分型与处理。中华创伤杂志， 1994； 10（ 2）： 60

6. Nacierio DA. Chest Injuries, Physiologic Principles and Emergency Management. Edlst New York:Grune and Stration. 1971;321-327