Pathophysiology • Derangements in the flow of air, blood, or both in

combination• Chest wall injures rib fractures• Direct lung injures lung contusions• Space-occupying lessions pneumothoraces,

hemothoraces, hemopneumothoraces• Cardiac injures chamber rupture• Severe great vessels injures thoracic aortic

disruption

TRAUMA THORAX

RAPIDLY LETHAL LESIONie. Lesion that could kill the patient in a matter of minutes

• airway obstruction

• tension pneumothorax

• open pneumothorax

• massive haemothorax

• flail chest

• cardiac tamponade

Potensially lethal lesions,.i.e. lesions that can kill the patient in matter of hours

• pulmonary contusion

• aortic rupture

• tracheobronchial rupture

• oesophageal rupture

• diaphragmatic rupture

• myocardial contusion

NON IMMEDIATELY LIFE THREATENING LESIONS

• Haemothorax• simple pneumothorax• rib fractures• sternal fractures• soft tissue lesions• traumatic chylothorax• intrathoracic foreign bodies• subcutaneous emphysema• others.

Clinical Presentation

• Varies widely from minor report to florish shock• Clinical history time of injury, mechanism,

velocity&deceleration, assosiated injury, silent future

• 3 broad categories : (1) chest wall fracture, dislocation, and barotrauma (including diaphragmatic injury); (2) blunt injuries of the plaurae,lungs, and aerodigestive tracts; and (3) blunt injuries of the heart, great vessels

Imaging studies• CXR should not wait CXR for diagnose

emergency measurement• Chest CT-scan should restricted to

undetected or occult injury is considered• Aortogram standard for diagnosis of blunt

aortic injures• Thoracic US pericardial effusions or

tamponade• Contrast Esophagogram for esophageal

injures

Rib Fractures• Most common blunt thoracic injuries, rib 4-10

most frequently involved• Inspiratory chest pain, pain over the fractures site• Tenderness and crepitus over the site of fracture• Mostly do not need surgery, pain control the

goal of treatment• Early mobilization and aggressive pulmonary toilet• Surgical Hemostasis if lacerates intercostal artery

Flail Chest• >3 ribs fractures in >2 places free floating and unstable

chest wall or Costochondral separation • Pain over fracture site, pain upon inspiration, dyspnea.• Paradoxal inspiration (sucking chest) chest wall move

inward with inspiration and outward with expiration• Labored respiration due to paradoxal motion

respiratory distress

Treatment : Flail Chest• Endotreacheal intubation and positive

pressure mechanical ventilation• Stabilize chest wall internal fixation

Clavicular fracture

• Tenderness and tenderness over the site• Proximal segment displaced superiorly

action sternocleidomastoideus• Mostly can be managed without surgery• Immobilization figure eight, clavicle

strap, sling.• Oral analgesia

Sternal Fracture• Inspiratory pain, local tenderness, swelling,

ecchiymosis, crepitus• Associated injuries : rib fractures, long bone fracture,

close head injury• Blunt cardiac injury 20%• No therapy specifically analgesia and minimize

activities of pectoral and shoulder muscle• Most important exclude blunt myocardial injury• Open reduction & fixation badly displaced wire

suturing and placement of plates and screw

Scapular fracture

• Uncommon• Associated injury : head, chest, abdomen• Exclude major vascular injury• Shoulder immobilization sling or

shoulder harness• Early ROM exercise prevent shoulder

contracture

Blunt diaphragmatic injuries

• Mostly left side• Must considered abdominal injury

with dyspnea and respiratory distress• Hypovolemic shock major splenic or

hepatic injury• Approached laparotomy suture with

polypropylene or dacron

Pneumothorax

• Rib fracture or barotrauma• Dyspnea, decreased breath sound and

hyperresonance to percussion• Chest tube + suction sistem -20 cmH2O

(pleur-evac) WSD if the lung remains fully expanded chest tube remove CXR

Tension pneumothorax

• Ventile mechanism lungs collaps respiratory distress

• Diminished or absent of breath sound, hemithorax hyperresonant to percussion, trachea deviated

• Immediate decompression with needle thoracostomy (large bore nedle 14-16G) Chest tube

• Pain control

Open Pneumothorax

• Caused by penetrating trauma rarely due to blunt trauma

• Respiratory distress lung collaps

• Placing occlusive dressing over wound chest tube

Hemothorax

• Accumulation of blood within the pleural space

• Lacerations internal mammary vessels or other major thoracic vessels

• Chest tube, massive (1500mL or 200-300 mL/h) thorachotomy

Pulmonary contusion and other parenchymal injures

• Transmition of force to the lung parenchym lung contusion with hemorrage into the lung tissue

• Clinical finding depent to the extent of the injury

• Pain control, pulmonary toilet, sumplemental oxygen (intubation with mecanical ventilation)

• Surgical haemostatis laceration or avulsion

Blunt tracheal injury• Fracture, lacerations, and disruptions• Respiratory distress, cannot speak, stridor, other sign

associated w pneumothorax n subcutaneous emphysema

• Many die before can reach defenitive care life trheatening require immediate surgical repair to establishment of an adequate airway

• Endotracheal intubation flexible bronchoscope tube placed distal site of injury

• Always prepared to perform emergency trecheotomy• Surgical repair restoration of airway continuity w

primary end-to-end anstomosis

Blunt bronchial injuries

• Laceration, tear, or disruption of a major bronchus is life threatening many die before treatment

• Respiratory distress n physical sign consistent w pneumothorax

• Require surgical repair secure airway• Ipsilateral thoracotomy on the affected side w

single-lung ventilation debridemant n end-to-end ansstomosis

Blunt esophageal injuries

• Rare because protected location in posterior mediastinum

• Caused by a sudden increase intraluminal pressure from a forceful blow to the epigastrium

• Spillage GI contents into the chest• Upper abdo & thoracic pain ass w thypnea,

tachycardia, subcutaneus emphysema.

Treatment : Blunt esophageal injuries

• Fluid resuscitation n broad-spectrum iv antibiotic n anaerob AB

• Surgery debridemant w primary anatomosis well-vascularized autologous tissue (parietal pleura n intercostal muscle) Thal Patch

• Poor general condition esophageal diversion (a cervical esophagostomy), the distal esophagus stapled, gastrostomy for decompression, and wide mediatinal drainage w chest tube.

Blunt cardial injuries

• Cause by : MVA (most common), falls, crush injuries, violent, sport injury, ect

• Range varies from mild trauma ass w arrythmias to severe rupture valve, septum or myocardial

• Clinical varies from chest pain to cardiac tamponade to complete cardivascular collaps

• Treatment cardiosintesis to cardiorrhapy w cardiopulmonar by pass

Blunt injuries of the thoracic aorta and major thoracic arteries

• Mechanism injury: rapid deceleration sharing force, direct compression

• Many die before reaching defenitive care• Treatment: endovascular stent grafts,

arteriorraphy w cardiopulmonary by pass

Blunt injury of the superior vena cava and major thoracic veins

• Rare, usually ass w injuries other major thoracic vascular structures

• Treatment : venorrhaphy w cardiopulmonary by pass

• Injured subclavian or azigous veins if difficult to repair can be ligated