Thoracic Trauma : Clinical Indicators

Introduction to Thoracic Trauma

Thoracic trauma constitutes 25% of all severe injuries. A contributory factor in 50% of trauma deaths, most of these cases are caused by bleeding. 80% of cases are managed nonoperatively.

Clinical Indicators of Potential Ongoing Bleeding in Torso Trauma

1. Physiological Indicators:
   • Increasing respiratory rate
   • Increasing pulse rate
   • Falling blood pressure
   • Rising serum lactate
2. Anatomical Indicators:
   • Visible bleeding
   • Injury in close proximity to major vessels
   • Penetrating injury with a retained missile

Life-Threatening Injury

• Life-threatening injuries can be called the ‘’Deadly Dozen
• Deadly Dozen is a list of 12 pathologies that have the potential to cause death after thoracic trauma.
• Six of those 12 conditions have been categorized as immediate life-threatening, and these conditions must be sought during the primary survey. 
• There are six that are potentially life-threatening. So, these six potentially life-threatening conditions are to be sought during the secondary survey.
• Immediately Life-Threatening 
  • Airway obstruction
  • Open pneumothorax
  • Tension pneumothorax
  • Massive hemothorax
  • Flail chest
  • Pericardial tamponade.
• Potentially Life-Threatening
  • Aortic injuries
  • Tracheobronchial injuries
  • Myocardial contusion
  • Rupture of the diaphragm
  • Esophageal injuries
  • Pulmonary contusion

Intercostal Drain (ICD) 

• ICD is inserted in thoracic trauma
  •  In a grossly unstable patient, where physical examination is inconclusive and radiological investigations are unnecessary, the insertion of an underwater chest drainage tube can be a diagnostic as well as a therapeutic procedure.
• The ICD is put
  •  along the upper border of the lower Rib
  • There are intercostal blood vessels and nerves that are basically traveling in the intercostal groove, and this intercostal groove runs along the lower border of the rib.
  • Insert it in the Triangle of Safety.
    • Anteriorly: Lateral Border of Pectoralis Major.
    • Laterally: Lateral Border of Latissimus Dorsi
    • Inferiorly: 5^th Intercostal Space
    • Superiorly: Base of Axilla

• After the ICD is inserted, it is connected to the underwater seal to prevent environmental air from going inside.
• underwater Seal
  •  The water seal helps disconnect the environment in the thoracic cavity from the external atmosphere. This tube is placed effectively under the water. The water column moves up and down, so there's going to be an oscillatory movement of the water column inside that intercostal tube. 
• The best space to put the ICD is the 5^th ICS in the midaxillary line.
• Sizes used are 28Fr and 32Fr tubes and ensure all holes are inside the chest.

• An underwater drainage device provides 20 cm of H₂O suction.
• The patency of the ICD is checked by the Movement of the air-liquid column in the ICD tube in correspondence with respiration. If the column is not moving, it implies that the lung has fully expanded.
• An ICD is removed when the fluid coming is < 50 ml/day or when the lung is fully expanded, and the tube is removed in full Inspiration.

RIB Fracture  

• Rupture of the thoracic aorta: Related to fractures of the first and second ribs, bilateral clavicular fractures, and fractures of the sternum, thoracic spine, or scapula.
• Fracture of the lower ribs: Related to injury of the liver or spleen.
• Fracture of ribs: Injury to lung parenchyma or thoracic wall vasculature causing pneumothorax, hemothorax, or lung contusion.
• The most common Ribs Fractured During CPR (cardiopulmonary resuscitation) are the 3rd–5th ribs.
• Treatment of the simple rib fracture excludes Strapping as it restricts the movement of the lungs, which might further injure the lung parenchyma.
• For Simple nondisplaced fractures, Analgesics are the treatment of choice. For Displacement fractures, the internal fixation procedure is used.

Immediately Life-Threatening conditions

1. Airway Obstruction
   • Early intubation is very important in cases of neck hematoma or possible airway edema.
   • Airway distortion may be insidious and progressive, and this can make delayed Intubation difficult in later stages.
2. Pneumothorax
   •  Pneumothorax is air in the thoracic cavity.
   • the types of Pneumothorax
     • Simple Pneumothorax (Open/Closed)
     • Tension Pneumothorax

• Simple/Open Pneumothorax:
  • The continuity in the wall of thoracic cavities is breached, and there is a two-way movement of the air between the thoracic cavity and the external environment. 
  • In other words, the air can enter the thoracic cavity and leave the thoracic cavity.
• Simple/Closed Pneumothorax: 
  • There is no breach between the wall of thoracic cavities. 
  • Air can enter the thoracic cavity from the lungs and return to the trachea and bronchial tree. 
  • That is what makes it a two-way communication between the lung parenchyma and the thoracic cavity, and this is called a simple closed pneumothorax.
• Tension Pneumothorax
  • In Tension pneumothorax, the whole point of a flap valve. The air might be able to enter the thoracic cavity, but it will not be able to leave the lungs.
  • Tension inside the thoracic cavity will increase, causing the lungs to collapse and hemodynamic instability.
  • The flap valve can be in between the lung parenchyma and thoracic cavity or the thoracic cavity and external atmosphere.
  • Causes of Tension pneumothorax
    • Penetrating chest trauma
    • Blunt chest trauma with a parenchymal lung injury and an air leak that did not spontaneously close.
    • Iatrogenic lung injury (e.g., due to central venipuncture) and mechanical positive pressure ventilation.
• Presentation of tension pneumothorax
  • Respiratory Distress
  • The trachea is deviated (away from the side of the pneumothorax).
  • Absent Breath Sound
  • Resonant note on percussion.

Difference between Tension Pneumothorax and Simple Pneumothorax

The first investigation for Pneumothorax is an X-ray chest, which will show us a blackout with a collapsed lung.

• The USG of the Thorax is performed as part of e-fast, which shows that the Seashore sign is a normal finding. It tells us that the lungs are expanding, coming in, hitting the thoracic cavity, and going back.
  • Air causes many artifacts in pneumothorax, and because of this, a barcode or stratosphere sign is found in the USG.
• In cases of Tension pneumothorax in children, insert a wide-bore needle in the 2^nd Intercostal space in the midclavicular line.

Management of Simple Pneumothorax

Insertion of an Intercostal Drain in the Triangle of Safety

Management of Tension Pneumothorax  

• Emergency Management:
  • Children: Wide Bore Needle Insertion in the 2^nd Intercostal Space in the Mid Clavicular Line.
  • Adult: Inspection of a Wide Bore Needle in the 5^th Intercostal Space in the Mid Axillary Line.
• Definitive Management:
  • ICD Insertion in the triangle of safety.

1. Hemothorax 
   • Hemothorax is the presence of Blood In the thoracic cavity.
   • Clinical features of hemothorax
     • Respiratory distress
     • The trachea is deviated (away from the side of the Hemothorax)
     • Absent breath sounds
     • Dull note on percussion: It is suggestive that the patient is having hemothorax.
     • The first investigation we will order for Hemothorax is an X-ray chest.

• Diagnosis Of Pneumothorax: A diagnostic test is put in a needle and aspirated, and then blood comes out, which gives confirmation of the pneumothorax. For the treatment, put in an intercostal drain.
• Causes Of Hemothorax
  • Laceration to pulmonary parenchyma
  • Injuries to intercostal vessels

Indications of the Thoracotomy 

• Initial tube thoracostomy drainage of >1000 ml in cases of a penetrating injury or >1500 mL Blunt injury.
• Ongoing tube thoracostomy drainage of >200 ml/hr for 3 consecutive hours in non-coagulopathic patients
• Caked hemothorax despite the placement of two chest tubes

1. Flail Chest

• the initial treatment of choice for Flail Chest Endotracheal intubation and mechanical ventilation

• When labeling that person as having flail chest features, it needs to fulfill certain criteria.
  • There should be two fractures in the same rib, and that should continue for at least three consecutive ribs.
  • Another criterion If the patient is not having two fractures in the same ribs but is having two fractures in the same ribs on the opposite side, this has to continue for the three consecutive ribs.
• Pericardial Tamponade
  • Pericardial tamponade is a life-threatening condition characterized by the accumulation of blood in the pericardial space, which surrounds the heart. 
  • It is more commonly caused by penetrating trauma rather than blunt trauma.
  • The pericardial sac, which contains the heart, is non-distensible, meaning it cannot expand or accommodate extra fluid. As a result, even a small amount of blood can increase the pressure inside the sac and compress the heart.
  • It also causes obstruction of the venous return.
  • The increased pressure on the heart chambers impairs the heart's ability to fill with blood during the diastolic phase, leading to decreased cardiac output and potentially fatal consequences.
• Clinical Features of Pericardial Tamponade(Beck’s Triad)
• Pericardial tamponade is associated with Beck's Triad, which includes the following three characteristic signs:
• Raised JVP (Jugular Venous Pressure): The elevated pressure in the pericardial sac impedes venous return to the heart, leading to an observable increase in jugular venous pressure.
• Muffled Heart Sounds: Blood in the pericardial space dampens heart sounds during auscultation. This muffling effect is an essential clinical clue for diagnosing pericardial tamponade.
• Decreased Cardiac output: The blood pressure may drop to dangerously low levels due to reduced cardiac output.

Distinguishing between Tension Pneumothorax and Cardiac Tamponade

• Clinical Diagnosis of Pericardial Tamponade
  • The initial diagnosis of pericardial tamponade is often made based on clinical features, particularly Beck's Triad.
  • E-FAST (Extended Focused Assessment with Sonography for Trauma): E-FAST is a rapid bedside ultrasound examination commonly used in trauma situations.
    • It involves placing a probe on the epigastric region to assess various structures, including the heart.
    • Visualizing the pericardial space and the heart's movement within it can be valuable in detecting pericardial effusion or tamponade.
  • Chest X-ray: It’s not very valuable. A finding of an enlarged, globular-shaped heart shadow on a chest X-ray, especially in a patient with a history of trauma, could suggest the possibility of pericardial tamponade.
• Management of Pericardial Tamponade
  • Traditional management includes needle pericardiocentesis, which involves inserting a needle through sub xiphoid space and aspiration.
  • However, this approach has limitations.
    • Mostly, the blood is clotted; aspiration might be ineffective → Dry tap.
    • Additionally, there is a risk of not properly entering the pericardial space with a needle, → can cause iatrogenic injury to the heart.
  • It should be regarded as a desperate temporizing measure in a transport situation (under electrocardiogram control).
  • Correct immediate treatment for pericardial tamponade is operative via a subxiphoid window or via open surgery.
  • Ideally, it should be done in the operating room, but if time does not permit, it can be done in the emergency room.
  • In Emergency surgery, the Patient is evaluated in the emergency room, and for any reason, if the patient needs surgery, they are shifted to the operating room.

Potentially Life-Threatening 

1. Aortic Injuries

• It can be potentially life-threatening, often resulting from severe trauma like road traffic accidents (RTA) or falls from height.
• The aorta is a major blood vessel that can experience rupture due to decelerating forces acting on the body during such incidents.
• These forces cause internal organs to keep moving even when external motion stops suddenly, straining aortic attachments.
• Most people die at the scene due to tears of intima and media.
• Survivors may have an incomplete laceration at the ligamentum arteriosum of the aorta. 
• Aortic injuries can lead to a widening of the mediastinum ? Contained hematoma.
• Common Sites of Aortic Rupture:
  • The most common site of rupture in aortic injuries is the connection of the aorta to the left subclavian artery, known as the ductus arteriosus.
  • Key signs include:
    • Persistent hypotension
    • Gross disparity between blood pressure readings in between 2 upper limbs or upper and lower limbs
  • Widened pulse pressure.
  • Chest wall contusion
• CXR changes in aortic injuries
  • Chest X-rays can diagnose aortic injuries, which may reveal a widened mediastinum, the most common X-ray finding in Thoracic Trauma.
  • Shifting of Trachea/Oesophagus to right
  • Depression of left main stem bronchus
  • Widened paratracheal stripe/paraspinal interfaces
  • The space between the aorta and pulmonary artery obliterated
  • Rib fracture/left hemothorax
• Diagnosis by:
  • Angiography
  • CT angiogram.
• Treatment: Repair and replacement. Ideally, they should undergo endovascular repair.

2. Tracheobronchial Injury

• Tracheobronchial Injury is a potentially life-threatening condition commonly caused by trauma. It can lead to severe subcutaneous emphysema with respiratory compromise.
• A chest drain placed on the affected side ? causes a large air leak, and the collapsed lung may fail to re-expand.
• Diagnosis of Tracheobronchial Injury: To diagnose tracheobronchial injury, a bronchoscopy is typically performed. This procedure involves inserting a thin, flexible tube with a camera into the airways to visualize and assess any damage or abnormalities.
• Chest X-ray in Tracheobronchial Injury: A chest X-ray can be helpful in identifying a tracheobronchial injury. If there is a shift in the mediastinum or persistent bubbling in the chest tube, it may indicate an ongoing issue.
• Treatment of Tracheobronchial Injury: Managing tracheobronchial injuries can be complex. It often involves selective intubation and the use of cuffed tubes to ventilate the unaffected side of the airway. Surgical repair may be necessary to address the injury effectively.

3. Blunt Myocardial Injury

• Definition: Blunt myocardial injury is a condition caused by trauma or impact to the chest region, leading to damage to the heart muscle.
• Severity: While this injury can be serious, it may not always lead to immediate hemodynamic instability or fatality.
• Diagnosis:
  • Suspect Blunt Myocardial Injury: Look for chest trauma and abnormal early ECG findings in patients.
  • Diagnostic Tests:
    • 2D echocardiography or transesophageal echocardiography 
    • Cardiac Enzyme Markers: Traditional markers like CK-MB may not be helpful in diagnosing this injury.
  • Those who develop conduction abnormalities are at risk of developing sudden dysrhythmias and should be closely monitored.
  • Limited Cases of Sudden Collapse: Although rare, a few patients might experience sudden deterioration; close monitoring is necessary.

4. Diaphragmatic Injury And its Management

• Diaphragmatic injuries can result from penetrating trauma and are more common than those caused by blunt trauma.
• The presentation of diaphragmatic injuries may be asymptomatic>> Respiratory distress.
• Diagnosis:
  • Diaphragmatic injuries are suspected when the entry point of the trauma lies between the nipples and costal cartilage.
  • Asymptomatic patients may require careful evaluation to detect diaphragmatic injuries.
  • Diagnostic laparoscopy is the investigation of choice for diagnosing diaphragmatic injuries.
  • Laparoscopy allows visualization of the defect and aids in ruling out any other intra-abdominal pathologies.
• Management:
  • Conservative management is not suitable for diaphragmatic injuries, as the defect does not heal spontaneously.
  • Operative repair is the preferred approach for managing diaphragmatic injuries.
  • Simple suturing is sufficient for small defects in the diaphragm.
  • Using a patch, mesh, or non-absorbable sutures can be effective in cases of larger defects.
  • Non-absorbable sutures are crucial for repair, as the diaphragm's tissue does not have the potential to heal itself.
  • Leaving the defect untreated could lead to delayed herniation of abdominal organs over time.

5. Esophageal Injuries 

• Esophageal injuries are potentially life-threatening conditions that can occur after penetrating trauma > blunt trauma, with hydrogen-containing substances being a common cause. 
• Features of Esophageal Injuries:
  • Odynophagia (pain in swallowing saliva/food/ fluid)
  • Subcutaneous emphysema
  • Pleural effusion, air in the peri-esophageal space
  • Unexplained fever
• Diagnosis of Esophageal Injuries:
  • Mortality rates rise exponentially if treatment is delayed.
  • Water-soluble contrast studies are commonly used for diagnosis, where contrast material is administered through an esophagogram.
  • Esophagoscopy
• Management of Esophageal Injuries:
  • Operative repair of any defect and drainage.
  • Minimally invasive techniques, such as thoracoscopic or laparoscopic approaches, may be employed for select cases.

6. Pulmonary Contusion

• Pulmonary contusion is a common and potentially lethal injury that can occur after blunt trauma> penetrating trauma.
• Cause: flail segment or fractured ribs.
• This is a very common, potentially lethal injury and the major cause of hypoxemia after blunt trauma.
• It can result from various causes, such as falls, motor vehicle accidents, or gunshot wounds.
• The natural progression of pulmonary contusion is worsening hypoxia for the first 24-48 hrs.
• Diagnostic Approach:
  • X-rays, which may not immediately reveal the contusion, or Contrast-enhanced CT scans for more accurate evaluation, can aid in diagnosis.
• Delayed findings are hemoptysis or blood in the endotracheal tube.
• MANAGEMENT:
  • Mild Cases:
    • Oxygen support: Patients with mild contusion may require supplemental oxygen to maintain adequate oxygen saturation.
    • Pain management: Adequate analgesia given.
    • Chest physiotherapy: This involves tapping the back of the patient to facilitate the removal of secretions from the lungs, reducing the risk of secondary infections. (Pulmonary toileting)
  • Moderate to Severe Cases:
    • Mechanical ventilation: 
    • Normovolemia critical:
    •  It is crucial to maintain normal volume status for adequate tissue perfusion, avoiding both overhydration and underhydration. 

Indications for Operative Management in Thoracic Trauma

• Penetrating Thoracic Injury: If a patient has a penetrating thoracic injury and has lost more than 1.5 liters of blood or if there is ongoing tube output of more than 200 mL per hour for three consecutive hours or longer, thoracotomy is indicated. 
• Cake Hemothorax: In cases of severe hemothorax, where blood accumulates in the chest cavity and forms clots? , and it doesn’t resolve after two chest tubes? are placed, thoracotomy is necessary to remove the accumulated blood and clots. 
• Injury to the Descending Aorta: If there is an injury to the descending aorta (the largest artery in the body), surgical intervention is essential. The damaged aorta needs to be repaired to prevent life-threatening bleeding.
• Pericardial tamponade: Thoracotomy is preferred.
• Cardiac Herniation: The preferred surgical technique in such cases is a cooperative technique, either subxiphoid or thoracotomy, to address cardiac herniation effectively.
• Massive Air Leak in Chest Tube with inadequate ventilation: When there is a massive air leak in the chest tube, and the lung fails to re-expand adequately, operative intervention may be required to repair the air leak and restore proper lung function.
• Diagnosed Mainstem Bronchus Injury: If a mainstem bronchus injury is diagnosed through endoscopy or imaging, operative management is necessary to repair the damaged bronchus and restore normal airflow to the lungs.
• Completely Open Pneumothorax: In cases of completely open pneumothorax, where there is a wide opening in the chest wall allowing air to enter the pleural space, surgical intervention is required to close the opening and prevent further complications.
• Esophageal perforation
• Air Embolism: If there is a confirmed air embolism, where air bubbles enter the bloodstream and cause blockages, operative management is necessary to remove the air and prevent serious consequences.

Types Of Emergency Thoracic Surgery

• Emergency Department Thoracotomy (EDD): Performed in the emergency department to control hemorrhage and decompress the chest quickly. 
• Emergency Sternotomy: Used to quickly access the heart and major vessels. Often performed before transferring the patient to the operating room. It is done for anterior mediastinal structures and the heart.
• Emergency Planned Thoracotomy: Shifting the patient immediately to the operating room for surgery.
• Rationale for Emergency Department Thoracotomy:
  • Done to save time in critical situations like massive trauma or polytrauma patients.
  • Allows quick control of hemorrhage and decompression of the chest.
  • Internal cardiac massage can be performed if the heart is completely stopped.
  • Beneficial for patients with minimal signs of life and penetrating injuries.
• Survival Rate after Thoracotomy Based on Blood Pressure:
  • Blood pressure > 60 mmHg: 60% chance of survival.
  • Blood pressure 40-60 mmHg: 30% chance of survival.
  • Blood pressure < 40 mmHg: 3% chance of survival.
• Planned emergency thoracotomy:
  • It implies an emergency thoracotomy performed as a planned procedure in the operating room, directed at the management of a specific injury.
  • The most common incision is left Anterolateral Thoracotomy (to access the left side structures).
  • Clamshell Incision: Joining left and right anterolateral thoracotomy incisions in the midline. 

Hope you found this blog helpful for your NEET SS Surgery Trauma preparation. For more informative and interesting posts like these, keep reading PrepLadder’s blogs.