TORSO TRAUMA

Clinical indicators of potential ongoing bleeding in torso trauma

• . Physiological Increasing respiratory rate

• Increasing pulse rate
• Falling blood pressure
• Rising serum lactate

• Anatomical Visible bleeding Injury in close proximity to major vessels

• Penetrating injury with a retained missile
THORACIC INJURIES

• Investigations

•Ultrasound – extended focused assessment with

sonar for trauma Extended focused assessment with sonar for trauma
(eFAST) is becoming the most common investigation.
• The technique uses sonar assessment in the chest, looking for a cardiac tamponade
or free blood and air in the hemithorax on each side
• , and assessment for blood in the abdominal cavity, in the paracolic gutters,
subdiaphragmatic spaces and pelvis
• Underwater chest drain In the physiologically grossly
unstable patient, where physical examination is inconclusive
and there is no time for radiological investigations,
• insertion of an underwater chest drainage tube can be a
diagnostic procedure as well as a therapeutic one, and the
benefits of insertion often outweigh the risks
•Chest radiograph In those cases where the patient is haemodynamically
unstable or the spine is at risk
• , an anteroposterior (AP) supine chest radiograph is usually the simplest initial investigation, and
will provide good information regarding tracheal deviation, lung and mediastinal pathology, as well
as skeletal injury.
• In penetrating injury, it may be more helpful for the radiograph to be performed with the patient
positioned erect, as this will best reveal a small pneumothorax, fluid meniscus, air–fluid level or
the presence of free gas under the diaphragm, indicating the presence of a hollow abdominal
viscus perforation.
• Note that up to 300 mL of blood may pool behind the domes of the diaphragm, and may not be
visible even in the erect view. The presence of thoracic skeletal injury should alert the clinician to
the possibility of adjacent thoracic or abdominal visceral injury.
• Rupture of the thoracic aorta can be related to fractures of the first and second rib, bilateral
clavicular fracture and fracture of the sternum, thoracic spine or scapula.
• Fracture of the lower ribs can be related to injury of liver or spleen.
• Fracture of ribs, irrespective of site, can be related to injury to the lung parenchyma or thoracic
wall vasculature, causing pneumothorax, haemothorax or lung contusion
• Computed tomography scan The computed tomography (CT) scan
with contrast allows for three­dimensional reconstruction of the chest and abdomen, as well as of the bony
skeleton.
• It has become the principal and most reliable examination for major injury in thoracic trauma.
• In blunt chest trauma, the CT scan will allow the definition of fractures, as well as showing haematomas,
pneumothoraces and pulmonary contusion.
• In penetrating trauma, the scan may show the track or presence of the missile and allow the proper
planning of definitive surgery. However, although the presence of an isolated rupture of the diaphragm with
migration of abdominal contents into the chest can be detected by CT scan
• , in injury without migration the diagnosis will not be obvious.
• The pitfalls of investigation are: ● failure to assess tracheal shift immediately
above the sternal notch clinically (deviation of the trachea occurs away from the affected side in tension
pneumothorax, and towards the affected side in lung collapse);
• ● failure to percuss and auscultate both front and back in a supine patient (an inflated lung will ‘float’ on a
haemothorax, so auscultation from the front may sound normal);
• ● failure to pass a nasogastric tube if rupture of the diaphragm is suspected; a chest radiograph will show the
nasogastric tube apparently within the chest cavity;
• ● a supine chest radiograph can show a haemothorax as a homogenous increase in opacity of the hemithorax; this
can cause confusion between the darker side and the lighter side, as to which may be a haemothorax (less
radiolucent), or a pneumothorax (more radiolucent). Look carefully for lung markings, and don’t drain the wrong side;
• ● pursuing radiological investigation (radiography or CT scan) instead of resuscitation in the unstable patient
MANAGEMENT

• Closed management of chest injuries ●

• ● About 80% of chest injuries can be managed with the insertion of an intercostal drain only ●
• ● Do not close a sucking chest wound until a drain is in place ●
• ● If bleeding persists, the chest will need to be opened and direct haemostatic control is obtained
• Immediate life-threatening injuries

Airway obstruction
important, particularly in cases of neck haematoma or possible airway oedema.
Early intubation is very

• Airway distortion can be insidious and progressive and can make delayed intubation more difficult if not
impossible.
• Tension pneumothorax A tension pneumothorax develops when a ‘one­way valve’ air
leak occurs either from the lung or through the chest wall.
• Air is sucked into the thoracic cavity without any means of escape, completely collapsing then
compressing the affected lung.
• The mediastinum is displaced to the opposite side, decreasing venous return and compressing the
opposite lung.
• The most common causes are penetrating chest trauma, blunt chest trauma with a parenchymal lung
injury and air leak that did not spontaneously close, iatrogenic lung injury (e.g. due to central
venepuncture) and mechanical positive pressure ventilation.
• The clinical presentation is dramatic. The patient is increasingly
restless with tachypnoea, dyspnoea and distended neck veins (similar to pericardial tamponade).

• Clinical examination may reveal tracheal deviation; this is a late finding and is not necessary
to clinically confirm diagnosis. There will also be hyper­resonance
• and decreased or absent breath sounds over the affected hemithorax
• . Tension pneumothorax is a clinical diagnosis and treatment should never be delayed by waiting for radiological

confirmation Treatment consists of immediate decompression, initially by rapid insertion of a large­bore

cannula into the second intercostal space in the mid­clavicular line of the affected side
• , then followed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line.
• Pericardial tamponade Pericardial tamponade needs to be
differentiated from a tension pneumothorax in the shocked patient with distended neck veins.
• It is most commonly the result of penetrating trauma.
• Accumulation of a relatively small amount of blood into the non­distensible pericardial sac can produce
compression of the heart and obstruction of the venous return, leading to decreased filling of the
cardiac chambers during diastole.
• All patients with penetrating injury anywhere near the heart plus shock must be considered to have a
cardiac injury until proven otherwise.
• Classically, the presentation consists of central venous pressure elevation,
• decline in arterial pressure with tachycardia and muffled heart sounds
• and further diagnostic investigations will be needed to make the diagnosis is those cases that are not
clinically obvious. These include an eFAST showing fluid in the pericardial sac.
• This is the most expeditious and reliable diagnostic tool, or chest radiography looking for an enlarged
heart shadow.
• Pericardiocentesis is a temporising measure only, with a high complication rate and is not a substitute
for immediate operative intervention
• Open pneumothorax (‘sucking chest wound’) This is due to a
large open defect in the chest (>3 cm), leading to immediate equilibration between intrathoracic and atmospheric
pressure.
• If the opening in the chest wall exceeds about two­thirds of the diameter of the trachea, then with each inspiratory
cycle, air will be preferentially drawn through the defect, rather than through the trachea.
• Air accumulates in the hemithorax (rather than in the lung) with each inspiration, leading to profound hypoventilation
on the affected side and hypoxia.
• If there is a valvular effect, increasing amounts of air in the pleura will result in a tension pneumothorax (see above)
• . Initial management consists of promptly closing the defect with a sterile occlusive plastic dressing (e.g. Opsite®),
taped on three sides to act as a flutter­type valve.
• A chest tube is inserted as soon as possible in a site remote from the injury site.
• Massive haemothorax The most common cause of massive haemothorax in
blunt injury is continuing bleeding from torn intercostal vessels or occasionally from the internal
mammary artery secondary to fractures of the ribs.
• In penetrating injury, a variety of viscera, both thoracic and abdominal (with blood leaking through a
hole in the diaphragm from the positive pressure abdomen into the negative pressure thorax) may be
involved.
• Accumulation of blood in a haemothorax can significantly compromise respiratory efforts, compressing
the lung and
• preventing adequate ventilation.

• Presentation is with haemorrhagic shock, flat neck veins, unilateral absence of breath sounds and
dullness to percussion.

•
Theinitial treatment consists of correcting the hypovolaemic shock, insertion of an
intercostal drain and, in some cases, intubation. Initial drainage of more than 1500 mL of blood or ongoing
haemorrhage of more than 200 mL/h over 3–4 hours is generally considered an indication for urgent thoracotomy.
• Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding,
an empyema or fibrothorax later.
• Clamping a chest drain to tamponade a massive haemothorax is not helpful
TREATMENT

• . The following points are important in the management of an open pneumothorax/haemothorax:

• ● a common problem is using too small a tube – a 28FG or larger tube should be used in an adult;
• ● if the lung does not reinflate, the drain should be placed on low­pressure (5 cm water) suction;
• ● clot occlusion of a chest drainage tube may result in ‘no’ drainage, even in the presence of ongoing
bleeding;
• ● a second drain is sometimes necessary (but see Tracheobronchial injuries);
• ● a chest radiograph can help identify the presence of blood;
• ● physiotherapy and active mobilisation should begin as soon as possible.
FLAIL CHEST
• This condition usually results from blunt trauma associated with multiple rib fractures, and is defined as
three or more ribs fractured in two or more places
• . The blunt force typically also produces an underlying pulmonary contusion
• . The diagnosis is made clinically in patients who are not ventilated, not by radiography.
• To confirm the diagnosis the chest wall can be observed for paradoxical motion of a chest wall segment
• . On inspiration, the loose segment of the chest wall is displaced inwards and therefore less air moves
into the lungs.
• On expiration, the segment moves outwards (paradoxical respiration).
• Voluntary splinting of the chest wall occurs as a result of pain, so mechanically impaired chest wall
movement and the associated lung contusion all contribute to the hypoxia.
• There is a high risk of developing a pneumothorax or haemothorax.
• The CT scan, with contrast to display the vascular structures and a 3­D reconstruction of the chest wall,
is the gold standard for diagnosis of this condition.
TREATMENT

• Currently, treatment consists of oxygen administration,

• adequate analgesia (including opiates) and physiotherapy.
• If a chest tube is in situ, topical intrapleural local analgesia introduced via the tube, can also be used.
• Ventilation is reserved for cases developing respiratory failure despite adequate analgesia and oxygen.
• Surgery to stabilise the flail segment using internal fixation of the ribs may be useful in a selected group
of patients with isolated or severe chest injury and pulmonary contusion.
POTENTIALLY LIFE THREATENING DISEASES

• Thoracic aortic disruption

• Traumatic aortic rupture is a common cause of sudden death after an automobile collision or fall from a
great height.
• The vessel is relatively fixed distal to the ligamentum arteriosum, just distal to the origin of the left
subclavian artery.
• The shear forces from a sudden impact disrupt the intima and media. If the adventitia is intact, the
patient may remain haemodynamically stable.
Aortic disruption should be clinically suspected in patients with gross asymmetry in systolic
blood pressure (between the two upper limbs, or between upper and lower limbs), widened pulse
pressure and chest wall contusion.
Erect chest radiography can also suggest thoracic aortic disruption,
the most common radiological finding being a widened mediastinum
The diagnosis is confirmed by a CT scan of the mediastinum , or possibly by transoesophageal echocardio
graphy,
in unstable patients who cannot be moved to the scanner. Initially, management consists of control of the
systolic arterial blood pressure (to less than 120 mmHg)
. Thereafter, an endovascular intra­aortic stent can be placed,
or the tear can be operatively repaired by direct repair or excision and grafting using a Dacron graft
• Tracheobronchial injuries Severe subcutaneous emphysema
with respiratory compromise can suggest tracheobronchial disruption.
• A chest drain placed on the affected side will reveal a large air leak and the collapsed lung may fail to re­
expand.
• Bronchoscopy is diagnostic.
• Treatment involves intubation of the unaffected bronchus followed by operative repair.
• Referral to a trauma centre is advised.
• Blunt myocardial injury Significant blunt cardiac injury that causes
haemodynamic instability is rare.
• Blunt myocardial injury should be suspected in any patient sustaining blunt trauma who develops early
ECG abnormalities.
• Two­dimensional echocardiography may show wall motion abnormalities.
• A transoesophageal echocardiogram may also be helpful.
• There is very little evidence that enzyme estimations have any place in diagnosis.
• All patients with myocardial contusion diagnosed with conduction abnormalities are at risk of developing
sudden dysrhythmias and should be closely monitored.
• Diaphragmatic injuries Any penetrating injury below the fifth intercostal space
should raise suspicion of diaphragmatic penetration and, therefore, injury to abdominal contents.
• Blunt injury to the diaphragm is usually caused by a compressive force applied to the pelvis and abdomen.
• The diaphragmatic rupture is usually large, with herniation of the abdominal contents into the chest.
• Most diaphragmatic injuries are silent and the presenting features are those of injury to the surrounding
organs.
• There is no single standard investigation
• . Chest radiography after placement of a nasogastric tube may be helpful (as this may show the stomach
herniated into the chest).
• Contrast studies of the upper or lower gastrointestinal tract, CT scan, ultrasound and diagnostic peritoneal
lavage all lack positive or negative predictive value.
• The most accurate evaluation is by video­assisted thoracoscopy (VATS) or laparoscopy, the latter offering the
advantage of allowing the surgeon to proceed to a repair and additional evaluation of the abdominal organs.
• Operative repair is recommended in all cases.
• All penetrating diaphragmatic injury must be repaired via the abdomen and not the chest, to rule out
penetrating hollow viscus injury.
• Oesophageal injury Most oesophageal injuries result from penetrating trauma;
blunt injury is rare. A high index of suspicion is required.
• The patient can present with odynophagia (pain on swallowing saliva, foods or fluids), subcutaneous or
mediastinal emphysema, pleural effusion, air in the perioesophageal space and unexplained fever.

• A combination of oesophagogram in the decubitus position and oesophagoscopy

confirm the diagnosis in the great majority of cases.
• The treatment is operative repair of any defect and drainage.
• Pulmonary contusion Pulmonary contusion occurs more frequently
following blunt trauma, usually associated with a flail segment or fractured ribs.
• This is a very common, potentially lethal injury and the major cause of hypoxaemia after blunt trauma.
• Following gunshot wounds, there is an area of contusion from the shock wave of the bullet
• . The natural progression of pulmonary contusion is worsening hypoxaemia for the first 24–48 hours.
• Chest radiographic findings may be typically delayed. Contrast CT scanning can be confirmatory.
• Haemoptysis or blood in the endotracheal tube is a sign of pulmonary contusion.
• In mild contusion, the treatment is oxygen administration, pulmonary toilet and adequate
analgesia.
• In more severe cases mechanical ventilation is necessary.
• Normovolaemia is critical for adequate tissue perfusion and fluid restriction is not advised.
EMERGENCY DEPARTMENT THORACOTOMY OR
STERNOTOMY EDT SHOULD BE RESERVED FOR THOSE PATIENTS
SUFFERING PENETRATING INJURY IN WHOM SIGNS OF LIFE ARE STILL PRESENT

• The aim of EDT is to perform:

• ● internal cardiac massage;
• ● control of haemorrhage from injury to the heart or lung;
• ● control of intrathoracic haemorrhage from other sources;
• ● control of massive air leak;
• ● clamping of the thoracic aorta to preserve the blood supply to the heart and brain, and cutting off the
arterial supply distally, in a moribund patient with a major distal penetrating injury.