Thoracic Trauma 1

THORACIC TRAUMA EXAMINATION
OBJECTIVES
1 Present a brief overview of thoracic anatomy and respiratory physiology.
2 Define blunt chest trauma and penetrating chest trauma.
3 Describe the injuries that can occur with each type of thoracic trauma.
4 Perform examinations and recognize the main symptoms of injuries caused by thoracic
trauma.
Overview of thoracic anatomy
Overview of pleural cavity
Overview of respiratory physiology
- During inhalation, Increased the thoracic volume leads to lower intrathoracic
pressure than outside. Air passes from the outside into the lungs, where the exchange
of O2 and CO2 takes place
- During exhalation, Reducing the thoracic volume, which results in higher pressure in
the thorax compared to the outside. Air from the lungs, carrying carbon dioxide is
expelled.
The pleural cavity plays an important role in respiratory physiology
+ The pleural cavity is a potential, closed space. Normally, this space maintains a
negative pressure ranging from -5cmH2O to -20 cmH2O.
+ Maintaining negative pressure in the pleural cavity ensures that the parietal and
visceral pleurae stay closely apposed.
+ When the pleural cavity contains substances (air, blood, fluid, etc.), affecting
respiratory function and manifesting as clinical symptoms.
 Regulation of respiratory activity is controlled by:
- The somatic nervous system
- The autonomic nervous system
- The concentration of oxygen in the blood
 Normally, the pressure in both lungs and the alveoli is equal according to Laplace's
law:
P= 2T/r
(T is the surface tension of the alveoli and r is the radius of the alveoli).
- When producing sound or speaking, the vibrations of sound waves can be felt with
the hand when placed on the chest. These vibrations are called tactile fremitus.
- Typically, both lungs are equally filled with air, so percussion of the thorax produces a
resonant sound.
- When the alveoli expand during inhalation and contract during exhalation, sounds
known as bronchial breath sounds or vesicular breath sounds are produced
symmetrically in both lungs.
Overview of Thoracic trauma
Approximately 50% of chest injuries are caused by traffic accidents,

while the remaining causes include occupational accidents (physical
altercations, and falls from heights ), domestic accidents,...
All types of thoracic trauma can affect the lungs, heart, and major blood
vessels to varying degrees, potentially leading to cerebral hypoxia.
Classification of thoracic trauma
Depending on the severity and cause of the injury, thoracic trauma is

classified into two types:
- Blunt thoracic trauma: After the injury, the pleural cavity is not open to
the outside.
- Penetrating thoracic trauma: After the injury, the pleural cavity is open
to the outside.
Signs of injury in the pleural cavity
Hemothorax: "3 decreases" syndrome
Pneumothorax: Galliard’s triad

Examination of thoracic trauma
General principles
 Investigate thoroughly the situations and mechanism of the injury to
visualize potential injuries that may have occurred.
 Carefully inquire about the functional symptoms and first aid.
 Physical examination thoroughly to identify all relevant physical sign.
 Assign paraclinical examination appropriately.
Blunt chest trauma
1. Chest wall
Soft tissue contusions
Rib fractures:
- Uncomplicated Rib Fractures
- Complicated rib fractures
Sternum fractures are often accompanied by injuries to the mediastinal organs
Scapular fractures (rare)
Rib fractures
When three or more consecutive ribs are fractured at both ends, a flail chest is formed
2. Lung and pleural injuries
Complications may include:
a. Subcutaneous emphysema: indirect sign in bronchial rupture and
pneumothorax
b. Stable Pneumothorax:
- The patient may experience stable dyspnea
- Examination: Galliard's triad.
- X-ray: hyperlucency and absence of vascular markings.
c. Tension Pneumothorax - Valvular pneumothorax
c. Tension Pneumothorax - Valvular pneumothorax
- Respiratory condition
- Skin and mucous membranes condition
- Obvious chest asymmetry, possibly accompanied by extensive
subcutaneous emphysema, deviation of the cardiac apex, and widening of
the intercostal spaces
- Galliard’s triad, characterized by hyperresonance (as if tapping on a
drum)
- X-ray shows hyperlucency over an entire lung field.
d. Hemothorax
- Acute blood loss syndrome (Hypovolemic shock).
- "3 decreases" syndrome.
- X-ray shows a hazy appearance at the lung base with a
Damoiseau curve.
e. Hemopneumothorax
Picture 7.5. Lung and pleural injuries

f. Pulmonary contusion
g. Pneumothorax
h. Mediastinal emphysema
i. Cardiac tamponade: Blood accumulation in the pericardial sac

Open thoracic trauma (Penetrating
thoracic trauma)
1. Open chest wound
2. Open pneumothorax (Communicating pneumothorax)
3. Tension pneumothorax (Valvular pneumothorax)

1. Open chest wound
In the affected thoracic cavity, there is no longer any pleural space, causing
the lung to collapse. As a result:
- During inhalation: Air enters through the damaged chest wall,
compressing the collapsed lung and pushing the mediastinum towards the
unaffected side.
- During exhalation: Air exits from the affected thoracic cavity, and
the mediastinum is pulled back towards that side.
- The mediastinum flutter with each breath.
2. Open pneumothorax
Air stagnation in the lungs a growing accumulation of CO2.
- Dyspnea.
- Sucking chest wound
- Decreased tactle fremitus.
- Hyperresonance on percussion.
- Decreased or absent breath sounds.
3. Tension pneumothorax
Air can enter from the outside through the chest wall wound during
inhalation but cannot escape during exhalation, creating a one-way valve
effect on the chest wall.
Conclusion
 Chest trauma is a very common injury, potentially leading to rapid
death.
 Understanding the mechanism of injury and conducting a thorough
examination to accurately diagnose the effects of chest trauma
REFERENCES
1. Lê Cao Đài, Nguyễn Thấu, Đồng Sĩ Thuyên (1981), Chấn thương ngực, Nhà xuất bản Y học, Hà NộI, tr.
15-293.
2. Nguyễn Đoàn Hồng (1983), “Khám bệnh nhân chấn thương lồng ngực”, Bài giảng triệu chứng học
ngoại khoa, tr. 87-94.
3. Nguyễn Công Minh (2005), Chấn thương ngực, Nhà xuất bản Y học, chi nhánh Thành Phố Hồ Chí Minh,
tr. 1-20.
4. Brock M. V., Mason D.P. and Yang S.C. (2005), “Thoracic trauma”, Surg. of the Chest, Sabiston-Spencer,
7th Ed. Ed by F.W. Sellker, P. J. del Nido and S. J. Swanson. Elsevier Saunders, Philadelphia, pp. 79-103.
5. Wisner D. H. (1995), “Trauma to the Chest”, Surg. of the chest, Sabiston-Spencer, 6th Ed. W. B. Saunder
Co., Philadelphia, tr. 456-493.
REVIEW QUESTIONS
Question 1: Thoracic trauma can be caused by:

a. Blunt objects striking the chest or strong shock waves transmitted to it.
b. Collapsing walls or a tree falling onto the chest.
c. Falls from heights or impact against the steering wheel of a car.
d. All of the above.
Question 2: Simple rib fractures in closed chest trauma:
a. Are a rare type of injury.
b. Ribs 1 to 3 are the most easily fractured.
c. Often fracture at the anterior or lateral aspect.
d. Rib fractures heal easily and typically form good callus.
Question 3: Flail segment can lead to:
a. Cardiac tamponade and reversed respiration.
b. Reversed respiration and mediastinal flutter.
c. Mediastinal pneumothorax and respiratory failure.
d. Mediastinal flutter and distended neck veins.
Question 4: The main signs of a tension pneumothorax are:
a. Subcutaneous emphysema, acute respiratory failure, and mediastinal shift
towards the unaffected side.
b. Acute respiratory failure, absent breath sounds, subcutaneous emphysema,
mediastinal shift towards the unaffected side, and hyperresonant on
percussion.
c. Mediastinal shift towards the unaffected side, mediastinal pneumothorax, and
loss of vesicular breath sounds.
d. Acute respiratory failure, mediastinal shift towards the unaffected side, and
distended neck veins.
Question 5: Open pneumothorax:
a. Sucking chest wound.
b. Leads to lung collapse.
c. Causes decreased cardiac output and respiratory failure.
Question 6: Diagnosis of hemothorax is based on:
a. The "3 decreases" syndrome + acute blood loss syndrome + chest X-ray.
b. Beck's triad + chest X-ray.
c. Respiratory failure syndrome + chest CT scan.
d. Internal bleeding syndrome + chest ultrasound.
Question 7: When encountering an open pneumothorax, the following
should be done immediately:
a. Intubate and bag-mask ventilate.
b. Manage shock, ensure ventilation, and transport the patient
immediately to a specialized hospital.
c. Seal the opening in the chest wall using any available materials.
d. Perform closed chest drainage.
Question 8: Blunt thoracic trauma:
a. Can be very severe or very mild.
b. 50% of cases are due to traffic accidents.
c. Often associated with other injuries.
Question 9: Tests valuable in diagnosing pneumothorax is:
a. Chest ultrasound.
b. Complete blood count (CBC).
c. Chest X-ray.
d. Bronchoscopy.
Question 10: Diaphragmatic injury from penetrating fractured ribs can
occur due to the following ribs:
a. 5- 6
b. 7- 8
c. 9- 10
d. 11- 12

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THORACIC TRAUMA EXAMINATION

1 Present a brief overview of thoracic anatomy and respiratory physiology.

2 Define blunt chest trauma and penetrating chest trauma.

Approximately 50% of chest injuries are caused by traffic accidents,

Depending on the severity and cause of the injury, thoracic trauma is

Pneumothorax: Galliard’s triad

Picture 7.5. Lung and pleural injuries

i. Cardiac tamponade: Blood accumulation in the pericardial sac

1. Open chest wound

2. Open pneumothorax (Communicating pneumothorax)

3. Tension pneumothorax (Valvular pneumothorax)

Question 1: Thoracic trauma can be caused by:

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