Thoracic Surgery
Lecture 3
Thoracic Injuries: - Account for 25% of all injuries,
usually they life-threatening and occur due to bleeding
but fortunately 80% can be managed conservatively by
proper Dx and resuscitation.
Immediate Life-Threatening Injuries: -
1. Air Way Obstruction: - Early preventable trauma
deaths are usually due to lack of or delay in air way
control.
Air way obstruction in trauma usually caused by: - 1.
Dentures, teeth, secretions, and blood 2. Bilateral
mandibular fracture. 3.expanding neck hematoma cause
compression and deviation of trachea. 4.Laryngeal or
Tracheal injuries.
Mx: - Early endotracheal intubation is important
especially in case of neck hematoma or airway edema
with protection of cervical spine if their injury is
suspected to prevent damage to cervical cord.
2. Cardiac Tamponade
3. Tension Pneumothorax: - develops when a one-way
valve air leak occurs either from the lung or through the
chest wall, air is forced into the thoracic cavity without
any mean of escape, completely collapsing the affected
lung, the Mediastinum is displaced to the opposite side,
decreasing the venous return and compressing the
opposite lung.
Etiology: -
1. Penetrating chest trauma
2. Blunt chest trauma with parenchymal lung injury and
air leak that did not close spontaneously
3. Iatrogenic lung puncture e.g., from Subclavian central
venous insertion.
4. mechanical positive pressure ventilation.
C.F: - 1. The Pt. is panicky with dyspnea, tachypnea and
distended neck veins with cyanosis.
O/E: - tracheal deviation, hyper resonant and absent
breath sounds over the affected hemithorax
Tension Pneumothorax is a clinical Dx. And Rx
must not be delayed waiting for Radiological
confirmation.
Rx: - 1. Rapid insertion of large bore needle into 2nd
intercostal space in the Mid-clavicular line of the
affected hemithorax.
2.insertion of chest tube through 5th ICS between anterior
and mid axillary line and direct it to apex of hemithorax.
4. Open Pneumothorax: - is due to large defect in the
chest wall > 3 cm leading to equilibration between
intrathoracic and atmospheric pressure, air accumulate in
hemithorax with each inspiration leading to profound
hypoventilation on the affected side and hypoxia.
Mx :- 1. close the defect with a sterile occlusive plastic
dressing taped on three sides act as a flatter-type valve.
2.a large bore chest tube is inserted in a site away from
the site of injury, if the lung doesn’t expand the drain
must be connected to low pressure suction, a 2nd drain is
sometimes necessary
3. debridement and closure of chest wall defect usually
done in the operative room.
5. Massive Hemothorax: - in blunt trauma is caused by
continuous bleeding from torn intercostal or internal
mammary artery.
Accumulation of blood in the hemithorax compress the
lung and prevent adequate ventilation.
C.Fs :- pt. present with signs of hemorrhagic shock
(tachycardia and hypotension) with flat neck veins ,
unilateral absence of breath sounds and dullness to
percussion.
Rx :- 1. insertion of chest tube to remove the blood
completely
2. correct hypovolemic state by using central venous line
and replacement by crystalloid and colloids, sometimes
Endotracheal intubation may be necessary.
3. initial drain > 1500ml or continuous bleeding > 200ml
/hr. for 3 hours indicates urgent Thoracotomy
6. Flail chest :- usually result from blunt trauma when 3
or more ribs fractured at 2 or more places producing a
loose segment of chest wall moves paradoxically with
respiration i.e. moves inwards during inspiration this
together with lung contusion and pain result in hypoxia ,
a hemothorax and /or pneumothorax may be associated.
Mx 1. Oxygen administration 2.Adequate
analgesia and physiotherapy 3. chest tube insertion
when necessary.
Potentially Life Threatening injuries :-
1. Thoracic Aortic disruption :- Traumatic aortic rupture
is common cause of sudden death after Blunt trauma e.g.,
automobile collision or fall from height ,with
deceleration the aortic arch moves anteriorly while the
descending aorta is relatively fixed distal to ligamentum
arteriosum just distal to origin of subclavian A. this will
produce a shearing forces from the sudden impact will
disrupt the intima and media, if the adventitia is intact the
Pt. may remain stable but require Urgent Rx.
Dx :- Pt. with blunt chest trauma + Asymmetry of upper
and Lower limb Pressure + widen Pulse pressure , We
must suspect the injury , CXR in erect position shows
Widen Mediastinum
Dx is confirmed by Arch Aortography OR CT
angiography
Mx :- 1. control systolic BP < 100 mm Hg.
2. Use of Endovascular intra-Aortic Stent can be placed
or by surgery either repair OR Excision and grafting
using a Dacron graft.
2. Tracheobronchial injuries :- Pt. present with severe
subcutaneous emphysema with respiratory compromise ,
chest tube shows massive air leak and lung fail to expand
, Bronchoscopy is diagnostic
Rx :- ETI of unaffected side followed by operative repair
of the injury.
3. Blunt Myocardial injury
4. Diaphragmatic injury: - any penetrating injury below
5th ICS suspect it and Diagnostic Laparoscope maybe
required.
Blunt chest trauma can cause diaphragm rupture which
may be missed, it occurs mostly on left side.
Dx: - CXR after placement of Nasogastric tube can show
the stomach herniated to chest
Rx: - Diaphragm rupture when Dx Acutely must be
repaired through laparotomy this will help to examine
abdominal structures to exclude injury, but when Dx is
missed initially, and injury discovered later it must be
repaired by thoracotomy.
5. Esophageal injury: - mostly caused by penetrating
trauma , it must be kept in mind , Pt. present with
odynophagia (pain on swallowing of food or fluids ) ,
subcutaneous or mediastinal emphysema , pleural
effusion , air in retroesophageal space and unexplained
fever with in 24 hours of onset of injury.
Dx: - Esophagogram in supine position + Esophagoscopy
Rx: - Operative repair and drainage.
6. Pulmonary contusion: - caused by bleeding into lung
parenchyma secondary to blunt trauma, Pt. present with
hypoxemia within 24 – 48 hours of injury, sometimes
with hemoptysis.
Dx by CXR which shows opacified lung.
Rx O2 administration + analgesia + chest physiotherapy,
in severe cases mechanical ventilation is required.
