THORACIC INJURIES
Tension pneumothorax:
When the lung wound is behaving as a check valve, some air will escape into the pleural cavity
with each inspiration or cough. Gradually, intrapleural pressure will build up, the lung
collapses, and tension pneumothorax may develop. A shifting of the mediastinum and
compression of the large veins result in a decrease cardiac output that may lead to sudden
death. The diagnosis should be instantly made by observation of a patient with dilated neck
veins making respiratory effort but not respiratory motion, and unable to move air. It is
immediately confirmed by hyperresonant percussion note over the injured hemithorax and
absent or distant breath sound.
The immediate release of tension by placement of large bore needle, followed immediately
by insertion of thoracostomy tube is lifesaving.
Open pneumothorax:
The sucking chest wound is one in which a segment of the chest wall has been destroyed such
that negative intrapleural pressure sucks air directly through chest wall defect rather than
through trachea. The wound should have a cross sectional area exceed that of the trachea.
The diagnosis is made by noting the patient with normal or collapsed neck veins who is
making respiratory motion but not moving air.
The patient is stabilized by any mechanical covering over the open wound. A watertight
dressing should be placed and an intercostal catheter inserted into pleural cavity.
Rib fracture:
An inward displacement of the fracture fragments at the time of injury may lacerate the lung parenchyma
and produce pneumothorax with bleeding into pleural cavity. hemothorax of significant degree occurring
with fracture is usually due to laceration of intercostal artery rather than laceration of the lung, and it may be
life threatening.
The diagnosis of rib fracture may be implied from pleuritic type of pain and marked tenderness over the
fracture area. Chest X-ray is mandatory to exclude associated complications.
The principle goal of treatment for patient without serious injury is relief of pain. Adhesive strapping of the
chest should be avoided in all but very young patient.
Massive flail chest:
Whenever severe blunt injury result in two point fractures of four or more ribs, a Large segment of the chest
wall become flail. On inspiratory effort, the negative pressure in the chest pulls the unstable segment of the
wall inward in a paradoxical movement. The patient may be unable to develop sufficient intratracheal
negative pressure to maintain adequate ventilation, and atelectasis, hypoxia, and hypercapnia occur. the
patient who is awake may exhibit a very rapid shallow breathing pattern at or above 40/min.
When massive flail chest is diagnosed , endotracheal intubations and positive pressure controlled ventilation
is mandatory.
Hemothorax:
Intrathoracic bleeding occur with any form of chest injury that disrupts the tissue. Bleeding
from the lung will generally stop before sufficient volume has been lost to mandate
emergency thoracotomy. It can be estimated that 10 percent of the patient with traumatic
hemothorax will require thoracotomy for control of bleeding. The main concerns in the
management of patient with traumatic hemothorax are how much bleeding has occurred, is it
continuing, and , if stopped and clotted, when should clot be removed. Chest x-ray finding are
guides to the assessment extent of hemothorax. Four to fife hundred milliliters of blood may
be hidden by the diaphragm on upright chest x-ray.
A small hemothorax that produce little more than blunting of the costophrenic angle on the
chest x-ray dose not require initial treatment but x-ray follow up at appropriate intervals.
When the hemothorax exceed the amount that fill the costophrenic angle one or more large
intrapleural catheter Should be used. if the initial drainage of blood flowed by continued
bleeding in the absence of clotting defect, a decision to operate must be made, ordinary it will
be bleeding intercostal vessel, since bleeding from the lower pressure pulmonary system will
almost always stopped. A massive hemothorax of 1500 ml or more acutely removed from
pleural space as thoracostomy tube is placed should be emergency case and immediate
thoracotomy is advised.
pulmonary contusion:
Is the consequence of blunt trauma to the lung. serial x-rays begun right after the injury show
fluffy infiltrate that progress in extent and density over a period of 24 to 48 hours. Treatment
of pulmonary contusion must include an accurate clinical assessment of the patient’s
respiratory exchange and careful monitoring by serial measurement of arterial blood gases. A
high percent of patients may require temporary assisted ventilation.
Other injuries:
• Sternal fracture.
• Diaphragm rupture.
• Tracheal and bronchial injury with massive air leak.
