ROKHAN UNIVERSITY

SURGERY DEPARTMENT

THORACIC INJURY

G SURGEON
DR AKHTAR GUL “NASIRI”
HEMOTHORAX
introduction
✓ It is blood in pleural cavity. It causes pain, shock, as it is
very irritant to pleural cavity.
✓Causes
✓ Trauma.
✓ Postoperative: pulmonary, cardiac, esophageal
surgeries, cervical sympathectomy, leak from CVP
monitor line.
✓ Tumors of lung, mediastinum, pleura.
✓ Leaking aneurysms.
✓ Spontaneous.
There may be rib fractures in traumatic hemothorax.
 CLASSIFICATION OF THORACIC TRAUMA
▪ Types of hemothorax on the base of blood collection in pleural
cavity
▪ Mild: 500 ml
▪ Moderate: 500-1000ml
▪ Severe : >1000 ml
▪ Cause of death
▪ Severe compression of lungs and mediastinal shift
▪ Hypovolemic shock due to hemorrhage
CLINICAL FEATURES
• Pain in the chest, tenderness
• Difficulty in breathing, dullness on percussion diminished
breath sounds
• Features of shock
Investigations
♦ Chest X-ray.
♦ Aspiration (pleural tap).
♦ Chest CT scan.
TREATMENT
❖ ICT placement in the mid-axillary line in the 6th intercostal space.
❖ Antibiotics, bronchodilators.
❖ Thoracotomy:
❖ Indications for thoracotomy
❖ Initial chest tube output of 1500 ml of blood or persistent drainage
of 200-300 ml/hr. over 3-4 hrs
❖ Clotted hemothorax is difficult to manage. It requires thoracotomy,
evacuation and decortication of lung. Initially liquefaction of the
clot is tried by infusing of streptokinase and trypsin into the pleural
cavity
 CARDIAC TAMPONADE
▪ Introduction
▪ Rapid accumulation of fluid or blood in the pericardial space causing increase in the intrapericardial
pressure is called as cardiac tamponade.
▪ This results in compression of cardiac chambers.
↓
venous return
↓
cardiac output
▪ Causes
▪ Trauma
▪ Progressive pericardial effusion due to tuberculosis, viral, bacterial infections
▪ Often, uremia can cause significant pericardial effusion
▪ Clinical features
▪ Hypotension.
▪ Widened cardiac dullness.
▪ Muffled or decreased heart sounds.
▪ Increased venous pressure with raised jugular veins.
▪ Pulsus paradoxus (pulse becomes weaker on inspiration than expiration).
▪ In severe cases, heart is unable to expand causing shock and often sudden death.
▪ Beck’s triad

Hypotension
Muffled heart sounds
Raised jugular venous pressure
▪ Investigation
Chest X-ray and U/S confirms the diagnosis.

▪ Treatment
♦ Pericardial tap, as early as possible to allow heart to
expand adequately.
♦ Occasionally, open pericardiotomy is required.
DIAPHRAGMATIC INJURIES
INTRODUCTIONS
▪ Any penetrating injury below the fifth intercostal space
should raise suspicion of diaphragmatic penetration and,
therefore, injury to abdominal contents.
▪ Either on right or left side, resulting from road traffic accidents,
crush injuries, penetrating injuries, or blunt injuries.
▪ Patient is under shock.
▪ On right side along with the liver, the intestines may also get
herniated.
▪ Patient is pale, presents with respiratory distress, guarding and
rigidity over the abdomen.
INVESTIGATION
• X-ray chest and abdomen.
• U/S abdomen.
• Often CT scan of abdomen and chest is done.
▪ Treatment
▪ Immediate laparotomy and exploration is done. Tear in the
diaphragm is sutured.
▪ Associated injuries in liver or spleen or bowel are treated
accordingly.
▪ Adequate blood transfusion and antibiotics is required.
▪ Ventilator support is often necessary
ESOPHAGEAL INJURY
▪ Introduction
▪ Most esophageal injuries result from penetrating trauma
▪ Instrumental injuries—commonest cause, 75% commonest site is just above the level of
cricopharyngeus.
▪ Clinical features
▪ Chest pain, vomiting, shock, subcutaneous emphysema.
▪ The patient can present with odynophagia (pain on swallowing saliva, foods or fluids)
▪ subcutaneous or mediastinal emphysema, pleural effusion, air in the periesophageal space and
unexplained fever.
▪ Diagnosis
▪ A combination of CT with oral contrast and esophagoscopy confirm the diagnosis
▪ treatment
▪ Mortality increases if surgery not done within 12-24hrs
▪ NG tube for gastric aspiration
▪ Repair of esophagus
▪ Pleural drainage
 SHOCK LUNG (STIFF LUNG)
▪ Development of microthromboembolism in small lung vessels following extensive
intravascular coagulation, leading to pulmonary consolidation, which reduces the lung
compliance markedly, causing severe depression of gas exchange in the lung—a stiff
lung
▪ causes
▪ Major chest trauma.
▪ Septicemia.
▪ Massive blood transfusions.
▪ DIC.

▪ treatment
▪ Endotracheal intubation.
▪ Ventilator support with IPPV.
▪ Antibiotics.
▪ High dose of steroids.
▪ Bronchodilators.
▪ The cause is treated.
MEDIASTINAL EMPHYSEMA
▪ It is the presence of air in the mediastinum.
▪ causes
▪ Trauma
▪ Inflammation (tracheobronchial tumors)
▪ External causes (esophageal perforation, tracheobronchial injury)
▪ Idiopathic (spontaneous rupture of alveoli )
▪ Clinical features
▪ Retrosternal pain
▪ Tachypnea
▪ Neck vein distention
▪ Cyanosis
▪ Subcutaneous emphysema
▪ treatment
▪ Treat the cause
▪ If needed thoracotomy
STERNUM FRACTURE
▪ Blunt trauma
▪ May be ribs fracture also present
▪ Mostly fracture occur in the body of sternum
▪ Fracture may be seen on lateral chest x-ray
▪ If the fracture is stable only analgesic is required
▪ If fracture is not stable and there was underling structure injury the
operative treatment with sternal fixation Is required