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Thoracic Trauma

December 2012

DOI:10.5772/54139

In book: "Current Concepts in General Thoracic Surgery" (pp.42)
Chapter: 11
Publisher: InTechOpen
Editors: Lucio Cagini

Authors:

Milos Arsenijevic

University of Kragujevac

Right flail chest with right-sided pulmonary contusion. Chest radiograph findings and chest CT

Rupture of the trachea-iatrogenic injury

…

Foreign body in intermediate broncus

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Chapter 11

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Thoracic Trauma

Slobodan Milisavljević, Marko Spasić and Miloš Arsenijević

Additional information is available at the end of the chapter

http://dx.doi.org/10.5772/54139

1. Introduction

Thoracic trauma is a significant cause of morbidity and mortality in both adults and children.

It is a leading cause of death in approximately 25% of multiple trauma patients and, when

associated with other injuries, it causes death in additional 50% of multiple trauma patients,

usually as a result of hypoxia and hypovolemia. When cardiac trauma is not involved,

mortality from isolated penetrating chest injury is low (<1%), but if cardiac trauma is present,

mortality rises to about 20%. The most important issue with thoracic trauma is to prevent

lethal outcomes, because many of these wounds are fatal shortly after the injury or a few hours

afterwards. Thoracic injury may occur in isolation (isolated thoracic trauma), or in the presence

of polytrauma. According to etiology, thoracic injuries are divided into: blunt traumas and

penetrating chest wounds. Specific injuries are: pulmonary barotraumas, burns of the

tracheobronchial tree resulted from aspiration, blast lung injury, parenchymal lung damage

from aspiration, and iatrogenic injury. Fractures associated with the chest wall may be caused

by a direct force, and the tissues and organs of the chest may be damaged including

contusions, lacerations or rupture. In addition, traumatic forces can act indirectly; in such cases

the effect of a traumatic force is manifested after the disintegration of the tissue (air embolism

resulting from the entrance of air into the pulmonary veins after lung laceration).[1]

The most common mechanisms of blunt trauma are road traffic accidents (70%), while

drivers and front seat passengers in motor vehicles are most exposed to risk, and motorcycle

drivers are much less frequently injured (10%), but with the highest percentage of death at

the site of accidents (30%).[2,3] There are five types of motor vehicle-related injuries: head-

on collision, side impact crashes, rear impact crashes, rotational impact and rollover, and

injuries resulted from deceleration (deceleration injury) and crushing (crush injuries). At

deceleration, a rapidly moving body is brought to a sudden halt, and injuries occur at the

time of the abrupt impact of the body, damaging the chest wall, while internal organ injuries

result from reflex glottic closure and therefore rapidly increasing intra-thoracic pressure.

The transverse thoracic diameter increased rapidly, and when the traumatic force

Current Concepts in General Thoracic Surgery

198

overcomes the elastic limit of the lungs the tracheobronchial tree injuries occur along with

the injuries of the lung parenchyma, diaphragm, and mediastinal structures. The

mechanism of deceleration injury is identical to the falls. [3]

Penetrating thoracic wounds occur as a consequence of side arms or firearms and are

classified into three groups:

1. " Sleeper " wounds (no exit wound)

2. Perforating wounds (entrance wound and exit wound)

3. Wounds in which the projectile penetrates through the whole intra-thoracic cavity and

remains in the subcutaneous tissue.

A common feature of all penetrating wounds is in direct communication between the

external environment and the pleural space. If a defect in the chest wall is large, an open

pneumothorax occurs. In small defects, wounds close spontaneously due to the contraction

of muscle or blood clotting. However, it should be always borne in mind that establishing

communication between the external environment and the pleural space leads to suction of

air and devitalised tissue in the pleural space, favouring the infection development and

further complicating the clinical management of the injuries.[4-6]

2. Pathophyslogy of thoracic trauma

Traumatic force with thoracic trauma impairs lung function by causing:

1. Disorder in the mechanics of breathing

2. Disruption in ventilation-perfusion relationship

3. Gas exchange abnormalities of alveolocapillary membrane

3. Disorder in the mechanics of breathing

Disorders in the mechanics of breathing with thoracic trauma are caused by blunt trauma

related to rib fractures and flail chest and are accompanied with hypoventilation, atelectasis,

difficult expectoration of sputum from the tracheobronchial tree, the development of

bronchopneumonic complications, acute respiratory failure and even death, especially with

elderly patients with penetrating injuries with direct communication between the external

environment and the pleural space, leading to the occurrence of pneumothorax,

haemothorax, traumatic diaphragmatic rupture and ruptured large airway. The presence of

air or blood in the pleural space leads to the collapse of the lungs, the development of

arteriovenous shunt and hypoxia. Disorder of breathing mechanics may threaten the life of

the injured because it leads to respiratory disturbance, hypoxia and cyanosis, as in the case

of tension pneumothorax.[1-6]

4. Disruption in ventilation - perfusion relationship

Normal blood oxygenation and elimination of CO2 depends on the ventilation-perfusion

relationship in the lungs. In thoracic trauma the disorder in ventilation-perfusion relationship

Thoracic Trauma 199

appears with the lung collapse or mechanical obstruction of the large airway. Lobar collapse

or the whole lung collapse is accompanied by perfusion through collapsed parenchyma, but

since oxygenation is not maintained, it leads to systemic hypoxia. Impaired lung perfusion

may appear following vascular thrombosis in damaged lung parenchyma and/or massive

fat microembolism, disseminated intravascular coagulation (DIC) and acute respiratory

distress syndrome (ARDS).[1-6]

5. Gas exchange abnormalities of alveolocapillary membrane

The alveolocapillary membrane is composed of the surfactant layer, the surface of

macrophages, alveolar epithelium, the interstitial space and the capillary endothelium. In

thoracic trauma direct damage to the alveolocapillary membrane may occur, as in the case of

lung contusion, smoke inhalation, aspiration of gastric contents, heart failure and

pulmonary interstitial oedema due to the excessive use of infusion solutions and blood

transfusion. The most important factors that later damage the alveolar membrane are:

ARDS, the development of hyaline membrane and alveolar oedema, terminal airway

collapse and occlusion of blood capillaries, acid-base disturbance due to hypoxemia and

hypercapnia, pulmonary hypertension, increased interstitial fluid pressure which increases

the capillary resistance and disseminated intravascular coagulation.[2-6]

6. General surgical assessment of thoracic trauma

6.1. Introduction

A comprehensive and thorough examination of the injured and the assessing the injury

severity must be done shortly, sometimes during the immediate treatment of potentially

lethal injuries. Upon the arrival to the surgery, initial examination and assessment are

important. It is of decisive importance for the injured, regardless of difficulties that may

arise from the very beginning. The main task of a surgeon is to assess the state of the injured

in order to detect or prevent life-threatening conditions. Conditions in case of thoracic

trauma require medical emergency care, often immediately upon the patient’s admission to

hospital. These are:[7]

 airway obstruction

 massive haemothorax

 tension pneumothorax

 open pneumothorax

 flail chest

 cardiac tamponade

These states should be distinguished from other possible severe lesions that need to be

treated by surgery. The surgeon must perform a physical examination and must ensure

quick resolution, when the situation is complex and laboratory tests and a chest X-ray are

time-consuming. Physical examination and clinical judgment are needed to decide upon the

necessity for tracheostomy, chest drainage, emergency pericardiocentesis or thoracotomy. In

Current Concepts in General Thoracic Surgery

200

certain cases, the information gained from arterial blood gas analysis directs towards the

diagnosis of acidosis, hypoxemia, or alkalosis. Physical examination is important regarding

the patient health history. Such information may result in the proper assessing the injury-

related condition, and also may be a guideline for additional therapeutic procedures which

are not directly due to trauma. Data on hypertension, cardiac arrhythmias, cardiomegaly,

diabetes, renal failure, peripheral arterial occlusive disease, phlebothrombosis,

hepatomegaly and splenomegaly, pulmonary emphysema and chronic obstructive

pulmonary disease, possible alcoholism or alcoholism findings, and taking drugs or

sedatives may be very significant.

6.2. Attitudes in thoracic trauma surgery

The first priority in the evaluation and treatment of thoracic injury is restoring of the airway

passages, safety of lung ventilation and cardiovascular stability. Blood gas analysis can

provide useful information when the circulatory system is preserved. The decision

regarding the widening of airway passages can be made only on the basis of clinical

observation. Tachypnoea (respiratory rate >30 breaths per minute) or clinical signs of

increased respiratory muscle fatigue are common symptoms of respiratory insufficiency

which requires urgent consideration. Endotracheal intubation and mechanical ventilation

are indicated in patients with clinical signs of respiratory fatigue and tachypnea of over 35

breaths per minute, in patients in a state of shock, and in patients with associated

craniocerebral injuries. Circulatory status is evaluated and adjusted simultaneously with the

widening of the airway passages. In patients with hypotension it is necessary to evaluate the

state of intra-thoracic organs in order to identify the cause of shock [8-10] induced by:

 tension pneumothorax

 haemothorax

 cardiac tamponade

 cardiac dysfunction after myocardial contusion

 air embolism

 large intra-thoracic vessel injuries

 massive contusion of lung parenchyma

 rupture of the diaphragm

Data on the mechanism of injury may be valuable for surgeons while assessing the types

and characteristics of thoracic injuries. For example, patients who were run over in road

traffic accidents or those crushed in motor vehicle accidents are expected to have severe

intra-thoracic injuries. Deceleration injuries indicate potential injuries to large blood vessels

(aortic arch and thoracic aorta) or large airway (trachea and main bronchi). In patients

admitted with symptoms of hypotension diagnostic procedure begins with the examination

of the neck veins. Distended (swollen) neck veins may point to possible cardiac compression

shock, caused by tension pneumothorax or cardiac tamponade, while hypovolaemic shock is

mainly associated with the neck vein collapse. Examining the chest wall during spontaneous

respiration may indicate paradoxical breathing due to flail chest. Palpation may reveal the

Thoracic Trauma 201

unstable chest wall integrity due to fractures or subcutaneous emphysema crepitation,

which may be associated with the development of pneumothorax. Pain and tenderness may

occur over the rib, sternum and clavicle fractures. Isolated chest trauma resulting from blunt

trauma is very rare. Blunt thoracic trauma in polytraumatized patients is mainly associated

with extra-thoracic injuries. The most common injuries among the associated extra-thoracic

injuries and chest injuries are:

 Cranial injuries

 Abdominal injuries

 Extremity fractures

 Pelvic fractures

 Vertebral fractures

Associated extra-thoracic injuries occur in approximately two thirds of multiple trauma

patients (Shor et al, 1987; Besson and Saegesser 1983; Glinz 1991) [3,11,12]. Main cause of

haemodynamic instability in half of the injured patients with systolic pressure less than 100

mm Hg on admission to hospital is in severe intra-abdominal injury. Localization of

penetrating thoracic injuries is important; entrance and/or exit wounds should be observed,

but such wounds should not be probed. If the entrance penetrating injury is below the fifth

rib, it is necessary to investigate the possibility of diaphragmatic rupture and intra-

abdominal organ injury. The integrity of the diaphragm may be checked by using different

techniques: video-assisted thoracoscopy, thoracoscopy, laparoscopy, laparotomy, and

thoracotomy. Exploration of the abdomen in haemodynamically unstable patients with

multiple chest and abdominal injuries is recommended first. Then abdominal bleeding is

controlled, providing the intra-thoracic organs are stable. Finding the cause of intra-

abdominal bleeding, the chest organ injuries may be explored and treated. Chest

radiography is necessary if there is no need for emergency thoracotomy or if developing

tension pneumothorax is excluded. Besides the investigation of the usual effects of thoracic

trauma, particular attention is paid to possible injury-related complications or injuries that

may be easily overlooked in the initial evaluation. The most common injuries that may be

overlooked on the initial chest radiography in multiple trauma patients are:

 soft tissue injury

 bone injury

 ruptured diaphragm

 mediastinal expansion

 foreign body

 pneumomediastinum

Up to 35% of the patients with thoracic trauma along with a ruptured diaphragm appear to

have normal or nearly normal results on initial radiographic findings. In patients with

penetrating injuries it is useful to mark the entrance wound with an X-ray sensitive marker.

It is useful to mark the initial localization of the foreign body inside the chest because it may

move later, or cause embolism. Low-speed projectile wounds cause minimal injury to the

chest wall, except when associated with intercostal vascular injury or internal mammary

Current Concepts in General Thoracic Surgery

202

artery. Penetrating chest wall injuries are treated conservatively for possible massive

bleeding. In the case of bleeding vessels, the therapy should include thoracotomy and

ligation of the injured vessels. High-speed projectiles and firearms at close range have high

penetrating power causing the considerable destruction in the projectile trajectory and

surrounding tissue. Surgical treatment and debridement of the devitalised tissue is indicated

in most cases. Chest wall trauma often indicates possible associated intra-abdominal

injuries. According to some authors, diaphragmatic rupture and abdominal organ injuries

are possible in such cases.[13] In such haemodynamically stable patients the integrity of the

diaphragm may be assessed using laparoscopy. Similarly, in cases where diaphragmatic

rupture is initially recognized, laparotomy is performed to inspect the abdomen and treat

the diaphragmatic rupture. Laparotomy is also indicated in haemodynamically unstable

patients with penetrating trauma to the chest wall and in patients with blunt trauma in the

same area, since in such cases intra-abdominal injury may be expected. Chest wall injuries

and intra-thoracic injuries are common in road accidents. In such cases common extra-

thoracic injuries significantly complicate the patient's condition. It is not rare that other

injuries are even more severe than the thoracic injury itself.[14] Complex polytrauma

requires multiple specialist input, but output is often uncertain, especially in patients with

severe intra-thoracic and craniocerebral injuries. After the initial treatment of life-

threatening conditions, thoracic trauma is further managed with pain control and chest

physiotherapy. Poor thoracic pain management and insufficient chest physiotherapy, i.e.

poor respiratory hygiene, necessarily lead to various pulmonary complications.

Thoracotomy or thoracoscopy are indicated in the cases of: [15-18]

 open pneumothorax

 penetrating injuries due to foreign bodies or suspected foreign bodies

 bleeding complications of chest drain

 massive haemoptysis

 continuous air leak from the chest drain and permanent collapse of the lung

 tracheobronchial injury

 cardiac tamponade

 damage to large blood vessels and heart injuries

 diaphragm injuries and oesophagus injuries

 Thoracoabdominal injuries associated with intra-thoracic organ injuries

 complication of the injury - evacuation of coagulum or decortication (empyema)

7. Diagnostic procedures with thoracic trauma

7.1. Chest radiography and other techniques in the diagnosis of chest trauma

Chest radiography is the first-line diagnostic tool providing additional information in the

diagnosis and evaluation of thoracic injuries.[19] The initial radiograph includes assessment

of the injury and disorders directly or potentially threatening to a patient's life.

Notwithstanding the objective limitations of the methods on the basis of clinical and

radiographic findings, in many cases the surgeon may decide about the appropriate surgical

Thoracic Trauma 203

treatment. In unconscious patients with multiple traumas chest radiography is useful

immediately after the admission, after the establishment of airway passages (usually

endotracheal intubation) and the insertion of nasogastric or orogastric tubes (used to

determine the position of the mediastinum). In patients with penetrating injuries entrance

and exit wounds should be marked with radiosensitive markers. Radiographs are normally

taken in the AP or PA views. It is desirable to take a radiograph in inspiring, but if taken

during expirium it may be useful in detecting small pneumothorax. Native radiographs may

be used for evaluation of chest wall integrity, primarily to detect rib fractures and to

examine the spine and mediastinum. Lateral decubitus radiographs are useful for the

detection of air and liquid collection. Patient’s position during exposure may be important

in evaluation findings. A surgeon carefully and systematically interprets chest radiographs

in order not to overlook some possible injuries. Then, the surgeon must check: [20]

1. The correct placement of the endotracheal tube: A surgeon must be sure that the tube

is not positioned too high in the trachea, just below the vocal cords, as there is a risk of

pulling it out while dealing with the patient; or the tube may be placed too deep –

commonly in the right main bronchus to prevent the ventilation of the left lung.

2. Pneumothorax: The finding can easily be overlooked in the rush or when the

radiograph is not carefully analyzed. Special attention must be paid to the lateral side of

the chest and the possible costophrenic angles with increased lucency.

3. Tension pneumothorax: a typical radiograph shows increased lucency in the ipsylateral

hemithorax, along with the diaphragm depression and shift of the trachea and

mediastinum to the opposite side (easily noticeable if nasogastric tube is placed).

4. Haemothorax: Shaded area of hemithorax can be seen in X-ray findings. An X-ray

reveals a shadow in the hemithorax due to persistent bleeding. However, in minor

bleeding there is no characteristic radiographic finding and the interpretation is more

difficult. In such cases, it is useful to compare the findings of both hemithoraces and

spot X-ray shadowed areas, particularly in the costophrenic angles. When the

radiograph is taken in the supine position, the blood may spread in the posterior part of

hemithorax, which appears as the slight shadow of hemithorax on the X-ray through

which the normal lung pattern is shown.

5. Mediastinal emphysema: There is no air in the mediastinum under usual conditions.

When the X-ray shows the presence of air in the mediastinum and neck, especially

when it is associated with pneumothorax (chest drain does not encourage lung re-

expansion), tracheobronchial rupture should be considered.

6. Lung contusion: It cannot be seen on initial radiographs, but it is indicated by lung

parenchyma diffuse shadows.

7. The protrusion of intra-abdominal organs into the thorax: Diaphragm injury is

followed by herniation of intra-abdominal organs into the chest. On the left side the

finding of hydroaeric collection may be mistaken for hydropneumothorax. Therefore, it

is useful to place a nasogastric tube indicating the character of the injury. Radiographic

diagnosis of diaphragmatic rupture on the right side is sometimes very difficult. The

liver is most commonly herniated organ, and then the only possible finding is the

elevation of the right hemi-diaphragm.

Current Concepts in General Thoracic Surgery

204

8. Fractures: Rib fractures are sometimes difficult to recognize in the native radiographs.

Therefore, a detailed physical examination is necessary. However, multiple fractures

such as flail chest are easily detectable. Attention should be paid to possible fractures or

vertebral dislocation, fractures of clavicle and humeral condylar fractures.

9. Projectiles in the thorax: Any penetrating wound of the chest should be examined

radiographically, especially in order to understand the direction of projectile

penetration, the scope of organ damage and the position of the projectile in the chest.

When a projectile enters from one side of the body to the other, or when it passes

through the mediastinum, additional examination of the oesophagus, aorta and trachea

should be performed for potential harm. Laparotomy is indicated when the projectile is

located under the diaphragm and the entrance wound is above it.

10. Mediastinal expansion: Extended mediastinal shadow is a major finding indicating

aortic rupture. When the initial radiograph shows extended mediastinal shadow,

especially in the supine position, it is necessary and useful to take a posterolateral

radiograph in the standing position. Mediastinal shadow wider than 8 cm most likely

indicates the transection of the aorta and aortography should follow. Other

radiographic findings indicating the aortic rupture are shadowing in the

aortopulmonary window, depression of the left main bronchus, nasogastric tube

deviation to the right, fractured ribs on the left side and left haemothorax.

In some cases, when the patient's condition is relatively stable, it is recommended to use

thoracic computed tomography (chest CT) in additional diagnostic procedure. Using CT

scan with contrast pleural space, lung parenchyma and mediastinum can be evaluated more

precisely.

Another useful method is ultrasound scan of the abdomen and chest, especially for

evaluation of the subdiaphragmatic space findings and when small collections of fluid in the

pleural space are detected, and also for cardiac evaluation, especially when blood is present

in the pericardial space. Ultrasound scan is simple, fast, non-invasive and reliable technique

applicable to different body parts, such as the abdomen and thorax (evaluation of the

subdiaphragmatic space including the liver, spleen, pancreas, retroperitoneal space, kidney,

diaphragm; detection of the subphrenic collection; detection of small collections of fluid in

the pleural space that cannot be seen in standard chest radiographs). Echocardiography,

transesophageal echocardiography (used to assess the functional state of the heart and

collection of blood in the pericardial space), and Color Doppler (used for the evaluation and

detection of injuries to the brachiocephalic vessels) are also in current use. Ultrasound of the

abdomen and thorax is becoming a routine diagnostic method that is used along with chest

radiography. Fast and careful radiographic evaluation is indicated in patients with thoracic

trauma. Native thoracic radiography is still the primary diagnostic tool. However, in

modern and well equipped facilities chest CT and MSCT and ultrasound scan of the

abdomen and chest have an important role in the diagnosis of thoracic trauma. Quick and

qualitative diagnostics and therapeutics are possible only in direct cooperation between

surgeons and radiologists, not only in taking and interpretation of radiographic or

ultrasonographic findings, but also in monitoring the effects of the therapy applied or

Thoracic Trauma 205

dealing with possible complications. VATS (Video-Assisted Thoracoscopy) has become

widely used surgical procedure in the evaluation of thoracic trauma. Indications of VATS in

thoracic trauma patients are signs of mild or moderate prolonged bleeding in

haemodynamically stable and conscious patients, haemothorax, early treatment of

fibrothorax, treatment of empyema in the initial stage of fibrin barrier formation, diaphragm

injury (the advantage of VATS over laparoscopy is in fact that in laparoscopic procedure air

may enter the pleural cavity and cause tension pneumothorax), traumatic chylotorax,

removal of foreign bodies from the pleural cavity or the peripheral lung, evaluation of

pericardium conditions, the heart and large vessels.

8. Monitoring of thoracic trauma

The surgeon must always have sufficient useful information about the patient's condition in

order to be able to act in a timely way, monitoring the use of diagnostic and therapeutic

procedures. Most reports deal with ideal conditions and well-equipped institutions

providing optimal medical treatment and care. Of course, it is not always possible and

therefore it is necessary to list the parameters applicable in most institutions. Minimal

necessary parameters that are regularly monitored in all patients with thoracic trauma,

immediately upon their admission in surgical unit and later, are the following: [23-27]

 Arterial pressure

 Arterial pulse and heart rate (obtained by electrocardiogram - ECG)

 Central venous pressure (in patients with shock and mechanical ventilation)

 Volume of urine (measured by urinary catheter in patients with shock)

 Cardiac index

 Arterial PO2, PCO2 and pH

 Haematocrit value

Monitoring of arterial pressure, pulse, haematocrit, and the volume of urine can be used as

general parameters in the assessment of fluid replacement. Analysis of arterial blood gases

is a very useful test of pulmonary function and in calculating the degree of metabolic

acidosis, if occurs. In cases with permanent loss of circulating fluid (mostly due to bleeding),

which is constantly replaced, it is necessary to insert a central venous catheter for pressure

monitoring in order to calculate fluid volume replacement. Initial haematocrit values may

be unreliable, especially in patients with excessive blood loss who receive crystalloid

solutions. It is known that the restoration of circulating volume and haemodilution after a

large amount of crystalloid solution is a slow process. Therefore, haematocrit value cannot

be considered a parameter indicating the volume of blood loss or replacement in cases when

acellular solutions are used in restoration of circulating volume. Haematocrit value can be

accepted as a useful tool for determining the type of fluid rather than the fluid volume

replacement. Thus, it cannot be accepted as a tool for estimating blood loss or for calculating

fluid replacement and correction of fluids. Specific issues are control and blood pressure in

patients who had greater blood loss and adequate compensation within a relatively short

period of time (up to 2 hours). It is believed that the value of blood pressure in such patients

Current Concepts in General Thoracic Surgery

206

after replacement should be lower if compared to the value before the injury. In other

words, restoring blood pressure to normal values before the injury may result in

hypervolaemia. It is satisfying to stabilize the systolic pressure at 90 mmHg or slightly

above in order to correct hypovolemia and to prevent hypervolemia. Care must be taken in

patients who had hypertension before the injury, because the pressure for lower values of 80

to 100 mmHg still may be a sign of hypovolemia and incomplete and inadequate volume

replacement, regardless of the normal pressure that may be satisfying for the surgeon (90

mmHg or slightly above). Monitoring of patients cannot be exclusively based on

physiological parameters, although it is desirable to conduct such monitoring for each of the

injured patients. The benefits of such patient monitoring are particularly in careful

interpretation of the obtained values in correlation with therapeutic procedures and the

patient’s recovery.

9. Shock in thoracic trauma

In a large number of casualties, shock is a consequence of hypovolemia, loss of circulating

volume (haemorrhage) or loss of tissue fluids (burns). In the early stages of shock, venous

flow to the heart (preload) is reduced due to the loss of circulating fluid, which decreases

stretching of the cardiac muscle of the right and left ventricles resulting in decreased cardiac

output and the development of hypotension and tissue hypoperfusion. The body strives to

maintain a normal circulating volume by moving fluid from tissues into blood vessels, by

increasing heart rate due to activation of the sympathetic nervous system and reduction the

inhibitory effects of the parasympathetic nervous system, by vasoconstriction in the

splanchnic bed and limb peripheries, and by fluid retention in the body due to the reduction

of diuresis. In later stages of shock, at the cellular level hypoxia is compensated by anaerobic

metabolism and lactic acid production, leading to the development of metabolic acidosis. If

the shock is left untreated, tissues swell, oedema occurs and the cells lose functions. In order

to prevent further cell damage, circulating fluid should be immediately compensated and

adequate tissue oxygenation should be provided. It is believed that the average blood loss

per fractured rib is approximately 150ml, and in haemothorax it can be 2-2.5L and above. In

suspected case of shock, the condition of the injured should be quickly evaluated including:

mental status (conscious people breathe spontaneously, they are able to communicate

normally and adequate oxygenation and perfusion of the cortex are provided).

Hypovolemia accompanied by subsequent hypoxia leads to changes in the level of

consciousness, (from anxiety, through confusion and aggressiveness, to the development of

coma and death), the colour of the skin and visible mucous membranes (hypovolemic

patients are pale, their skin is cold and occasionally bedewed with sweat, with possible

signs of cyanosis), the heart rate (the presence of a radial pulse implies that the systolic

blood pressure is less than 90 mmHg, while the absence of radial pulse and the presence of

femoral pulse imply systolic pressure of 80-90 mmHg; the pulse of carotis communis implies

systolic pressure of 70 mmHg), and capillary charge and blood pressure control. Symptoms

of shock can be easily identified, but they are not perceived before blood loss exceeds 30% of

circulating volume. The first signs of hypovolemic shock are the symptoms of peripheral

Thoracic Trauma 207

vasoconstriction and tachycardia and decreased pulse pressure. The goal of initial

resuscitation is to achieve blood pressure, which ensures adequate tissue perfusion, i.e.

blood pressure of 90 mmHg. In a state of shock, the priorities are ensuring the patient’s

airway, provision of supplemental oxygen (10-15 L/min) in case of respiratory distress using

mask-balloon ventilation, and measures to stop both external and internal bleeding. A large-

bore cannula should be inserted in the antecubital fossa in order to compensate the lost

volume. If it is not possible, the cannula should be placed into the femoral vein or the central

vein. Crystalloid solutions, colloids and blood transfusions are used to restore the volume.

Crystalloids are saline-based fluids that remain only temporarily in the circulation (30

minutes) before passing into the intracellular space. They are useful for the immediate

replacement of the circulating volume. Initially, two liters of crystalloid (Hartmann's

solution or Ringer’s lactate) should be infused. The advantages of crystalloids over other

solutions are in their low cost, simple production, and long shelf life. Besides, they do not

have allergenicity, do not cause coagulation problems and do not transmit transmissible

diseases. Colloidal solutions are blood-derived, gelatin-derived or dextran-derived

products. The advantages of these solutions are in their low cost, simple production, and

long shelf life, as well as in lost volume replacement on a one-to-one basis, in their

remaining in the circulation for long periods and avoiding disease transmission, while the

disadvantages are in their occasional causing allergic reactions and coagulation disorders.

The shock causes pain, so the injured should be given painkillers, fractures should be

stabilized and immobilized. Distention of the stomach may be complicated by regurgitation

and aspiration of gastric contents in the airway, and may be prevented by nasogastric

suction. Endotracheal intubation and mechanical ventilation with high concentrations of

inspired oxygen protect the airway from aspiration and ensure adequate ventilation and

oxygenation. In patients with shock the following parameters should be monitored: heart

rate and blood pressure, capillary refill time, respiration rate (frequency and symmetry of

the chest) and neurological status. In addition to these basic parameters, it is desirable to

monitor the following: pulse oximetry, diuresis (adults over 50 m/h, children 1-2 ml/kg/h),

central venous pressure and blood gas analysis.

10. Acute respiratory distress syndrome (ARDS)

Acute respiratory distress syndrome (ARDS) is a life-threatening respiratory failure

manifested by non-cardiogenic pulmonary oedema, hypoxemia, decreased lung compliance,

high intrapulmonary shunt and progressive pulmonary fibrosis in the late stage of

development. The American-European Consensus Conference of 1994 proposed new

definitions:

1. Acute lung injury (acute lung injury – ALI)

2. Acute respiratory distress syndrome (ARDS)

In the first group are injured with mild hypoxemia (relation between the partial pressure of

oxygen in arterial blood and fractional inspired oxygen concentration at the level of 300)

(Pa02/Fi02). In the second group are injured with severe hypoxemia (relation between the

Current Concepts in General Thoracic Surgery

208

partial pressure of oxygen in arterial blood and fractional inspired oxygen concentration at

the level of 200) (Pa02/Fi02). The other three characteristics – their acuteness, bilateral

infiltrates on chest radiography and pulmonary artery occlusion pressure of 18 mmHg – are

common to both illnesses.

Predisposing risk factors for ARDS are classified into two groups. In the first group are

pulmonary contusion, aspiration of gastric contents, pneumonia, inhalation injury and

drowning. In the second group are: severe traumatic shock and need for repeated

infusion/transfusion, head trauma, abdominal sepsis, burns, fat embolism, excessive volume

replacement and disseminated intravascular coagulation. From a pathophysiological point

of view, ARDS occurs as the consequence of the systemic inflammatory response of the

injured. Neutrophil activation, aggregation and degranulation lead to the release of oxygen

free radicals and proteases; monocytes/macrophages activation leads to the formation of

arachidonic acid metabolites (prostaglandin, leukotrienes, prostacyclin); T-cells release

cytokines (interleukins) inducing the damage of the capillary endothelium. Platelet

activation and aggregation and fibrinolysis lead to microthrombosis causing further damage

to microcirculation. Severe injury to type I pneumocytes and capillary endothelial cells leads

to increased permeability of the alveolar membrane, so that the alveoli become

progressively filled with exudate which is rich in plasma proteins, erythrocytes, platelets

and leukocytes, which eventually leads to the development of interstitial and alveolar

pulmonary oedema. Alveolar obliteration and surfactant dysfunction lead to numerous

microatelectasis and increasing intrapulmonary shunt. Pulmonary circulation responds to

hypoxemia with vasoconstriction, reducing blood flow to the unventilated alveoli, which is

a strong risk factor for pulmonary hypertension and the load on the right heart, causing

severe hypoxemia. The first exudative phase is followed by the second proliferative phase

when type 2 pneumocytes proliferate and transform into pneumocite type 1, resulting in the

regeneration of the alveolar membrane. In the third fibrotic phase large amounts of collagen

accumulate in the lungs and pulmonary fibrosis is developed.

Clinical manifestation of ARDS depends on its causes. Very soon after the injury, during the

first 12-24 hours, tachypnea and tachycardia occur. The patients use auxiliary respiratory

muscles, and on auscultation they have high-pitched expiratory crackles. Arterial blood gas

analysis indicates progressive hypoxia, hypercapnia, and acidosis. Chest X-ray shows

diffuse spotty infiltrations becoming confluent with progressive clinical deterioration of

ARDS. Prognosis of ARDS is uncertain and depends on the severity of the injury. Prevention

of ARDS includes correction of disturbed ventilation and haemodynamics. The treatment of

ARDS requires mechanical ventilation in order to achieve adequate oxygenation. The

primary function of mechanical ventilation is to keep the alveoli open as long as possible,

which is achieved by intermittent positive pressure ventilation with or without positive end-

expiratory pressure. In the treatment of ARDS, fluid should be reduced in order to prevent

pulmonary oedema. The intravascular volume should be maintained at the lowest level.

Vasopressors and inotropes are used when the system is unable to maintain the perfusion

by replacing of intravascular volume. Use of aerosolized surfactant was first appreciated

while the nitric oxide, when inhaled, is a powerful pulmonary vasodilator. Glucocorticoids

Thoracic Trauma 209

and other anti-inflammatory agents do not have significant effects on ARDS.

Glucocorticoids are more efficient in preventing fibrosing alveolitis.

Figure 1. ARDS caused by left-sided pneumothorax

11. Blunt chest injuries

Blunt chest injuries are: contusions and haematoma in the chest wall, rib fractures, flail

chest, broken sternum, blunt injury to the lung parenchyma, traumatic injuries to the trachea

and major bronchi, traumatic pneumothorax, and traumatic haemothorax.

11.1. Contusions and haematomas of the chest wall

Chest wall contusion and haematoma are the most common thoracic injuries. As a result of

blunt trauma to the chest wall massive bleeding may occur due to injured blood vessels in

the skin, sub-cutaneous tissue, muscles, and intercostal blood vessels. Bleeding or

extrapleural haematoma, manifested on X-ray as a semicircular model growing from the

pleura, may appear in the chest wall, muscles of the chest wall, around the ribs and in the

sub-pleural space. Most extrapleural haematomas do not require surgery because of the

small amount of spilled blood. Only large haematomas or haematoma infection require

surgical intervention

11.2. Rib fractures

Rib fractures are among the most common chest injuries, as a result of direct or indirect

blunt force. Rib fractures occur in about 35% - 40% of thoracic injuries. Characteristics of rib

injuries depend on the type of impact against the chest wall. Spontaneous rib fractures may

be caused by a terrible cough (from rib VI to IX). Pathological rib fractures due to metastatic

tumour or some other bone disease is very rare. In elderly patients, rib fractures may result

Current Concepts in General Thoracic Surgery

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from the chest injuries – after relatively low impact trauma. Even isolated rib fractures in

elderly people can be a cause of death, with the range 10-20%. Rib fractures in children are

rare, but when they occur they are clinical signs of thoracic injury, since the chest wall in

children is very flexible, as opposed to adults. The mortality rate for rib fractures in children

is about 5%. Lower chest wall injuries in children, but without rib fracture, is often

associated with injuries to the diaphragm, spleen and liver. Discontinuity in the ribs without

dislocation of sternal rib ends may be not revealed in the initial radiograph, but can be

diagnosed as soon as callus begins forming. Rib cartilage fractures and fractures of the

costochondral junctions cannot be seen on chest X-ray. They can be detected by careful

physical examination, detection of crapitation and tenderness on palpation. Most common

rib fractures are from rib IV - IX. In patients with serial rib fractures from IV-IX rib particular

patience should be paid for possible intra-abdominal injuries. First, second and third ribs are

relatively protected in blunt force trauma, supported by the strong back muscles and front

pectoral muscles. The first and second ribs are further protected with the clavicle, scapula

and shoulder harness. Only a severe traumatic force may break the first and second ribs.

These fractures indicate possible associated injuries of large blood vessels in the aortic arch

or injury to the tracheobronchial tree. In such cases, the mortality rate of up to 36% has been

recorded. Anteroposterior compression of the chest causes the fractures of the lateral rib

ends, which are then directed outwards. Injuries of the pleura or lungs rarely occur in such

cases. Traumatic force may direct broken ribs to collapse inwards, leading to the subsequent

lacerations of the intercostal vessels, pleura and lungs and may cause haemothorax,

pneumothorax or haemopneumothorax. Specific symptom of rib fracture is pain. It increases

with coughing, deep breathing or movement. The patient prevents the injured area from

moving which consequently leads to hypoventilation. Decreased chest-wall movement and

bad respiratory hygiene can cause atelectasis and pneumonia or the development of an

infection. Oral/parenteral analgesics, intercostal nerve block, and intrapleural catheter

analgesia or transcutaneous electrical nerve stimulation are used as methods of pain relief in

chest trauma. Immobilization of the chest wall in order to achieve analgesia, especially

thoracic cingulum, is not justified. However, in clinical practice, there is a relatively good

Figure 2. Serial fracture of ribs. Chest radiograph findings and MSCT

Thoracic Trauma 211

experience with unilateral fixation using adhesive materials (wide-strip leucoplast), in

patients with individual rib fractures followed by severe pain. Fixation is performed during

respiration in end-expirium by placing leucoplast between the edge of the sternum and the

spine on the side of the fracture. Physical therapy is indicated in patients with serial rib

fracture, and in more complex cases frequent bronchoaspiration is recommended for better

hygiene of the tracheobronchial tree and prevention of atelectasis.

11.3. Flail chest

Flail chest is a medical condition when several adjacent ribs are double-broken unilaterally or

bilateral fractures occur in the costochondral area associated with/without sternum fracture.

The frequency of flail chest is about 5%, and road crashes account for most flail chest injuries.

Pathophysiologically, the segment of the chest wall moves paradoxically, during the

inspiratory phase it is drawn inward, while the expiratory phase it is drawn outward,

preventing the air flow to the injured side. Firstly, deoxygenated air is retained within the

injured side, but later it moves to the unharmed side, which leads to the disorders of

ventilation and low vital capacity. According to the location, flail chest may be: anterior,

lateral, bilateral and posterior. Anterolateral and posterolateral types also occur. Flail chest is

diagnosed on the basis of physical examination of the injured, chest radiography and

computed tomography of the chest. The treatment of flail chest can be divided into

conservative and operative. In spontaneously breathing patients with posterior type or other

types of flail chest where there are no difficult ventilation problems, analgesics and early

physical therapy will help. In patients with severe disorders of ventilation, the application of

mechanical ventilation with positive end-expiratory pressure (PEEP) will result in chest wall

stabilization. Surgical treatment of the flail chest includes internal stabilization of the chest wall

and can be early and late. Early internal stabilization is applied during the first 24 hours after

injury, while late stabilization is performed 48-72 hours following injury.

Figure 3. Right flail chest with right-sided pulmonary contusion. Chest radiograph findings and chest CT

Current Concepts in General Thoracic Surgery

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Figure 4. Anterior right-sided flail chest. Mechanically ventilated patient (internal stabilization). Right

sided flail chest drainage and internal and external stabilization

Figure 5. Patient’s condition after the treatment of flail chest

11.4. Fractures of the sternum

Sternal fractures result from severe blunt trauma. They are often associated with multiple

rib fractures. Sternal fracture is typically transverse and localized to the upper and middle

parts of body of sternum. Mediastinal organs distortions may be expected with sternal

fracture, primarily myocardial contusion (with typical precordial pain and dyspnoea). The

fracture may be diagnosed on physical examination, detection of swelling, deformity and

local tenderness. It can be confirmed with cephalometric chest radiographs, because the

dislocations can be difficult to see in the anteroposterior projection. Sternal fracture is

treated with rest, analgesics and airway hygiene. If the broken fragments were pushed over

to the mediastinum because of the costochondral disruption, reduction surgery and internal

fixation would be indicated.

Thoracic Trauma 213

Figure 6. Sternal fracture

11.5. Lung parenchymal injuries

11.5.1. Lung contusion

Lung contusion is the most common manifestation of blunt chest trauma and represents

parenchymal laceration accompanied by intra-alveolar haemorrhage. A pulmonary

contusion is caused directly by blunt trauma to the chest wall, seriously damaging the

parenchyma along with interstitial oedema and haemorrhage, and leading to

hypoventilation in poorly ventilated parts of the lungs. Contusion may cause damage to a

segment, several segments, or an entire lobe of the lung. Intrapulmonary haematoma occurs

when larger blood vessels in the lung are injured. The diagnosis of pulmonary contusion is

based on anamnesis, physical examination (gurgling sounds on auscultation), chest

radiography and CT. Chest radiography may show irregular nodular infiltrates,

homogeneous infiltrates and diffuse parenchymal infiltrates which disappear soon after the

injury. Chest CT is much more detailed than standard radiography, and four types of

lesions may be observed. Type I lesions are small parenchymal cavitary lesions or

hydroaeric fluid collections. Type II lesions are hydroaeric and air cavitary lesions in parts

of the lung in the paravertebral region. In type III besides hydroaeric and air cavity lesions

in the peripheral lung fields there are always rib fractures. Type IV lesions result from the

avulsion of pleuropulmonal adhesions, where the lung is drawn back due to a sharp blow to

the chest wall. Complications of lung contusions may be immediate and secondary.

Immediate complications include bronchopleural fistula, pneumothorax, haemothorax,

subcutaneous emphysema, mediastinal emphysema, intrapulmonary haematoma, air

embolism, haemoptysis, hypoxemia, arterio-venous shunt, and pulmonary hypertension.

Secondary complications are atelectasis, pneumonia, empyema, sepsis, ARDS, lung abscess,

and barotrauma. Pulmonary contusions require patient-specific treatment. Respiratory

hygiene and pain relief are particularly important. A contusion involving more than 30% of

lung parenchyma requires mechanical ventilation. Emergency surgery is needed in 5% of

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lung contusion cases, i.e. the injuries with a massive air leak, injuries with massive intra-

thoracic haemorrhage (1500ml of blood on insertion of the thoracic drain and 200ml of blood

every 3-4 hours, with continuous replacement), unilateral injuries with massive

haemoptysis, and air embolism.

Figure 7. Lung contusion

11.5.2. Traumatic injuries of the trachea and bronchi

Traumatic injuries of the trachea and bronchi may occur as a result of blunt chest trauma,

which is more often, or as a result of penetrating chest trauma in more rare cases. Blunt

chest trauma may result in cleavage between the trachea and bronchi as a consequence of

anteroposterior compression of the chest and the rapid increase in intraluminal pressure

producing the airway rupture, or chest trauma may cause a sudden chest expansion with

lung sliding laterally and, eventually, over-expansion and airway rupture. Traumatic

ruptures of the bronchus are four times more likely than rupture of the trachea and usually

occur within 1-2.5cm of the tracheal carina. The clinical manifestations of traumatic injuries

to the trachea and bronchi are non-specific and variable. The clinical features may be

divided into early and late symptoms and clinical signs. Early symptoms include

haemoptysis, localized pain, neck contusion, subcutaneous emphysema, hoarseness,

inspiratory stridor, progressive dyspnoea and auscultatory findings of "crackling"

synchronized with the heartbeat and breathing (Hamman 's sign). Late signs and symptoms

are dyspnoea and stridor (from scarring and stenosis) and distal infections of the lung

parenchyma. Traumatic injuries of the trachea and bronchi are not often diagnosed

immediately, but a few days, months or even years after the injury. Diagnosis is based on

clinical findings, X-ray, CT and bronchoscopy. Acute injuries of the trachea and bronchi are

amenable to surgical treatment, by means of suture, and chronic stenosis of the trachea and

bronchi is treated with bronchoplastic reconstruction.

Thoracic Trauma 215

Figure 8. Rupture of the trachea - iatrogenic injury

11.5.3. Foreign bodies in the Tracheobronchial tree

Aspiration of the foreign body in the tracheobronchial tree is often seen at the injured with

lost consciousness, at patients with the swallowing disorder, at intoxicated patients and

small children. Clinical picture of the aspiration can be divided in three stages: first (acute)

stage, second (asymptomatic) stage and third (late) stage. In the first stage, immediately

after aspiration, symptoms of acute obstruction of the tracheobronchial tree occur in the

form of a fit of coughing and cyanosis. After some time acute symptoms cease and there is

an asymptomatic phase in duration of a few days, months or years. In the late stage the

appearance of the high temperature, cough, wheezing – as well as the hemoptisis is present.

Diagnosis is based on the standard radiography of the chest, in case of a radiosensitive

foreign body, while the final diagnosis is made by the brochoscopy. Treatment includes

Figure 9. Foreign body in intermediate broncus

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Figure 10. Foreign body in right main stem bronchus (dental prosthesis)

bronchoscopic extraction of the foreign body, specially in the case of fresh aspiration. At

chronical foreign bodies, with developed granular tissue around the foreign body, the

attempt of the bronchoscopic extraction can cause copious bleeding or perforation of the

tracheobronchial tree, and in that cases mostly the operative treatment is applied,

thoracotomy and brochotomy, or resection of lung parts distally from the area of

obstruction.

11.5.4. Traumatic Injuries of Diaphragm

Traumatic injuries of diaphragm occur as a consequence of blunt and penetrating injuries of

the chest, while the iatrogenec injuries of diaphragm are extremely rare. At blunt trauma

around 1% to 4% of the injured occur, at penetrating injuries of the lower one third of the

chest there are 15% of stab wounds and around 45% gunshot wounds. Mechanism of the

diaphragm injury occurrence is explained by the deceleration. Injuries of the left diaphragm

are more frequent due to the protective role of the liver toward the right diaphragm. In case

of the left diaphragm injury, depending on the localization and rupture size, the stomach,

omentum, small and large intestine, spleen, kidney can prolapse into the chest, while at the

rupture of the right diaphragm the liver prolapses into the chest. Clinically the traumatic

injury of diaphragm is manifested by early and late symptoms, when clinical picture may

vary from the complete absence of symptoms to the stage which directly endanger the life of

the injured. At the prolapse of intraabdominal organs into the chest, the combined

respiratory and digestive symptoms occur. As the result of the prolapse of intraabdominal

organs into the chest, most frequently of stomach, the paradoxal breathing with

development of compressive gastrothorax, lungs collapse, hypoventilation and hypoxia

occur. Late symptoms, that can occur after a few years or decades from the injury, are strong

pain within the chest, dyspnea and signs of obstruction in small and large intestine.

Diagnosis is made based on the clinical picture and radiographic findings. In some cases, by

Thoracic Trauma 217

the auscultation the intestinal peristalsis can be heard in the chest. Final diagnosis is made

by radiography methods. At these injuries, hydroaeric collection can be noticed on the

native radiography, which must dyagnostically differ from the hydropneumothorax.

Diagnosis of the stomach prolapse is made by the placement of nasogastric tube with

contrast. Also, in diagnosis can be applied CT scan of the chest, MRI, liver scintigraphy and

ultrasonographic examination of the thoracoabdomial region. Treatment of the traumatic

rupture of diaphragm is surgical, it is adviced to treat fresh ruptures by the approach

through laparotomy, while at old ruptures the adviced approach is through thoracotomy,

due to adhesions in the chest.

Figure 11. Traumatic rupture of the right diaphragm

Figure 12. Traumatic rupture of the left diphragm, with the prolapse of stomach (visible after

placement of left - sided thoracic drainage tube)

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Figure 13. Posttraumatic right - sided diaphragmatic hernia (traffic accident)

Figure 14. Post - traumatic right - sided diaphragmatic hernia (intraoperative findings)

Figure 15. Traumatic rupture of the left diaphragm, with prolapse of intraabdominal organs

Thoracic Trauma 219

11.5.5. Traumatic pneumothorax

Pneumothorax marks the presence of air in the pleural space. Traumatic pneumothorax

occurs as a consequence of blunt or penetrating injury of the chest, it can be developed at the

time of injury, soon after injury or afterward. At the blunt injury of the chest, associated

with the rib fracture, the laceration of the parietal and visceral pleura is most frequently

caused by the fractured and/or dislocated rib ends. Laceration of visceral pleura and lung

parenchyma has as the consequence the occurrence of pneumothorax, and the laceration of

parietal pleura can contribute to the development of subcutaneous emphysema. However,

at most injured with traumatic pneumothorax there is no the associated rib fracture.

Mechanism of the pneumothorax occurrence in such cases can be explained on one of the

following ways:

 During sudden chest compression, the increase of alveolar pressure occurs and it may

cause the alveolus rupture. Air that comes out in the interstitial area by dissection

toward the visceral pleura or mediastinum results in pneumothoracs or mediastal

emphysema.

 Increase of pressure in the tracheobronchial tree, in the phase when the glottis is closed,

has the impact on the increase of pressure especially in the level of the bifurcation of the

trachea and/or bronchial tree, where lobar bronchi separate. Due to that the rupture of

the trachea or bronchi may occur. Laceration of the lung tissue is rare, but possible.

Mechanism of the pneumothorax occurrence at the penetrating injury of the chest is easy to

understand, for the wound in thoracic wall enables the communication with external

surroundings and the air directly enters in the pleural space. In such cases the visceral

pleura is often injured, enabling the entry of air from alveoli to the plural area. Blunt injuries

of the chest in peacetime conditions often occur due to the traffic accidents. In traffic

traumatology the five types of collisions are common: head - on, lateral, rare -end, rotating

(turning around) and rollover. Each of mentioned types has its characteristics, but the

mutual characteristic for all types is that they cause decelerational injuries. Mechanism that

causes deceleration injuries is the same at falls from height (accidental or suicidal). During

haulting of the object which moves with huge speed, the blow in the chest suddenly

increases intrathoracic pressure, compresses lungs and with instinctive closed glottis, the

disintergration of the lung parenchyma and central respiratory paths. Beside the chest injury

in these situations injuries of thoracic wall structures are apparent, as other mediastinal

organs (aorta, heart, trachea).

Penetrating injuries occur by the effect of firearms or cold weapons. Injuries' seriousness

depend on the damage of interthoracic structures.

Penetrating wounds of thoracic wall may be classified in three groups:

1. « Blind » injuries without exit wound

2. Perforating wounds with the entrance and exit wound

3. Wounds where projectile passed through the whole intrathoracic area and stopped near

the skin or in the extrathoracic soft tissues

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At injuries of the chest by firearms the important fact is if the injury were developed by

projectile of high or small speed. Mutual pathophisiological mechanism for penetrating

injuries is creating of communication between pleural space and external surroundings.

Immediate consequence of such communication is the occurrence of pneumothorax. Large

defect on the chest wall as a consequence has the occurrence of open pneumotorax.

Treatment of the broadly open wounds on the chest wall proceeds in two phases:

1. Operative debridement with removal of devitalized tissue and foreign bodies

2. Closing of the opening of thoracic wall

Pneumothorax is surgically treated by the thoracic drainage. Narrow penetrating wounds of

the chest wall are often spontaneously closed, due to the muscle contraction or the

tamponade occurs by blood coagulation. Air in the pleural space enters during the

penetration or immediately after that. Penetrating injuries can provoke massive

contamination of the pleural space, since in the moment of creating the communication with

external surroundings it comes to the air suction with it, parts of the cloths and devitalized

tissue. Presence of foreign bodies in the pleural space is favourable for development of a

bacterial infection that can seriously complicate further course of the treatment. Pressure in

the pleural space is negative in comperison with the atmospheric pressure during entire

respiratory cycle. Negative pressure is a consequence of mutual relation between the lung

tendency to collapse and thoracic wall to be expanded. Alveolar pressure is always higher

than the pleural pressure. When communication arises between the alveolar and pleural

spaces, the air passes from alveoli into pleural space, until there is a gradient of the pressure

or until the communication is not closed. Air letting through into the pleural space is limited

by the lung collapse and effect of closing the lung lesion. Most important pathophysiological

consequence of the pneumotorax are decrease of the vital capacity and partial oxygen

pressure in blood. Decrease of the vital capacity is well tolerated by the injured who were

healthy before pneumotorax development. However, in case when the lung function is

damaged by the previous lung diseases, any decrease of the vital capacity can cause the

respiratory insufficiency with alveolar hypoventilation and respiratory acidosis. Lung

collapse of 10% and less does not create more substantial ventilation disorders. Such

collapse is marked as the minor pneumotorax. Moderate pneumotorax has the collapse of 10

- 60%, and large pneumotorax has over 60%. From pathophysiological point of view, the

most important is the classification of traumatic pneumothorax to the following categories:

1. Simple or partial

2. Open or absorbing

3. Tension

Any injury of the chest can result with one of the mentioned types of pneumothorax.

However, open pneumothorax is often associated with penetrating injury, while tension and

simple pneumothorax are mainly seen at the blunt injury of the chest.

Simple pnemothorax often develops due to the laceration of the lung parenchyma fractured

rib ends, or due to the gunshot wounds and stab wounds. Increase of the interalveolar

Thoracic Trauma 221

pressure due to the effect of trauma causes rupture of alveoli and entry of the air into

pleural space. Open pneumothorax appears due to the direct communication between

pleural space and external surroundings. Disorder of the physiology of breathing in such a

case depends on the size of perforation on the chest wall. Course and severity of

pathophysiological changes depends on the age of the injured, state of respiratory system

before injury, fixed condition of mediastinum, adhesions. Tension pneumothorax occurs

when the pressure in the pleural space becomes positive in all phases of the respiratory

cycle. Since the affected lung collapses, accumulation of an air from the external

surroundings causes development of the positive pleural pressure that further pushes

mediastinum toward healthy side. Positive pleural pressure can be so high to push or cause

the inversion of ipsilateral diaphragm. Mechanism for development of the tension

pneumothorax is connected with the specified type of a one-way-valve (valve mechanism).

Valve is open during inspirium, so that the air enters into pleural space, and it is closed

during expirium.

Traumatic pneumothorax occurs due to the entry of air in the pleural space, thus

disintegrating the following structures:

 External part of thoracic wall

 Lung parenchyma

 Tracheobronchial tree out of the part covered by the mediastinal pleura

 Oesophagus and mediastinal pleura

 Diaphragm and associated perforations of intestines

At traumatic pneumothorax, the most frequent symptom is pain due to the chest wall injury.

Occurrence of isolated traumatic pneumothorax apart from the pain may be followed by a

certain degree of dyspnea which does not endanger the injured. Clinical picture of the open

pneumothorax is significantly distinct, dyspnea and pain are dominant (specially locally in

the area of wound on the chest wall). Often the sound of air suction through the wound can

be heard during the inspirium. Locally, in the area of wound, a certain degree of

subcutaneous emphysema is distinct. By inspection, decrease of respiratory mobility of

affected hemithorax is noticiable. Percutaneously there is hypersonority, weaken or

inaudible murmur is heard by auscultation. Pulse is accelerated, the fall of arterial pressure

is present in case of distinct haemorrhage. Tension pneumothorax directly endangers the life

of the injured and it belongs to the group of medical emergencies. Pathophysiology of the

tension pneumothorax is not explained in its entirety, but it is considered that the basic

disorders are related to the decrease of heart beat volume and progressive hypoxia. For

diagnosis the clinical examination of the injured is often sufficient and only possible.

Radiographic confirmation of the diagnosis requires a certain time, that is intolerable risk in

some cases for the injured. Typical clinical picture of the tension pneumothorax shows a

sever respiratory disorder of the ventilation, distinct tachypnea, cyanosis of the head and

neck, tachycardia, hypotension, distension veins on the neck and profuse perspiration. By

inspection it is obvious that affected hemithorax is significantly expanded in comparison

with the opposite side, with distinct presence of subcutaneous emphysema. Percutaneously

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there is a tympanism, while auscultatory findings on lungs show an absence of breathing

murmur on affected side. At atypical clinical picture, the tension pneumothorax may imitate

the state of acute tamponade of the heart or massive hemothorax. Radiography is a basic

additional diagnostical method in diagnosis of the chest trauma. Position of the injured

during the imaging has the impact on the quality of the chest radiography and possibility

for correct interpretation. General state of numerous injured, specially the polytraumatized

patients, has the impact on the position for imaging. It is desirable that the imaging is

performed in the standing position, when it is not possible, it can be the sitting position or

semi-lying position. Correct interpretation of the chest radiography includs the assessment

of the bony structure state of the chest, position and shape of the diaphragm and

phrenicocostal sinuses, position of the mediastinum and trachea and the state of the lung

parenchyma from the apex to the lung base. Radiographic diagnosis of the pneumothorax is

made easily, when the line of visceral pleura is approved on the PA chest X - ray. Definitely

radiological recognition of the pneumothorax depends on the lung collapse degree. Small

pneumothorax is better presented on the standard radiography in the standing position

during maximal expirium. In fact, in such a way radiological density of the collapsed lung

parenchyma increases, while the density of air in the pleural space is not changed.

Radiography of the chest in position of a lateral decubitus enables that the free air in the

pleural space is lifted. Increased distance between the lungs and thoracic wall is present, for

the easily identification of the visceral pleura line. When the air enters into the pleural space,

lungs collapses, thoracic cavity is expanded. Radiographic air is presented as a zone of

homogenous light with absence of the lung ornaments at the periphery. Collapsed lung is

separated from this zone by the line of the visceral pleura.

At the side of pneumotorax, the pleural pressure gets to be less and less negative, i.e. it

increases. Pleural pressure within the cotralateral pleural space is unchanged so that the

mediastinum can be removed toward that side. Ipsilateral diaphragm is lowered due to

decrease of the transdiaphragmaic pressure. Interpretation of radiographic imaging made in

lying positions is more difficult. By initial radiological examination of the injured in lying

position, the pnumothorax can be overlooked, in case of development of the tension

pneumothorax can be fatal for the injured. Pain is a dominant symptom at the chest injury,

causing the unproper ventilation presence and the standstill of the secretion in the

tracheobronchial tree. For this fact it is necessary, during treatment and first aid

administration of the injured, to realize proper analgesia with holding of passage for

respiratory paths. Progressive dyspnea and cyanosis point to the development of the tension

pneumothorax. First aid at the tension peumothorax is comprised of decompression, by the

needle placement of the large diameter through second inter-rib area in the midclavicular

line. Needle should stay « in situ » in the pleural space up to the definitive treatment of the

pneumothorax. By procedure of needle placement, the tension pneumothorax becomes the

open pnumothorax, easier to bear. At the open pneumothorax hermetisation of the wound is

performed on the chest wall, taking into account to prevent development of the tension

pneumothorax. Methods of treatment of traumatic pneumothorax are an observation,

exsufflation (needle aspiration) and thoracic drainage. Observation is rarely applied.

Thoracic Trauma 223

Figure 16. Traumatic right - sided hemopneumothorax

Figure 17. Traumatic left-sided hemopneumothorax

Figure 18. Tension left - sided pneumothorax and control radiography after left - sided thoracic drainage

Current Concepts in General Thoracic Surgery

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Exsufflation is suitable for fine decompression of the pleural space at the tension

pneumothorax, when it is not possible to perform thoracic drainage. However, a method is

rarely applied as the definite procedure for solving of traumatic pneumothorax. Thoracic

drainage is a method often used during definite treatment of the traumatic pneumothorax.

11.5.6. Subcutaneous emphysema

Subcutaneous emphysema defines the presence of the air within the subcutaneous tissue,

and at traumatized patients it is most frequently, but not only, associated with the chest

injury and occurrence of pneumothorax. Air in the subcutaneous tissue may be the

consequence of:

 Wound that results in interruption of integrity of soft tissue of the chest wall

 Injuries of parietal and viscelar pleura enable that air from the chest or pleural space

enters into subcutaneous tissue

 Mediastinal or retroperitoneal air which by dissection pass up to the chest wall, neck

and face, or down toward loins and abdominal wall

 Infection at which occurs the gas formation.

Subcutanous emphysema may expend very quickly up to the neck and face or down to the

scrotum. Clinical diagnosis of subcutaneous emphysema can be made palpably according to

the characteristic sign of crepitation. At each injured patient with the subcutaneous

emphysema, the radiography of the chest is necessary for the diagnosis of possible

pneumothorax (often followed by such an occurrence). In terms of therapy the approach to

the patient with subcutaneous emphysema is aimed to solving of basic leison, being the

cause of the subcutaneous emphysema. In case when the emphysema occurs due to the

injury of chest and parietal pleura and consequential pneumothorax, the thoracic drainage is

identified. Wounds on the chest wall, through which the air can penetrate into subcutaneous

tissue, must be treated according to surgical principles.

Figure 19. Subcutaneous emphysema – traffic accident

Thoracic Trauma 225

Pneumomediastinum marks the presence of the air in the mediastinum, and it can be caused

by:

 Injuries of tracheobronchial tree or oesophagus

 Lung barotrauma with alveolar disruption

 Retroperitoneal air which by dissection enters mostly in mediastinum

11.5.7. Traumatic hemothorax

Hemothorax marks the presence of blood within the pleural space. Mostly hemothorax

occurs as a consequence of the penetrating or blunt trauma of the chest. In rare cases,

hemothorax can be a consequence of iatrogenic injury for example, during placement of

catheter into the subclavian artery, or internal jugular vein or during translumbar

aortography. Hemothorax is rarely a consequence of the pulmonary embolism or rupture of

undiagnosed aneurysm of thoracic aorta. Blood can get to the pleural space after injury of

the chest wall, diaphragm, lungs or mediastinum (in the first place of large blood vessels).

After injury of thoracic spine, especially vertebrae at the level Th4 - Th6, the hemothorax can

be developed, even a few days after the injury. Blood that gets into the pleural space quickly

coagulates, but most frequent is an occurrence of the defibrinogenation of coagulation due

to the heart and lungs movement, when the blood accumulation is slow and in smaller

quantity. Localization, i.e. encapsulation of accumulated blood occurs relatively quickly and

when the blood collection is not found and removed, the development of empyema is

possible. In case that the bloody leak in the pleural space occurs related to a certain disease,

diagnostical procedure, in terms of defining of the clean blood presence, is aimed at

determining of haematocrits of pleural fluid. In most cases, however the pleural fluid is

macroscopic with blood characteristics, the haematocrit of pleural fluid is under 5%.

Hemothorax is diagnosed in such cases when the haematocrit of pleural fluid is at least 50%

from the haematocrit in the peripheral blood. Traumatic hemothorax is the frequent findings

within the surgical centers that treat the trauma. Incidence of the hemothorax is high at the

blunt trauma, up to 37%, associated with the pneumothorax (hemopneumothorax) even up

to 58%. Occurrence of the hemothorax is almost equally frequent without rib fracture (35%)

or associated with rib fracture (38%). At patients with rib fracture, the occurrence of

hemothorax is more frequent when the fractured rib-ends are dislocated.[29] When during

the occurrence of hemothorax the arterial bleeding is diagnosed, there is no doubt that the

thoracotomy will be applied as a therapy. Massive intrathoracic haemorrhage indicates an

urgent thoracotomy and treatment of the bleeding place.[30] Hemothorax causes locally an

atelectasis of lungs due to the compression causing that way, when the bleeding is massive,

respiratory disorders. In some cases of massive hemothorax, the movement of mediastinum

in opposite side is possible. Beside the local compressive effect, hemothorax causes

hypovolemic problems which are expressed in a degree that depends on the quantity of lost

blood in the pleural space.[32] Diagnosis of traumatic hemothorax must be taken into

account at each blunt or penetrating chest injury. Hemothorax, after thoracic trauma, is

Current Concepts in General Thoracic Surgery

226

often diagnosed by findings of pleural fluid at radiography of the chest. However, this

method is not sufficient in all cases, or at least it is not proved to such a degree that it can be

the only one during the examination of the injured. Smaller intrapleural collections can be

hardly noticed at classical radiography, especially when the quantity of the discharged

blood is small or when smaller leaks occur on both sides. Difficulties in such cases occur in

the interpretation of radiography. When a patient is in the lying position, only slightly

shadowing of hemithorax is recorded as a consequence of blood spillage along the back

chest wall. Through such a shadow, the silhouette of the lung blood vessels can be obviously

seen. Presence of a small hemothorax is hard to define in the lying position, especially when

the noticeable contusion injuries of lungs are present and at subcutaneous emphysema,

because it should be thought of the presence of a certain lung collapse. It is recommended to

perform the radiography of the chest wall in standing position whenever it is possible,

although hemothorax does not have to be found initially in that position. At imaging

performed in standing posterioanterior (PA) or side position of a patient, free pleural fluid is

collected by the effect of gravitation in the back costophrenic sinus, shadowing the

costophrenic angle. In rare cases blood can be collected in the subpulmonary way between

lungs and diaphragm when the costophrenic sinus is free, and the outline of diaphragm is

partially changed. When the imagining is performed in PA position, the apex of

diaphragmatic cupola is directed laterally toward the chest wall and the mistake in

interpretation that it is the rupture of diaphragm is possible. However, at the side

radiography the shadowing of the back costophrenic sinus is found and the angulation of

the anterior shadow area of the alleged diaphragm, i.e. leak in the level of union with a large

incision. Development of traumatic hemothorax can occur immediately after injury or the

bleeding into thoracic cavity occurs later, i.e. after a few hours, even a few days later.

Postponed occurrence of hemothorax is recorded after blunt and also after penetrating

injury of the chest wall.[33,34] Patients with thoracic trauma, particularly those with

assessment that it is potentially severe injury, should be followed by radiography in the

period of at least -6 hours after the injury. In that period a small hemothorax and

pneumothorax can be found. At penetrating injuries, with initially found hemothorax,

development of pneumothorax can be found in over 80% cases.[35,36] Ultrasonography of

the chest is an useful method in finding out of smaller pleural blood leaks, particularly at the

lying patients and patients without consciousness. Computerized tomography (CT) is a

very sensitive method for finding out even small intrapleural collections of fluid. It is

proved method for differentiation of hydrothorax from hemothorax.[21] However, this

method is rarely applied at the acute injured patients. CT of the chest can be used later for

evaluation and differentiation of the lung atelectasis, rupture of diaphragm or finding out of

extrapleural haematoma. Such states in the native radiography are manifested by

shadowing hardly differentiated from the presence of the free fluid in the pleural cavity. CT

of thorax is useful method and during the control of treatment effect, particularly in cases of

the occurrence of encapsulation of hemothorax and ineffective drainage. Therapeutic

approach of a surgeon toward each inury of the chest must be active, regardless of the

Thoracic Trauma 227

known fact that in most cases may come to the spontaneous hemostasis. Such an attitude

includs the constant observation of the injured, evacuation of collected blood, fight against

atelectasis and follow up of effects of applied surgical treatment. Basic aims of the

hemothorax therapy are: evacuation of collected blood from the pleural space, realization of

the full reexpansion of lungs and realization of tamponade of the bleeding area by bringing

lungs in an immediate contact with parietal pleura. Compensation od the lost blood is

performed, in terms of therapy, parallelly with local treatment of hemothorax. It depends on

the volum of lost blood.[36,37] Treatment of traumatic hemothorax depends on many

parameters as: general state of the injured, state of the vital functions, character of the injury,

i.e. is it the question of isolated thoracic injury or the injury is a part of politrauma, states of

the injured part of the chest (unilateral, bilateral) and the occurance of bony structure

fractures, combideness of many associated intrathoracic injuries, quantity of lost blood and

possible area of bleeding, if the bleeding is recorded immediately after admission or it is

determined a few hours or days after injury, if it is possible to apply conservative or it is

necessary to apply immediately operative treatment, if there is associated pneumothorax

with hemothorax, ect.[29,38,39] Most cases of traumatic hemothorax are treated without

application of thoracotomy. By thoracentesis (pleural punction with application of large -

bore needle) or thoracic drainage it is possible to solve hemothorax, i.e. evacuate entire

quantity of blood from the pleural space. Attitudes related to the application of these

therapeutical models are not clearly separated, particularly in relation to the thoracentesis.

Thoracentesis is often applied at a uncomplicated hemothorax with smaller quantity of

blood and at the injured where the shadow of the leak without the lung collapse is present

during the clinical observation. In most cases they are patients with injuries caused by the

effect of a weaker blunt stricking force and those with fractures of one to three ribs. Basic

precondition for success of this method is that the blood in the pleural space is not

coagulated. Some chest surgeons apply thoracentesis in diagnostical purposes as the first

method for the recorded leak in order to orient themselves referring to the character of

bleeding, i.e. to define if the obtained blood was immediately coagulated. Thoracic drainage

is applied in most cases not only as the first therapeutic method but it is most frequently

definitive therapeutic procedure. By thoracic drainage 85% of patients with chest injury are

treated. At right diagnosed indications for thoracic drainage, the possibility of occurence of

later complications is decreased.[40-42] Success of the thoracic drainage depends on several

factors:

 General state of the injured

 Indication for drainage

 Choice of diameter and quality of thoracic drains and drainage systems

 Control of functioning of the entire drainage system, chest drains passing through and

early detection of the problem in relation to that.

Indications for thoracic drainage are divided to absolute and relative.

Absolute indications for thoracic drainage at thoracic trauma are the following:

Current Concepts in General Thoracic Surgery

228

 Traumatic pneumothorax regardless of the degree of collapse

 Tension pneumothorax

 Pneumothorax on both sides regardless of the degree of lung collapse

 Massive hemothorax previously proved

 Associated collection of blood and air - hemopneumothorax, one - sided or on both

sides.

In later clinical course of hemothorax, indications for drainage, i.e. re - drainage are related

to the occurence of complication:

 At development of acute empyema of pleura

 Encapsulated hydroaeric collections

 Other collections of fluid and air.

Figure 20. Left - sided traumatic hemothorax – Traffic accident

Figure 21. Right - sided traumatic hemothorax – Traffic accident

Thoracic Trauma 229

Figure 22. Fall from the height – traffic accident (child 8 years)

When the general endotracheal anaesthesia is planned for the surgery on the out thoracic

organs at injured patients with the thoracic trauma or when the artificial ventilation by

positive pressure is indicated, the attention should be paid to the possibility of development

of the tension pneumothorax that in the aim of solving requires an urgent thoracic drainage.

Preventive drainage of the thorax is not indicated when the obvious signs of pneumothorax

are not present.

11.5.8. Types of drainage systems of pleura

There is more drainage systems used during thoracic drainage. In order to use in full the

therapeutic effect of each system it is necessary to know the working principles each of

them. Basic working principle of each drainage system is to: provide continued one-way

evacuation, drainage of air and fluid from the pleural space into drainage collector, in the

way that there is no possibility for an air circulation or fluid in the opposite direction, i.e.

toward the pleural space. Basic aim of thoracic drainage is to evacuate the pleural content

(air and fluid) and to achieve full reexpansion of lungs.

Classical drainage system is comprised of one bottle, which at the same time serves for

collection of drainage content and as the water valve. Opening of the thoracic chest tube is

connected to the rigid tube, passing through the stopper of sterile bottle. Top of the rigid

tube is dived for around 2 cm under the surface of the physiological salt solution poured

into the bottle. On the stopper of a bottle there is one more opening through which the tube

is inserted, used for air egress (air valve). Top of the tube is above the fluid level. Such a

system can be used for so-called submerged drainage, without active suction, or the tube of

a valve is connected with the active suction, when the system is used for the active

aspiration. Drainage system with two bottles is more reliable for the drainage of large

quantity of fluid pleural content. Bottle which is closer to the patient serves as the collector

of drainage fluid content, with second bottle the system of water valve is provided, similary

to the system of one drainage bottle. Drainage system with three bottles is marked as the

Current Concepts in General Thoracic Surgery

230

system for controlled suction of the pleura fluid content. Third bottle, added to the system of

two bottles, serves for control of the active aspiration. It is connected to the second bottle

that has the function of the water valve. Bottle for the pressure control for performance of

the active suction has rigid tube, similar to the one on the second bottle, and on the stopper

there is the connection linked with the source of active suction. System with three bottles is

quite massive and it is not practical for patients who need transport. Commercial systems,

for one-time usage, are designed according to the principle of functioning of the system with

three bottles and they are considered to be fully proper for successful thoracic drainage.

These systems are manufactured sterile and they are made of the plastic material, simple

and practical for use. Most famous are Pleur-Evac and Argyl Double-Seal Units.

Figure 23. Drainage system one - bottle

Figure 24. Drainage system two - bottles

Thoracic Trauma 231

Figure 25. Drainage system three - bottles

Figure 26. Commercial drainage system

11.5.9. Types of thoracic drainage

Practically, thoracic drainage can be performed in two different ways by:

 Operative thoracostomy – by classical incision of thorax in general or intravenous

anesthesia, dissection and blunt preparation and placement of large-bore thoracic drain

under finger control. Position of the patient is the lying, in decubitus on healthy side.

 Trocar thoracostomy – drainage is performed in local anesthesia by placemnt of the

chest tube of narrow lumen through a metal thoracic trocar. Through previously

performed incision on the chest wall, it is penetrated by sharp stiletto into the pleural

space. During performance of drainage there is no possibility of digital control of the

Current Concepts in General Thoracic Surgery

232

lung parenchyma position in relation to the top of stiletto of the trocar. Variant of

drainage by the trocar is the application of the commercial trocar catether, where the

trocar is placed inside of thoracic drain. By trocar thoracostomy the chest wall is less

damaged and the intervention is performed significantly more rapid, compered with

the operative thoracostomy. Patient position is the sitting position with antebrachial

region leaned against the backed chair or it is the lying position on the back.

Figure 27. Operative thoracostomy

Proper premedication of a patient is obligatory regardless which of the mentioned ways is

used by the suregeon. Position of the patient during performance of thoracic drainage is

mostly defined by his general state.

By placement of thoracic chest tube, several favors are realized in hemothorax treatment:

 In most cases the complete evacuation of blood from the pleural space is possible

 It is possible to stop the bleeding completely that occurs due to the damage of pleural

space

 Easy and simple control of the quantity of lost blood and assessment of the bleeding

degree are possible, important for defining of the volume necessary for restoring

Thoracic Trauma 233

 Possibility for the occurence of bacteria infection is decreased due to the encapsulation

of hematoma and development of empyema, i.e. fibrothorax

 Finally, in modern conditions there is a possibility of the blood autotransfusion,

evacuated by the thoracic drain

Choice of thoracic chest tubes at fresh bleeding is mostly aimed in direction of placement of

drains of a large-bore lumen (Fr 30 - 32, and according to some autors even Fr 36 - 40) for in

that way the possibility of drains blockage with bloody coagulum is decreased.

Recommendation for the massive hemothorax is to place a large - bore thoracic drain

through IV and V interspace of ribs in the midiaxillary line. Drain is placed upward, for

during drainage there is a possibility of the diaphragm damage due to its elevation caused

by trauma, or within the thoracic cavity prolapsed intra-abdominal organs can be damaged

at cases with the diaphragm rupture. Control of thoracic drain function is important and it is

necessary to be constant. Passage of drains and quantity of evacuated content are controlled.

It is necessary to control radiographic and roentgenoscopic states of extended lungs,

diaphragm position and drain position. Control of functioning and efficiency of drains is

important in order to prevent infection and development of empynema and if needed, when

the thoracic drainage does not achieve a goal, to apply other models of treatment, i.e.

thoractomy in the aim of haematoma removal and stopping of bleeding. Best way of

prevention in infection development is an urgen and complete evacuation of blood from the

pleural cavity. [29-31,33,40] It is useful to apply parenteral therapy of antibiotics. Indication

for urgent thoracotomy is often connected with the occurence of massive hemothorax due to

injuries of intrathoracic organs that can not be treated in a conservative way. Urgent

thoracotomy is indicated at the hemothorax, complicated by a heart tamponade, injury of

large intrathoracic blood vessels, primary pleural contamination, debridement of devitalized

tissue, open thoracic wounds and at the tracheobronchial injuries.[41 – 44] Indications for

urgent thoracotomy are special. After placement of thethoracic chest tube and assessment of

the volume of continued pleural bleeding, i.e. quantity of lost blood in continuity through

the thoracic drain. General rules include the rule that urgent thoracotomy is indicated in

case if the constant loss at thoracic chest tube is 200ml per hour, in case that there is no

indications to stop the bleeding. Of course, in order to make decision related to the

thoracotomy and assess the state in the pleural cavity in such cases it is necessary to perform

control by the radiography and radioscopy. When the continued loss of blood at the thoracic

drain is determined and radiographic findings of hemothorax shadowing, the thoracotomi

is necessary.[40,45] Indications for urgent thoracotomy are identical at the blunt and

penetrating injuries. At each patient it is necessary to observe carefully all parameters,

supposed for indication for surgical treatment, i.e. thoracotomy. Resectional lung surgery

are rarely applied, mainly in cases of increased laceration of lung parenchyma and

development of increased intrapulmonary haematoma, devitalization of lung parenchyma

and injury of lung bood vessels.[43,44] It is proved that pneumonectomy should in any case

be avoided, for the mortality rate after such an operation is almost 100%, i.e. such a

resection should be performed only if there is no other choice. [46 – 48] Wedge - shaped

resection is most often, resection of segments and lobectomy, it is possible to apply staplers.

[43,44] At the presence of associated hemothorax and pneumothorax one should think of the

Current Concepts in General Thoracic Surgery

234

possibility of injury of large respiratory paths, trachea and bronchi. When their fissure is

determined, an urgent thoracotomy is indicated and the sutura of respiratory paths with

caring for the site of bleeding. Thoracotomy is necessary at the traumatic hemothorax at

around 20% of the injured. In medern conditions in cases of the occurence of hemothorax

the video-assisted thorascopic surgery (VATS) can be applied, but up to recently

experiences are still rather modest that it can be accepted that this surgical method belongs

to the routine therapeutic methods.[49,50] Main pleural complications of traumatic

hemothorax are: retention of blood coagulum in the pleural space, infection in the pleural

space, effusion of the pleura and fibrothorax. In most cases surgical recommedation is to

remove surgically the formed coagulum from the pleural area due to possible complications,

in the first place the infection and development of empyema and fibrothorax.[51]

Development of empyema can be expected at 1% - 4% cases. Application of antibiotics

during the treatment of hemothorax by thoracic drainage is useful in the reduction of the

occurence of empyema and pneumonia. If the thoracic trauma is combined with abdominal

trauma, at extended thoracic drainage the possibility of the occurence and development of

the pleural infection i.e. empyema is more definite. Complications of the pleural empyema

are solved by the thoracotomy and decortication of the lung.[52,53] Occurence of the pleural

effusion is possible after completed treatment and removal of thoracic drain. Development

of leak is possible, regardless of the fact that residual hemothorax is present or not, but it is

significantly more rare, when it is not present (at around 13% without residual hemothorax

and around 34% of cases with the retention of the residual hemothorax, i.e. formed

coagulum that can not be removed by thoracic drain).[54] Occurance of pleural leak is an

indication for pleural punction (thoracocentesis), with the aim to determine the character of

pleural fluid and to prevent development of the empyema. After completed treatment of the

Figure 28. Penetrating injury – firearms

Thoracic Trauma 235

Figure 29. Penetrating injury – knife wound

hemothorax, in the period of a few weeks or months, due to the noticiable adhesions, the

fibrothorax can be developed. Fibrothorax is developed at around 1% of treated patients

from hemothorax and it is more frequent at patients with hemopnemotorax, or when in the

early phase after injury the pleural infection appears. Complications due to the fibrothorax

can be solved by the lung decortication.

Author details

Slobodan Milisavljević*, Marko Spasić and Miloš Arsenijević

Clinic for General and Thoracic Surgery, Clinical Center »Kragujevac«, Kragujevac, Serbia

Faculty of Medical Sciences, University of Kragujevac, Serbia

12. References

[1] LoCicero J, Mattox KL: Epidemiology of chest trauma, Surg Clin North Am 69:5,1989

[2] Shorr RM, et al: Blunt chest trauma in elderly. J Trauma 29:234,1989

[3] Besson A, Saegesser F: Color Atlas of Chest Trauma and Associated Injuries Vol.1

oradell.NJ:Medical Economics,1983,p.9.

[4] E. Q. Haxhija, H. Nöres, P. Schober and M. E. Höllwarth. Lung contusion-lacerations

after blunt thoracic trauma in children Pediatric Surgery International 2004; 20(6): 412-

414, DOI: 10.1007/s00383-004-1165-z

* Corresponding Author

Current Concepts in General Thoracic Surgery

236

[5] Shackford SR. : Blunt chest trauma: the intensivists’s perspective. Intensive Care Med

1:125,1986

[6] MD R. Stephen Smith et al, Preliminary report on videothoracoscopy in the evaluation

and treatment of thoracic injury The American Journal of Surgery 1993;166(6):690–695

[7] Hood-Boyd-Culliford: Thoracic Trauma, W.B Saunders Company, 1989

[8] Galan G,et al: Blunt chest injuries in 1696 patients, Eur J Cardiothorac Surg 6:284,1992

[9] Glinz W: Symposium paper: priorities in diagnosis and treatment of blunt chest

injuries. Injury 17:318, 1986

[10] Kulshrestha P, et al: Chest injuries. A clinical and autopsy profile, Trauma 28:844,1988

[11] Serife Tuba Liman, Akin Kuzucu, Abdullah Irfan Tastepe, Gulay Neslihan Ulasan and

Salih Topcu Chest injury due to blunt trauma Eur J Cardiothorac Surg 2003;23 (3): 374-

378

[12] Glinz W: Causes of early death in thoracic trauma. In Webb WR, Besson A (eds):

Thoracic Surgery: Surgical Management of Chest Injuries. Vol.7. St.Louis: Mosby-Year

Book, 1991.

[13] Murray JA,et al: Penetrating left thoracoabdominal trauma: the incidence and clinical

presentation of diaphragm injuries, J Trauma 43:624, 1997

[14] Campbell DB: Trauma to the chest wall, lung, and major airways. Semin Thorac

Cardiovasc Surg 4:234, 1992

[15] Feliciano DV, Bitando CG, Mattox KL, et al: A 1 year experience with 450 vascular and

cardiac injuries, Ann Surg 199:177, 1984

[16] Feliciano DV, Bitando CG, Cruse PA, et al: Liberal use of emergency center

thoracotomy, Am J Surg 152:654, 1986

[17] Fisher RP, Jelense S, Perry ST Jr: Direct transfer to operating room improves care of

trauma patients: A simple economically feasible plan for large hospital JAMA 240:1731,

1978

[18] Flynn TC, Ward RE, Miller PW: Emergency department thoracotomy Ann Emerg Med

11:413, 1982

[19] U. Obertacke , Th. Joka , M. Jochum , E . Kreuzfelder, W. Schönfeld und M. Kirschfink.

Posttraumatische alveoläre Veränderungen nach Lungenkontusion Uniallchirurg

1991;94: 134-138

[20] Pearson FG, Deaslauriers J, Ginsberg RJ, Hiebert CA, McKneally MF, Urschel HC Jr

(edts): Trauma, Pathophysiology and initial management, In Thoracic Surgery,

Churchill Livingstone, p. 1532, 1995

[21] P Sinha and P Sarkar. Late clotted haemothorax after blunt chest trauma. J Accid Emerg

Med. 1998; 15(3): 189–191

[22] Sisley AC, et al: Rapid detection of traumatic effusion using surgeon-performed

ultrasonography J Trauma 44:291, 1998

[23] MD Hiram C. Polk Jr Factors influencing the risk of infection after trauma The

American Journal of Surgery 1993;165(2):2S–7S

[24] Shorr RM, Crittenden M, Indeck M, et al: Blunt thoracic trauma, Ann Surg 206:200, 1987

[25] Valeri CR: Optimal use of blood products in the treatment of hemorrhagic schock. Surg

Rounds 4:38, 1981

Thoracic Trauma 237

[26] J. Verheij,A. van Lingen, P. G. H. M. Raijmakers, E. R. Rijnsburger,D. P. Veerman W.

Wisselink, A. R. J. Girbes and A. B. J. Groeneveld. Effect of fluid loading with saline or

colloids on pulmonary permeability, oedema and lung injury score after cardiac and

major vascular surgery. Br. J. Anaesth 2006; 96(1): 21-30

[27] West JG, Trunkey DD, Limm RC: Systems of trauma care Arch Surg 114:445, 1979

[28] Webb WR, A Besson: Thoracic Surgery: Surgical Management of Chest injuries. Vol 7.

International Trends in General Thoracic Surgery

[29] Mattox KL, Allen MK: Systematic approach to pneumothorax, haemothorax,

pneumomediastinum and subcutaneous emphysema, Injury 17:309, 1986

[30] Jordi Freixinet, Juan Beltrán, Pedro Miguel Rodríguez, Gabriel Juliá, Mohammed

Hussein, Rita Gil, Jorge Herrero Indicators of Severity in Chest Trauma. Archivos de

Bronconeumología ((English Edition)) 2008;44(5):257–262

[31] Weil PH, Margolis IB: Systematic approach to traumatic hemothorax, Am J Surg

142:692,1981

[32] Roy-Camille R, Beurier J, Maretingnon M et al: Les epanchements intra-thoraciques

associes aux fractures due rachis dorsal. In Buff HU and Glinz W. editors:

Respiratorische insuffizienz bei Mehrfachverletzten, Erlang, 1976

[33] Ross RM, Cordoba A: Delayed life-treatening hemothorax associated with rib fractures,

J Trauma 26:576, 1986

[34] Kathirkamanathan Shanmuganathan, MD, Junichi Matsumoto, MD. Imaging of

Penetrating Chest Trauma. Radiol Clin N Am 2006: 225-238

[35] Muckart DJ: delayed pneumothorax and haemothorax following observation for stab

wounds of the chest, Injury 16:247, 1985

[36] Beal AC, Craword HW and DeBakey ME: Conditerations in the management of acute

traumatic hemothorax, J Thorac Cardiovasc Surg 52:351, 1966

[37] Weil PH anb Margolis IB: Systematic approach to traumatic hemothorax, Am J Surg

142:692, 1981

[38] Cordice JWV and Cabezon J: Chest trauma with pneumothorax and hemothorax, J

Thorac Cardiovasc Surg, 50:316, 1965

[39] Symbas PN: Acute traumatic hemothorax, Ann Thorac Surg 26:195, 1978

[40] MD Jeffrey R. MacDonald, MD Richard M. McDowell. Emergency department

thoracotomies in a community hospital. Journal of the American College of Emergency

Physicians 1978; 7(12): 423–428

[41] Glinz W: Symposium paper: priorities in diagnosis and treatment of blunt chest

injuries, Injury 17:318, 1986

[42] Hood-Boyd-Culliford: Thoracic Trauma, W.B. Saunders Comp, 1989

[43] Asensio JA et al: Stapled pulmonary tractotomy: a rapid way to control hemorrhage in

penetrating pulmonary injuries J Am Coll Surg 185:486, 1997

[44] Wall MJ et al: Pulmonary tractotomy as an abbreviated thoracotomy technique. J

Trauma 45:1015,1998

[45] Sturm JT: Hemopneumothorax following blunt trauma of the thorax, Surg Gynecol

Obstet 144:539, 1975

Current Concepts in General Thoracic Surgery

238

[46] Bowling R, et al: Emergency pneumonectomy for penetrating and blunt trauma, Am

Surg 51:1365, 1985

[47] Moheb A. Rashid, Thore Wikström, Per Örtenwall. Outcome of lung trauma. European

Journal of Surgery 2000;166(1):22–28

[48] Baumgartner F, et al: Survival after pneumonectomy: the pathophysiologic balance of

shock resuscitation with right heart failure, Am Surg 62:967, 1996

[49] Meyer DM, et al: Early evacuation of traumatic retained hemothoraces using

thoracoscopy: a perspective, randomized trial, Ann Thorac Surg 64:1396, 1997

[50] Heniford BT, et al: the role of thoracoscopy in the management of retained thoracic

collections after trauma, Ann Thorac Surg 63:940, 1997

[51] A.V. Manlulu, T.W. Lee, K.H. Thung, R. Wong and A.P.C. Yim. Current indications and

results of VATS in the evaluation and management of hemodynamically stable thoracic

injuries. Eur J Cardiothorac Surg 2004;25 (6): 1048-1053.

[52] LeRoux BT, et al: Suppurative diseases of the lung and pleural space. Part I: Empyema

thoracis and lung abscess. Curr Probl Surg 23:1, 1986

[53] Aguilar MM, et al: Posttraumatic empyema. Risk factor analysis Arch Surg 132:647,

1997

[54] Hanna JW, Reed JC, Choplin RH: Pleural infections: a clinical-radiologic review J

Thorac Imaging 6:68, 1991

Article

Full-text available

Apr 2020
Chin J Traumatol

Physical traumas are tragic and multifaceted injuries that suddenly threaten life. Although it is the thirdmost common cause of death in all age groups, one out of four trauma patients die due to thoracic injuryor its complications. Blunt injuries constitute the majority of chest trauma. This indicates the importanceof chest trauma among all traumas. Blunt chest trauma is usually caused by motor vehicle accident, falling from height, blunt instrument injury and physical assault. As a result of chest trauma, many injuries may occur, such as pulmonary injuries, and these require urgent intervention. Chest wall and pulmonary injuries range from rib fractures to flail chest, pneumothorax to hemothorax and pulmonary contusion to tracheobronchial injuries. Following these injuries, patients may present with a simple dyspnea or even respiratory arrest. For such patient, it is important to understand the treatment logic and to take a multidisciplinary approach to treat the pulmonary and chest wall injuries. This is because only 10% of thoracic trauma patients require surgical operation and the remaining 90% can be treated with simple methods such as appropriate airway, oxygen support, maneuvers, volume support and tube thoracostomy. Adequate pain control in chest trauma is sometimes the most basic and best treatment. With definite diagnosis, the morbidity and mortality can be significantly reduced by simple treatment methods.

Rapid detection of traumatic effusion using surgeon-performed ultrasonography - Discussion

Article

Feb 1998
J Trauma Inj Infect Crit Care

Hemopneumothorax following blunt trauma of the thorax

Article

Jul 1976
J TRAUMA

Acute Traumatic Hemothorax

Article

Sep 1978
ANN THORAC SURG

Panagiotis N. Symbas

Stapled Pulmonary Tractotomy: A Rapid Way to Control Hemorrhage in Penetrating Pulmonary Injuries

Article

Nov 1997
J AM COLL SURGEONS

J Asensio

Preliminary report on videothoracoscopy in the evaluation and treatment of thoracic injury1

Article

Dec 1993
AM J SURG

A prospective trial of videothoracoscopy was conducted at an urban trauma center between February 1992 and February 1993 to determine the efficiency of this less invasive method of evaluation and treatment. Twenty-four consecutive patients with chest trauma (penetrating, n = 22; blunt, n = 2) were examined thoracoscopically for clotted hemothorax that otherwise would have been treated with thoracotomy (n = 9), suspected diaphragmatic injury (n = 10), and continued bleeding (n = 5). To ensure maximal exposure, general anesthesia with a double-lumen endotracheal tube was used in each patient. Clotted hemothorax was successfully evacuated in eight of nine patients (89%). Diaphragmatic laceration was suspected in 10 patients (2 abnormal chest radiographs, 8 proximity penetrating wounds) and confirmed thoracoscopically in 5. In four patients, diaphragmatic lacerations were successfully repaired with thoracoscopic techniques. Five patients underwent thoracoscopy for continued hemorrhage (greater than 1,500 mL per 24 hours) after tube thoracostomy. Intercostal artery injury was confirmed in all patients, and diathermy provided hemostasis in three patients without thoracotomy. No complications occurred. These data suggest the following: (1) Videothoracoscopy is an accurate, safe, and minimally invasive method for the assessment of diaphragmatic injuries, control of continued chest wall bleeding, and early evacuation of clotted hemothorax. (2) This technique should be used more frequently in patients with thoracic trauma. (3) Technical advances may expand the therapeutic role of thoracoscopy.

Systems of trauma care

Article

Jan 1979
Arch Surg

Emergency department thoracotomies in a community hospital

Article

Dec 1978
JACEP

In 4 1/2 years (July 1973 to December 1977), 28 thoracotomies were performed by emergency physicians in the emergency department of a 540-bed community hospital, which averaged 25,800 visits per year. Two patients had sustained crush injuries of the chest in traffic accidents, and 26 had penetrating chest and/or abdominal trauma. Twenty-three of the patients had no vital signs and were clinically dead on arrival. Of these, four (17%) were resuscitated and transported to the operating room; three (13%) were long-term survivors and two left the hospital with no serious sequelae. The other five patients arrived with some vital signs but subsequently had cardiopulmonary arrests in the emergency department. Three (60%) were initially resuscitated using thoracotomy and transported to the operating room but there were no long-term survivors among this group of five. Of the 28 patients who underwent thoracotomies in the emergency department, one in four (7/28; 25%) were initially resuscitated, and one in nine (3/28; 11%) were long-term survivors. Thoracotomy in a community hospital emergency department by emergency physicians can be life-saving.

Rapid Detection of Traumatic Effusion Using Surgeon-Performed Ultrasonography

Article

Feb 1998
J TRAUMA

In the injured patient, rapid assessment of the thorax can yield critical information for patient management and triage. The objectives of this prospective study were (1) to determine if experienced surgeon sonographers could successfully use a focused thoracic ultrasonographic examination to detect traumatic effusion, and (2) to compare the accuracy and efficiency of ultrasonography with supine portable chest radiography. Surgeon-sonographers performed thoracic ultrasonographic examinations on patients with blunt and penetrating torso injuries during the Advanced Trauma Life Support secondary survey. All patients also underwent portable chest radiography. Performance times for ultrasonography and chest radiography were recorded. Comparisons were made of the performance times and accuracy of both tests in detecting traumatic effusion. In 360 patients, there were 40 effusions, 39 of which were detected by ultrasonography and 37 of which were detected by chest radiography. The 97.5% sensitivity and 99.7% specificity observed for thoracic ultrasonography were similar to the 92.5% sensitivity and 99.7% specificity for portable chest radiography. Performance time for ultrasonography was significantly faster than that for chest radiography (1.30 +/- 0.08 vs. 14.18 +/- 0.91 minutes, p < 0.0001). Surgeons can accurately perform and interpret a focused thoracic ultrasonographic examination to detect traumatic effusion. Surgeon-performed thoracic ultrasonography is as accurate but is significantly faster than supine portable chest radiography for the detection of traumatic effusion.

Direct transfer to operating room improves care of trauma patients. A simple, economically feasible plan for large hospitals

Article

Nov 1978

As evidenced in a nine-year experience with more than 4,000 patients, the operating room is an ideal receiving area for severely injured patients. This system, which reduces mortality, morbidity, and suffering incurred by severely injured patients, is both feasible and economical for many large metropolitan hospitals.

Trauma to the chest wall, lung, and major airways

Article

Aug 1992
Semin Thorac Cardiovasc Surg

D B Campbell

Thoracic Trauma

Figures

Recommendations

III41007

Multidetector Computed Tomography of Nonosseous Thoracic Trauma

[Thoracic trauma: an analysis of 521 patients]

[Treatment of thoracic trauma].

Purtscher's retinopathy - Report of two cases

Major abdominal and thoracic trauma associated with spinal cord injury: Problems in management