Slide Guide

Chapter 4
Thoracic Trauma

SLIDE 4-1 Title Slide

■■Introduce the topic and explain to students that, based on their preparation for the
course, a series of questions will be asked throughout the lecture. Their active partici-
pation and responses are expected.
■■ Emphasize that this lecture summarizes the information provided throughout the
course, and that all major components will be covered in depth during individual
lectures, skill stations, and demonstrations.
■■Because you will use the slide show to emphasize key points, it is important to be
familiar with every slide. Proper sequencing of questions and responses facilitates an
interactive presentation.
■■ Be sure to carefully manage the time allotted for this lecture.

SLIDE 4-2 Chapter Statement

SLIDE 4-3 Case Scenario

■■Describe the scenario.

1
2 CHAPTER 4 n Thoracic Trauma

SLIDE 4-4 Objectives

■■Review the objectives as provided on the slide.
■■Emphasize the clinical and other important aspects of the approach to the injured
patient with thoracic injuries.
■■Note: This lecture focuses on the ABCDE approach to the initial assessment and man-
agement processes of identifying and treating patients who sustain thoracic trauma.
The first case scenario presented in this session focuses on the life-threatening airway
and breathing injuries of tension pneumothorax, open pneumothorax, and flail chest
with pulmonary contusion.
■■The injuries to be identified and treatment initiated during the primary survey are:
airway obstruction, tension pneumothorax, open pneumothorax, flail chest and
pulmonary contusion, massive hemothorax, and cardiac tamponade.
■■ The potentially life-threatening injuries to be identified with treatment initiated during
the secondary survey are: simple pneumothorax, hemothorax, pulmonary contusion,
tracheobronchial tree injury, blunt cardiac injury, traumatic aortic disruption, traumatic
diaphragmatic injury, and blunt esophageal rupture.
■■Subcutaneous emphysema, thoracic crush injuries, and sternal, rib, and clavicular
fractures have the potential to do significant harm.
■■These objectives relate to the lecture/interactive discussion. There may be additional
objectives related to this topic that will be covered in the skill stations and the initial
assessments. Please refer to the Student Manual for the complete list of objectives
related to this topic.

SLIDE 4-5 Thoracic Trauma

■■Emphasize that chest injuries remain a significant cause of morbidity and mortality
among trauma patients.
■■Life-threatening injuries associated with thoracic injuries are identified in the primary
survey by carefully assessing thepatient’s ABCs.
■■Identified injuries usually require simple interventions to secure the airway, reexpand
the lung, drain the pleural space, and improve breathing mechanics.
■■ Most penetrating wounds to the chest require a thoracostomy tube.
■■A minority of patients with chest injuries require urgent surgical exploration due to
bleeding.
■■Use the final point to elicit the six life-threatening injuries on the subsequent slide.

SLIDE 4-6 Thoracic Trauma: What are the immediately life-

threatening chest injuries?
 CHAPTER 4 n Slide Guide 3

SLIDE 4-7 Thoracic Trauma: What are the immediately life-

threatening chest injuries?
■■ Direct the discussion to prioritize treatment based on the ABCDE algorithm.
■■ Emphasize that these life-threatening injuries are treated as they are identified.
■■ This list may be used as a tool to briefly contrast the pathophysiology and clinical signs
that the student might see. For example, contrast the pathophysiology of hypoxia from
airway obstruction with tension pneumothorax.
■■Emphasize that these life-threatening injuries and related problems are resolved as
they arediscovered.
■■At this point in the lecture, it is not necessary to spend a lot of time on specifics
because each injury is discussed in detail during the lecture.
■■Emphasize key recognition factors for each injury listed on this slide.

SLIDE 4-8 Thoracic Trauma: What are the pathophysiologic

consequences of these chest injuries?

SLIDE 4-9 Thoracic Trauma: What are the pathophysiologic

consequences of these chest injuries?

SLIDE 4-10 Primary Survey: Identification of Thoracic Injury

■■Thoracic injuries are identified by primary survey signs: tachypnea, respiratory distress,
hypoxia, tracheal deviation, breath sounds, percussion abnormalities, and chest wall
deformity.
4 CHAPTER 4 n Thoracic Trauma

SLIDE 4-11 Laryngeotracheal Injury: Airway Obstruction

■■You may use prompts, such as speaking in a hoarse or quiet voice, noisy breathing,
and stridor.
■■The students should determine that the treatment goal is to establish a definitive
airway.
■■Briefly query the students about the use of endotracheal intubation versus tracheos-
tomy versus surgical cricothyroidotomy. Explain that these skills are discussed and
practiced during the skills stations later on the first day of the course.

SLIDE 4-12 Tension Pneumothorax

■■How do I identify a tension pneumothorax? How do I differentiate a tension pneumo-
thorax from cardiac tamponade and hemorrhagic shock?
■■During the discussion of differentiating a tension pneumothorax from cardiac tampon-
ade and hemorrhagic shock, relate that blunt injury is a more likely cause of tension
pneumothorax.
■■Cardiac tamponade occurs more often with penetrating trauma.
■■If hypovolemia exists, the patient’s neck veins will not be distended.

SLIDE 4-13 Open Pneumothorax

■■Describe the pathophysiology of an open pneumothorax using the illustration on the
slide to explain ineffective ventilation and the rationale and technique for partially
occlusive dressing.
■■Emphasize the need for the chest tube to be placed in a separate location for manage-
ment.

Photograph courtesy of Francisco De Salles Collet E.

Silva, MD, FACS, Brazil

SLIDE 4-14 Flail Chest and Pulmonary Contusion

■■How do I treat patients with a flail chest and/or pulmonary contusion?
■■Emphasize that the treatment goal is to reexpand the lung, e.g., with CPAP (positive
pressure) or physiotherapy, and to avoid progressive atelectasis.
■■Analgesia is an important adjunct, but oversedation will promote hypoventilation and
atelectasis.
 CHAPTER 4 n Slide Guide 5

SLIDE 4-15 Massive Hemothorax

■■ What is the cause? How do I determine the patient has a massive hemothorax?
■■Note that this type of injury results in breathing and circulation problems.
■■Neck veins are usually flat because of volume loss, but may be distended if massive
hemothorax has caused mediastinal shift.

SLIDE 4-16 Cardiac Tamponade

■■ Ensure that the students understand that blunt trauma to the chest can cause cardiac
tamponade, but that most survivors of cardiac tamponade have an anterior or poste-
rior penetrating wound to the chest.
■■ During the discussion about signs and symptoms of patients with cardiac tamponade,
emphasize the fact that not all findings must bepresent.
■■ Explain that cardiac tamponade should be suspected when patients have a penetrating
parasternal wound. Clinical signs may include hypotension and dyspnea, or the patient
may verbalize that he or she senses he or she is dying.

SLIDE 4-17 Resuscitative Thoracotomy: When to Consider

Resuscitative Thoracotomy
■■Patients with a penetrating injury and PEA, especially when loss of signs of life is
recent, are appropriate candidates forresuscitative thoracotomy.
■■ A qualified surgeon must be present at the time of the patient’s arrival to determine
the need for and potential success of an emergency department resuscitative thora-
cotomy.
■■ Once the chest is opened, bleeding must be controlled.

SLIDE 4-18 Thoracic Trauma: Secondary Survey Potentially

Life-threatening Chest Injuries
■■After the students identify the potentially life-threatening chest injuries, ask how these
injuries can threaten life, i.e., what is the pathophysiology associated with each injury?
■■Emphasize that simple pneumothorax and pulmonary contusion are the most common
thoracic injuries.
Subject is continued on thenext slide.
6 CHAPTER 4 n Thoracic Trauma

SLIDE 4-19 Thoracic Trauma: What adjunctive tests are used

during the secondary survey to allow complete
evaluation for potentially life-threatening thoracic
injuries?

SLIDE 4-20 Thoracic Trauma: What adjunctive tests are used

during the secondary survey to allow complete
evaluation for potentially life-threatening thoracic
injuries?
■■Chest x-ray
■■ FAST
■■ ECG
■■Pulse oximetry

SLIDE 4-21 Simple Pneumothorax

■■How do I identify and treata simple pneumothorax?
■■The students should understand that a pneumothorax can occur after blunt or pen-
etrating injury to the chest, although it may not be apparent on physical examination.
■■After describing how to identify and treat this injury, ask about the usefulness of
obtaining a chest x-ray, which can help identify this injury.
■■ Remind students of the need to assess for subcutaneous emphysema.
■■The presence of decreased breath sounds is not always a helpful indicator for a pneu-
mothorax, especially if the patient is hyperventilating from pain or is in shock.
■■The students should know that this injury is treated with tube thoracostomy.

SLIDE 4-22 Tracheobronchial Tree Injury

■■How do I identify and treata tracheobronchial injury?
■■Explain that a strong suspicion of a tracheobronchial injury should be raised if the lung
does not properly inflate after insertion of a chest tube, or if there is a persistent air leak
after chest thoracostomy.
■■The students should indicate that a bronchoscopy may be needed after the patient is
completely assessed, and that tracheobronchial injuries require operative repair.
 CHAPTER 4 n Slide Guide 7

SLIDE 4-23 Pulmonary Contusion

■■ How do I identify and treat a pulmonary contusion?
■■A pulmonary contusion can be mild to severe and may cause very little hypoxia to
severe hypoxia.
■■ The diagnosis can be confirmed by a chest x-ray or a CT scan of the chest.
■■Most pulmonary contusions increase in size and severity after fluid resuscitation.
■■The students should know that treatment includes normovolemia and maneuvers to
maintain lung volumes.

SLIDE 4-24 Hemothorax

■■How do I identify and treat a hemothorax?
■■The students should relate that a hemothorax is suspected in cases of hypotension
without obvious sources of blood loss or when there are decreased breath sounds and
dullness to percussion over ahemithorax.
■■Emphasize that hemothorax is a common source of shock.
■■Hemothorax is confirmed primarily by chest x-ray.
■■The students should relate that initial treatment is tube thoracostomy. Autotransfusion
also may be useful.
X-ray courtesy of Ray McGlone, Royal Lancaster
Infirmary, UK.

SLIDE 4-25 Blunt Cardiac Injury

■■How do I identify and treat a patient with blunt cardiacinjury?
■■Spectrum of injury includes asymptomatic dysrhythmias to cardiogenic shock.
■■The students should relate that blunt cardiac injury is rare.
■■The patient with blunt cardiac injury usually presents with an abnormal ECG within the
first 24 hours of injury.
■■Ask the students about mechanism of injury. They should respond that it results from a
direct blow to the chest and heart that affects the cardiac conductionsystem.
■■Pitfalls include the elderly patient with myocardial ischemia who may already have an
abnormal cardiac rhythm.
■■ Caveat: dysrhythmias that do not compromise blood pressure may not require treatment.

SLIDE 4-26 Traumatic Aortic Disruption

■■How do I identify and treattraumatic aortic disruption?
■■The students should know that a patient who sustained a rapid deceleration or ac-
celeration injury is at risk for an aortic injury.
■■The students also should relate a high index of suspicion for an aortic disruption when
the x-ray shows a widened mediastinum.
■■Surgical consultation is necessary.
■■ Adjuncts to confirm the diagnosis are on the next slide.

X-ray used with permission of Trauma.org, courtesy of

Dr. Hairul Ahmad.
8 CHAPTER 4 n Thoracic Trauma

SLIDE 4-27 Traumatic Aortic Disruption

■■ How do I confirm the diagnosis of an aortic disruption?

SLIDE 4-28 Diaphragmatic Injury

■■How do I identify and treattraumatic diaphragmatic injury?
■■Ask the students about causes of a diaphragmatic injury. They should relate that it
takes a significant transmission of force to rupture thediaphragm.
■■Explain that diaphragmatic rupture is diagnosed with greater frequency on the left side.
■■An elevated diaphragm on the chest x-ray should raise the suspicion for a ruptured
diaphragm.
■■Explain that an elevated hemidiaphragm can be misinterpreted as a hemothorax.
■■ Diaphragmatic rupture requires an operation to repair the injury.
X-ray courtesy of Ray McGlone, Royal Lancaster
Infirmary, UK.

SLIDE 4-29 Fractures and Associated Injuries

■■What associated injuries should I suspect and assess for when my patient has fractures of
the chest wall?
■■Explain that the location of the fracture provides clues about other possible injuries.
■■ The students should understand that it requires a significant force to fracture ribs 1–3.
■■Patients with these fractures commonly have many associated injuries and are at a
higher risk for mortality.
■■Fractures of ribs 4–9 are commonly associated with flail chest, pulmonary contusion,
and pneumothorax.
■■Lower rib fractures are associated with intraabdominal injury.
■■Time permitting, review diaphragmatic excursion and its relationship to intraabdominal
injuries and lower thoracic injuries.

Photograph courtesy of Kimball I. Maull, MD, FACS,
USA.
CHAPTER 4 n Slide Guide 9
SLIDE 4-30 Traumatic Asphyxia
■■What is traumatic asphyxia and how doI manage it?
■■Explain that traumatic asphyxia is commonly associated with the acute, temporary
compression of the superior vena cava.
■■Venous return is impaired from the upper torso and head.
■■Petechiae occur, as well as brain edema.
■■Most cases are mild, with the patient recovering after the weight is removed from the
chest and the head iselevated.
■■Associated injuries must betreated.
■■You may use the photograph to summarize the various signs and symptoms of this
injury. Note the area of plethora that begins just above the nipple line and especially
of the face. The patient’s eyes are bloodshot.
SLIDE 4-31 Esophageal Injury
■■What is esophageal injury and how do I manage it?
■■Explain that esophageal injury is uncommon and difficult to diagnose. Be aware of
unexplained pain and/or shock.
■■Radiographs demonstrate mediastinal air.
■■Signs and symptoms may include mediastinal air, unexplained shock, unexplained left
hemothorax/effusion.
■■Investigations include contrast studies and endoscopy.
■■An early diagnosis is key to the treatment of an esophageal injury, as well as antibiot-
ics and surgery.
SLIDE 4-32 Subcutaneous Emphysema
■■What type of injury should I suspect with this patient, and how do I treatit?
■■The students should suspect subcutaneous emphysema in this patient, which can be a
disturbing visual sign in some patients.
■■This appearance usually indicates an airway injury that may or may not require opera-
tive intervention.
■■A blast injury might be another cause.
■■The first step in confirming the diagnosis is to evaluate a chest x-ray or a CT of the
chest and identify a pneumothorax.
■■If present, insertion of a chest tube is needed to reexpand the lung. Caution the
students about applying an occlusive dressing around the chest tube in this type of
patient to avoid the risk of increasing the patient’s subcutaneous emphysema. If the
lung can be expanded, this finding is self-limited.
10 CHAPTER 4 n Thoracic Trauma

SLIDE 4-33 Pitfalls

■■What pitfalls should I avoid?
■■Application of an occlusive dressing over a wound associated with a simple pneumo-
thorax can produce a tension pneumothorax.
■■Attention to chest tube placement and thorough evacuation of the pleural space is
important to reduce the risk of a retained hemothorax and infectious complication.
■■Adequate pain relief must be achieved to avoid complications from rib fractures.
■■The elderly with comorbidities are at high risk for complications if adequate ventilation
and lung expansion are not maintained.

SLIDE 4-34 Case Scenario

■■Revisit the Case Scenario that was presented at the beginning of the slide set to give
students the opportunity to apply what they’velearned in this lesson.

SLIDE 4-35 Questions

■■Allow for adequate time for additional questions from the students and further discus-
sion before proceeding to the summary slide.

SLIDE 4-36 Summary

■■These summary points relate to the lecture/interactive discussion. Please refer to the
Student Manual for the complete Summary related to this topic.