Thoracic trauma, Rib Fractures, Sternal Fractures, scapular and clavicles fractures, pneumothorax, hemothorax, pulmonary contusion

Question 1

Which are the most common major thoracic injuries?

Answer 1

Rib fractures are the most common major thoracic injuries. Up to 40% of all thoracic trauma
patients present with rib fractures.

Question 2

Which is the most prominent symptom in cases of isolated rib fractures?

Answer 2

in cases of isolated rib fractures, the diagnosis is primarily clinical. The most prominent
symptom is exquisite focal pain exacerbated by deep breathing. Palpating may produce
tenderness or crepitus of the rib fragments.

Question 3

What is the primary therapy for isolated rib fractures?

Answer 3

The primary therapy for isolated rib fractures is pain control in conjunction with aggressive
pulmonary toilet injuries

Question 4

What is the definition of multiple rib fractures?

Answer 4

Fractures of three or more ribs are noted as multiple rib fractures

Question 5

What does flail chest mean?

Answer 5

3 or more rib fractures in 2 or more places causing floating segment

A flail chest is a segment of the chest wall that does not have bony continuity with the rest
of the thoracic cage. The condition usually results from blunt trauma associated with
multiple rib fractures

Question 6

How can you explain the paradoxical movement of the flail segment in thoracic trauma patients with flail chest?

Answer 6

The paradoxical movement of the flail chest segment is caused by negative intrapleural
pressure generated during inspiration. Paradoxical flail segment motion allows to and fro gas.

The severity of this paradoxical motion and the physiological effect is determined by three factors: pleural pressure, the extent of the flail, and the activation of intercostals muscles during inspiration.

Question 7

Which is the classical mechanism of sternal fractures?

Answer 7

The classic mechanism of sternal fractures is a direct impact of the sternum of an
unrestrained driver against the steering column of an automobile in a deceleration crash

Question 8

For which thoracic injury associated with sternal fractures following motor vehicle crashes
must be thought?

aka. what thoracic injury is assocaited with sternal fractures?

Answer 8

Myocardial contusion. It is the most important thoracic injury associated with sternal fractures following motor vehicle crashes. A baseline ECG should be obtained especially in patients over age 40. Patients like this with significant anterior chest trauma will have transient right ventricular dysfunction but need for cardiac monitoring is based upon the associated injuries and underlying cardiac rather than the sternal fracture.

Question 9

What is the usual clinical presentation of sternal fracture?

Answer 9

The clinical manifestations of sternal fractures include anterior chest pain, tenderness, ecchymosis swelling, and a palpable deformity and motion of the fracture fragments upon respiration.

Question 10

. Which are the clinical signs of clavicular fracture?

Answer 10

Clinical signs of clavicular fracture are tenderness crepitus and palpable deformity. The
ipsilateral shoulder may be positioned inferiorly and medially if the fracture is displaced.

Question 11

. Fractures of the scapula are uncommon. Why?

Answer 11

Fractures of the scapula are uncommon due to the location(deep location protected by back muscles) and its structure (plane and thick bone), fractures of the scapula are uncommon.

Question 12

What is the definition of pneumothorax?

Answer 12

Pneumothorax is a collection of air in the pleural space that causes the lung to collapse.
Pneumothorax is classified into 3 types: spontaneous, traumatic and iatrogenic
pneumothorax.

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Question 13

On pathophysiological point of view, traumatic pneumothorax is divided in 3 subtypes.
Which are they? Which is the most severe type?

Answer 13

On pathophysiological point of view, traumatic pneumothorax is divided in simple, open and
tension. Tension pneumothorax is the most severe type.

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Question 14

When does tension pneumothorax develop?

Answer 14

A tension pneumothorax develops when a one way valve air leak occurs, either from the
lung or through the chest wall. Air is forced into the thoracic cavity without any means of
escape completely collapsing the affected lung. The mediastinum gets displaced to the opposite side decreasing venous return and compressing the opposite lung.

Question 15

When does open pneumothorax develop?

Answer 15

Open pneumothorax develops as a result of a large open defect in the chest leading to
equilibration between intrathoracic and atmospheric pressure. Air accumulates in the
hemithorax with each inspiration leading to profound hypoventilation and hypoxia.

Question 16

What is the definition of simple pneumothorax?

Answer 16

Simple pneumothorax is defined as a collection of air trapped in the pleural space.

Question 17

What is the treatment of open pneumothorax during the primary survey?

Answer 17

The treatment of the open pneumothorax during primary survey is aimed at returning
normal ventilation and closing the chest wound. The first step is place an occlusive dressing
over the chest wound to promote normal ventilation. A standard method involves placing a non porous dressing over the wound and taping it on 3 sides. This acts as a one way valve allowing air to escape during expiration but becomes occlusive during inspiration.

Question 18

18. What is the treatment of the tension pneumothorax during primary survey?

Answer 18

Treatment is aimed at decompressing the chest to release the trapped air from the pleural cavity. Convert tension into open pneumothorax and after that try to place a nonporous dressing over the wound and taping it onto 3 sides. This acts as a one way valve allowing air to escape during expiration but becomes occlusive during inspiration.

Question 19

What is the clinical presentation of tension pneumothorax?

Answer 19

The clinical presentation of tension pneumothorax is dramatic. The patient is panicky with tachypnoea, dyspnea, and distended neck veins. Clinical examination can reveal tracheal
deviation , hyper resonance and absent breath sounds over the affected hemithorax.

Question 20

What is the clinical presentation of open pneumothorax?

Answer 20

Clinical examination in patients with open pneumothorax can establish: visible chest wall
defect, dyspnea, tachypnea, cyanosis, asymmetrical chest expansion, hypotonia, decreased
breath sounds on the side of the injury.

Question 21

. Which are the lethal six major injuries in thoracic trauma?

Answer 21

The lethal 6 major injuries in thoracic trauma are: airway obstruction, tension
pneumothorax, cardiac tamponade, open pneumothorax, massive hemothorax, and flail
chest. They are immediate life threatening injuries that require evaluation and treatment
during primary survey.

Question 22

Which are the hidden six major injuries in thoracic trauma?

Answer 22

Which are the hidden six major injuries in thoracic trauma are: thoracic aortic disruption,
tracheobronchial disruption, myocardial contusion, traumatic diaphragmatic tear,
esophageal disruption and pulmonary contusion. They are potentially life threatening
injuries that should be detected during secondary survey.

Question 23

What is the definition of hemothorax?

Answer 23

Hemothorax is the accumulation of blood in the pleural space caused by bleeding from the
chest wall, lung parenchyma or major thoracic vessels. It occurs in roughly 25% of patients
with chest trauma.

Question 24

. What is the typical presentation in patients with hemothorax?

Answer 24

decreased breath sounds unilaterally or bilaterally, dyspnea, tachypnea, and dullness to
percussion over the affected side.

Question 25

What is the definition of massive hemothorax?

Answer 25

Accumulation of greater than 1500mL of blood is considered a massive hemothorax that can
have disastrous results. A massive hemothorax is commonly due to penetrating trauma with
Hilar or systemic vessel disruption. A left sided massive hemothorax is more common than
the right sided one and is typically associated with aortic rupture.

Question 26

There are 5 indications for performing an urgent thoracotomy. Which are they?

Answer 26

❖ 1500mL of blood evacuated after initial chest tube insertion
❖ 200mL/hr for >4 consecutive hours
❖ >150mL/hr for 3 hours for the elderly
❖ Hemodynamically instability systolic blood pressure despite aggressive
blood/volume resuscitation. <80mmHg
❖ At least 2 functioning chest tubes are in place and signs of exsanguination occurs.

Question 27

What is the definition of cardiac tamponade?

Answer 27

Cardiac tamponade is a life threatening, rapid compression of the heart which prevents the heart from beating. It is caused by the accumulation of blood in blood clots compressing and
preventing the heart from filling with blood with each contraction. Constriction of the heart leads to a decrease in cardiac output, perfusion and eventually venous flow. Without
intervention, the heart is unable to fill and pump effectively and cardiac arrest occurs.

Question 28

What is the definition of becks triad?

Answer 28

Becks triad is a complex of three associate symptoms that are classic to the diagnosis of
cardiac tamponade. These signs include: increased central venous pressure (distended neck veins), decline in
arterial pressure and muffled heart tones.

Question 29

What is the ultimate treatment of cardiac tamponade?

Answer 29

The ultimate treatment of tamponade is drainage or removal of blood and clots from the
pericardial sac, preferably by needle paracentesis guided by echocardiography or
computerised tomography. The needle tip would be evident on imaging, which help ensure
safety when penetrating the pericardium. Trauma patients who undergo a
pericardiocentesis will usually require surgical inspection and possible repair of the heart.

Question 30

Except in cardiac tamponade, becks triad may be established in one more major thoracic
injury. Which is this?

Answer 30

Becks triad may be established in tension pneumothorax. Pericardial tamponade needs to be
differentiated from tension pneumothorax

Question 31

What is the definition of myocardial contusion?

Answer 31

Myocardial contusion means trauma to the myocardium, with extravasation of erythrocytes
into the muscle wall, along with necrotic areas of myocardial fibres, myocardial edema,
interstitial and subendocardial haemorrhage

Question 32

What is the most frequent scenario for myocardial contusion?

Answer 32

The most common frequent scenario for myocardial contusion is an unrestrained driver in a
high speed crash, hitting the steering wheel with his chest.

Question 33

Which side of the diaphragm is more prone to injury and why?

Answer 33

The left side of the diaphragm is more prone to injury (65-85%) 1 because it is not protected
by the liver. The left posterolateral portion of the diaphragm is the weakest, and therefore
the most common site of rupture and herniation.

Question 34

What is the definition of pulmonary contusion?

Answer 34

Pulmonary contusion is the bruising of lung tissue resulting from a shock wave of force
through the parenchyma. Diffuse haemorrhage follows as well as interstitial and alveolar
edema causing impairment of gas exchange at the gas tissue interface.

Question 35

. Which is the most common potentially lethal chest injury?

Answer 35

Pulmonary contusion is the most common potentially lethal chest injury.

Question 36

The management of patients who sustain pulmonary contusion is based on 3 factors which
are they?

Answer 36

The management of patients who sustain pulmonary contusions is based on overall stability
of the patient, adequacy of oxygenation and pulmonary mechanics. For patients who do not
need ventilatory support, the following criteria should be met:
❖ PaO2 more than 60 on 50% inspired oxygen
❖ Respiratory rate less than 24bpm
❖ Spontaneous tidal volume more than 5ml/kg
❖ Vital capacity exceeding 10ml/kg

Question 37

Mediastinal and subcutaneous cervical emphysema is an evidence of what kind of injury in thoracic trauma?

Answer 37

Mediastinal and deep cervical emphysema must be seen as evidence of an aero digestive
injury in thoracic trauma.

Question 38

The mortality in oesophageal injuries rises exponentially if treatment is delayed more than
12-24 hours. Why?

Answer 38

The mortality in oesophageal injuries rises exponentially if treatment is delayed more than
12-24 hours due to severe deep neck phlegmona or acute necrotising mediastinitis
developing. The esophagus has no serosal covering and any perforation results in direct
drainage into the mediastinum- rapid development of sepsis