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Mortality associated with thoracic trauma requiring exploration?

Operative mortality of patients requiring emergency thoracotomy:

  • 67% of patients blunt injury
  • 17% of patients with penetrating injury


Overall mortality of thoracic trauma



Extent of the diaphragm

Skin margin:

Anterior: umbilicus and nipple (fourth intercostal space)

posterior: inferior tip of the scapula posteriorly.


The bony landmarks for the diaphragm extend from T8 to L1.

With expiration, the diaphragm rises to the level of the nipple and T5.


Superior margin  of the chest

zone 1 of the neck :

cricothyroid membrane to the sternal notch


Volume which the pleura can accommodate

In the adult, each pleural space can accommodate as much as 3 L of blood. This large volume loss will cause rapid progression to class IV hemorrhagic shock and exsanguination


Volume which the pericardium can accommodate

In contrast, the pericar- dium can only acutely accommodate an additional 100 to 200 mL of blood before venous return and diastolic filling are impaired, causing cardiac tamponade and shock.


Class I hemorrhage - volume of blood loss

Class I:

Blood Volume Loss <15%

Adult blood loss <750 ml


Class II hemorrhage - volume of blood loss

Blood Volume Loss: 15-30%

Adult: 750-1500 ml of blood loss


Class III hemorrhage - volume of blood loss


Blood Volume Loss: 30-40%

Adults: 1500-2000 ml blood loss


Class IV hemorrhage - volume of blood loss




Class I hemorrhage -Characteristics

  • Blood Volume Loss:  % & ml 
  • Cardiovascular: 
  • pH
  • Respiratory
  • Neurologic
  • Skin
  • Delayed Capillary Refill
  • Renal



Blood Volume Loss <15%

Adult blood loss <750 ml


  • Heart Rate normal or mild increase
  • Pulses normal
  • Blood Pressure normal

pH normal

Respiratory: Rate normal

Neurologic: Slightly anxious


  • Warm and pink
  • Capillary Refill brisk (<2 seconds)

Renal: Normal urine output

Adults: >0.5 ml/kg/hour (>30 cc/hour)

Children: >1 ml/kg/hour

Infants <1yo: >2 ml/kg/hour


Class II hemorrhage - Characteristics

  • Blood Volume Loss:% / ml 
  • Cardiovascular
  • pH
  • Respiratory
  • Neurologic
  • Skin
  • Renal


  • Blood Volume Loss: 15-30%
  • Adult: 750-1500 ml of blood loss
  • Cardiovascular
    • Tachycardia
    • Diminished peripheral pulses
    • Blood Pressure normal
  • Normal pH
  • Respiratory
    • Mild Tachypnea
  • Neurologic
    • Irritable
    • Confused
    • Combative
  • Skin
    • Cool extremities
    • Mottling
    • Delayed Capillary Refill
  • Renal
    • Oliguria
    • Increased specific gravity


Class I hemorrhage % volume blood loss

class I 40%


Class IV  Shock: % volume blood loss



Among severely traumatized patients, __of deaths are thought to be secondary to chest trauma.



?% of unrestrained individuals in MVC sustain chest trauma



Initial management of tracheobronchial injury

Intervention will be directed initially toward the pneumo- thorax, as the tracheobronchial injury (TBI) is often not yet suspected. Persistent pneumothorax or air leak after placement of a chest tube should alert the physician to the possibility of a TBI. Insertion of a second chest tube is required in these cases. TBI must be suspected if a patient deteriorates rapidly following endotracheal intubation. Because of positive pressure ventilation and loss of negative intrathoracic pressure on inspiration, air leak is increased, followed by increasing difficulties with oxygenation and ventilation.


Anatomy of most tracheobronchial injuries

most within 2 cm of the carina most within the right mainstream bronchus followed by lower trachea


Tension Pneumothorax presentation (two ways)

  • An awake patient:
    • Able to mount a compensatory response increasing his respiratory rate, tidal volume, negative inspiratory pressure, and chest expansion. --> The physiologic insult: primarily hypoxic with progressive respiratory decompensation; hypotension is the terminal event of hypoxic cardiac failure or respiratory arrest.
  • Sedated and ventilated patients:
    •  cannot compensate, and show a greater degree of impeded venous return from both the intrapleural pressure and the PPV. The deterioration is much more rapid, resulting in more rapid cardiogenic shock once the central venous pressure equals the intrapleural pressure, and causing complete obstruction of venous return.


how often is a classic tension ptx seen in an awake vs intubated patient

TPTX show that tracheal devi- ation, oxygen desaturation, and hypotension are actually INCONSISTENT findings in (awake) spontaneously ventilating patients (


warning signs of tension ptx on ventilated patient

PPV who suddenly deteriorates with falling SaO2, rapidly becomes hypotensive without a clear reason, becomes difficult to bag, or shows raised peak inspiratory pressures on a ventilator


Indications for immediate needle decompression

1. Traumatic arrest 2. Loss of blood pressure or pulse during resuscitation 3. Increased difficulty to bag/raising peak ventilatory pressures combined with hypotension 4. Hypotension or hypoxia/respiratory distress with decreased/absent breath sounds on one side or palpable subcutaneous emphysema.


% of lung contusion which requires mech ventilation



Rib fractures consistent with lower abdominal injuries



How much blood need be in the chest to see on cxr



comparison of sensitivity of E-Fast and cxr in showing blood in the pleurae

Many CXRs done in trauma are performed on the supine patient,--> portable CXR on a supine patient has a sensitivity of 40% to 60% in ruling out hemothorax. E-FAST can identify as little as 20 mL of fluid in the pleural cavity, and has shown sensitivities of greater than 96% in detecting hemothorax.


Massive hemothorax

A massive hemothorax is defined as the presence of 1500 mL or more of blood in the thoracic cavity, and is the classic indication to proceed with an urgent thoracotomy.


The most common complication after pericardiotomy for trauma is

postpericardiotomy syndrome.


___% of caustic injections occur in children __ years old

80% of caustic ingestion occurs in children


how long until the caustic effects of a swallowed battery

Severe injury results within 1 hour of ingestion from the extravasation of highly toxic potassium or sodium hydroxide contained in the battery


important difference in accidental ingestions vs suicide attempts

volume - accidental are significantly less


factors which determine the severity of the effect of a caustic ingestion

1. pH of the ingested substance 2. Whether the substance is solid or liquid 3. Duration of exposure 4. Quantity ingested


Anatomically, where in the esophagus are caustic injuries the most severe

at areas of the greatest narrowing, with the greatest narrowing


time course of esophageal injury to the esophagus

However in the ensuing 24 to 48 hours the damaged layers begin to degenerate and become infi ltrated with lymphocytes. Angiogenesis and migration of fi broblasts begin between the second and fourth day after injury. By 1 week, the necrotic tissue has sloughed off and ingrowth of granulation tissue begins. The wound is clearly demarcated by this time, and the risk of perforation is probably the highest owing to the low tensile strength of the collagen deposited in the wound.


Gastric lavage with corrosive injury to esophagus

Gastric lavage is also contraindicated, owing to the risk of esophageal perforation and aspiration of gastric contents.


First degree mucosal injury to esophagus - depth



First degree mucosal injury to esophagus - endoscopic appearance

Mucosal hyperemia and edema


Second degree mucosal injury to esophagus - depth

Transmucosal, with or without involvement of muscularis.


Second degree mucosal injury to esophagus - endoscopic appearance

Hemorrhagic, exudative, ulcerative pseudomembranes


Third degree esophageal injury - depth

Full-thickness injury with extension into periesophageal Complete obliteration of esophageal lumen by massive tissue. May involve mediastinal or intraperitoneal organs.


when should endoscopy be fist performed after caustic ingestion

early because the risk of rupture increases at 24 to 72 hours


Steps to address  potential sytemic air embolization? 


(1)Ventilation :
(a)Positive pressure ventilation should be avoided if possible.
(b)If intubation and assisted breathing is required, pressures should be minimal.
  1. Vigorous hyperventilation is not desirable.
  2.  Selective lung ventilation with a double-lumen tube or endobronchial blocker can exclude the damaged lung.-->
(c)stopping ongoing gas entrainment.
(d)Cross-contamination of the other lung by blood is also arrested.
(2)Oxygenation & Gas
  1. 100% oxygen administration is good, irregardless of measured oxygen saturation.
  2. Room air (80% nitrogen) is essentially insoluble in blood.
  3. Intravascular oxygen bubbles will resolve much faster than air emboli.
(b) Nitrous oxide:
  1. increases bubble sizeà should be avoided
(3)Intravascular Volume Status
(a)should be kept generous within limits
(b)volume depletion enhances the pressure gradient from airway to pulmonary veins, potentially worsening this complication.
(4)If Hemotypsis is present:
(a)prompt bronchoscopy may exclude large airway injury.
(a)Emergency thoracotomy with mass hilar clamping may be necessary if:
  1.  cardiac tamponade cannot be excluded
  2. lung bleeding continues.
(b)Intracoronary Air
  1. should lead to Trendelenberg positioning
  2. aspiration of air from the left ventricular apex.
  3.  Institution of cardiopulmonary bypass has also been advocated..
(c) Hyperbaric therapy?
  1. After hemodynamics have been stabilized hyperbaric therapy may be of benefit if cerebral air embolism has occured.

Emergency thoracotomy - steps if intracoronary air is seen? 

  • Intracoronary Air
  • should lead to Trendelenberg positioning
  • aspiration of air from the left ventricular apex.
  •  Institution of cardiopulmonary bypass has also been advocated..