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girdle away from the thorax. The muscular, vascular, and nervous
components of the shoulder and arm are severely compromised.
Physical findings include significant hematoma formation and edema
in the shoulder area. Neurologic deficits include loss of sensation and
motor function distal to the shoulder. Pulses in the arm are typically
decreased or lost due to axillary artery thrombosis. No specific medical
therapy has been developed for this devastating injury. Surgery is
rarely indicated early in the course of this injury. If the affected limb
retains sufficient neurovascular integrity and function, operative fixation
may be indicated to restore shoulder stability. Many scapulothoracic
dissociations result in a flail limb that is insensate or is associated with
severe pain due to proximal brachial plexus injury. An above-the-elbow
amputation may be the best approach for these patients.
IX. Chest wall defects
The management of large, open chest wall defects initially requires
irrigation and debridement of devitalized tissue to avoid progression
into a necrotizing wound infection. Once the infection is under control,
subsequent treatment depends on the severity and level of defect.
Reconstructive options range from skin grafting to well vascularized
flaps to a variety of meshes with or without methylmethacrylate. The
choice of reconstruction depends upon the depth of the defect.
X. Traumatic asphyxia
This curious clinical constellation is the result of thoracic injury due to
a strong crushing mechanism, as might occur when an individual is
pinned under a very heavy object. Some effects of the injury are
compounded if the glottis is closed during application of the crushing
force. Patients present with cyanosis of the head and neck,
subconjunctival hemorrhage, periorbital ecchymosis, and petechiae of
the head and neck. The face frequently appears very edematous or
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moonlike. Epistaxis and hemotympanum may be present. A history of
loss of consciousness, seizures, or blindness may be elicited. Neurologic
sequelae are usually transient. Recognition of this syndrome should
prompt a search for associated thoracic and abdominal injuries. The
head of the patient's bed should be elevated to approximately 30° to
decrease transmission of pressure to the head. Adequate airway and
ventilatory status must be assured, and the patient is given supplemental
oxygen. Serial neurological examinations are performed while the
patient is monitored in an intensive care setting. No specific surgical
therapy is indicated for traumatic asphyxia. Associated injuries to the
torso and head frequently require surgical intervention.
XI. Blunt diaphragmatic injuries
Diaphragmatic injuries are relatively uncommon. Blunt mechanisms,
usually a result of high-speed MVAs, cause approximately 33% of
diaphragmatic injuries. Most diaphragmatic injuries recognized
clinically involve the left side, although autopsy and CT scan–based
investigations suggest a roughly equal incidence for both sides. This
injury should be considered in patients who sustain a blow to the
abdomen and present with dyspnea or respiratory distress. Because of
the very high incidence of associated injuries, e.g., major splenic or
hepatic trauma, it is not unusual for these patients to present with
hypovolemic shock. Most diaphragmatic injuries are diagnosed
incidentally at the time of laparotomy or thoracotomy for associated
intra-abdominal or intrathoracic injuries. Initial chest radiographs are
normal. Findings suggestive of diaphragmatic disruption on chest
radiographs may include abnormal location of the nasogastric tube in
the chest, ipsilateral hemidiaphragm elevation, or abdominal visceral
herniation into the chest. In a patient with multiple injuries, CT scan is
not very accurate, and MRI is not very realistic. Bedside emergency
ultrasonography is gaining popularity and could be helpful, and case
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reports in the literature have supported its use in the evaluation of
diaphragm. Diagnostic laparoscopy and thoracoscopy have also been
reported to be successful in the identification of diaphragmatic injury.
A confirmed diagnosis or the suggestion of blunt diaphragmatic injury
is an indication for surgery. Blunt diaphragmatic injuries typically
produce large tears measuring 5-10 cm or longer. Most injuries are
best approached via laparotomy. An abdominal approach facilitates
exposure of the injury and allows exploration for associated abdominal
organ injuries. The exception to this rule is a posterolateral injury of
the right hemidiaphragm. This injury is best approached through the
chest because the liver obscures the abdominal approach. Most injuries
can be repaired primarily with a continuous or interrupted braided
suture (1-0 or larger). Centrally located injuries are most easily repaired.
Lateral injuries near the chest wall may require reattachment of the
diaphragm to the chest wall by encirclement of the ribs with suture
during the repair. Synthetic mesh made of polypropylene or Dacron is
occasionally needed to repair large defects.
Left Diaphragmatic hernia with left colon in chest cavity.
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Blunt Injuries of the Pleurae, Lungs, and Aerodigestive Tracts
Pneumothorax
Pneumothoraces in blunt thoracic trauma are most frequently caused
when a fractured rib penetrates the lung parenchyma. This is not
absolute. Pneumothoraces can result from deceleration or barotrauma
to the lung without associated rib fractures. Patients report inspiratory
pain or dyspnea and pain at the sites of the rib fractures. Physical
examination demonstrates decreased breath sounds and hyperresonance
to percussion over the affected hemithorax. In practice, many patients
with traumatic pneumothoraces also have some element of hemorrhage,
producing a hemopneumothorax. Patients with pneumothoraces require
pain control and pulmonary toilet. All patients with pneumothoraces
due to trauma need a tube thoracostomy. The chest tube is connected
to a collection system (eg, Pleur-evac) that is entrained to suction at a
pressure of approximately -20 cm water. The tube continues suctioning
until no air leak is detected. The tube is then disconnected from
suction and placed to water seal. If the lung remains fully expanded,
the chest tube may be removed and another chest radiograph obtained
to ensure continued complete lung expansion.
Pneumothorax left side.
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Hemothorax
The accumulation of blood within the pleural space can be due to
bleeding from the chest wall (eg, lacerations of the intercostal or
internal mammary vessels attributable to fractures of chest wall
elements) or to hemorrhage from the lung parenchyma or major thoracic
vessels. Patients report pain and dyspnea. Physical examination findings
vary with the extent of the hemothorax. Most hemothoraces are
associated with a decrease in breath sounds and dullness to percussion
over the affected area. Massive hemothoraces due to major vascular
injuries manifest with the aforementioned physical findings and varying
degrees of hemodynamic instability.
Hemothoraces are evacuated using tube thoracostomy. Multiple chest
tubes may be required. Pain control and aggressive pulmonary toilet
are provided. The chest tube output is monitored closely because
indications for surgery can be based on the initial and cumulative
hourly chest tube drainage. This is because massive initial output and
continued high hourly output are frequently associated with thoracic
vascular injuries that require surgical intervention. Large, clotted
hemothoraces may require an operation for evacuation to allow full
expansion of the lung and to avoid the development of other
complications such as fibrothorax and empyema. Thoracoscopic
approaches have been used successfully in the management of this
problem.
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Pneumothorax left chest cavity
Open pneumothorax
This injury is more commonly caused by penetrating mechanisms but
may rarely occur with blunt thoracic trauma. Patients are typically in
respiratory distress due to collapse of the lung on the affected side.
Physical examination should reveal a chest wall defect that is larger
than the cross-sectional area of the larynx. The affected hemithorax
demonstrates a significant-to-complete loss of breath sounds. The
increased intrathoracic pressure can shift the contents of the mediastinum
to the opposite side, decreasing the return of blood to the heart,
potentially leading to hemodynamic instability.
Treatment for an open pneumothorax consists of placing a 3-way
occlusive dressing over the wound to preclude the continued ingress
of air into the hemithorax and to allow egress of air from the chest cavity.
A tube thoracostomy is then performed. Pain control and pulmonary
toilet measures are applied.
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Tube-drainage of left chest cavity.
After initial stabilization, most patients with open pneumothoraces
and loss of chest wall integrity undergo operative wound debridement
and closure. Those with loss of large chest wall segments may need
reconstruction and closure with prosthetic devices such as
polytetrafluoroethylene patches. Patch placement can serve as
definitive therapy or as a bridge to formal closure with rotational or
free tissue flaps. With low chest wall injuries, some authors describe
detaching the diaphragm, with operative reattachment at a higher
intrathoracic level. This converts the open chest wound into an open
abdominal wound, which is easier to manage. Traumatic pulmonary
herniation through the ribs, though uncommon, may occur following
chest trauma. Unless incarceration or infarction is evident, immediate
repair is not indicated.
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Tension pneumothorax
The mechanisms that produce tension pneumothoraces are the same as
those that produce simple pneumothoraces. However, with a tension
pneumothorax, air continues to leak from an underlying pulmonary
parenchymal injury, increasing pressure within the affected hemithorax.
Patients are typically in respiratory distress. Breath sounds are severely
diminished to absent, and the hemithorax is hyperresonant to percussion.
The trachea is deviated away from the side of the injury. The mediastinal
contents are shifted away from the affected side. This results in decreased
venous return of blood to the heart. The patient exhibits signs of
hemodynamic instability, such as hypotension, which can rapidly
progress to complete cardiovascular collapse. Immediate therapy for
this life-threatening condition includes decompression of the affected
hemithorax by needle thoracostomy. A large-bore needle (ie, 14- to 16gauge) is inserted through the second intercostal space in the
midclavicular line. A tube thoracostomy is then performed. Pain control
and pulmonary toilet are instituted.
Pulmonary contusion and other parenchymal injuries
The forces associated with blunt thoracic trauma can be transmitted to
the lung parenchyma. This results in pulmonary contusion, as
characterized by development of pulmonary infiltrates with hemorrhage
into the lung tissue. Clinical findings in pulmonary contusion depend
on the extent of the injury. Patients present with varying degrees of
respiratory difficulty. Physical examination demonstrates decreased
breath sounds over the affected area. Other parenchymal injuries (eg,
lacerations) can be produced by fractured ribs and, rarely, by deceleration
mechanisms.
Pain control, pulmonary toilet, and supplemental oxygen are the primary
therapies for pulmonary contusions and other parenchymal injuries. If
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the injury involves a large amount of parenchyma, significant pulmonary
shunting and dead space ventilation may develop, necessitating
endotracheal intubation and mechanical ventilation. Laceration or
avulsion injuries that cause massive hemothoraces or prolonged high
rates of bloody chest tube output may require thoracotomy for surgical
control of bleeding vessels. If central bleeding is identified during
thoracotomy, hilar control is gained first. Once the extent of injury is
confirmed, it may become necessary to perform a pneumonectomy,
keeping in mind that trauma pneumonectomy is generally associated
with a high mortality rate (>50%).
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Pediatric Trauma
Trauma is the leading cause of paediatric mortality in the industrialized
countries and it is responsible for about 40% of deaths in children
under 15 years of age. It far outweighs any other cause of death in
children. The traumatic injuries of children are most frequently
associated with falls, followed by sports injuries and motor vehicle
related injuries. The leading cause of death in 0-15 years old children
was motor vehicles traumas (31%), followed by drownings (13%) and
burns (12.5%). Motor vehicle crashes (RTAs) are responsible for 7.2
deaths per 100 000 while drownings cause 2.8 deaths per 100 000,
pedestrian injuries 2.4 deaths per 100 000, fires 2.3 deaths per 100
000, and homicide (mostly child abuse) cause 1.9 deaths per 100000.
The rate of each type of injury changes with different age ranges. The
rate of drowning deaths in under 5-years-olds is twice that of 5-10
years-olds or 11-14-years-olds. Pedestrian injury death rates are
almost twice as high in both under 5 years old and 5-10 years old
children than they are in 11-14 years old children.
Fire deaths (burns and smoke inhalation) at 5.2 per 100000 in under 5
years old children, are two times the rate for older children. These
different rates of death are a reflection of the activities of the children
at different ages, the physiological adaptability of the child to injury
and the type of the sustained injury.
Mortality differs by mechanism, location and severity of injury, as well
as by age and sex. Motor vehicle crashes were the most frequent cause
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