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Questions and Answers
The pediatric thorax is more susceptible to fractures due to calcification and osteoporosis.
False
Acceleration-deceleration injuries can cause shearing, tearing, and traction forces on fixed structures such as the aorta.
True
Flail chest is a type of open pneumothorax.
False
Traumatic rib fractures are often associated with lung contusion.
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Sternal fractures are common and occur in up to 50% of chest trauma cases.
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Tracheobronchial tree injuries require immediate surgical intervention in case of unstable airway.
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Haemothorax is always associated with a flail chest.
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Primary repair is a management option for tracheobronchial injuries.
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The primary survey in the initial evaluation of chest trauma involves a detailed physical examination.
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Foreign bodies in the airway are always chronic.
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The goal of the initial evaluation of chest trauma is to identify and manage all injuries, including non-life-threatening ones.
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Cervical esophageal injuries are the most common type of esophageal injuries.
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A chest X-ray is not a useful investigation for esophageal injuries.
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Diaphragmatic injuries are always diagnosed immediately.
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Blunt cardiac injuries always result in rupture of the myocardium.
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All esophageal injuries require immediate surgical repair.
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Tracheobronchial injuries can be managed with lung resection.
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Foreign bodies in the esophagus are always chronic.
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The mortality rate of blunt aortic injuries is 50% within 6 hours.
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Myocardial contusion is reported in 40% of autopsy series of patients with BCI.
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Elective surgery is preferred for myocardial rupture.
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The most common site of blunt aortic injuries is the aortic arch.
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A widened mediastinum is a radiographic feature associated with thoracic aortic injury.
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Endovascular stents are a type of open surgical procedure for blunt aortic injuries.
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Tricuspid valve repair is recommended for penetrating cardiac injuries.
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Aortic disruption is typically managed with conservative therapy.
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Study Notes
Tracheobronchial Tree Injuries
- Conservative treatment for tracheobronchial tree injuries
- Surgical approach based on location and extension of injury
- Cervical collar incision for proximal trachea
- Right postero-lateral thoracotomy for lower trachea, carina, right main bronchus (RMB), and proximal left main bronchus (LMB)
- Left postero-lateral thoracotomy for distal LMB
- Management options: primary repair, sleeve resection, lung resection
Foreign Body in the Airway
- Management of foreign body in the airway:
- Acute: urgent bronchoscopy with or without bronchotomy
- Chronic: bronchoscopy with precaution, with or without lung resection
Esophagus Injuries
- Esophagus injuries are rare, often caused by blunt trauma or penetrating injuries (stab or trans-mediastinal gunshot)
- Cervical esophageal injuries are most common
- Clinical features:
- Pneumothorax (left)
- Haemothorax without rib fractures
- Lower sternum or epigastric pain (severe blunt trauma)
- Particulate matter in the ICD
- Penetrating injury that has crossed mediastinum
- Odynophagia
- Dysphagia
- Surgical emphysema
- Mediastinitis
- Investigations: combination of clinical suspicion, CXR, water-soluble contrast swallow, and oesophagoscopy
- Management:
- Timing: 24 hours, debride and drainage, surgical repair or resection with delayed reconstruction
- Approach: via right posterolateral thoracotomy (RPLT) for upper esophagus, or left posterolateral thoracotomy (LPLT) for lower esophagus
- Complications: mediastinal contamination, abscess formation, empyema thoracis
Foreign Body in the Esophagus
- Types of foreign bodies: bone, meat, battery, coin
- Clinical presentation:
- Acute: dysphagia, choking, hematemesis
- Chronic: hemoptysis, coughing when feeding
- Management: oesophagoscopy with or without mediastinal drainage and repair
Diaphragmatic Injuries
- Often occult, easily missed, and commonly detected on the left side
- Marker of severe thoracoabdominal trauma
- Causes: blunt, penetrating (stab or iatrogenic-ICD)
- Clinical features:
- With or without signs of bowel obstruction, drainage of peritoneal content via chest drain
- NGT in the chest (CXR)
- Herniation of GIT
- Acute, delayed, and common on the left side
- Investigations: CXR (elevated hemidiaphragm, haemo-pneumo), swallow and follow-through, contrast-enhanced CT scan
- Management: surgical repair via thoracotomy, thoraco-abdominal incision, or laparotomy, laparoscopy
Cardiac Injuries
- Penetrating and blunt cardiac injuries
- Blunt cardiac injuries (BCI):
- Pathology: patchy areas of muscle necrosis, hemorrhagic infiltrate, rupture of small vessels, hemorrhage into interstitium and around muscle fibers
- R.Madansein, Department of Cardiothoracic Surgery, UKZN
- Frequency of Injury: 20-25% of thoracic deaths worldwide
- Male vs female, age, blunt, penetrating, and transfixing mechanisms
Thoracic Trauma
- Thoracic injury accounts for 20-25% of thoracic deaths worldwide
- Mechanism of injury:
- Penetrating: high velocity (gunshots), low velocity (stab wounds)
- Blunt: direct (assault and blast), indirect (falls, MVA - acceleration-deceleration injuries, crush injuries, and shearing forces)
- Transfixing
- Special factors: pediatric thorax (more cartilage, absorbs forces), geriatric thorax (calcification and osteoporosis, more fractures)
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Description
This quiz covers the management of tracheobronchial tree injuries, including conservative and surgical approaches based on location and extension.
