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MINISTRY OF HEALTHCARE OF UKRAINE
DANYLO HALYTSKY LVIV NATIONAL MEDICAL UNIVERSITY
SURGICAL DEPARTMENT #1
THORACIC TRAUMA
Guidelines for Medical Students
LVIV – 2019
Approved at the meeting of the surgical methodological commission of Danylo
Halytsky Lviv National Medical University (Meeting report № ___ of _____________
___2019)
Guidelines prepared:
LUKAVETSKYJ Oleksij Vasylovych – PhD, professor, chief of Surgical
Department #1 at Danylo Halytsky Lviv National Medical University
VARYVODA Eugene Stepanovych − PhD, associate professor of Surgical
Department #1 at Danylo Halytsky Lviv National Medical University
CHEMERYS Orest Myroslavovych – PhD, assistant professor of Surgical
Department #1 at Danylo Halytsky Lviv National Medical University
STOYANOVSKY Igor Volodymyrovych – PhD, associate professor of Surgical
Department #1 at Danylo Halytsky Lviv National Medical University
Referees:
Responsible for the issue first vice-rector on educational and pedagogical affairs at
Danylo Halytsky Lviv National Medical University, corresponding member of
National Academy of Medical Sciences of Ukraine, PhD, professor M.R. Gzegotsky
I. Background
About 15% of war injuries involve the torso. Those injuries involving the
vasculature of the mediastinum (heart, great vessels, and pulmonary hilum) are
generally fatal on the battlefield. Injuries of the lung parenchyma (the vast majority)
can be managed by the insertion of a chest tube and basic wound treatment. Although
penetrating injuries are most common, blunt chest trauma may occur and can result in
disruption of the contents of the thorax, as well as injury to the chest wall itself. Blast
injuries can result in the rupture of air-filled structures (the lung), as well as penetrating
injuries from fragments.
The protection afforded by body armor greatly reduces the incidence of thoracic
injuries, compared with extremity or head/neck injuries. Unfortunately, not all
individuals have such protection; some tactical situations limit the use of body armor
and some sustain chest injuries despite protection. In addition, military surgeons
routinely treat injured civilians.
II. Learning Objectives
1. To study the etiological factors of thoracic trauma, classification, clinical
signs, diagnostic methods, treatment and complications (α = I).
2. To know the main causes of the thiracic injury, typical clinical course and
complications, diagnostic value of laboratory and instrumental methods of examination
and the principles of the modern conservative and surgical treatment (α = II).
3. To be able to collect and analyze the complaints and disease history,
thoroughly perform physical examination, determine the order of the most informative
examination methods and perform their interpretation, establish clinical diagnosis,
justify the indications for surgery, choose adequate method of surgical intervention
(α = III).
4. To develop creativity in solving complicated clinical tasks in patients with
atypical clinical course or complications of thoracic trauma (α = ІV).
III. Purpose of personality development
Development of professional skills of the future specialist, study of ethical and
deontological aspects of physicians job, regarding communication with patients and
colleagues, development of a sense of responsibility for independent decision making.
To know modern methods of treatment of patients with thoracic trauma and its
complications.
IV. Interdisciplinary integration
Subject To know To be able
Previous subjects
1. Anatomy and
Physiology
Anatomical structure,
blood supply, innervation
of the organs of thoracic
cavity
Determine the topographic
location of thoracic unjuries
V. Content of the topic and its structuring
Anatomical Considerations
Superior border is at the level of the clavicles anteriorly and the junction of the
C7 – Th1 vertebral bodies posteriorly. The thoracic inlet at that level contains major
arteries (common carotids and vertebrals), veins (anterior and internal jugulars),
trachea, esophagus, and spinal cord.
Within or traversing the container of the chest itself are the heart and coronary
vessels, the great vessels - including arteries (aortic arch, innominate, right subclavian,
common carotid, left subclavian, and descending aorta), veins (superior and inferior
vena cava, azygous vein, and brachiocephalic vein), and pulmonary arteries and veins
- distal trachea, and main stem bronchi, lungs, and esophagus.
The inferior border is described by the diaphragm, attached anteriorly at the Th6
level and gradually sloping posteriorly to the Th12 level.
Physiology of Breathing At its simplest the respiratory system is composed of three main components:
• a membrane across which gas exchange takes place,
2. Pathomorphology
and Pathophysiology
Etiological factors of
disease
Describe macroscopic
changes of thorax and
identify morphological forms
3. Propedeutics of
internal diseases
Sequence of patient’s
survey and physical
examination of the injured
patients
Determine the patients
complaints, medical history
of the disease, perform
primary wound debridement
4. Pharmacology Groups and
representatives of
antibiotics, analgesics,
antiinflammatory drugs,
colloid and crystalloid
solutions
Prescribe conservative
treatment of patient with
thoracic trauma
5. Radiology Efficiency of radiological
investigation in patients
with thoracic trauma
Indications and descrition of
x-ray, ultrasound, CT scan
examination
Future subjects
Anesthesiology and
Critical Care
Medicine
Clinical signs urgent
conditions that occur in
patients with
complications of thoracic
injuries, methods of
diagnosis and
pharmacotherapy
Determine the symptoms of
urgent conditions, differential
diagnosis and treatment
• a bellows mechanism to move gases to and from the membrane,
• and a control mechanism that drives the process while monitoring and making
adjustments.
We will consider each component in turn. Trauma patients may suffer
compromise at all three levels.
The control mechanism Breathing is automatic and subconscious with a conscious over-ride control
mechanism. The automatic control center (central pattern generator) is located in the
medulla oblongata of the brain stem and is the primary source of automatic respiratory
rhythm determining rate and depth of breathing. At rest the pacemaker cells discharge
every 5 seconds giving a resting breathing rhythm of approximately 12 breaths per
minute. The brain stem automatic control center has inspiratory and expiratory neurons
and receives input from chemoreceptors (CO2, O2, pH etc), mechanoreceptors (in the
ventilatory tissues), nociceptors, pathways that integrate breathing with other
physiologic processes (such as swallowing), and from higher centers with behavioral
and volitional activity (e.g. speech and breath-holding). Although the higher centers
have neurons providing input to the automatic control center they are not dependent
upon the automatic control center for their effect on breathing. Sensory receptor
information from within the lungs is conveyed to the brain in the vagus nerve. The
pacemaker cells have, amongst other receptors, opioid mu-receptors on their surface.
The effective neurologic output of the control mechanism is via the peripheral
nerves to:
• the muscles of ventilation
‣ diaphragm
‣ intercostals
• accessory muscles of ventilation:
• those affecting patency of the airways:
‣ oro-facial
‣ larynx
‣ pharynx
• and those attaching upon and affecting the chest wall:
‣ sternocleidomastoid
‣ pectorals
‣ abdominal wall muscles, etc.
Diagnosis and Management: Knowledge of the mechanism of injury (eg, blast, fragment, among others) may
increase the index of suspicion for a particular injury. A complete and accurate
diagnosis is usually not possible because of the limited diagnostic tools available in the
setting of combat trauma. Nonetheless, because injuries to the chest can profoundly
affect breathing and circulation (and, on rare occasion, the airway), a complete and
rapid assessment of each injury is mandatory.
- If the casualty is able to talk without hoarseness or stridor, there is reasonable
assurance that the airway is intact.
Primary assessment The purpose of the primary survey is rapid targeted assessment of the airway,
breathing, and circulation to identify those injuries that MUST be corrected
immediately to prevent rapid death.
The conditions to look for during rapid and systematic primary survey are:
• tension pneumothorax
• open pneumothorax
• flail chest
• massive haemothorax
• cardiac tamponade
The airway (with C-spine control), breathing and circulation are assessed with
the patient usually in a supine position (unless airway management mandates an erect
posture) and adequate exposure. Control of the examination environment is necessary
to prevent undue cooling of the patient and to preserve dignity.
Airway assessment and management has been addressed in previous chapters.
Breathing and chest examination follows a rapid and clinically fluid progression
through inspection, palpation, percussion and auscultation.
Secondary survey Conditions to think about during the secondary survey are:
• lung contusion
• cardiac contusion
• rib fractures and flail segment
• blunt aortic injury
• oesophageal injury
• diaphragmatic rupture
During a more methodical examination of the respiratory system consider what
may be found and be recorded with:
Inspection:
• signs of cyanosis?
• depth and rate of breathing?
• use of accessory muscles?
• tracheal tugging?
• dilated neck veins?
• obvious wounds?
- penetration points
- open fractures
- abrasions, bruising associated with deceleration injury / blunt trauma
• don‟t forget the posterior chest
Palpation:
• tracheal position - is it deviated to one side?
• chest wall deformity?
• normal chest wall excursion?
• asymmetric chest wall movement?
• flail chest segment?
• crepitus from rib fractures?
Percussion:
• resonant - is it normal?
• hyper-resonant - is there a pneumothorax?
• dull to percussion - is there haemothorax? or collapse? is it too early for
dullness from lung contusion or consolidation?
• do percussion notes change with altered posture from supine to erect?
Auscultation:
• Are breath sounds present and normal?
• Are breath sounds present throughout both lung fields?
Pulse-oximetry and chest x-ray (CXR) are adjuncts to your assessment; therefore
do not wait for their availability before starting your assessment. Act to treat what you
find that is of immediate threat to the patient.
Life-Threatening Injuries
Injuries requiring urgent intervention, include tension pneumothorax, massive
hemothorax, and cardiac tamponade.
1. Tension pneumothorax. A patient with a known chest injury presenting with an open airway and difficulty
breathing has a tension pneumothorax until proven otherwise. It requires rapid
decompression and the insertion of a chest tube. Needle decompression alone is
insufficient.
2. Massive hemothorax. The return of blood on chest tube placement may indicate a significant intrathoracic
injury. Generally, the immediate return of 1,500 cc of blood mandates thoracotomy.
When initial blood loss is <1,500 mL, but bleeding continues such that ongoing blood
transfusions are required and all other sources of hemorrhage are eliminated, then
thoracotomy may be indicated. Needle decompression will not identify hemothorax.
3. Cardiac tamponade. - Distended neck veins (may be absent with significant blood loss) in the presence of
clear breath sounds and hypotension indicate the possibility of life-threatening cardiac
tamponade.
- Fluid resuscitation may temporarily stabilize a patient in tamponade.
Perform an ultrasound if time permits.
If positive, proceed to the OR (pericardial window, sternotomy, thoracotomy). Any
pericardial blood mandates median sternotomy/thoracotomy.
A negative ultrasound requires either repeat ultrasound or pericardial window,
depending on the level of clinical suspicion.
Pericardiocentesis is only a stopgap measure on the way to definitive surgical repair.
Open pneumothorax (hole in chest wall) is treated by placing a chest tube through
a separate incision and sealing the hole. Alternatives include one-way valve chest
dressings or a square piece of plastic dressing taped to the chest on three sides as a
“flap valve.”
Flail chest (entire segment of the chest wall floating due to fractures of a block of
ribs, with two fractures on each rib) is commonly associated with pulmonary contusion
under the flail segment. Patients with flail chest should be monitored closely for
respiratory distress. Pain control is essential and may require intercostal nerve blocks
or epidural catheters to optimize pulmonary mechanics. Patients with evidence of
respiratory distress, poor or marginal oxygenation, or ventilation should be intubated
and mechanically ventilated prior to air evacuation.
Surgical Management
Most penetrating chest injuries reaching medical attention are adequately treated
with tube thoracostomy (chest tube) alone.
Tube Thoracostomy (Chest Tube)
Indications.
- Known or suspected tension pneumothorax.
- Pneumothorax (including open).
- Hemothorax.
How to make procedure:
- In cases of tension pneumothorax, immediate decompression with a large bore
needle may be lifesaving. An IV catheter (14 gauge, 3.25 inches in length) is inserted
in the midclavicular line in the second interspace (approximately 2 fingerbreadths
below the clavicle on the adult male). Do not place medial to the nipple to avoid
cardiac or vascular injury. Entry is confirmed by the sound of air passing through
the catheter, if a pneumothorax was actually present. This must be rapidly followed
by the insertion of a chest tube.
- In a contaminated environment, a single gram of IV Cefazolin (ANCEF) is
recommended.
-If time allows, prep the anterior and lateral chest on the affected side with
povidone-iodine.
- Identify the incision site along the anterior axillary line, intersecting the 5th or 6th
rib. This is at nipple level in males and at the inframammary crease in females.
- Inject a local anesthetic in the awake patient, if conditions allow.
- Make a transverse incision, 3-4 cm in length, along and centered over the rib,
carrying it down to the bone.
- Insert a curved clamp in the incision, directed over the top of the rib, and push into
the chest through the pleura. A distinct pop is encountered when entering the chest, and
a moderate amount of force is necessary to achieve this entry. A rush of air out of the
chest will confirm a tension pneumothorax. Insertion depth of the tip of the clamp
should be limited by the surgeon’s hand to only 3 or 4 cm to make sure that the clamp
does not travel deeper into the chest, resulting in damage to underlying structures.
- Spread the clamp gently and remove. The operator’s finger is then inserted to
confirm entry.
- Insert a chest tube (24-36 Fr gauge) into the hole. All chest tube side holes must be
in the pleural space (ie, not just below skin level). If no chest tubes are available, an
adult endotracheal tube may be used.
- Attach a chest tube to a Heimlich valve, sealed Pleurovac, or bottles. In a resource-
constrained environment, a cutoff glove with a slit in the end, or a Penrose drain may
be attached to the end of the chest tube.
- Secure the tube with sutures, if possible, and dress to prevent contamination.
Resuscitative Thoracotomy - Only indicated in penetrating injury in extremis or with recent loss of vital signs.
- If performed, a rapid assessment of injuries should be made; and, in the case of
unsalvageable injuries, the procedure should be immediately terminated.
Procedure - With the patient supine, make an incision in the left inframammary fold starting
at the lateral border of the sternum extending to the midaxillary line.
-The procedure should be abandoned upon discovery of devastating injuries to
the heart and great vessels.
- An immediate right chest thoracostomy should be performed concurrently. If
bleeding is identified, a rapid extension across the midline should be done, crossing
through the sternum with a Lebsche sternum knife and performing a mirror-image
thoracotomy. When doing this procedure, you will cut across both internal mammary
arteries, which will be a significant source of bleeding and must be clamped as soon as
possible.
- Elevating the anterior chest wall will expose virtually all mediastinal structures.
- Open the pericardium and assess the heart. Use an anterior longitudinal incision
to avoid phrenic nerve injury.
Priorities are to stop bleeding and restore central perfusion. - Holes in the heart and/or great vessels should be temporarily occluded.
Temporary occlusion can be achieved with fingers, side-biting clamps, or Foley
catheters with 30 cc balloons. Any other sterile device of opportunity is acceptable. A
finger is usually sufficient, and less traumatic.
- Major pulmonary hilar injuries should be cross-clamped en masse.
- Distal thoracic aorta should be located, cross-clamped, and cardiac function
restored via defibrillation or massage. (Make sure to open the mediastinal pleura over
the aorta to securely apply the vascular clamp.)
- If unable to restore cardiac function rapidly, abandon the operation.
- With successful restoration of cardiac function, injuries should be more definitively
repaired.
Median Sternotomy
In general, exposure to the heart and great vessels is best achieved through a
median sternotomy. For proximal left subclavian artery injuries, additional exposure
(trap door) may be necessary.
Indications:
- suspected cardiac injury.
- positive pericardiocentesis/subxiphoid pericardial window.
- suspected injury to the great vessels in the chest.
- suspected distal tracheal injury.
How to make procedure:
- In the supine position, make a midline skin incision from the sternal notch to just
below the xiphoid.
- Through blunt/sharp dissection, develop a plane for several centimeters both
superiorly and inferiorly beneath the sternum.
- Divide the sternum with a sternal saw or Lebsche knife. Keep the foot of the
knife/saw tilted up toward the undersurface of the sternum to avoid cardiac injury.
Bone wax can be used to decrease bleeding on the cut edges of the sternum.
- Separate the halves of the sternum using a chest retractor.
- Carefully divide the pericardium superiorly, avoiding the innominate vein, and
exposing the heart and base of the great vessels.
- Close with wire suture directly through the halves of the sternum, approximately 2
cm from the edge, or around the sternum through the costal interspaces using wire
sutures. Large, permanent sutures can be used if wire is unavailable.
- Place one or two mediastinal tubes for drainage, exiting through a midline stab
wound inferior to the mediastinal skin incision.
Thoracoabdominal injuries.
Indication.
- Combined thoracic and abdominal injuries.
How to make procedure:
- The resuscitative thoracotomy can be continued medially and inferiorly across the
costal margin into the abdominal midline to complete a thoracoabdominal incision.
- Alternatively, a separate abdominal incision can be made.
- With right-sided lower chest injuries, the liver and retrohepatic vena cava can be
exposed well using a right thoracoabdominal approach.
Heart.
The usual result of high-velocity injuries to the heart is irreparable destruction of the
muscle.
- Isolated punctures of the heart should be exposed (opening the pericardium) and
occluded by finger pressure. Other methods include the use of a Foley catheter or skin
staples.
- Use pledgeted horizontal mattress sutures (2-0 PROLENE) on a tapered needle for
definitive repair. Care must be taken to avoid additional injury to coronary vessels.
Extreme care must be taken to avoid tearing the cardiac muscle. Autologous
pericardium can be used if commercial pledgets are not available.
- Atrial repairs may include simple ligature, stapled repair, or running closures.
- Temporary inflow occlusion may prove helpful in repair.
- More complex repairs are impractical without cardiac bypass.
Lung.
-Tube thoracostomy alone is adequate treatment for most simple lung parenchymal
injuries.
- Large air leaks not responding to chest tubes or that do not allow adequate
ventilation will require open repair (see section on “Tracheobronchial Tree”).
- Posterolateral thoracotomy is preferred for isolated lung injuries. Anterior
thoracotomy may also be used.
- Control simple bleeding with absorbable suture on a tapered needle. Alternatively,
staples (eg, TA-90) may be used for bleeding lung tears.
Tracheobronchial tree.
- Suspect the diagnosis with massive air leak, frothy hemoptysis, and
pneumomediastinum.
- Confirm by bronchoscopy.
- Airway control is paramount.
- Median sternotomy is best approach.
- Repair over endotracheal tube with absorbable suture— may require segmental
resection. Bolster with pleural or intercostal muscle flap, especially between the
trachea and esophagus.
Temporizing measures include:
-Single lung ventilation.
- Control the airway through the defect.
Esophagus. -Isolated thoracic esophageal injuries are exceedingly rare. They will usually be
diagnosed incidentally associated with other intrathoracic injuries.
-Diagnostic clues include pain, fever, leukocytosis, cervical emphysema, Hamman’s
sign, chest X-ray evidence of pneumothorax, mediastinal air, and pleural effusion.
Contrast swallow may confirm the diagnosis.
-Start IV antibiotics as soon as the diagnosis is suspected, and continue post-op until
fever and leukocytosis resolve. This is an adjunctive measure only. Surgery is the
definitive treatment. -For stable patients in a forward location, chest tube drainage and a nasogastric tube
placed above the level of injury are temporizing measures. Ideally, primary repair is
performed within 6–12 hours of injury. Beyond 12 hours, isolation of the injured
segment may be necessary.
-Locate the injury by mobilizing the esophagus. Primarily repair with a single layer
or two layers of 3-0 absorbable sutures and cover with the pleural or intercostal muscle
flap.
-Drainage with chest tubes (one apical, one posterior) is recommended.
-If unable to primarily repair (as with a large segmental loss or severely
contaminated/old injury), staple above and below the injury, place a nasogastric tube
into the upper pouches, and place a gastrostomy tube into the stomach. Drain the chest
as indicated previously. Complex exclusion procedures are not indicated in a forward
operative setting.
-An alternative when the esophageal injury is too old for primary repair is to close
the injury over a large T-tube, which converts the injury to a controlled fistula. The
mediastinum is then widely drained using chest tubes or closed-suction catheters
placed nearby. After a mature fistula tract is established, slowly advance the T-tube;
later, the mediastinal drains can be slowly advanced.
Diaphragm. All injuries of the diaphragm should be closed.
-Lacerations should be reapproximated with nonabsorbable 0 or 2-0 running or
interupted sutures.
-Care should be exercised in the central tendon area to avoid inadvertent cardiac
injury during the repair.
-If there is significant contamination of the pleural space by associated enteral
injuries, anterior thoracotomy and pleural irrigation and drainage with two well-placed
chest tubes should strongly be considered.
-Inadequate irrigation and drainage, such as when attempted through the
diaphragmatic defect via the abdomen, can lead to a high incidence of empyema.
Blunt cardiac injury (BCI)
Blunt cardiac injury (BCI) encompasses a wide spectrum of clinical manifestations,
ranging from an asymptomatic myocardial bruise to cardiac rupture and death. Blunt
injury to the heart is involved in up to 20% of all motor vehicle collision deaths. The
incidence of BCI in all blunt thoracic trauma patients is approximately 20 %; however,
in patients with severe thoracic injury or multiple injuries, the incidence of BCI may
be as high as 76 %. No gold standard exists for the diagnosis of BCI. A mechanism of
injury consistent with BCI, combined altered cardiac function, provides a practical
means of diagnosing BCI. Attention has focused on identifying those patients who will
develop complications as a result of BCI. The difficulty in defining this phenomenon
has led to a classification that defines BCI according to the sequela of the injury: BCI
with cardiac free wall rupture; BCI with septal rupture; BCI with coronary artery
injury; BCI with cardiac failure; BCI with complex arrhythmias and BCI with minor
ECG or cardiac enzyme abnormalities.
Mechanism of injury
BCI arises from a variety of mechanisms including:
- Direct precordial impact
- Crush injury resulting from compression between the sternum and spine
- Deceleration or torsion causing a tear in the heart at a point of fixation, such as
between the right atrium and vena cava
- Hydraulic effect resulting in rupture, such as that seen during an abrupt abdominal
compression that results in significantly elevated venous pressure that is transmitted to
the right atrium or ventricle
- Blast injury
Diagnosis of BCI
Few clinical signs or symptoms are specific for BCI. The most common finding
associated with BCI is chest pain. This pain may or may not be anginal in nature, and
it is usually a result of associated thoracic trauma. Because BCI is usually the result of
a high-velocity impact, associated injuries are common. Dyspnea, chest wall
ecchymoses, flail chest, and sternal fractures should raise suspicion for BCI. Cardiac
dysfunction can cause distended neck veins if hemorrhage has been minimal. Although
ausculatory findings such as a thrill, murmur, or rub should raise suspicion for BCI,
these findings are usually not present. Physical exam findings concerning for BCI are
often the result of cardiac dysfunction, and they are typified by dysrhythmias, global
cardiac ischemia, or low cardiac output and hypotension. Controversy exists regarding
the utility of using ECG, cardiac enzymes, and echocardiography to diagnose BCI.
Management of BCI
Therapeutic interventions currently focus on the treatment of BCI-related
complications. BCI with minor ECG or cardiac enzyme abnormalities rarely produce
clinically significant sequela, and these minor abnormalities usually resolvev without
any intervention within 24 hours. Anecdotal reports have shown that antiarrhythmias
can treat BCI with complex arrhythmias. BCI with heart failure requires a precise
understanding of the preload and afterload characteristics of both ventricles. Left
ventricular function is evaluated best by transesophageal echocardiography. Either
transesophageal echocardiography or right heart catheterization can be used to evaluate
the function of the right ventricle. These investigations can be used to quantitate
volume loading of the heart to restore adequate cardiac output. Additionally, high
pulmonary vascular resistance resulting from pulmonary contusion, mechanical
ventilation, or acute respiratory distress syndrome (ARDS) can be diagnosed, allowing
for interventions to reduce right ventricular work. Low cardiac output, resulting from
dysfunction of either , may respond to inotropic support. A cardiothoracic surgeon
should be consulted for any patient suspected of having BCI with cardiac-free wall
rupture, septal rupture, coronary artery injury, or valve injury.
I. Plan and structure of class
#
Main stages of the
class, their
function and
meaning
Learning
objective in
the levels
of
mastering
Methods of
teaching and
control
Guidelines
Time
distributi
on
1.
2.
3.
Preliminary stage
Arrangements
Determining the
relevance,
educational
objectives and
motivation
Control of the
intput level of
knowledge, skills
and abilities:
1. Etiology and
pathogenesis
2. Clinical signs
3. Diagnosis
І
ІІ
ІІ
Survey
Survey, tests
1. Relevance
2. Educ. objectives
Questions
Questions, II level
MCQs
5 min.
5 min.
45 min.
4. Treatment
ІІ
Clinical
cases, MCQs
Clinical
cases, MCQs
Typical clinical
cases, II level MCQ
Typical clinical
cases, II level MCQ
4. Main stage
Formation of
students
professional skills:
1. Master the skills
of the physical
examination
2. Perform
physical
examination of
the patient with
thoracic trauma
3. Plan the patients
laboratory and
instrumental
examinations
4. Differential
diagnosis
5. Treatment
schemes
ІІІ
Practical
training
Practical
training
Practical
training
Practical
training
Practical
training
6. Patients with
thoracic trauma
7. Patients with
thoracic trauma
Clinical cases, III
level MCQs
Diagnostic
algorithms,
atypical clinical
cases
Typical and
atypical clinical
cases
95 min.
5.
6.
Final stage
Correction of the
professional skills
and abilities
Summarizing class
ІІІ
Personal
skills
control,
analysis and
evaluation of
the results of
clinical
work,
clinical
cases, level
III MCQs
Clinical cases and
III level MCQs
Results of patients
examination,
30 min.
7.
Homework
(recommendation
of basic and
additional
literature)
MCQs and clinical
cases solutions
Oriented card for
independent work
with literature
II. Materials for classes
Questions (α =І, α =ІІ)
1. Etiology and pathogenesis of thoracic trauma.
2. Classification of thoracic trauma.
3. Clinical signs of thoracic trauma.
4. Laboratory diagnosis of thoracic trauma.
5. Role of localization procedures in diagnosing of thoracic trauma.
6. Differential diagnosis of thoracic trauma.
7. Treatment of thoracic trauma.
8. Complications of thoracic trauma.
MCQs (α =ІІ)
1. Name the most common thoracic injury in blunt trauma?
A. Hemothorax
B. Flail chest
C. Rib fracture
D. Sternal fracture
E. Pericardial tamponade
Correct answer: C
2. Which statement concerning 1st and 2nd ribs fractures is wrong?
A. Require high force
B. Frequently have injury to aorta
C. Frequently have injury to bronchi
D. May injure subclavian artery/vein
E. Causes pulsus paradoxicus
Correct answer: E
3. Most oftenly fracture of 11th or 12th ribs are associated with:
A. Flail chest
B. Damage to underlying abdominal solid organs (liver, spleen, kidney)
C. Injury to aorta
D. Injury to bronchi
E. Pneumothorax
Correct answer: B
4. Select the proper intervention for a life-threatening injury of the chest: OPEN
PNEUMOTHORAX
A. Endotracheal intubation
B. Cricothyroidotomy
C. Subxiphoid window
D. Tube thoracostomy
E. Occlusive dressing
Correct answer: E
5. Select the proper intervention for a life-threatening injury of the chest: TENSION
PNEUMOTHORAX
A. Endotracheal intubation
B. Cricothyroidotomy
C. Subxiphoid window
D. Tube thoracostomy
E. Occlusive dressing
Correct answer: D
Typical clinical cases (α =ІІ)
1. A 31-year-old man is brought to the emergency room following an automobile
accident in which his chest struck the steering wheel. Examination reveals stable vital
signs, but the patient exhibits palpable 7 rib fractures from the right side and
paradoxical movement of the right side of the chest. Chest x-ray shows no evidence of
pneumothorax or hemothorax, but a large pulmonary contusion is developing. Proper
treatment would consist of which of the following?
A. Tracheostomy, mechanical ventilation, and positive end-expiratory pressure
B. Stabilization of the chest wall with sandbags
C. Stabilization with towel clips
D. Immediate operative stabilization
E. No treatment unless signs of respiratory distress develop
Answer: A
2. A 45-year-old man was a passenger in a car when he was T-boned by a truck at
a high speed. He is short in breath, complains of severe pain in the chest, and is hypoxic
on the pulse oximeter. The breath sounds are diminished on the left and the percussion
note is completely dull. He rapidly becomes tachycardic and hypotensive.
A. Cardiac tamponade
B. Tension pneumothorax
C Open pneumothorax
D. Flail chest
E. Massive hemothorax
Answer: E
Atypical clinical case (α =ІIІ)
3. A 25-year-old man is shot in the left lateral chest. In the emergency department,
his blood pressure is 120/90 mm Hg, pulse rate is 104 beats per minute (bpm), and
respiration rate is 36 breaths per minute. Chest x-ray shows air and fluid in the left
pleural cavity. Nasogastric aspiration reveals blood-stained fluid. What is the best step
to rule out esophageal injury?
A. Insertion of chest tube
B. Insertion of nasogastric tube
C. Esophagogram with gastrografin
D. Esophagoscopy
E. Peritoneal lavage
Answer: D
VIII. Literature
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vehicular trauma: a crash injury research and engineering network (CIREN) study.
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