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I am going to be talking about the management of thoracic trauma, the injuries. I'm going to be talking about our six lethal injuries, blast injury and how to stop bleeding in the chest. But I want everybody to understand that even if the surgeon performed heroic surgery in the chest, it's the post operative care. That is the most important thing in determining whether the casualty makes a good recovery. And I put this slide up because this is something I tell my students over and over again that good pain control mobilization and sitting the patient up. These are the foundations of a good postoperative recovery and prevention of complications. 90% of patient's with chest trauma can be managed with oxygen painkillers and perhaps a chest strain. This is in spite of the fact that chest trauma causes 25% of trauma deaths. And of course, there was always a trap for the unwary doctor who doesn't consider whether the chest trauma is combined with an abdominal injury. And this should always be considered. And that is because we know that a bullet, an explosive fragment does not respect anatomy and can traverse from the abdomen or the chest or vice versa very easily. So the goals of treating anybody with chest trauma is to improve oxygenation, stop bleeding and prevent infection. At the start of this talk, I mentioned that there were six lethal injuries. There are also six hidden chest injuries that can be dangerous to the patient later on in their stay. And together these 12 injuries make up what I call the dirty dozen. So we'll talk about the lethal six. The first is obstruction to the air airway. And of course, the first actions to deal with this to clear the oropharynx using suction to maintain the airway, using adjuncts such as Goodale airway or to perform a definitive airway typically via cricothyroidotomy unless your at least this is with you. In which case, endotracheal tube with rapid sequence induction is a good alternative. The next of the lethal six tension pneumothorax becomes apparent in the context of a patient with penetrating injury to the chest. When that patient becomes short of breath, very agitated and physiologically unstable. It can sometimes be difficult to diagnose because the classical features of neck vein distension and hyper resonant percussion may not be present. And drug keel shift away from the side of the injury is a very late sign. So for these reasons, if a patient with penetrating trauma to one side of the chest presents with instability, agitation and severe shortness of breath and urgent chess war decompression using needle thorough synthesis is the right and life saving treatment. One should follow up the needle thorough synthesis with formal insertion of a chest tube. The third of the lethal six is open pneumothorax. This is typically seen when a large shell fragment pierces the chest and removes a sizable chunk of chest wall creating a defect in the chest wall which preferentially n trains air during the spiritually movements. The diagnosis is made by listening to the sound that the air makes through the wound and it's called a sucking chest wound. There are special realized valved dressings that one can use to seal the wound. But in the absence of these a impermeable dressing placed over the wound that's taped around the wound on three sides will create a valve and stop the movement of air into the chest in theater. The correct surgical treatment is to remove damaged tissue, to wash out the pleural cavity, to place chest strains and to mobilize soft tissue to close the defect in the chest wall. Sometimes chest will reconstruction cannot be done at the first surgical episode and must be deferred until later on when the patient is physiologically more stable. The next of the lethal six is massive hemothorax such as on this chest X ray here which shows a white out on the right side of the chest. Probably the most reliable clinical feature is that of shock with low BP and tachycardia, it can be difficult to make the diagnosis using the traditional features of reduced breath sounds and dullness to percussion, especially in the busy resuscitation room. The management of shock is urgent venous access and replacement of lost blood volume with blood transfusion and placing a large board, chest drain on the affected side. After placing the chest strain. If 1.5 liters of blood in an adult drains out immediately, then that is considered to be a strong indication for thoracotomy because it is unlikely the bleeding will stop by itself. An alternate figure as an indication for thoracotomy is 200 mils per hour for more than four hours. However, the most important indicator for thoracotomy is continued instability. Despite blood volume resuscitation, one word of warning about the chest drain output is that sometimes if there's a clot in the chest drain, then what comes out may not be representative of how much the patient is bleeding because of this obstruction to drainage. The next of the lethal six injuries is flail chest, which is the term in English that we give to an injury that causes multiple fractures along the same segment of rib and chest wall. The flail chest is sometimes accompanied by so called paradoxical motion of the injured portion of the chest because it is disconnected from the rest of the structure of the chest. And when the patient breathes in the flail chest area exhibits paradoxical motion by becoming depressed. And when the patient breathes out the segment exhibits paradoxical motion by standing out and becoming more prominent. At least this is what the textbooks say. But in real life, because there is so much muscular spasm over the area, particularly in well muscled young men, that this feature is often absent. The mainstay of treatment for these patient's is to treat any associated hemo or pneumothorax and to maintain adequate oxygen saturation through the use of supplementary oxygen and effective analgesia, whether that is opioid or more preferably some form of regional anesthesia, so that the patient can breathe with as much freedom as possible in many centers. Now, flail chest is managed using rib fixation and in my center, this is certainly an option for patient's who sustained flail chest because it probably allows for reduced and jeezy requirements and earlier release from high dependency areas. The evidence is not clear yet and we are awaiting the results of a randomized controlled study into this. But it is something that can be very useful if you have the facilities to do this. What are the indications for intervening in someone who has sustained severe thoracic trauma? Well, indications for intubating and ventilation. Some rough rules of thumb. Arms follows. Firstly, if despite good analgesia, the patient is breathing strenuously using their accessory muscles of respiration. And of course, the other indications are saturations less than 90% despite high flow oxygen or rising level of carbon dioxide and arterial blood gases indication indicating that the patient is becoming tired and cannot pencil eight. Now, moving on to another of the lethal six and this is cardiac tamponade due to penetrating injury in military or combat circumstances. This is not usually because of gunshot wound because that causes outright death. Most circumstances in conflict situations where cardiac tamponade occurs is due to explosive fragment, um artillery or other indirect fire rather than a gunshot wound. The key investigation is focused sonography for trauma to pick up a rim of fluid around the heart which in the context of penetrating injury to the chest, makes the diagnosis of cardiac temperature. If you don't have this in your emergency room, this test in the emergency room and there was a patient with penetrating trauma to the chest who is shocked and who has distended neck veins and who's agitated and who is deteriorating. Then it is acceptable to make a presumptive diagnosis and to perform thoracotomy after intubating the patient and to make the diagnosis of thoracotomy. On the other hand, if the patient is stable and the surgeon is not sure whether or not there is a breach of the pericardium or not, they can take the patient to theater and perform a sub xiphoid pericardial window which allows surgical exploration of the pericardium. And if that is positive, then they convert, convert to thoracotomy or sternotomy to repair the heart at that point. So that was the lethal six. But there is another lethal injury which I want to briefly talk about as well which is blast lung, which is something which is uh seen far more in combat and military circumstances than is the case in normal civilian practice, blast into which the lungs is caused by exposure to the overpressure of a nearby explosion. It is worse when the explosion occurs in a constrained or an enclosed space. Survivors can rapidly develop a respiratory failure due to hemorrhages within the parent came a of the lung. This chest x rays, typical patient's with blast lung. They have these patchy hormone ary infiltrates which are bilateral. And for this reason, these kind of chest x rays are known as a butterfly pattern. These patient's require sophisticated ventilation in um intensive care units. And to that end, if you are looking after such patient's in a smaller hospital is wise to transfer them to tertiary level facility because they will require very sophisticated ventilation to get them through their respiratory failure. So that's my description of the lethal six. So what I want to do now is talk you through the techniques of how to stop bleeding in the chest in the emergency department or the operating theater. So I want to make it clear that there are two types of reasons or indications. Uh Thoracotomy in trauma emergent indications where you have to do something within the next few minutes and urgent indications or reasons where you don't have to do something immediately now. But you might have to in the next hour or so. The first of the emergent indications that's generally accepted is that you have a patient with a penetrating chest injury and you can tell that they are about to arrest in front of you. In other words, in other words, they are exceptionally agitated, there is low BP, uh there is extreme tachycardia and perhaps even bradycardia as they begin to decompensate and you will be aware that this patient is going to die unless you do something that is the first emergent indication. And in that circumstance, the decision making is easy. The second emergent indication where you think you might have to do something right away is when you are presented with a patient who is in cardiac arrest. So not about to have a circulator arrest, but who is in cardiac or circulatory arrest and they have a penetrating chest wound. Now, for this type of patient, whether you decide to do thoracotomy or not, depends how long they have been in cardiac arrest because clearly if they've been in cardiac arrest for a long time, then thoracotomy is probably futile. But if they've been in cardiac arrest for a short time, and by that, I mean, less than 10 minutes and they've been having cardiopulmonary resuscitation throughout that time, then it is acceptable to perform the thoracotomy and I would not consider that futile under those indications. So those are the emergent indications. Now, let's talk about the urgent indications where you think you might have to do some kind of chest surgery, but it doesn't need to be right now. The indications are as follows. Firstly, massive hemothorax, which you've already spoken about, which is a large volume of blood draining from the chest drain, perhaps around 1500 mils straight away or more than 200 mils an hour for four hours. The second urgent indication is not bleeding from the chest strain, but excessive bubbling from the chest strain combined with dropping oxygen saturations and the patient becoming agitated. Or if it's if the patient's already intubated and inability to satisfactorily ventilate the patient. These things are what are known as a massive air leak. And I've already mentioned that patient's with cardiac tamponade. The way you've identified, there is some blood around the heart with a corresponding chest injury. And that is also an indication for thoracotomy. But if the patient is comparatively stable, then it doesn't have to be done immediately. There is time to take the patient theater in a controlled manner. So really the job of the clinical team leader when resuscitating a patient who they think might need an operation or treatment of their chest injury, it's very simple. All they have to decide is whether or not the patient is so sick that the patient has to be operated on the emergency department. In other words, emergency thoracotomy or whether they can survive the trip to theater and proceed in a more controlled way. This is a crucial decision for the team leader to make. Fortunately, most times, the patient's won't need surgery when, when they have a chest wound, as I mentioned earlier, it's usually just chest drain and pain relief if they do need surgery. Fortunately, most of them are physiologically stable enough to go to theater in a controlled manner. It is the minority of cases that will need urgent surgeon, emergent surgery in the emergency department. And if we do have to do that, there is only one technique that one needs to learn. And that's called the clam shell thoracotomy. So I'm going to talk you through now, some of the techniques which are useful to stop bleeding in the chest. And the first of these is the clam shell thoracotomy. When I started treating trauma patient's 20 years ago, this was an unpopular incision because cardiac surgeons did not like it, but it was popular amongst trauma surgeons. And this is the technique of choice to use down in the emergency department. So if you need to do a clamshell thoracotomy for cardiac tamponade, this is how you, you started. You make an incision from the sternum that passes just beneath the nipple and curves around to the posterior exupery line following the curve of the ribs. This corresponds to the fourth or the fifth intercostal space in a woman. One will need to displace the breast tissue superior early but the incision in that case usually causes around the inframammary old. So same, same rib space, fourth or fifth intercostal space. But the tissue, the breast tissue needs to be pulled. Superior lee so that there was adequate exposure, use a knife to cut to all the tissues rapidly. And then I prefer to use a knife to pierce the pleural membrane in one spot. Then you can take a pair of scissors and you can incise the intercostal muscles and the pleura in one to get access to the left lower cavity. Next step is once you're in the pleural cavity and you have, you have divided the intercostal musculature and flora is to insert your rib, spreading or finish keto retractor like this. This is the alternative way of putting the finish keto in, but it is not a good way because it gets in the way of extending the incision. So through this part of the incision, through the left anterolateral thoracotomy, the next thing to do is to find and identify the pericardium and to grasp it with forceps so that one can incise it and relieve the tamponade. It's important to avoid the phrenic nerve, which as you can see here is running laterally down the side of the pericardium and it's usually quite obvious it's a pierce, the pericardium. Sometimes it's necessary to use a blade carefully because it is so full of blood that it can be difficult to grasp with the forceps. Once you have pierced it, then you can use scissors to open up the pericardium like so, and then to deliver the heart, delivering the heart is made easier if you extend the incision transversally. So you're turning the incision into letter T with the base of the t in the inferior part of the pericardium. If there is a tamponade that that will be relieved and the patient's physiology should improve, it will usually be obvious where the wound in the heart is because it will be bleeding at this point. All one does is to put a finger on the wound to control the hemorrhage. Meanwhile, the knife is past the assistant who then makes the same incision on the right side of the chest, exactly the same as before. And the second furniture too is placed on the opposite side and then the sternum maybe divided with a jiggly saw or a pair of tough cut shears. The Finnish eto's are then opened up fully and one can sweep the loose sternal attachments off so that the whole of the mediastinum, including the pericardium and both lungs can be easily seen. If the patient's circulation has been restored through relief of the tamponade, then the patient will start bleeding from internal memory arteries which need to be controlled. The next step is to identify the place where the heart is injured. Usually it is the right side of the heart, either the right atrium or the atrial appendage or the right ventricle because patient's with left ventricular left sided heart injuries usually die before they get to hospital because the tamponade is very high pressure. Not always do they die, but usually through natural selection, it's right sided injuries that the surgeon or the emergency position will have to deal with in the hospital. Injuries to the atrial appendage are very easily controlled with a side biting clamp and then it's straight forward just to under sewed and repair the injury. The three or 40 praline or monofilament suture is the ideal suture to use for these repairs of the heart. Sometimes the right atrium is a good place to cannulate to give volume in patient's with severe injuries. And it's straightforward again to put a foley catheter into a stab incision in the right atrium and then to infuse the blood like so the more sophisticated way of doing this because there will inevitably be some blood leaking around where you put the foley catheter in is to actually put a purse string suture around the foley catheter before you place it. And then to put it in that way, it will stop bleeding or control the the entry point into the atrium more thoroughly. But it's acceptable in an emergency to simply put a foley catheter through a small stab incision into the right atrium between inflate the balloon and then to apply some traction uh to prevent the leaking ventricular injuries. It's difficult to grasp these with, with side biting clamps. Typically, they will be controlled with finger pressure and then under running the injury using pledgeted sutures to prevent the sutures from tearing through the muscle. In dire circumstances, it is acceptable to staple the myocardium using skin staplers. These can then be reinforced with normal sutures and the staples removed. Once control has been achieved, the next emergency I want to talk about is bleeding from the lung. And if there is catastrophic from bleeding from the lung, then the best way to control it is to control the root of the lung. And there are many ways to do this. One can use fingers, one can use instruments, but the root of the lung is a good place to start when you're dealing with catastrophic bleeding from the lung because of course, by controlling it, you'll control the bleeding. Controlling the root of the lung is made easier if one divides the inferior pulmonary ligament, which is some tissues extending in fairly from the root of the lung towards the diaphragm, rather like my, the cuff of my sleeve is what it feels like and you divide it with a pair of scissors. Uh and that then gives you a much cleaner approach to put a clamp on or just to put your fingers on the hilum of the lung to control the bleeding. Once the clamp is applied, in fact, before the clamp is applied, it's important to tell. The honest is because there are profound physiological changes as soon as you include the circulation to one lung. If one cannot control the bleeding from the lung, then it is acceptable to perform a pneumonectomy. But it is associated with a death rate of at least 50%. So for that reason, it's best to try or one can to control bleeding from the lung. Um And I will show you how to do that using this technique called tractotomy. So what can imagine in this example, a bullet or fragment has passed in the lung, there are some bleeding deep within. And in order to get access to this bleeding portion of the lung, one needs to lay open the track in a controlled way. The best way of doing this is to take a G I A stapler and put one limb through the track and the other limb outside and then simply to divide, attract and open it up, which enables then the surgeon to put in sutures along the bullet track to stop bleeding. If you don't have G I A staplers, then it's acceptable to use a soft bowel cloud down the track to grasp the tissue like it's demonstrated here and then to simply cut it to expose the bleeding tract for injuries, two portions of the lung which cause severe contusion. It's acceptable to use G I A stapler to resect that portion of the lung in a non an atomic resection. But again, if you don't have a gi staple, it, you can simply take a noncrushing clamp and apply it across the base of the area that you want to resect and then to cut it and then over. So the chest is then simply closed, using whichever large suture you have available with four chest strains to, to each side and then 1/5 chest strain over the pericardium. The final injury pattern that it's important to know about is injuries to the root of the neck. These injuries may involve branches of the aorta. If you have this kind of injury on a patient who is unwell, then please consider median sternotomy to get at the root of the aorta and the aortic branches uh like. So, so these branches are the break of catholic, the left common carotid and left clave in and one can get control of them within the chest before going into the injured portion of the route of the neck. So that uh there is control before going into the hematoma. In this case, a median sternotomy has done to expose the break of catholic before exploring the origin of the right common carotid and the extent and the incision has been extended up into the neck. One can see all the way from the arch there aorta to get control of the origin of the common carotid before going into the hematoma. Final slides, just concerned the subject of aortic clamping aortic clamping is not really useful for controlling bleeding within the chest. It might be useful for controlling bleeding within the abdomen occasionally. But in the chest, it is not really a useful tool. But if you are going to do it, the simple way of doing is just simply to press with your thumb over the aorta rather than unless your surgeon rather than to try and dissect out the aorta because it can be fraught with problems where you knock off an intercostal artery and cause bleeding. So if you're not used to this and you want to control the aorta, my advice is simply to press on the aorta, which of course, is less injurious to it than a clamp. If you want to find the aorta, the lung needs to be displaced to the front, you simply run your fingers around the back of the rib cage and then the first soft structure you encounter on the left side of the dorsal spine, that's the aorta there. So I think that concludes my lecture. Remember the most important lesson is once the patient is stable and you've stopped the bleeding and so on and so forth, getting their pain control sorted, getting them mobilized early. Uh The most important things to prevent complications.