What Is Thoracic Trauma?

Thoracic trauma Injuries caused by car accidents, crush injuries, falls, and sharp injuries. According to the nature of the violent injuries, chest injuries can be divided into blunt injuries and penetrating injuries; according to whether the injury causes pleural cavity and External communication can be divided into open injuries and closed injuries.

Sun Shaolin	(Resident)	Department of Thoracic Surgery, the First Affiliated Hospital of China Medical University
Liu Hongxu	(Chief physician)	Department of Thoracic Surgery, the First Affiliated Hospital of China Medical University

Western Medicine Name: Chest injury

English name: Thoracic trauma
Affiliated Department: Surgery-Cardiothoracic Surgery

Causes of chest injury

Thoracic trauma is caused by car accidents, crush injuries, falls, and sharp injuries, including chest wall contusions, lacerations, fractures of ribs and sternum, pneumothorax, hemothorax, lung contusions, trachea and main bronchial injuries, heart injuries , Diaphragm injury, traumatic asphyxia, and sometimes combined with abdominal injury.

Classification of chest injuries

According to the different nature of injury violence, chest injury can be divided into blunt injury and penetrating injury; according to whether the injury causes the pleural cavity to communicate with the outside world, it can be divided into open injury and closed injury ^[1] .

Chest injury blunt chest injury

Blunt chest injury is caused by decelerating, squeezing, impacting or impact violence. The injury mechanism is complex, with ribs or sternum fractures. It is often combined with other parts of the injury. It is easy to be misdiagnosed or missed early after injury. Blunt contusions and lacerations are common. Tissue edema secondary to extensive blunt contusion in the heart and lung tissue often leads to acute respiratory distress syndrome, heart failure, and arrhythmia. Most patients with blunt injuries do not need thoracotomy.

Chest injury penetrating chest injury

Penetrating chest injuries are caused by firearms, blades or sharps. The damage mechanism is relatively clear. The scope of the injury is directly related to the wound path. Early diagnosis is easier. Progressive hemothorax caused by laceration of organs and tissues is a rapid progress of the injury. 2. The main cause of death of patients, a considerable part of patients with penetrating chest injury need open surgery.

Emergency treatment of chest injury

Emergency treatment of chest injury includes emergency treatment before admission and emergency treatment after admission.

Pre-hospital treatment of chest injury

Including basic life support and emergency management of severe chest injuries.

The basic life support principles are: maintaining breathability, providing oxygen, controlling external bleeding, replenishing blood volume, analgesics, fixing long bone fractures, protecting the spine (especially the cervical spine), and transporting them quickly. Serious life-threatening thoracic trauma requires special emergency treatment at the scene: tension pneumothorax needs a thoracentesis needle with closed flaps or closed drainage of the thorax; open pneumothorax must quickly bandage and close the chest sucking wound, when conditions permit Place the above-mentioned puncture needle or drainage tube; artificially assisted breathing for flail chest with large area of softened chest wall.

In- hospital emergency treatment of chest injury

Most chest injuries can be relieved through simpler treatments, and even save lives. Only 10% -15% of patients need thoracotomy. Therefore, it is necessary to strictly grasp the indications for surgery and the timing of surgery for chest trauma. If there are clear surgical indications, the chest should be opened in time.

Indications for chest injury emergency thoracotomy

Progressive pleural cavity hemorrhage

2. Cardiac Vascular Injury

3. Severe lung laceration or trachea or bronchial injury

4. Esophageal rupture

5. Combined chest and abdominal injuries

6. Large chest wall defect

7. Large foreign body in chest

Chest injury with symptoms

Chest injury rib fracture

1. Etiology and pathogenesis: direct or indirect violence on the chest wall can cause rib fractures, which account for more than 60% of all chest trauma. Rib fractures caused by different external violent modes of action can have different characteristics: rib fractures caused by direct violence acting on limited parts of the chest, the broken ends shift inward, and the intercostal blood vessels, pleura, and lungs can be punctured. Produces hemothorax or (and) pneumothorax. Indirect violence, such as when the chest is squeezed back and forth, fractures are mostly in the middle of the ribs, the stump is displaced outward, stabbing the soft tissue of the chest wall, and producing chest wall hematomas. Rib fractures caused by bullet wounds or shrapnel injuries are often comminuted fractures.

2. Clinical manifestations: Rib fractures mostly occur in the 4th to 7th ribs; the 1st to 3rd ribs are protected by the clavicle, scapula and shoulder strap muscle groups and are not easily broken; the 8th to 10th ribs are gradually shortened and connected to the cartilage ribs On the arch, there is elastic cushioning, and the chance of fracture is reduced; the 11th and 12th ribs are floating ribs, which have greater mobility and rarely fracture. However, when the violence is strong, these ribs can fracture. In children, the ribs are elastic and not easy to break, while in adults, especially the elderly, the ribs are weakened and easily broken.
With a single rib fracture, the patient reported chest pain, which worsened during deep breathing or coughing. There were no obvious local abnormalities, or mild subcutaneous tissue congestion and swelling, but tenderness at the fracture. A positive thoracic compression test (pressing the thorax back and forth with your hands can cause severe pain at the fracture site) is helpful in diagnosis.

Multiple ribs and multiple fractures became flail chests. Can produce softening of the chest wall, forming abnormal breathing movements. Severe flail chest with lung contusion can cause shortness of breath, cyanosis, and difficulty breathing, which is one of the causes of death from chest trauma. When the first or second rib fracture is combined with a clavicle fracture or a scapula fracture, attention should be paid to the presence of damage to the subclavian blood vessels, nerves, and thoracic internal organs. Fracture of the lower chest ribs, we should pay attention to the diaphragm or abdominal organ damage.

3. Diagnosis: A single rib fracture is positive based on local tenderness and thoracic compression tests, which is easy to diagnose. Multiple and multiple rib fractures are based on symptoms, abnormal breathing movements, a floating chest wall on examination, and chest X-rays, and the diagnosis is not difficult. A chest radiograph or rib image can confirm the diagnosis of rib fractures, and can show whether there is any damage to the internal organs of the chest and complications (such as pneumothorax, pulmonary contusion, mediastinal widening, etc.). It should be noted that if there is no obvious displacement of the ribs, or the junction of the ribs and the rib cartilage is broken, the chest radiograph may not be displayed, or the fracture line may not be seen. After 3-6 weeks, the X-ray chest radiograph will begin to show the epiphyseal shadow. Suspected lung contusion, chest CT examination should be performed to determine the location, scope and severity of the lung contusion, and intrapulmonary hematomas and pulmonary lacerations can sometimes be found. Severe multiple rib fractures or flail chests should be examined by continuous arterial blood gas analysis to determine the extent of hypoxemia.

4. Treatment: The principle of treatment of rib fractures is painful, keep the airway open, and prevent lung infections.

A single rib fracture does not require rehabilitation and fixation. The main treatment is analgesia, which can be taken orally. Multiple rib fractures and thoracic floating, the following appropriate methods should be used to eliminate abnormal breathing movements.

(1) Pressure dressing: apply external force to the softened area of the chest wall, or cover it with a thick dressing and fix it under pressure. This applies only to on-site first aid or to a lesser extent of chest wall softening;

(2) Traction fixation method: suitable for large chest wall softening;

(3) Surgical fixation method: It is applicable to patients who need chest exploration due to chest trauma complication. Patients with severe chest trauma and pulmonary contusion have significant breathing difficulties, cyanosis, respiratory rate> 30 or 8 times per minute, arterial oxygen saturation <90% or arterial oxygen pressure <60 mmHg, arterial carbon dioxide Partial pressure> 55mmHg, mechanical ventilation should be supported by tracheal intubation to support breathing. Positive pressure mechanical ventilation can correct hypoxemia and control abnormal breathing movements of the chest wall.

Thoracic wall wounds with open rib fractures need to be thoroughly debrided to fix the fracture ends. If the pleura has been punctured, a closed chest drainage should be placed. Antibiotics should be applied to prevent infection after surgery.

Chest injury pneumothorax

Pneumothorax is called pneumothorax. The formation of pneumothorax is mostly caused by the rupture of lung tissue, trachea, bronchus, and esophagus, and the escape of air into the pleural cavity, or the pleural cavity through the pleura due to a wound on the chest wall, the pleural cavity communicates with the outside world, and external air enters. According to the pleural cavity pressure, pneumothorax can be divided into closed pneumothorax, open pneumothorax and tension pneumothorax. Free pleural effusions are located in the upper thoracic cavity in different positions. When adhesions occur in the pleural cavity due to inflammation, surgery, or other reasons, pleural effusion will be limited to certain areas, resulting in limited pneumothorax.

(A) closed pneumothorax

The intrathoracic pressure of closed pneumothorax is lower than atmospheric pressure. The amount of air in the pleural space determines the degree of lung atrophy on the injured side. The collapse of the injured side reduces the breathing area, which will affect lung ventilation and ventilation functions, and the ventilation and blood flow ratio will also be unbalanced. Reduced negative chest pressure on the injured side can cause the mediastinum to shift to the healthy side. According to the amount and speed of gas accumulation in the pleural cavity, patients with mild symptoms may have no obvious symptoms, and severe patients may have difficulty breathing. The physical examination may reveal that the injured thorax is full, the breathing activity is reduced, the trachea is shifted to the healthy side, the injured chest is beaten during the examination, and the respiratory sound is reduced. X-ray of the chest can show different degrees of lung collapse and pleural effusion, and the liquid level can be seen with pleural effusion.

Patients with a longer pneumothorax and less accumulation of pneumothorax need no special treatment, and the accumulation of pneumothorax in the chest cavity can generally be absorbed by themselves within 1-2 weeks. Moderate or large pneumothorax requires pleural puncture or closed thoracic drainage to rule out pleural effusion and prompt lung expansion.

(Two) open pneumothorax

In open pneumothorax, outside air enters the pleural cavity freely through the chest wall defect with breathing. When the chest wall defect diameter is> 75px, the intrathoracic pressure is equal to atmospheric pressure, and the degree of dyspnea is closely related to the size of the chest wall defect. As the intrathoracic pressure on the injured side is significantly higher than that on the healthy side, the mediastinum is shifted to the healthy side, which also restricts the lung expansion on the healthy side. During exhalation and inhalation, the pressure of the pleural cavity on both sides is uneven and cyclic changes occur, which causes the mediastinum to move to the healthy side during inhalation and to the injured side during exhalation, which is called mediastinal flutter. Mediastinal flutter and displacement can affect vena cava blood flow and cause circulatory disturbances.
The main clinical manifestations are obvious dyspnea, nasal flaps, cyanosis of lips, and jugular vein distension. There is a wound on the injured chest wall that is accompanied by gas entering and exiting the chest cavity and making a sucking sound, which is called a chest sucking wound. The trachea was shifted to the healthy side, the drum sounds on the injured chest were percussed, the breathing sounds disappeared, and severe cases were accompanied by shock. Chest X-ray examination showed a large amount of gas in the chest cavity on the injured side, lung collapse, and the mediastinum moved to the healthy side.
First aid treatment points: Turn open pneumothorax into closed pneumothorax immediately, win time, and transfer quickly. Use sterile dressings or cleaning equipment to make air-impermeable dressings and compressions. Cover the wound with a hard end-exhale to suck the wound, and apply pressure bandaging. If the victim's breathing becomes worse during the transfer, the closed dressing should be opened during exhalation, and the wound should be closed after exhausting high pressure gas. Treatment after arriving at the hospital: give oxygen, replenish blood volume, and correct shock; debride, suture chest wall wounds, and perform closed chest drainage; give antibiotics to encourage patients to cough and sputum, and prevent infection; if serious internal organs are suspected Injuries or progressive bleeding require open chest exploration.
(Three) tension pneumothorax

For the formation of a valve at the trachea, bronchus or lung injury, gas enters the pleural cavity with each inhalation and accumulates, resulting in pleural cavity pressure higher than atmospheric pressure, also known as high-pressure pneumothorax. The injured lung was severely collapsed, the mediastinum was significantly displaced to the healthy side, and the healthy lung was compressed, resulting in impaired vena cava return. Intrathoracic pressure above atmospheric pressure drives gas through the bronchi, loose connective tissue around the trachea, or parietal pleural lacerations, into the mediastinum or chest wall soft tissue, forming mediastinal emphysema or subcutaneous emphysema of the face, neck, and chest.
Patients with tension pneumothorax show severe or extreme dyspnea, irritability, disturbance of consciousness, sweating, and cyanosis. The trachea was obviously moved to the healthy side, the jugular vein was swollen, and there were subcutaneous emphysema. The chest on the injured side was full, and drum sounds on percussion; auscultatory breathing sounds disappeared. A chest X-ray showed severe pleural effusion, complete collapse of the lungs, displacement of the mediastinum, and signs of mediastinum and subcutaneous emphysema. During thoracentesis, it can be seen that the high-pressure gas pushes the empty needle core outward. Many patients have circulatory disturbances such as fast pulses and low blood pressure.
Tension pneumothorax is a critical illness that can be fatal quickly. Pre-hospital or in-hospital emergency needs to use a thick needle to puncture the pleural cavity for decompression. In case of emergency, a soft plastic bag with small openings, balloons or condoms can be cut outside the needle handle. Do not enter the chest. For further treatment, closed chest drainage should be placed and antibiotics should be used to prevent infection. The exhaust hole of the closed drainage device is externally connected with a suction device capable of adjusting constant negative pressure, which can expedite gas removal and promote lung retension. Twenty-four hours after the leak ceased, X-ray examination confirmed that the lungs had been stretched before removing the thoracic drainage tube. When the air leak persists and it is difficult to re-expand the lungs, open thoracotomy or video thoracoscopy should be considered.

Indications for closed thoracic drainage:

Medium and large pneumothorax, open pneumothorax, tension pneumothorax;

Thoracic puncture for those who cannot recover the lower lung;

Pneumothorax or pneumothorax requiring mechanical ventilation or artificial ventilation;

Pneumothorax or hemothorax recurrence after removal of thoracic drainage tube;

thoracotomy.

Methods: The intubation site was determined according to clinical diagnosis. Pneumothorax drainage was generally in the 2nd intercostal space of the midline of the anterior chest wall, and hemothorax was in the 6th or 7th intercostal space between the midaxillary line and the posterior axillary line. Take the semi-recumbent position, sterilize the local infiltration anesthesia in the whole layer of the chest wall after sterilization, cut the skin, bluntly separate the muscle layer, and place the chest drainage tube with side holes through the upper edge of the ribs. The side hole of the drainage tube should penetrate 2 to 75px into the chest cavity. The drainage tube is connected with a closed drainage device to ensure that the air and liquid in the chest cavity can smoothly flow out of the chest cavity under the pressure of 0.29 to 0.39kPa (3 to 100pxH2O), and the outside air and liquid will not be drawn into the chest cavity (Figure 36-5). . The drainage tube is often squeezed after the operation to keep the lumen unobstructed, and the timing of the drainage fluid is recorded. After drainage, the lungs are well expanded and no gas or liquid has been discharged. The drainage tube can be removed and the wound can be closed when the patient takes a deep breath. ^[2]

Chest injury hemothorax

1. Overview: Pleural hemorrhage is called hemothorax, and 70% of all chest injuries have different degrees of hemothorax. Coexistence with pneumothorax is called hemopneumothorax. When a large amount of blood accumulates rapidly in the thorax, which exceeds the defibrin function of the lungs, pericardium, and diaphragm muscles, the blood in the thorax coagulates to form a clotting hemothorax. A fibrous plate is formed after the clot is mechanicalized, restricting lung and thorax movements and impairing respiratory function. Blood is a good medium. Bacteria that invade through wounds or ruptures in the lungs can quickly breed and multiply in the blood, causing infectious hemothorax, and eventually pus hemothorax. Hemorrhage in the pleural space caused by persistent massive bleeding is called progressive hemothorax. A small number of wounded due to the activities of broken ribs puncture the intercostal blood vessels or blood clots at the rupture of blood vessels, and the delayed occurrence of blood in the chest cavity is called delayed hemothorax.

2. Clinical manifestations: The clinical manifestations of hemothorax are related to bleeding volume, speed, and personal fitness. Generally speaking, an adult's hemothorax volume 0.5L is a small amount of hemothorax, 0.5 to 1.0L is a medium amount, and> 1.0L is a large amount. The wounded will have low blood volume shock manifestations such as paleness, fine pulse, decreased blood pressure and poor filling of peripheral blood vessels; they have shortness of breath, full intercostal space, trachea shift to the healthy side, dull dullness and respiratory sounds on the injured side Reduce the clinical and chest X-ray findings of isopleural effusion. Hemothorax of more than 200ml can be found in the standing chest radiograph, and the chest blood volume 1000ml in the supine position is easily ignored. A non-coagulated blood sample from a pleural cavity can be diagnosed.

The following signs indicate the presence of progressive hemothorax:

Continuously increase the pulse rate and decrease the blood pressure, or the blood pressure is still unstable even after replenishing blood volume;

Closed chest drainage volume exceeds 200ml per hour for 3 hours;

The amount of hemoglobin, red blood cell count, and hematocrit progressively decreased. The amount of hemoglobin and red blood cell count that drained pleural hemorrhage was similar to that of peripheral blood.

Infectious hemothorax should be considered if:

systemic manifestations of chills, high fever and other infections;

Withdraw 1ml of pleural hemorrhage, add 5ml of distilled water, no infection is reddish and transparent, turbidity or floc appear infection;

The proportion of red blood cell and white blood cell count in the absence of infection in the thorax should be similar to the surrounding blood, that is, 500: 1, and the white blood cell count increased significantly during the infection, the ratio reached 100: 1;

Hematogenous smear and bacterial culture found pathogenic bacteria. When closed thoracic drainage is reduced and physical and radiological findings reveal evidence of persistent hemothorax, coagulative hemothorax should be considered.

3. Treatment: Treatment of non-progressive hemothorax can be treated with thoracentesis or closed chest drainage according to the amount of blood accumulated. In principle, hemostasis should be expelled in time to promote lung retension, improve respiratory function, and use antibiotics to prevent infection. Because persistent hemothorax increases the likelihood of coagulative or infectious hemothorax, indications for closed thoracic drainage should be relaxed. Progressive hemothorax should be performed in time for thoracotomy. Coagulation hemothorax should be operated as soon as possible after the injured person's condition is stable, to remove the blood clot, and to remove the capsule formed by the mechanization of the blood clot on the pleural surface. Infectious hemothorax should promptly improve thoracic drainage and drain infectious hemorrhage and pus; if there is no obvious effect or poor lung retension, surgical infection should be removed as soon as possible and the purulent fibrous membrane should be stripped. In recent years, video-assisted thoracoscopy has been used for the treatment of coagulative hemothorax and infectious hemothorax. It has the advantages of less surgical trauma, accurate curative effect, and faster recovery of patients after surgery.

Chest injury sternal fracture

1. Cause: A sternal fracture is usually caused by the direct action of violence. The most common cause is a driver's chest hitting the steering wheel in a traffic accident. Most sternal fractures are transverse fractures, which occur at the junction of the sternal stem and body or at the sternal body. Fractures of multiple costal cartilage next to the sternal bone may cause sternal floating, leading to flail chest. Fractures of the sternum are prone to blunt heart injury, and trachea, bronchi, and large blood vessels in the chest and their branches are damaged ^[3] .

2. Clinical manifestations: Patients with sternal fractures have obvious chest pain, cough, pain aggravated during breathing and changing postures, accompanied by shallow breathing, weak cough, and increased respiratory secretions. The deformity of the sternal fracture was visible, and local tenderness was obvious. The displacement of the fracture stump is usually the fracture with the lower stump forward and the upper stump backward. The two overlap. Lateral and oblique X-ray films can be found fracture line of sternal fracture.

3. Treatment: The treatment of simple sternal fractures is mainly bed rest, local fixation, analgesia and prevention and treatment of complications. Broken sternal fractures should be reset as soon as possible on the basis of stable body conditions. Generally, under local anesthesia, the position of the thoracic spine overstretching, chest extension, and arms raised can be used to press down the fracture end overlapped by means of compression. Do not use violence to reset, so as to avoid combined injuries. Patients with obvious overlapping fracture ends, difficulty in manual reduction, or patients with floating sternal bones need to be surgically repositioned under general anesthesia, drilled near the fracture ends, and fixed with stainless steel wire. Those who use surgical fixation can get out of bed early, and those who reset by manipulation need to rest in bed for 2 to 3 weeks.

Chest injury lung injury

1. Etiology: According to the histological characteristics of the injury, lung injury includes lung laceration, lung contusion, and lung knock (shock) injury. Pulmonary lacerations with visceral pleural lacerations can cause hemopneumothorax, while those with intact pleural pleura can form intrapulmonary hematomas. Lung Blast Injury Lung tissue is damaged by high pressure air or water waves generated by the explosion. Lung contusion is mostly caused by blunt violence, causing damage to the lungs and vascular tissues. In the post-injury inflammatory response, capillary permeability increases, inflammatory cell deposition and release of inflammatory mediators cause edema in the injured area and large areas of the lung. Pulmonary and alveolar edema cause hypoventilation and lead to hypoxemia.

2. Diagnosis: The diagnosis and treatment of pneumothorax caused by pulmonary laceration are as described above. Intrapulmonary hematomas are mostly found on chest X-ray examinations, which appear as round or oval lungs with clear edges and dense masses, which are usually absorbed by themselves within 2 weeks to months. Patients with pulmonary contusion show dyspnea, hemoptysis, bloody foamy sputum, and lung snoring. In severe cases, hypoxemia occurs. Often accompanied by flail chest. X-ray chest radiographs show patchy infiltrates, which generally become more obvious 24-48 hours after injury, and the accuracy of CT examination is higher than that of X-ray examination.

3 Treatment principles:

Handle combined injuries in a timely manner;

keep the airway open;

oxygen inhalation;

Limit excessive input of crystal liquid;

give adrenocortical hormones;

Hypoxemia is supported by mechanical ventilation.

Chest injury trachea and main bronchus injury

The possible mechanisms of blunt trachea and main bronchial injury are:

Suddenly hold your breath when the chest is compressed, the sudden increase in pressure in the trachea and main bronchus causes rupture;

Squeeze the chest forward and backward to move the two lungs to the side. The trachea bifurcation is strongly pulled to cause the main bronchus to rupture at the beginning;

The shear force generated by deceleration and rotation acts on the main bronchus near the hilum and ruptures;

The head and neck are leaning back, the trachea is overextended and the trachea is broken at the entrance of the thorax. Penetrating tracheal and bronchial injuries are directly related to the trauma or ballistic path. Neck tracheal injuries are often accompanied by thyroid, large blood vessel, and esophageal injuries. Intrathoracic and main bronchial injuries are often accompanied by esophageal and vascular injuries. Endotracheal intubation, tracheotomy, endoscopy, and foreign body removal can all cause damage to the trachea or main bronchus by mistake.

(A) main bronchial injury

Occurred in the main bronchus segment 2 ~ 75px from the carina. The left main bronchus is longer and there is more chance of injury.

Clinical manifestations The main bronchial injury manifested as cough, hemoptysis, dyspnea, mediastinum and subcutaneous emphysema, tension pneumothorax or tension pneumothorax. One of the following conditions should be suspected of the main bronchial injury:

Severe mediastinum and subcutaneous emphysema in chest injury;

Tensile pneumothorax;

After the closed thoracic drainage is installed, there is a continuous leak and the lung cannot be re-expanded;

An orthotopic chest radiograph showed atelectasis, the apex of the lungs dropped below the plane of the main bronchus, and gas was found to accumulate below the deep cervical fascia in the lateral radiograph. Fiberoptic bronchoscopy helps determine the diagnosis and determine the site of injury.
Treatment first keeps the airway open, corrects shock, and relieves tension pneumothorax. A clear diagnosis should be made as soon as possible to open the chest for exploration and bronchoplasty. Early surgery helps to expand the lungs, prevent bronchoconstriction, and is easier to operate. Patients with advanced surgery all have atelectasis. The key to retaining the lung is whether the distal lung can be re-expanded. For the lung that cannot be re-expanded, lobes or pneumonectomy should be performed.

(B) tracheal injury

Blunt violence at the front of the neck can cause separation of the larynx from the trachea, tracheal rupture or rupture, and can also cause the destruction of multiple tracheal cartilage rings, causing softening of the trachea and suffocation. A backward displacement of the sternal fracture may tear the intrathoracic trachea. Tracheal injury is often associated with cervical, thyroid, esophageal, and cervical large vessel injuries.
Clinical manifestations The clinical manifestations of blunt tracheal injury are cough, wheezing, dyspnea, altered pronunciation, hemoptysis, subcutaneous or mediastinal emphysema in the neck. Some patients have sternal fractures. Penetrating tracheal injury can find the trauma and ballistics of the neck and chest, and gas can often escape from the wound with breathing. Patients often have hemoptysis, subcutaneous neck and mediastinal emphysema.
Endotracheal intubation should be performed urgently to prevent blood and secretion from flowing into the distal trachea to keep the airway open. The distal trachea may be retracted into the chest cavity when the trachea is transected or the laryngotracheal tube is separated. A low lateral neck incision is urgently made, and the paratracheal fascia is cut. After the finger is probed, the distal end is clamped with tissue forceps and inserted into the tracheal tube. When tracheal intubation is difficult, fiber bronchoscope can be inserted, and then intubated. If the tracheal wall is seriously contused when repairing the anastomosis, 2 to 4 tracheal rings can be removed, and then anastomosis is performed.

Chest injury heart injury

Heart injury can be divided into blunt heart injury and penetrating heart injury. Blunt injuries are mostly caused by impact, deceleration, compression, fall from height, impact, etc. in the chest area. Penetrating injuries are mostly caused by sharp, blade or firearms.
(A) blunt heart injury

The severity of blunt heart injury is related to the impact speed, mass, duration of action, cardiac contraction phase, and cardiac force area of blunt violence. Mild cases are mostly asymptomatic myocardial contusions, and severe cases may even cause heart rupture.

Clinical manifestations and diagnosis: Mild myocardial contusion may have no obvious symptoms, and moderate to severe contusion may appear chest pain, palpitations, shortness of breath, and even angina pectoris. Patients may have anterior thoracic wall soft tissue damage and sternal fractures. The commonly used auxiliary examinations are: electrocardiogram; echocardiogram; myocardial enzyme detection.

Treatment mainly includes rest, close monitoring, oxygen inhalation, and analgesia. Special clinical treatments focus on potentially fatal complications such as arrhythmia and heart failure.

(Two) penetrating heart injury

Most penetrating heart injuries are caused by firearms, blades or sharps.

Clinical manifestations and diagnosis: The pathophysiology and clinical manifestations of penetrating heart injury depend on the pericardium, the degree of heart injury, and the pericardial drainage. When the injuries and kinetic energy are small, the pericardial and cardiac fissures are small, and the pericardial fissures are easily blocked by blood clots and the drainage is not smooth, which leads to cardiac tamponade. The clinical manifestations are Baker's triad with elevated venous pressure, jugular vein distension, distant heart sounds, weak heartbeat, small pulse pressure, and decreased arterial pressure. When the injured body and the kinetic energy of injury are large, the pericardial and cardiac fissures are large, the pericardial fissures are not easily blocked by blood clots, and most of the bleeding flows into the chest cavity, which is mainly manifested by hemorrhagic shock.
Key points for diagnosis:

The chest wound is located at or near the projection area of the body surface of the heart;

short time after injury;

Baker's triad or signs of hemorrhagic shock and massive hemothorax. The condition of penetrating heart injury has progressed rapidly. Relying on chest X-ray, electrocardiogram, ultrasound, echocardiography, and even pericardial puncture is a time-consuming and inaccurate method. For those with short post-injury time, stable vital signs, and unable to rule out heart injuries, they should expand the wound tract under local anesthesia in the operating room with general anesthesia conditions to clear the diagnosis and avoid delaying the golden opportunity for rescue.
Treatment: Patients who have cardiac tamponade or hemorrhagic shock should immediately undergo thoracotomy in the emergency room. Under tracheal intubation under general anesthesia, the cut heart capsule relieves congestion, controls bleeding, and quickly replenishes blood volume. The iatrogenic heart injury that occurred during the cardiac interventional diagnosis and treatment should be terminated immediately after removal, the cardiac catheter should be removed, protamine should be given to neutralize the anticoagulant effect of heparin, and pericardial puncture and aspiration should be performed. Rescuing survivors of penetrating heart injury should pay attention to the presence of residual foreign bodies and other lesions in the heart, such as traumatic ventricular septal defect, valve damage, traumatic ventricular aneurysm, arrhythmia, pseudoaneurysm, or recurrent attacks. Pericarditis, etc. [3].

Chest injury diaphragm injury

Diaphragmatic injuries can be classified as penetrating or blunt diaphragm injuries according to the different types of traumatic violence. Penetrating injuries are mostly caused by firearms or blades. The depth and direction of the trauma are directly related to the affected thoracic and abdominal organs, and are often accompanied by hemorrhagic shock. The blunt injury is very traumatic and the injury mechanism is complicated, often accompanied by multiple site injuries. The clinical manifestations of diaphragmatic injuries are relatively mild, often hidden by other important organ injuries and missed diagnosis. It is not until a few years later that a diaphragmatic hernia has been detected.
(A) penetrating diaphragm injury

Penetrating injury to the lower chest or upper abdomen can involve the diaphragm, causing penetrating diaphragm injury. Simple diaphragmatic injuries caused by penetrating violence are rare. In addition to clinical manifestations such as massive external bleeding at the body wound, hemorrhagic shock and other clinical manifestations of thoracoabdominal or abdominal chest injury, hemothorax, pneumothorax, pericardial hemorrhage, abdominal hemorrhage, gas accumulation, and cavity organ perforation are usually present at the same time. Signs of peritonitis. Bedside B-ultrasound can quickly and accurately determine the situation of pleural and abdominal hemorrhage. Thoracocentesis and abdominal puncture are simple and effective measures for judging blood in the thorax and abdomen.

Emergency diagnosis and surgery for penetrating diaphragmatic injury. The chest sucking wound and tension pneumothorax were treated first, blood transfusion was given to correct shock, and surgery was performed quickly. According to the injury and clinical manifestations, a transthoracic or abdominal incision was selected to control bleeding in the thoracic and abdominal cavity, and the thoracic and abdominal organs were carefully explored, and the damaged organs and diaphragm muscles were repaired.
(B) blunt diaphragm injury

Blunt diaphragm injuries are mostly caused by sudden deformation of the lower thorax attached to the diaphragm and a sudden increase in pressure gradient between the thorax and abdomen. Traffic accidents and falls from heights are the most common causes of blunt diaphragm injuries. About 90% of blunt diaphragm injuries occur on the left. Diaphragmatic fissures caused by blunt injuries are large, sometimes over 250px, and are often located in the central tendon of the diaphragm and the attachment of the diaphragm. Abdominal internal organs can easily enter the thorax through the diaphragmatic fissure hernia. Common abdominal hernias that enter the thorax are the stomach, spleen, colon, small intestine, and liver. Severe blunt violence can not only cause diaphragmatic injury, but also often cause contusion and lacerations of the thoracic and abdominal cavity, and is often accompanied by injuries to the brain, spine, pelvis and limbs.
Blood pneumothorax and hernias into the abdominal cavity of the chest cause lung compression and mediastinal displacement, resulting in dyspnea, reduced chest breathing sounds on the injured side, dullness or drum sounds on percussion. Hernia into the thorax of the abdominal organs incarcerated and strangulation, abdominal pain, vomiting, abdominal distension and peritoneal irritation such as gastrointestinal obstruction or peritonitis manifestations. It is worth noting that the initial diagnosis after diaphragmatic rupture may be difficult to diagnose, and the clinical signs and chest X-ray examination results are not specific, and CT examination is helpful for diagnosis. Because the gas and contrast agent entering the intestine can transform part of the obstruction of the hernia into the intestine into a complete obstruction, double-barium gastrointestinal examination is forbidden. Patients with diaphragmatic hernia should be cautious for thoracentesis or closed thoracotomy, as it may damage the abdominal organs of the hernia into the thorax. For those with suspected traumatic diaphragmatic hernia, inflated military anti-shock pants are prohibited to avoid increasing intra-abdominal pressure.
Once the traumatic diaphragmatic rupture or diaphragmatic hernia is highly suspected or diagnosed, and the other organs have been stabilized, the diaphragm repair should be performed as soon as possible. Carefully explore the internal organs of the thorax and abdomen and treat them accordingly.

Traumatic asphyxia

Traumatic asphyxia is blunt violent action on the chest caused by extensive skin and mucosal peripheral capillary stasis and bleeding damage in the upper body. When the chest and upper abdomen are violently squeezed, the patient's glottis is tightly closed, and the intrathoracic pressure suddenly increases. .
The clinical manifestations are purple-blue petechiae and petechiae with pinpoint size on the skin of the face, neck, and upper chest, which are obvious on the face and orbit. There are ecchymosis and even bleeding in the oral cavity, bulbar conjunctiva, and nasal mucosa; bleeding from the retina or optic nerve can cause temporary or permanent visual impairment; rupture of the tympanic membrane can cause external ear canal bleeding, tinnitus, and even hearing impairment. After the injury, most patients have temporary disturbance of consciousness, irritability, dizziness, delirium, and even spasm of the limbs. The pupils can be enlarged or extremely narrowed. The above manifestations may be related to slight point hemorrhage and cerebral edema in the brain. If the intracranial vein ruptures, the patient may become unconscious or even die. The bleeding spots and ecchymosis caused by traumatic asphyxia can usually be absorbed and subsided after 2 to 3 weeks. In general, patients should be treated symptomatically under close observation. Those with combined injuries should be given active treatment for specific injuries.