Transcript physical signs of the thorax

LIDIA IONESCU
The 3 rd. Surgical Unit
The Thorax or Chest
 Region of the body between the neck and the
abdomen
 The framework of the wall- thoracic cage: vertebral
column, ribs, IC spaces, sternum, costal cartilages
 Communication with the neck- thotacic outlet
 Separated from the abdomen by the diaphragm
The thorax or Chest
 The cavity of the thorax: mediastinum and laterally,
pleurae and lungs
 The lungs are covered-thin membrane-visceral pleura
 The inner surface of the chest wall- parietal pleura
 Between lungs and thoracic wall- pleural cavity
Physical examination
 Detect the evidence of disease:
 Inspection
 Palpation
 Percussion
 Auscultation
EXAMINE THE CHEST
 INSPECTION
 CYANOSIS
 RR AND RHYTHM
 CHEST EXPANSION
 PARADOXICAL MOVEMENT
 DEFORMITIES
PECTUS EXCAVATUM
Pectum excavatum
Pectus carinatum
KYPHOSIS
SCOLIOSIS
Cyanosis
Bluish discoloration
Lack of O2 in the blood
Clubbing
 Exaggerated
anteroposterior and
longitudinal curvature
of the nails
 Loss of angle between
nail and nail bed
(demonstrated by
"Lovidond's diamond
sign")
 "Drumstick" or "parrot
beak" appearance of the
nail
Thoracic cage
Surface landmarks
Surface landmarks
Surface landmarks
Thorax- anterior aspect
 Suprasternal notch
 Sternal angle
 Xiphisternal joint
 Subcostal angle
 Costal margin
 Clavicle
 Ribs
 Axillary folds
Lines of orientation
 Midsternal line
 Midclavicular line
 Anterior axillary line
 Posterior axillary line
 Midaxillary line
 Scapular line
Lines of orientation
Lines of orientation
Lines of orientation
Diaphragm
Surface landmarks
Thorax-posterior aspect
 Spinous processes of the thoracic vertebrae
 Scapula: superior angle, inferior angle
EXAMINE THE CHEST
 PERCUSSION
 RESONANT SOUND- NORMAL
 HYPERRESONANCE- EXTRA AIR
 DULNESS- PLEURAL FLUID
EXAMINE THE CHEST
 PALPATION
 TRACHEA
 CHEST EXPANSION
 APEX BEAT
 AXILLAE
 BREASTS
EXAMINE THE CHEST
 AUSCULTATION
 VESICULAR
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BREATHING
WHEEZE
COARSE CRACKLES
FINE CRACKLES
PLEURAL RUB
CHEST EXPANSION
CHEST LANDMARKS
OF THE LUNGS
Surface landmarks
Surface landmarks
CHEST ASCULTATION
BREASTS
GYNECOMASTIA
AXILLARY PALPATION
LYMPHADENOPATHY
EXAMINE THE HEART AND CIRCULATION
 MEASURE BP
 JUGULAR VEINS
 NECK ARTERIES
 TRACHEA
 HEART
HEART LANDMARKS
POINT OF MAXIMUM IMPULSE
HEART INSIGHTS
Thoracic outlet syndrome
 Compression of the neurovascular bundle
 Causes: cervical rib or trauma arm/neck
 Cervical rib- enlarged transverse process-C7:
 free anterior end or connected to rib 1
 fibrous band/joint
 Pressure symptoms on lower trunk of BP- pain
forearm/hand , hand muscle wasting.
 Arterial/venous involvement is less common
Thoracic outlet obtruction
 Diagnosis- history and physical examination
 Ulnar nerve conduction studies- confirm dg.
 Treatment- decompress the TO-resecting cervical rib
Injuries to the thoracic cage
 Rib fractures
 Sternal fractures
 Flail chest
Rib fractures
 The most common injuries- blunt chest trauma
 Old people- minor trauma- rib fracture
 Fracture of the 1st rib- mark for severe lesions
 Fracture of the lower ribs- hepatic and splenic injury-
hemoperitoneum
 Treatment- IC nerve blocks/epidural anesthesia
 Complications: hemothorax, pneumothorax,
atelectasis, pneumonia.
Sternal fracture
 Rare fracture- car steering wheel- abrupt deceleration
 Associated injuries: pseudoaneurism, ruptured
esophagus, myocardial contusion, ruptured bronchus,
flail chest
 Diagnosis- mechanism of injury, physical
examination, CXR- lateral view
 Treatment- pain killers
Flail chest
 20% of pts. with severe blunt chest injury
 Multiple segmental rib fractures
 The stability of the chest is lost
 The flail segment- sucked in – inspiration/ driven out-
expiration= paradoxical respiratory movements
 Paradoxical respiration- movement of air between the
lungs- poor ventilation-poor oxygenation
 Treatment- pain relief, OTI with +p. if needed.
Chest trauma- case report
 A 32-year-old female patient suffered an automobile accident which resulted:
in left hemopneumothorax,
 left pulmonary contusion and
 double fractures extending from the third to the eighth left costal arches,
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as seen on chest X-rays and computed tomography scans of the chest.
 Tomography of the skull, cervical spine, abdomen, and pelvis, were normal
 Electrocardiogram and echocardiogram-WNL,
 Tests for muscle enzymes and markers of myocardial necrosis-WNL
 Water-sealed thoracic drainage was performed,
 Epidural catheter was inserted in order to provide continuous analgesia using
an infusion pump.
Case report
 Mechanical ventilation- not needed
 Chest deformation- surgical repair
Case report
 Reduction of the fractures and fixation of the ribs with
steel wires, perforating the extremities of the ribs with a
drill, passing the steel wire from one rib segment to
another, and tying it.
 A chest tube was inserted and left in place until the third
day.
 The patient evolved to excellent pain control and improved
respiratory dynamics.
 Postoperative X rays and tomography scans confirmed the
favorable result of the surgical treatment .
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2 .and
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Fractures
left rib
with callus formation
Flail chest
Flail chest
Multiple rib fractures
Pneumothorax
Rib fractures, left hemo-pneumothorax
Disorders of the pleural space
 Spontaneous pneumothorax
 Iatrogenic pneumothorax
 Traumatic pneumothorax
 Tension pneumothorax
 Sucking chest wound
Pneumothorax
 Spontaneous pneumothorax
 Iatrogenic pneumothorax
 Traumatic pneumothorax
 Tension pneumothorax
 “Sucking chest wound”
Pleural effusion
 Collection of pleural fluid
 Etiology:
 infection
 secondary from intra abdo. sepsis
 heart failure
 cirrhosis
 malignancy:
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primary mesothelial tumor,
bronchogenic carcinoma,
metastatic carcinoma
Pleural effusion
 Symptoms: chest pain, cough, dyspnea
 Signs: dullness on percussion, absent BS. on
auscultation
 Diagnosis: CXR, thoracocentesis- culture/Gram’s stain,
Rivalta reaction, cytology, biochemistry.
Hemothorax
 Blood accumulating within pleural space
 50%-70% of the pts. with blunt/penetrating chest
trauma
 Minimal bleeding- observation
 Extensive bleeding- prompt action
 Diagnosis- mechanism of injury, symtoms, signs,
CXR/CT
 Symtoms: chest pain, dyspnea/polipnea cyanosis,
 Signs: trauma mark, BS absent, BP, PR, capillary refill
Hemothorax
 Treatment:
 Pleural drainage tube,
 Oxygen
 Pain killers
 Exploratory thoracotomy
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massive initial drainage> 1000ml.
bleeding> 200ml/h
Case report
 Horner’s syndrome - triad of symptoms (miosis, ptosis, and
anhydrosis) resulting from disruption of the cervical sympathetic
pathways .
 In blunt trauma, it is usually associated with carotid artery dissection.
 A case of Horner’s syndrome in a 22-year-old man after blunt trauma to
the neck and head unrelated to carotid artery dissection
Case report
 A 22-year-old man was brought to the emergency
room after motorcycle fall, with history of
transitory loss of conscience.
 At hospital, he was alert and orientated, the
carotid pulses were symmetric, regular with no
bruits.
 The chest and the abdomen had no signs of
abnormalities.
Case report
The patient related moderate cervical pain but no
neurological deficits were noticed except for the
asymetric pupils that measured 5 mm on the right
and 2 mm on the left side.
Foto motor reflexes normal
The left eyelid was 1–2 mm lower than the right ,
The extraocular movements were intact and the
cranial nerve examination was normal.
Assimetric pupils and left semiptosis
Case report
 The chest X-ray did not reveal any rib, sternal fractures or mediastinal
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enlargement.
Skull computed tomography (CT) showed no abnormality so as the
carotid ultrasonography Doppler and the angio-tomography of the
head and neck.
Cervical spine CT showed a fracture of left C7 transverse process
Chest CT disclosed a mediastinal hematoma extending to the left lung
apex, exhibiting mass effect over surrounding structures without signs
of aortic dissection .
A conservative management was adopted and the patient left the
hospital three days later but still with the neurologic signs.
Follow up four weeks after discharge revealed a normal neurologic
examination and no complaints.
Mediastinal hematoma extending to the left apex
Case report
 Horner,s syndrome is an uncommon occurrence in all age
groups (0.08% of blunt trauma patients).
 Diagnosis is namely based on clinical findings, and after
careful history and examination, the physician must decide
whether further investigation is necessary.
 There is a wide variety of conditions that may cause this
syndrome, postsurgical and iatrogenic causes comprise
most of the cases.
 Penetrating neck injuries, cervical spine dislocation and
birth trauma are the major factors that lead to traumatic
injury to the oculosympathetic pathway.
Case report
A history of trauma preceding these findings should prompt the
clinician to consider that the carotid artery, which lies directly over the
sympathetic chain in the neck, may have been injured, particularly if
signs of head or neck trauma are present.
 The investigation of choice considered by some authors is a magnetic
resonance imaging and angiography scan of the head and neck.
 Therefore, to exclude carotid injury the authors performed an
ultrasonography Doppler and an angio-tomography what seems to be
less invasive and with a high sensivitity.
 The carotid dissection diagnosis implies an emergent condition that
can lead, if misdiagnosed, to major catastrophes including massive
ischemic stroke, even in a patient with minor symptoms at admission.
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Case report
 In this case further investigation showed a mediastinal and left lung
apical hematoma which probably caused compression of the
sympathetic ganglia, as the clinical findings appeared in first day of
trauma.
 The fracture of the left C7 transverse process could explain the cervical
pain and hematoma
 Mediastinal hematoma due to trauma is associated with sternal
fracture, aortic dissection and extrapericardial cardiac tamponade.
Case report
 In this case, the patient was hemodynamically
stable and no surgical intervention was necessary.
 This report illustrates a condition that can be seen
in the trauma emergency department and shows
that a meticulous investigation with proper
complementary exams is necessary because such
signs can be just the "iceberg tip".
Conclusion
 Horner’s syndrome is a very rare condition after
mild neck and chest trauma.
 The understanding of this clinical entity may help
the surgeon to make a better differential diagnosis
in trauma patients in whom correct and prompt
diagnosis can be lifesaving.
Case report 2
 41-year-old male developed a hemothorax after sustaining a stab
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wound in the right chest.
The patient was managed conservatively with thoracostomy tube
drainage for 3 days and was subsequently discharged home.
Two weeks later the patient returned to the hospital with pleuritic
chest pain and shortness of breath.
Imaging studies revealed a right-sided pleural effusion and an enlarged
cardiac silhouette, which was consistent with pericardial effusion as per
ultrasonography.
Thoracoscopic exploration revealed an enlarged heart, that following
pericardiotomy drained 400 mL of frank blood. Subsequently, cardiac
contractility improved, and no further bleeding was evident.
Case report 2
 The majority of patients suffering penetrating wounds to the heart do
not survive long enough to receive any medical assistance.
 However, among those who reach the hospital, most cardiac injuries
are discovered at admission and treated accordingly, whether initially
decompressed with a subxiphoid pericardial window, or approached
with an open thoracotomy.
 Infrequently, a penetrating injury to the heart may be missed on initial
assessment, the patient returning to the hospital a few weeks later with
different degrees of hemopericardium.
 Delayed hemopericardium after penetrating chest injury has been
described in the literature, with the therapeutic approach invariably
involving pericardiocentesis or open thoracotomy.
Case report 2
 Thoracoscopic pleuropericardial window has been
popularized as a way to drain different types of
pericardial effusion:
 with the advantage of better exposure than the
traditional subxiphoid pericardial window,
 but without the morbidity associated with an open
thoracotomy..
Case rerport 2
 A 41-year-old male was seen in the emergency department
after a stab wound to the right chest.
 At admission the patient was in stable condition, with a
CXR positive for hemopneumothorax, and without
evidence of cardiac enlargement.
 A thoracostomy tube was placed in the right hemithorax,
and 3 days later the patient was discharged after the chest
tube was removed and adequate lung expansion verified.
Case report 2
 Two weeks later, the patient returned to the emergency
department complaining of increasing right-sided pleuritic
chest pain and shortness of breath.
 Initial assessment revealed bilateral pleural effusions on
CXR predominantly in the right side, as well as an enlarged
cardiac silhouette .
 A thoracostomy tube was placed in the right chest again
and connected to wall suction, draining 300 mL of
serosanguineous fluid upon insertion.
CXR- right pleural effusion, increased cardiac size
Case report 2
 Further imaging studies included a 2-D echocardiogram,
which was positive for pericardial effusion.
 A CT of the chest showed bilateral pleural effusions and
fluid around the pericardium .
 The patient was taken to the operating room for
thoracoscopic exploration, with the presumptive diagnosis
of bilateral loculated hematomas and associated
hemopericardium.
Pleural effusions, fluid around pericardium
Case report 2
 It is worth mentioning that during the first admission,
pericardial ultrasound was not performed on the patient,
since at that point it was not yet readily available in the
emergency department.
 The operation was performed under general anesthesia
with double-lumen orotracheal intubation.
 The patient was placed in the right lateral position and
draped in the standard fashion as for a formal thoracotomy.
.
Case report 2
 After deflation of the left lung, a thoracoscope was
introduced one finger breadth below the tip of the scapula,
next to the posterior axillary line, in the 6th. IC space.
 Full assessment of the left hemithorax was performed, and
200 mL of blood was drained.
 During inspection, the heart was revealed to be enlarged,
suggesting a retained hemopericardium after penetrating
injury to the heart. After identifying the phrenic nerve, a 4
cm. longitudinal incision was made in the pericardial sac400 ml. of frank blood was drained from the pericardial
cavity, with immediate evidence of improved cardiac
contraction.
Case report 2
 The camera was advanced and introduced inside
the sac, visualizing sparse clots and no active
bleeding evident at that time.
 After complete inspection of the left hemithorax,
anterior and posterior chest tubes were left in
place for continuous drainage.
Case report 2
 The patient was then placed in the left lateral position to
approach the right hemithorax.
 Access was gained following the same landmarks used for
the left chest, and with selective deflation of the left lung.
 Full inspection of the right hemithorax revealed sparse
adhesions, and 400 mL of retained blood was removed.
 The adhesions were taken down, the chest cavity irrigated,
and a chest tube left in place.
Case report 2
 The patient tolerated the procedure and was
extubated on the first postoperative day.
 With drainage progressively decreasing, the
thoracostomy tubes were removed four days later.
 Chest films revealed no reaccumulation of pleural
or pericardial effusions.
 The patient was finally discharged with no major
complaints, and 8 months after surgical
intervention remains asymptomatic.
Case report 3
 A 65 years old female was a driver involved in a
front-impact car versus tree crash.
 The impact occurred slightly to the left of the car’s
centerline, with a 15–20" intrusion of the tree into
the engine compartment, displacing the front
bumper, grille and engine.
 The steering wheel was bent, and because neither
door could be opened, a rescue operation was
conducted to remove the driver’s door with a
hydraulic spreader to extricate the patient.
Case report 3
 Paramedics arrived within four minutes and found the
patient in the vehicle, complaining of severe chest pain and
dyspnea.
 There was no chest wall asymmetry or paradoxical
movement, and equal bilateral breath sounds were present.
 The patient was conscious and alert, recalling events and
denying loss of consciousness.
 Initial vital signs: Pulse 124, respirations 24, BP 108/78
Case report 3
 During the 14-minute extrication, the patient continued to
experience severe anterior chest pain and increasing
dypsnea.
 She became pale and more tachycardic.
 Hypotension developed, with palpable BP dropping to 80
systolic at approximately minute 10 of the extrication.
 Because the patient was becoming unstable, rescuers
expedited their efforts and decided to perform a rapid
extrication maneuver once the door was removed.
Case report 3
 Approximately one minute prior to successful extrication, the patient
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developed agonal breathing and her carotid pulses were lost.
Once the door was removed, the patient was moved onto a long
backboard, CPR was performed, and the patient was intubated and
transported to a Level 1 trauma center.
On arrival at the trauma center, resuscitation proceeded rapidly.
A focused assessment sonogram for trauma showed a pericardial
tamponade.
Surgeons performed an immediate thoracotomy and pericardiotomy,
which revealed a right atrial rupture .
Resuscitative efforts failed to return organized heart activity, and the
patient died.
Blunt cardiac injuries
 (BCI) is a spectrum of injuries ranging from asymptomatic myocardial
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contusion to cardiac chamber rupture and death.
Mechanisms by which BCI may occur include motor vehicle crashes,
falls from heights, direct blows to the chest and explosions.
The most common mechanism of BCI is an MVC.
Occasionally an isolated direct blow to the chest may cause
ventricular fibrillation and death, a condition termed commotio
cordis.
Differential dg.: hemorrhage, tension pneumothotrax, hypoxia.
Case report 3
 Rupture of a cardiac chamber, coronary artery or
intrapericardial portion of a great vessel leads to
cardiogenic shock from pericardial tamponade and
rapid death.
 Cardiac rupture is associated with a 60–100%
mortality rate in the literature.
Large tear in the right atrium
BCI
 BCI is difficult to diagnose without the aid of echocardio.
 Prehospital providers should inspect the scene of the injury
and surrounding circumstances, as well as conduct a
thorough physical exam.
 Patients may complain of chest pain, shortness of breath or
palpitations.
 Vital signs may be completely normal with minor
contusions, or demonstrate tachycardia, arrhythmia or
hypotension in more severe forms of injury.
BCI
 Although physical examination is non-specific,
sternal tenderness or ecchymoses may be found.
 On auscultation, the finding of a murmur, rub or
muffled heart sounds should raise suspicion of
BCI, but these findings aren’t typically present.
 Because BCI is often associated with other injuries
to the thorax, subcutaneous emphysema, flail
chest and bony crepitus secondary to rib fractures
may be present.