Overview The bony thorax supports the protection of the intra-thoracic organs and participates in the whistling motion. The heart and large blood vessels are located in the thoracic cavity, and trauma to the thorax can have an impact on whistling and circulation. Fractures of the sternum or ribs under the action of blunt violence can destroy the integrity of the bony thoracic contour and cause collision, compression, rotation and distortion of the heart and lungs within the thoracic cavity, resulting in extensive tissue contusions. Tissue edema secondary to contusions may lead to organ dysfunction or failure. Classification】 1.According to the different nature of injury violence, divided into blunt injuries and penetrating injuries 2.According to whether the pleural cavity and the external communication, divided into open chest injury and closed chest injury. The principles of pre-hospital emergency treatment: the principles are: maintaining a clear airway, oxygen, control of external bleeding, replenishment of blood volume, analgesia and rapid transport. 2, in-hospital emergency treatment: emergency open-chest exploratory surgery: ① progressive bleeding in the pleural cavity ② large-vessel injury to the heart ③ serious lung laceration or tracheal, bronchial injury ④ large foreign body retained in the chest cavity. 3, the ideal goal of thoracic trauma treatment is: ① restore effective ventilation; improve hypoxia ② bleeding has been controlled, hemodynamic stability ③ lung reopening, thoracic stability, pneumothorax, hemothorax no longer exist ④ re-establish the integrity of the diaphragm, and restore normal movement ⑤ combined injuries have been correctly handled. Rib fracture 【Pathophysiology】 When violence is applied to the ribs, the ribs can be bent inward and broken, and the fracture end can pierce the pleura, lung and intercostal vessels inward and cause complications such as pneumothorax or hemothorax. Multiple rib fractures will cause the local chest wall to lose the intact rib support and soften, resulting in paradoxical whistling motion, i.e., the chest wall of the softened area sinks in during inspiration and protrudes outward during whistling, also known as shackle chest. Diagnosis 】 1, clinical manifestations: rib fracture site has obvious pain and pressure pain, especially in deep whistling, coughing or turning position aggravated. If there is a large area of the “floating chest wall”, shortness of breath, cyanosis or inspiratory difficulties can occur. Squeezing the chest wall with both hands left and right or back and forth can cause severe pain at the fracture site or rubbing sound at the broken end of the bone, which is called a positive “thoracic squeeze test”. 2.X-ray examination: chest X-ray can show the site, nature and number of rib fractures, and can understand the presence of hemothorax and pneumothorax. Differential diagnosis】 Soft tissue contusion of chest wall: pain is obvious, but there is no bone rubbing sound on physical examination, and there is no sign of rib fracture on X-ray, but it should be noted that X-ray cannot show the sign of rib cartilage fracture. 【Treatment principles】 1.Closed single rib fracture: analgesia, cleaning of whistling secretions, fixation of the thorax. 2.Closed multiple rib fracture: local pressure bandage, ensure the ventilation of the whistle. 3.Open rib fracture: the chest wall wound should be thoroughly debrided and the chest cavity closed drainage. Pneumothorax I. Closed pneumothorax [Pathophysiology] Pneumothorax leads to pulmonary atrophy, which affects pulmonary ventilation and ventilatory function, and the increase of intrapulmonary pressure on the injured side can cause the mediastinum to shift to the healthy side. Diagnosis】 1. Clinical manifestations: (1) According to the amount and speed of pneumoperitoneum, the milder ones can be asymptomatic, and the more severe ones have obvious inspiratory difficulties. (2) Physical examination: fullness of the injured side of the chest, reduced whistling activity, displacement of the trachea to the healthy side, drum sound on percussion of the injured side of the chest, and reduced whistling sound. 2, X-ray examination: different degrees of pulmonary atrophy and pleural cavity pneumatization, with a small amount of pleural effusion in fashion. 【Treatment principles】 1.Patients with small amount of pneumothorax do not need special treatment. 2, a large number of pneumothorax need to perform pleural puncture, pumping out the accumulated air, or perform closed chest drainage. Open pneumothorax 【Pathophysiology】 1. disappearance of negative pressure in the pleural cavity: the amount of venous blood return is affected, the injured side of the lung is atrophied, and gas exchange is insufficient, causing hypoxia and carbon dioxide accumulation. 2, mediastinal flutter: whistling and inspiration, the pressure imbalance between the pleural cavity on both sides appears cyclical changes, so that the mediastinum moves to the healthy side during inspiration and to the injured side during whistling, called mediastinal flutter. (1) The patient has a history of trauma, shortness of breath, difficulty in whistling and cyanosis leading to shock. (2) chest wall wound open, inspiratory difficulties, can hear the air in and out of the pleural cavity sound. (3) physical examination: the injured side of the chest percussion drum sound, whistling sound is reduced or disappeared, trachea, heart displacement. 2.X-ray examination: lung atrophy on the injured side, pneumothorax, trachea, heart and other mediastinal organs are displaced. 【Treatment principles】 1.First aid treatment: sterile dressing such as petroleum jelly with cotton pad to seal the wound, so that the open pneumothorax becomes closed pneumothorax, and then pleural puncture to pump and decompress to relieve the difficulty of whistling. 2, further treatment: debridement, suturing chest wall wound, closed chest drainage. 3.Tension pneumothorax 【Pathophysiology】 1.The injured side of the lung is compressed and atrophied, and the ventilation volume is greatly reduced. 2, intrathoracic tension pushes the mediastinum to the healthy side, so that the healthy side of the lung is compressed. 3.The mediastinum is displaced, which can distort the vena cava, thus reducing the amount of cardiac blood return and causing circulatory failure. 4.The pressure in the lung keeps increasing, and the gas may also enter the soft tissue of the chest wall, forming extensive subcutaneous emphysema in the chest, neck, head and face. [Diagnosis] 1. Clinical manifestations (1) Difficulty in whistling, sitting up and whistling, cyanosis, irritability. (2) physical examination: fullness of the chest on the injured side, widening of the rib space, reduced whistling amplitude may have subcutaneous emphysema, percussion with a drum sound and loss of whistling sounds. 2.X-ray examination: large amount of air accumulation in the chest cavity, complete atrophy of the lung, displacement of the trachea and heart to the healthy side. 3.Pleural puncture: there is high pressure air rushing outward, the symptoms improve after pumping, but soon see aggravation again. Treatment principle】 1.First aid treatment: immediately puncture the pleural cavity with a thick needle in the 2nd intercostal space of the middle line of the injured side of the shrunken femur, which can play the role of exhaustion and decompression. 2.Further treatment: if there is still tension after repeated pumping, closed drainage of the pleural cavity is required. 3.If the tension cannot be relieved even after closed drainage, it means that there is a large bronchial rupture or extensive laceration of the lung, which needs to be explored by thoracotomy. 4, postoperative antibiotics to prevent infection. 5, 24 hours after the closed drainage leak has stopped, chest radiographs confirm that the lung has recovered before pulling out the pleural cavity closed drainage tube. Hemothorax 【Concept】 Blood accumulation in the pleural cavity caused by chest injury is called hemothorax, which can coexist with pneumothorax. Pathophysiology】 1.Forced lung atrophy, and pushed the mediastinum to the healthy side, thus seriously affecting the function of whistle circulation. 2.Signs of internal bleeding due to decreased blood volume. 3.A large amount of blood accumulates in a short period of time, and the action of defibrin is not perfect, and blood clots can be formed. After the clot is mechanized, fibrous tissue is formed to bind the lung and thorax, limiting the whistling motion and impairing the lung function. Diagnosis】 1.X-ray examination of small amount of hemothorax shows the disappearance of rib diaphragm angle. 2, medium amount of hemothorax (0,5-1L) and large amount of hemothorax (1L) or more, especially acute hemorrhage, may appear symptoms of hypovolemic shock such as fine and rapid pulse, decreased blood pressure, shortness of breath, and signs of pleural effusion such as intercostal fullness, displacement of trachea to the healthy side, and diminished or absent whistling sounds. The chest X-ray shows a large amount of fluid in the chest cavity on the injured side, and the mediastinum may be displaced to the healthy side. The combined pneumothorax shows the fluid level, and the pleural cavity is more clearly diagnosed by drawing blood by puncture. 3.The following signs suggest progressive hemothorax: ① blood pressure continues to fall, pulse rate gradually increases, blood pressure does not rise after blood transfusion and fluid replacement or falls rapidly after it rises again. ②Closed chest drainage of more than 200ml per hour for 3 hours ③Progressive decrease in hemoglobin, red blood cell count and hematocrit. The amount of hemoglobin and red blood cell count of the drained pleural effusion is close to that of the surrounding blood and rapidly coagulates. 4,, with the following conditions should be considered infectious hemothorax: with chills, fever; pleural effusion of blood RBC/WBC up to 100:1 can be identified as infectious hemothorax. 【Treatment】 1.Non-progressive hemothorax: (1) A small amount of hemothorax may not be aspirated, relying on self-absorption. (2) If the blood accumulation is large, early pleural puncture should be performed to promote the improvement of lung function. (3) Closed drainage of pleural cavity should be performed early to help observe whether there is progressive hemothorax. (4) Apply antibiotics to prevent infection. 2.Progressive hemothorax: timely open-chest exploratory surgery. 3.Coagulative hemothorax: (1) Several days after the cessation of bleeding, perform dissection to remove the accumulated blood and blood clots to prevent secondary infection or mechanization. (2) Mechanized blood clots should be performed early for blood clots. (3) Early administration of closed drainage of the pleural cavity will help to observe the presence of progressive hemothorax. (4) Application of antibiotics to prevent infection. Suppurative thorax 【Concept】 Suppurative thorax is a purulent infection in which purulent exudate accumulates in the pleural cavity. According to the pathological development-acute and chronic, according to the causative agent-suppurative, tuberculosis, specific pathogenic, according to the scope of the spread-complete abscess chest, limited abscess chest. Etiology】 1.Causing bacteria: pneumococcus and streptococcus are common. 2.The pathogenic bacteria enter the pleural cavity: ①Invade or break into the pleural cavity directly from the septic lesion, or contaminate the pleural cavity due to trauma surgery ②Invade the pleural cavity through the lymphatic route, through the lymphatic vessels. Such as subdiaphragmatic, hepatic and mediastinal abscesses, septic pericarditis. ③ Hematogenous dissemination: In systemic sepsis or septicemia, pathogenic bacteria can enter the pleural cavity through blood circulation. Pathology】 1. Acute phase: Infection invades the pleura and causes massive exudation of pleural fluid. Early pus is thin, contains leukocytes and fibrin, and is plasmacytic. If the exudate can be discharged during this period, the lung can be easily reopened. As the disease progresses, the pus cells and fibrin increase, and the exudate gradually changes from plasmacy to purulent, with fibrin deposited on the surface of the dirty and wall pleura. Initially, the fibrin membrane is not firmly attached, soft and easy to fall off, later, with the continuous thickening of the fibrin layer, toughness and easy to adhere, and the tendency to confine the pus, fibrin in the dirty pleura attached to the lung expansion will be limited. 2, chronic phase: capillaries and inflammatory cells form granulation tissue, fibrin deposition mechanization, forming tough thick dense fiber plate on the wall and dirty pleura, constituting the wall of the abscess cavity. The abscess cavity is filled with pus deposits and granulation tissue. The fiber plate fixes tightly bound lung tissue, pulls the thorax inward, displaces the mediastinum to the diseased side, and restricts the mobility of the thorax, thus reducing the whistling function. 3, the clinical name of abscess chest: ① when a large amount of exudate fills the whole pleural cavity, it is called full abscess chest. ②If accompanied by tracheal and esophageal fistula, there can be gas in the pus cavity and a liquid plane, which is called pus pneumothorax. A. Acute pneumothorax [Etiology] Most of them are secondary to infectious lesions in the lung or adjacent tissues (subdiaphragm, mediastinum). Some of them can be caused by trauma, intrathoracic surgery or systemic hematogenous infection. Diagnosis] 1. Clinical manifestations: The main symptoms are acute inflammation and fluid accumulation in the chest cavity, often with high fever, chest pain, chest tightness, shortness of breath, cough, loss of appetite, general malaise, and weakness. 2, physical examination: shortness of breath, slightly full thorax on the affected side, weakened whistling motion, weakened fibrillation, cloudy percussion, weakened or absent whistling sounds, and mediastinal displacement of the trachea to the opposite side. The signs of localized pus chest are often not obvious or there are local signs of the lesion site. 3.Laboratory examination: total leukocytes and neutrophils are significantly increased, and the nucleus is shifted to the left. 4. Chest X-ray examination, manifestation of fluid accumulation in the thoracic cavity. Treatment principle】 1.Select effective antibiotics. 2.Thoroughly drain the pus to make the lung reopen as soon as possible. 2, chronic pus chest [concept and etiology] 1, acute pus chest disease more than 6 weeks, the pus in the fibrin deposited in the dirty, wall layer pleura, and gradually thicken the mechanization, the formation of thick fiber plate, so that the lung can not expand, the pus cavity can not be reduced, resulting in the formation of chronic pus chest. 2, etiology: ① the diagnosis and treatment of acute abscess chest is not timely or improper drainage. ②The primary foci of infection in the chest or adjacent organs are not thoroughly treated, and the source of infection still exists (such as bronchopleural fistula). ③The presence of certain specific sources of infection, such as tuberculosis, amoeba, etc. Diagnosis】 1. Clinical manifestations: fever, malnutrition, malaise, shortness of breath, cough or pus sputum are often present. 2, physical examination of the affected side of the chest wall subsidence, narrowing of the rib space, restricted whistling motion, solid percussion, reduced or absent whistling sounds, mediastinal displacement, scoliosis of the crest and pestle fingers (toes). 3. Laboratory tests: anemia and hypoproteinemia, decreased liver and kidney function. 4. Chest X-ray can show pleural thickening, rib space narrowing, mediastinal displacement, and diaphragm elevation. Abscess imaging can show the location and size of the abscess cavity and the presence or absence of bronchopleural fistula. Chest CT and MRI examination can help to clarify the presence of other lesions in the chest. Principles of treatment】 1.Improve general condition, enhance healing and resistance to disease. 2.Eliminate pathogenic factors and infection and close the abscess cavity. 3, as much as possible to preserve and restore lung function 4, commonly used surgical treatment methods: (1) pleural fiber plate stripping ⑵ thoracoplasty ⑶ pleuropneumonectomy ⑷ tipped muscle flap or large omental graft filling. Pulmonary contusion [Classification] 1. Parenchymal lung injury: pulmonary contusion 2. Interstitial lung injury: tracheal rupture; bronchial rupture. Pathogenesis and pathophysiology】 1, pathogenesis: strong violence – chest wall subsidence chest diameter reduction, increased chest pressure resulting in pulmonary hemorrhagic edema. 2, pathophysiology: plasma and cellular exudation leading to traumatic wet lung. Decreased compliance and impaired ventilation leading to hypoxemia. [Diagnosis] 1, history + performance + chest X-ray: floating chest wall suggests pulmonary contusion. 2, three main features: dyspnea, hemoptysis, wet. 3, concomitant symptoms: hypoxia, cyanosis, hypotension. Chest film can be seen in the lung field speckle-infiltrate fusion, or bilateral massive infiltration, the initial X-ray performance of trauma is not obvious, while 24~48 hours after the injury change line obviously. 【Treatment principle】 1.Effective pain relief – facilitate coughing. 2.Clear the airway, make pneumonectomy early. 3.Mechanical ventilation: PEEP to promote the resumption of lung opening, improve oxygen supply. 4.Replenish blood capacity and eliminate pulmonary water: sodium restriction and glue preservation + cardiac diuresis. 5, anti-inflammatory + hormone activation. Heart injury I. Blunt heart rupture Most common right atrium, followed by left atrium – right ventricle – left ventricle few multi-chamber rupture. Ear rupture is the most common (thin wall). [Clinical manifestations] 1. Mild myocardial contusions may have no obvious symptoms, while moderate or severe contusions may present with chest pain, palpitations, shortness of breath, or even angina pectoris. 2.There may be soft tissue injury to the anterior chest wall and sternal fracture. 3.Cardiac tamponade/hemorrhage. Treatment】 1.Mainly rest, close supervision, oxygen, analgesia, etc. 2.Cesarean operation: 1）If the bleeding flow is large, immediately dissect the chest to stop the bleeding and repair the heart laceration. (2) heart filling, first do pericardial window. The cause of penetrating heart injury [etiology] firearms (penetrating injury), sharp objects (blind tube injury) medical source of injury. Clinical manifestations] 1, clinical performance depends on: the size of the fissure, the length of time. 2, pericardial filling type: 1) the causative agent and causative kinetic energy is small, pericardial fissure is small 2) Beck triad signs. (3) release the heart compression, control the heart bleeding, can successfully save the patient’s life. 3, hemorrhagic shock type: 1) the causative agent and the causative kinetic energy is large, the pericardial fissure is large 2) hemorrhagic shock. The fissure is not easily blocked by clots, and blood flows into the chest cavity in large quantities. 3) Even if the bleeding is controlled by decompression, it is difficult to correct the shock, and the success rate of resuscitation is low. Key points of diagnosis】 1.The chest wound is located in or near the area of the body projection of the heart. 2.Short time after injury. 3.Beck’s triad or signs of hemorrhagic shock and massive hemothorax. Treatment】 1.For those with cardiac compression or hemorrhagic shock, open-heart surgery should be performed immediately in the emergency room. 2, penetrating heart injury survived by resuscitation, should pay attention to whether there are foreign bodies and other lesions left in the heart.