Property of Prof Dr. Ahmed Deebis, Head of Cardiothoracic Surgery Department, Faculty of Medicine. University of Zagazig

1. Cardiothoracic Surgery
for undergraduate
Prof. Ahmed Deebis
Head of Cardiothoracic Surgery
Department - Zagazig University

2. Cardiothoracic Surgery
I: Thoracic Surgery
A. Chest Trauma
B. Surgery of Pleural
Diseases
C. Surgery of Pulmonary
Infections
D. Tumors of The Lung
E. Surgery of Mediastinum
II: Cardiac Surgery
A. Cardiac Operations and
Cardiopulmonary bypass.
B. Surgery for Valvular Heart
Diseases.
C. Surgery for Congenital
Heart Diseases.
D. Coronary Artery Bypass
Graft (CABG) Surgery

3. A: Chest Trauma
• The oldest known medical text for surgical
treatment of trauma is the Egyptian
Edwin Smith Papyrus in around 1600 BC. In
this Papyrus, chest injuries were first
described in detail.
• About 20% to 25% of all trauma-related
deaths, are related to chest injuries.

4. Chest trauma
i) Blunt chest trauma
• mostly caused by motor
accident, falls from height,
and blast Injuries
• 90% of blunt trauma can be
managed without
thoracotomy ( i.e. with
conservative management
or with intercostal tube
drainage )
ii) Penetrating chest trauma
• caused by gunshot, stab
wounds, and shrapnel.
• 70% to 85% of penetrating
trauma can be managed
without thoracotomy ( i.e.
with conservative
management or with
intercostal tube drainage ).

5. Primary and Secondary Survey Notes
Primary survey
Immediate life-threatening injuries to be sought
and treated:
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Flail chest
• Cardiac tamponade

6. Secondary Survey
• This is a more detailed and complete clinical
examination aimed at managing chest wall,
pulmonary, mediastinal, diaphragmatic and
other injuries.

7. Investigations
First line investigations performed once the
primary survey and management is established
include
• X-ray chest (C-spine and pelvis as indicated)
• Trans-thoracic echocardiography if pericardial
effusion suspected
• CT if there is any suspicion about injury to major
thoracic structures, and the patient is
haemodynamically stable
• Aortography if aortic injury is suspected

8. I: Chest Wall Injuries
(1) Rib fracture:
• The most common chest injury
• Usually caused by blunt trauma
• Uncommon in children [pliable ribs]
• The 4th
to 9th
ribs are the most commonly
fractured [thin and poorly protected].
• Fractures of the upper ribs (1, 2, and 3) indicate
major trauma
• Fractures of the lower ribs(8, 9, and 10) may be
associated with renal, hepatic or splenic injuries

9. Diagnosis of Rib fracture
Clinically:
• Local tenderness, bruising, pain on inspiration
or coughing.
Investigations:
• Chest X-ray,
• CT when suspected associated injuries.

11. Treatment of Rib fracture
1. Pain control, by:
i) Oral or intravenous analgesia,
ii) Intercostal nerve block, and/or
iii) Epidural anesthesia.
2. Optimization of pulmonary toilet (e.g. incentive
Spirometer, coughing & ambulation)
prevention of atelectasis.
3. Treatment of complications e.g. hemothorax or
pneumothorax.
N.B. :Chest strapping by binders, and rib belts is not
recommended as they cause reduction of ventilation of the
affected side that promote atelectasis.

12. (2) Flail chest:
• Multiple adjacent ribs are broken in multiple
places, leading to instability to a segment of
the thoracic wall that exhibit paradoxical
motion locally.
• A serious, life-threatening chest injury
• Most commonly seen in cases of significant
blunt trauma.
• often associated with underlying pulmonary
injury .

13. • The flail segment
impairs respiratory
mechanics,
--------hypoventilation,
poor pulmonary
drainage
and atelectasis.

14. (2) Flail chest: Cont,
Diagnosis:
• - Inspection: paradoxical movement is usually
diagnostic which is confirmed by palpation.
• - X-ray: Fractured ribs seen and may show
complication.
Complication:
• pneumothorax, hemothorax, lung contusion,
respiratory insufficiency.

15. Treatment of Flail chest
1. Adequate analgesia.
2. Mechanical ventilation:
indicated for a respiratory rate over 40
breath / min., PaO2 less than 60mmHg
despite 60% face mask oxygen, shallow.
respiration, depressed consciousness and/or
associated injuries.
3. Surgical fixation: may be indicated for
cosmetic deformity, thoracotomy for other
reasons (hemothorax) and failed weaning
from ventilation.
4. Treatment of complication.

16. II: Injuries of Lung Parenchyma and Pleura
(1) Pulmonary contusion:
• The most common injury in blunt trauma.
• Develops over 24-48hrs
• Based on alveolar rupture, oedema and blood
collection.
• Generally associated with concomitant
thoracic cage damage and other visceral
injuries but they can occur in isolation.

17. Pulmonary contusion, Cont.
Presentation:
• -Classic symptoms include dysnea, tachypnea,
hemoptysis, cyanosis and hypotension.
• -Decreased breath sounds and inspiratory rales
on the affected side.
Investigation:
• Chest X-Ray (patchy opacification, may
underestimate extent).
• CT scan is the study of choice.

18. Pulmonary contusion , Cont.
Management:
• Observation on supplementary oxygen.
• Chest physiotherapy.
• Patients with hypoxia PaO2 < 65 mmHg and SaO2 <
90 % should be intubated and ventilated.
• Cautious fluid administration.
• If large volumes of fluid necessary for resuscitation,
pulmonary artery catheter should be placed.

19. (2) Pneumothorax:
• Definition: Accumulation of air in the pleural
cavity.
• Either due to blunt trauma, penetrating
trauma, or iatrogenic
• Types:
i) Open pneumothorax.
ii) Closed pneumothorax.
iii) Tension pneumothorax.

20. i) Open Pneumothorax:
• Pleural cavity communicates with the atmosphere
• The wide communications to the outside result in:
 Total lung collapse on the affected side.
 Mediastinal flutter : The mediastinum is mobile, so
with inspiration the mediastinum moves towards the
healthy side and opposite on expiration. So,
paradoxical respiration in the healthy side occurs
 Impaired venous return

21. Open Pneumothorax: , Cont.
Diagnosis:
• By inspection revealed sucking wound.
• Chest X-ray: pneumothorax.
Treatment:
• Immediate airtight closure of thoracic wound using
gauze and adhesive tape so converting open to
closed pneumothorax but keep in mind the
possibility of developing tension pneumothorax so
it's better to leave one edge unsealed.
• Then insertion of intercostal tube and closure of the
defect

22. ii) Closed Pneumothorax:
• No communication to the atmosphere.
• Usually well tolerated.
Diagnosis:
• Decreased movement on the affected side.
• Trachea may be central or slightly shifted to
the healthy side.
• Hyperresonant on percussion.
• Diminished breath sound on auscultation.

23. ii) Closed Pneumothorax:
• Chest X-ray: The outline of the lung
is seen in the pleural space (which is
the visceral pleura), lateral to that
line jet black air seen with absence of
bronchovascular markings.
Treatment:
1- Observation if small.
2- Chest tube drainage (in the fifth
Intercostal space midaxillary line):
the best management even in small
pneumothorax in trauma patients.

24. iii) Tension Pneumothorax
• Life threatening condition.
• Developed when an injury to the lung or chest
wall allows air to continue to enter the pleural
space with each inspiration without being able
to exit during expiration.

25. Tension pneumothorax, cont.
• Through this valvular mechanism,
air will accumulate in the pleural
cavity with increased positive
pressure lung collapse on
the affected side with shift of
mediastinum to the other side
that leads kinking of the caval
veins resulting in impairment of
venous return and low cardiac
output.
• Also compression to the other
lung leads to significant hypoxia

26. Tension pneumothorax, cont.
Classic signs:
Shock (hypotension, tachycardia),
Hypoxia,
Distended neck veins.
Tracheal deviation to contralateral
side,
Hyperresonant and reduced
breath sounds,
Hyperexpanded hemithorax with
decreased expansion.

27. Tension pneumothorax, cont.
• Tension pneumothorax
is a clinical diagnosis
with no time for
investigation
• Chest X-ray: Shows,
collapse of entire lung,
depression of
diaphragm with
flattening of it's dome,
and mediastinal shift.

28. Tension pneumothorax, cont.
Treatment:
• Immediate decompression (live-saving):
If intercostal tube not available, insertion of
wide-bore cannula in the 2nd intercostal
space midclavicular line converts tension into
open pneumothorax, then intercostal tube
insertion once available.

29. (3)Traumatic Hemothorax:
• Bleeding into pleural space, resulting from
both blunt and penetrating chest injuries.
• Usually secondary to:
rib fractures,
lung trauma,
venous injury.
Rarely, due to arterial injury.

30. (3)Traumatic Hemothorax:, cont
Clinically:
Dullness on the affected side
Diminished breath sounds on the affected side
Decreased respiratory movement on affected
side.
 Hemorrhagic shock may be seen in patients with
massive hemothorax
 Tracheal deviation to contralateral side in massive
hemothorax

31. (3)Traumatic Hemothorax:, cont
Investigations:
• Chest X-ray (posteroanterior
and lateral):
< 300 ml of blood may be
hidden by diaphragm on erect
chest film
Supine CXR can easily miss
hemothorax
• Fast Ultrasound.
• CT scan.

32. Treatment of Traumatic Hemothorax:, cont
• High flow O2.
• Large bore (28-32F) chest drain/s.
• Thoracotomy is indicated for the following:
i) Injury with hemodynamic instability (< 80 mmHg
systolic) not responding to adequate resuscitation.
ii) Initial drainage of >1500ml from the inserted chest
tube.
iii) Persistent bleeding (>200-300 ml/h for 4 h).
vi) Retained clot (thoracoscopy may suffice).

33. III: Cardiovascular Injuries
(1) Cardiac contusion
It is any cardiac injury follows blunt trauma
not accompanied by cardiac chamber rupture
or injury to intracardiac structures.
It ranges from subepicardial or subendocardial
hemorrhages to extended foci of contusion.
Presented with pericardial pain not increased
by respiration, tachycardia, arrhythmia

34. (1) Cardiac contusion, cont.
Treatment
• ICU admission
• O2 Therapy to correct hypoxaemia
• Antiarrhythmic drugs
• Correction of hypovolemia guided by CVP.
• Treatment of pericardial effusion if present.

35. (2) Hemopericardium and cardiac tamponade
• Acute accumulation of more than 150ml of
blood in pericardium can cause life
threatening tamponade, as pericardium is a
fibrous structure with very slight elasticity
Causes:
• -Right ventricular lacerations more commonly
than left ventricular lacerations
• -occasionally injury to coronary vessels or
great vessels.

36. (2) Hemopericardium and cardiac tamponade, cont.
Diagnosis
• Classic triad of:
High venous pressure
Distant heart sounds
Hypotension
• Chest X-ray: not diagnostic
• Echocardiography: The diagnostic tool of
choice
• Pericardiocentesis: has both diagnostic and
therapeutic role

37. (2) Hemopericardium and cardiac tamponade, cont
Treatment:
• Pericardiocentesis for temporary relief
• Emergency thoracotomy is the treatment of
choice
Ventricular lacerations are repaired over
pericardial or Teflon pledgets.
Atrial lacerations are simply oversewen.
Coronary artery injury or intracardiac injuries
require cardiopulmonary bypass.

38. THANK YOU