Chest Trauma

Approximately a quarter of the deaths due to trauma are attributed to chest injury. Immediate deaths can result from disruption to the airway, injury to the great vessels or from injury to the heart.

The majority of chest injuries can be successfully managed with chest tube insertion and analgesia and do not require surgery.

Diagnostic Types

Based on the mechanism, these injuries can be broadly classified into penetrating and blunt. Clinical evaluation starts with obtaining a good history regarding the mechanism followed by clinical examination and most often a radiological evaluation. Do not delay treatment whilst waiting for an X-Ray if it is difficult to obtain. Further investigations may be needed in specific circumstances.

Rib Fractures

Rib fractures are sustained easily in the elderly and are very painful. Fractures can lead to trauma of the underlying lung resulting in pneumo- or haemothorax.

Management

Rib fractures are managed with analgesia alone as they tend to heal without complications.

Pneumothorax

Tension pneumothorax

Develop when air enters the pleural space and cannot leave, leading to an increase in the intrathoracic pressure on the affected side. The patient will be very restless and short of breath.

Clinical signs include absent breath sounds and resonance to percussion on the affected side with tracheal shift to the opposite side (may be difficult to detect).

Immediate management

• Needle decompression by introducing a large bore needle in the second intercostal space in the midclavicular line.
• This should be followed by insertion of a thoracic drain.
• Tension pneumothorax is a clinical diagnosis. Do not wait for an X-Ray.

Simple pneumothorax

A simple pneumothorax does not have an increase in intrathoracic pressure on the affected side. It can develop into a tension pneumothorax.

Management

• It should be treated with a thoracic drain especially if the patient is to be ventilated.

Flail Chest

Flail chest occurs when a segment of the thoracic cage is separated from the rest of the chest wall. This is usually defined as two or more fractures per rib in at least two ribs. The flail segment moves independently of the rest of the thoracic cage. This can lead to ventilatory failure. Presence of a flail chest implies significant transfer of energy to the chest with a potential for underlying lung contusion.

Management

includes provision of good pain relief and ventilatory support in the

presence of features of respiratory failure.

Haemothorax

Haemothorax is the presence of blood in the chest cavity. It commonly follows penetrating trauma. Large volumes may be lost into the chest leading to hypotension.

Management

The insertion of an intercostal tube to drain blood and re-expand the lung is often the only intervention needed.

However the following findings would require surgical referral:

• Haemothorax exceeding 1.5 litres upon initial drainage
• On-going blood losses of more than 250ml/hr after drain insertion.
• Failure of the lung to expand after chest drain insertion.

Pulmonary Contusion

Pulmonary contusion can occur in penetrating or blunt trauma. The presence of this condition may not be very clear at the time of initial presentation. A high degree of suspicion based on the mechanism of injury is necessary. The condition can progressively deteriorate resulting in ventilatory failure. X rays are not very specific in diagnosing the condition.

Management

Ventilatory support may be needed in severe cases.

Open (Sucking) Chest Wound

Open chest wounds can lead to complete collapse of the lung on the affected side because air is sucked into the chest cavity. The mediastinum may shift to the opposite side.

Management

As a temporary stabilising measure a dressing may be applied on top of the wound with three sides sealed to act as a 'valve'.

This will allow air to exit the wound while not allowing it to re-enter. Management is by the insertion of an intercostal drain (not through the wound).

Myocardial Contusion

This can follow blunt trauma (e.g. steering wheel injury with fracture of sternum).

An abnormal ECG and later signs of heart failure and low blood pressure indicate an underlying cardiac contusion.

Management

These patients will need admission to high level care for further management.

Pericardial Tamponade

Pericardial tamponade generally follows penetrating trauma of the heart. Blood accumulates in the pericardial space leading to cardiogenic shock. The classic Beck's Triad (elevated JVP, muffled heart sounds and hypotension) may be difficult to detect in the hypotensive trauma patient.

Management

The management consists of pericardial drainage (pericardiocentesis) followed by urgent surgical intervention for repairing the injury.

Rupture of the aorta

This has a very high immediate on-site mortality rate. It occurs in the presence of severe decelerating force such as car accidents or fall from significant heights.

Management

Stable patients should undergo further investigations if rupture of the aorta is suspected.

Rupture of trachea or major bronchi

This carries a mortality rate of up to 50%. The majority of bronchial ruptures occur within 2.5 cm of the carina. Clinical signs include shortness of breath, haemoptysis and collapsed lung on the affected side on X-Ray.

Management

This condition needs urgent surgical intervention.

Injury to the oesophagus

This generally follows penetrating trauma. Clinical signs may be few. Strong suspicion is necessary based on the path of penetration.

Management

Plain X-Ray is not very helpful and missed injuries can be fatal.

Contrast studies or endoscopy may be needed and surgeons should be involved very early in managing this condition.

Injury to the Diaphragm

This can follow blunt or penetrating trauma. The diagnosis is often missed initially.

The presence of bowel sounds in the chest on auscultation, or findings on X-Rays including visualisation of bowel in the hemithorax, elevation of the hemidiaphragm or appearance of the nasogastric tube in the chest are suggestive of an injury.

Management

Contrast studies may be needed in doubtful cases.

Surgeons should be involved in managing suspicious cases.