Chest Trauma

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Chest Trauma

• Gráinne Murphy
• Final Med
• April 2002

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Introduction

• Chest trauma is often sudden and dramatic
• Accounts for 25 of all trauma deaths
• 2/3 of deaths occur after reaching hospital
• Serious pathological consequnces -hypoxia,
  hypovolaemia, myocardial failure
  

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Mechanism of Injury

• Penetrating injuries
• E.g. stab wounds etc.
• Primarily peripheral lung
• Haemothorax
• Pneumothorax
• Cardiac, great vessel or oesophageal injury

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Blunt injuries

• Either - direct blow (e.g. rib
  fracture) - deceleration injury or -
  compression injury
• Rib fracture is the most common sign of blunt
  thoracic trauma
• Fracture of scapula, sternum, or first rib
  suggests massive force of injury

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Chest wall injuries

• Rib fractures
• Flail chest
• Open pneumothorax

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Rib fractures

• Most common thoracic injury
• Localised pain, tenderness, crepitus
• CXR to exclude other injuries
• Analgesia..avoid taping
• Underestimation of effect
• Upper ribs, clavicle or scapula fracture suspect
  vascular injury

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Flail chest

• Multiple rib fractures produce a mobile fragment
  which moves paradoxically with respiration
• Significant force required
• Usually diagnosed clinically
• Rx ABC Analgesia

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Flail chest
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Flail Chest - detail
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Open pneumothorax

• Defect in chest wall provides a direct
  communication between the pleural space and the
  environment
• Lung collapse and paroxysmal shifting of
  mediastinum with each respiratory effort
  tension pneumothorax
• Sucking chest wound
• Rx ABCsclosure of woundchest drain

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Lung injury

• Pulmonary contusion
• Pneumothorax
• Haemothorax
• Parenchymal injury
• Trachea and bronchial injuries
• Pneumomediastinum

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Pneumothorax

• Air in the pleural cavity
• Blunt or penetrating injury that disrupts the
  parietal or visceral pleura
• Unilateral signs ?movement and breath sounds,
  resonant to percussion
• Confirmed by CXR
• Rx chest drain

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Pneumothorax
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Tension pneumothorax

• Air enters pleural space and cannot escape
• P/C chest pain, dyspnoea
• Dx - respiratory distress - tracheal
  deviation (away) - absence of breath sounds
  - distended neck veins - hypotension

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• Surgical emergency
• Rx emergency decompression before CXR
• Either large bore cannula in 2nd ICS, MCL or
  insert chest tube
• CXR to confirm site of insertion

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Haemothorax

• Blunt or penetrating trauma
• Requires rapid decompression and fluid
  resuscitation
• May require surgical intervention
• Clinically hypovolaemia absence of
  breath sounds dullness to percussion
• CXR may be confused with collapse

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Heart, Aorta Diaphragm

• Blunt cardiac injury - contusion -
  ventricular, septal or valvular rupture
  
• Cardiac tamponade
• Ruptured thoracic aorta
• Diaphragmatic rupture

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Cardiac Tamponade

• Blood in the pericardial sac
• Most frequently penetrating injuries
• Shock, ?JVP, PEA, pulsus paradoxus
• Classically, Becks triad - distended neck
  veins - muffled heart sounds - hypotension
• Rx Volume resuscitation Pericardiocentesis

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Cardiac tamponade
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Aortic rupture

• Usually blunt trauma involving deceleration
  forces especially RTAs
• 90 die within minutes
• Most common site near ligamentum arteriosum
• Dx clinical suspicion, CXR, aortography,
  contrast CT or TOE
• Rx surgicalpoor prognosis

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Aortic rupture
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Iatrogenic trauma

• NG tubes -coiling -endobronchial
  placement -pneumothorax
• Chest tubes - subcutaneous -
  intraparenchymal - intrafissural
• Central lines - neck -
  coronary sinus - pneumothorax

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Line in jugular vein
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Misplaced nasogastric tube
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Chest trauma summary

• Common
• Serious
• Primary goal is to provide oxygen to vital organs
• Remember Airway Breathing Circul
  ation
• Be alert to change in clinical condition