Chest Trauma

Gráinne Murphy
Final Med
April 2002
 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
 Mechanism of Injury
Penetrating injuries
 E.g. stab wounds etc.
 Primarily peripheral lung
 Haemothorax
 Pneumothorax
 Cardiac, great vessel or oesophageal
injury
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
 Chest wall injuries

 Rib fractures
 Flail chest
 Open pneumothorax
 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
 Flail chest
 Multiple rib fractures produce a mobile
fragment which moves paradoxically
with respiration
 Significant force required
 Usually diagnosed clinically
 Rx: ABC
Analgesia
Flail chest
Flail Chest - detail
 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: ABCs…closure of wound…chest drain
 Lung injury
 Pulmonary contusion
 Pneumothorax
 Haemothorax
 Parenchymal injury
 Trachea and bronchial injuries
 Pneumomediastinum
 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
Pneumothorax
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
 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
 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
Heart, Aorta & Diaphragm
 Blunt cardiac injury
- contusion
- ventricular, septal or valvular
rupture
 Cardiac tamponade
 Ruptured thoracic aorta
 Diaphragmatic rupture
 Cardiac Tamponade
 Blood in the pericardial sac
 Most frequently penetrating injuries
 Shock, JVP, PEA, pulsus paradoxus
 Classically, Beck’s triad: - distended
neck veins - muffled heart sounds -
hypotension
 Rx: Volume resuscitation
Pericardiocentesis
Cardiac tamponade
 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: surgical…poor prognosis
Aortic rupture
 Iatrogenic trauma
 NG tubes: -coiling -endobronchial
placement -pneumothorax
 Chest tubes: - subcutaneous -
intraparenchymal - intrafissural
 Central lines: - neck -
coronary sinus -
pneumothorax
Line in jugular vein
Misplaced nasogastric tube
 Chest trauma: summary
 Common
 Serious
 Primary goal is to provide oxygen to
vital organs
 Remember
Airway
Breathing
Circulation
 Be alert to change in clinical condition