Chest Trauma

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: ABCsclosure of woundchest 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, Becks 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: surgicalpoor prognosis

Aortic rupture

Iatrogenic trauma
-coiling -endobronchial placement -pneumothorax Chest tubes: - subcutaneous - intraparenchymal - intrafissural Central lines: - neck - coronary sinus - pneumothorax

NG tubes:

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