Chest trauma

1. Chest Trauma
Gráinne Murphy
Final Med
April 2002

2. 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

3. Mechanism of Injury
Penetrating injuries
 E.g. stab wounds etc.
 Primarily peripheral lung
 Haemothorax
 Pneumothorax
 Cardiac, great vessel or oesophageal
injury

4.  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
Blunt injuries

5. Chest wall injuries
 Rib fractures
 Flail chest
 Open pneumothorax

6. 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

7. Flail chest
 Multiple rib fractures produce a mobile
fragment which moves paradoxically
with respiration
 Significant force required
 Usually diagnosed clinically
 Rx: ABC
Analgesia

8. Flail chest

9. Flail Chest - detail

10. 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

11. Lung injury
 Pulmonary contusion
 Pneumothorax
 Haemothorax
 Parenchymal injury
 Trachea and bronchial injuries
 Pneumomediastinum

12. 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

13. Pneumothorax

14. 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

15.  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

16. 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

17. Heart, Aorta & Diaphragm
 Blunt cardiac injury
- contusion
- ventricular, septal or valvular
rupture
 Cardiac tamponade
 Ruptured thoracic aorta
 Diaphragmatic rupture

18. 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

19. Cardiac tamponade

20. 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

21. Aortic rupture

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

23. Line in jugular vein

24. Misplaced nasogastric tube

25. 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