Chest trauma is common, with the most life-threatening injuries including tension pneumothorax, massive haemothorax, and cardiac tamponade. Simple injuries are typically diagnosed and treated with clinical exams, imaging, chest decompression, analgesia and physiotherapy. Severe chest trauma may require advanced life support like emergency thoracotomy or transfer to the operating room.

1. Chest TraumaChest Trauma
Dr Mike NoonanDr Mike Noonan

2. Overview
Introduction:
•Epidemiology
Pathophysiology of Chest Injuries:
•Hypoventilation
•Impaired Gas Exchange
•Shock
Management Principles:
•Chest Decompression
•Analgesia, Physiotherapy, Mobility and Nutrition
•Ventilatory Support
•Resuscitative Thoracotomy
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3. Epidemiology and Classification
Chest Injury:
•Common:
– Major chest trauma is 10th
most common injury via DRG classification
for all trauma admissions.
– 58 patients 2010-2011
•Primary cause of mortality in 20-25% of deaths
•Contribute to death in a further 25% of deaths
Classification:
•Blunt
•Penetrating
•Alfred: Major Trauma- 3.6% penetrating
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4. Trauma Service Audit 2010-11
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Injury Profile by AIS body region – major trauma
0
500
1000
1500
2000
2500
Head Legs Chest Spine Face Arms Abdomen External Neck
injuries
2009/10 2010/11

5. Pathophysiology
Pathophysiologic consequences of chest trauma:
•Hypoventilation
– Mechanical failure of ventilatory mechanism
•Hypoxia
– Secondary to hypoventilation
– Impaired gas exchange
•Shock
– Hypovolemia
– Pump (cardiogenic) failure
– Neurogenic shock due to spinal cord injury
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Decreased tissue oxygenation
Decreased tissue perfusion
Decreased tissue oxygenation
Decreased tissue perfusion

6. Spectrum of Injuries
• Rib fracture(s)
• Simple pneumothorax
• Simple haemothorax
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Cardiac tamponade
• Flail chest
• Pulmonary contusion
• Ruptured diaphragm
• Aortic Injury
• Oesophageal injury
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7. Scenario 1
51yo male. Fall against table while intoxicated.
PHx:
•Alcohol abuse
•Poorly controlled Insulin-requiring Type II DM
•HPT
•Smoker (20/day; 30 pkt year history)
On arrival:
•A: Speaking in full sentences. Cx collar applied
•B: RR 28. Satn
90% high flow oxygen. Complaining of right chest
pain and ‘unable to catch breath’. Decreased breath sounds on right
with subcutaneous emphysema.
•C: HR 95. BP 178/94. FAST negative.
•D: Agitated E4 V4 M6=14
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8. Scenario 1
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9. Scenario 1
Initial Management:
•O2 via Hudson mask, high flow.
•Set up for right ICC
•Intravenous access: warmed crystalloid. 8/24
Adjuncts to Primary Survey:
•CXR PXR
•ABGs:
– Type 1 or Type 2 respiratory failure
– CO2 retention
•Venous blood: Hb/U&E/LFTs/Clotting/EtOH/Glucose
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10. Scenario 1
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11. Scenario 1
ABG:
•pH 7.40
•pCO2 55
•pO2 110
•HCO3-
32
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Management Priorities?

12. Scenario 1
• Drainage of blood and pneumothorax to maximise ventilation: ICC
• Analgesia – CALL APS
– Systemic
– Local
– Regional
Patient needs to be able to deep breath and cough
• Position and mobility:
– Spine clearance so that the patient can be sat up
• Physiotherapy: chest as well as general mobility
• Optimisation of comorbidities:
– Diabetes
– EtOH withdrawal
– Nutrition
• ? ICU admission
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13. Scenario 2
19yo male. HSP MVA into tree.
At scene:
A: Grunting, obvious facial fractures. Cx collar applied
B: Decreased air entry right chest. Seat belt bruising right upper
chest wall. RR 26.
C: HR 135 with thready pulse. SBP 80/.
D: GCS E1 V2 M4=7
Initial Treatment:
•Cx collar. RSI.
•Right pneumocath.
•Iv access with 1.0 l Nsaline commenced. Pelvic binder applied.
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14. Scenario 2
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15. Scenario 2
On arrival (45 minutes post-accident):
•A: Intubated. Cx collar in situ.
•B: Absent air entry right chest. Satn
87% on 100% FIO2. Trachea
midline.
•C: HR 145. SBP 89 after 1.5 litres crystalloid. Cool, clammy, shut
down. Plethoric face(?). Deformed right femur.
•D: GCS E1 VT M1
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16. Scenario 2
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17. Scenario 2
Progress:
•Post ICC insertion:
– Improved air entry right chest
– HR 95 BP 115/62
– 200ml blood from right ICC
•FAST negative, PXR normal
•Femur reduced and splinted
•Further 1000ml Nsaline
Key Points:
•Tension Pneumothorax is a cause of shock- easy to treat!
•Do not need tracheal deviation
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18. Scenario 3
35 year old depressed man:
•Penetrating chest wound just above and medial to the left nipple
•Self presented to triage
On arrival:
•A: Speaking in short sentences, very agitated.
•B: Tachypnoeic with RR 34, Sat 89%
•C: HR 130, thready. SBP 90
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19. Scenario 3
Treatment:
• Supplemental Oxygen
• iv access: 500ml Nsaline
Progress:
• Became less agitated though drowsy. Airway maintained.
• B: RR 26. Sat 87%. Air-entry equal bilaterally.
• C: HR 140, thready. SBP80.
• Plethoric face and distended neck veins noted
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20. Scenario 3
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21. Scenario 3
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HaemopericardiumHaemopericardium
Right VentricleRight Ventricle

22. Scenario 3
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What does this patient need?
Where will this be performed?

23. Scenario 3
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•Identification of immediately life-threatening situation
(tamponade) via systematic attention to A, B and C.
•Transfer of the patient to theatre in a timely fashion,
or
•Perform emergency room thoracotomy if SBP
remains <70 mmHg despite iv resuscitation
NB: ATLS Guidelines 8th
edition: Treatment of Cardiac
Tamponade

24. Questions?
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25. Summary
• Chest trauma is common
• Most injuries are diagnosed with simple clinical and imaging
techniques
• Most life-threatening injuries can be managed with simple
procedures and attention to analgesia, physiotherapy and nutrition
• Severe chest trauma requires more advanced life support
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