Chest trauma accounts for 25% of all trauma deaths and can have serious pathological consequences if not treated promptly. The most common types of chest trauma are blunt injuries such as rib fractures and penetrating injuries such as stab wounds. Proper diagnosis and treatment of injuries is important to stabilize the patient and prevent complications such as tension pneumothorax, cardiac tamponade, and aortic rupture which can quickly lead to death if not addressed.

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 A irway B reathing C irculation Be alert to change in clinical condition