Chest trauma can be classified as either blunt or penetrating. Blunt chest trauma results from sudden compression or positive pressure to the chest wall from motor vehicle crashes, falls, or bicycle crashes. This can lead to hypoxemia from airway disruption, injury to the lung parenchyma or ribs, massive hemorrhage, collapsed lung, or pneumothorax. Rib fractures are the most common blunt chest injury and cause pain with breathing. Flail chest involves at least two fractures in two or more ribs, creating a floating segment that moves paradoxically with breathing and is associated with severe lung injury. Treatment for flail chest involves pain control, positive pressure ventilation, and sometimes surgical fixation of the fractures.

1. Chest Trauma

2. • classified as either blunt or penetrating

3. Classification of thoracic injuries
1. Chest wall
2. Pleural space
3. Pulmonary parenchyma
4. Mediastinal structures
a. Aerodigestive structures
 Trachea & bronchi
 Esophagus
b. Vascular structures
3

4. BLUNT TRAUMA
• Blunt chest trauma results from sudden
compression or positive pressure inflicted to
the chest wall
• Motor vehicle crashes (trauma due to steering
wheel, seat belt), falls, and bicycle crashes
(trauma due to handlebars) are the most
common causes of blunt chest trauma

6. Pathophysiology
• Hypoxemia from disruption of the airway;
– injury to the lung parenchyma, rib cage, and respiratory
musculature; massive hemorrhage; collapsed lung; and
pneumothorax
• Hypovolemia from massive fluid loss from the great
vessels, cardiac rupture, or hemothorax
• Cardiac failure from cardiac tamponade, cardiac
contusion, or increased intrathoracic pressure

7. Assessment
• When the injury occurred
• Mechanism of injury
• Level of responsiveness
• Specific injuries
• Estimated blood loss
• Recent drug or alcohol use
• Prehospital treatment

8. Medical Management
• The goals of treatment are to evaluate the
patient’s condition and to initiate aggressive
resuscitation.
– An airway is immediately established with oxygen
support and,
– in some cases, intubation and ventilatory support.
– Re-establishing fluid volume and negative
intrapleural

9. Rib fractures
• Most common injury
• Often following blunt thoracic
trauma
• At the site of force, latterally
• 20% mortality in the elderly
• Less common in children
• 1st to 3rd rib fracture: rare (high
mortality rate)
– Severe injury
– 30% mortality
• 5th to 9th . Common site
• 10th to 12th rib : associated with
laceration of spleen and liver
Effect
– Poor inspiratory effort
– Ineffective cough
– Atelectasis
– Pneumonia
9

10. Clinical manifestation
• Hx of trauma to the chest wall
• severe pain, point tenderness, and muscle spasm
over the area of the fracture, which is aggravated
by coughing, deep breathing, and movement.
• The area around the fracture may be bruised.
• To reduce the pain, the patient splints the chest
by breathing in a shallow manner and avoids
sighs, deep breaths, coughing, and movement.
10

11. Rib fractures
CXR:
• Lateral or anterior rib fractures will often be
missed
• Mainly for associated injuries
11

12. Rib fractures
Treatment
• CXR to exclude other injuries (50% sensitive)
1. Strong analgesics
2. Encourage breathing
3. Prophylactic antibiotics
4. Treat associated injuries
12

13. Sternal fractures
• Usually transverse fracture, majority at the sterno-manubrial
junction
• Associated injuries:
myocardial contusion, cardiac chamber rupture, transaction of the aorta
• Dx: X-ray (lateral)
Treatment
– Exclude life threatening injuries (ECG, CXR)
– Pain control
– Chest physiotherapy
– Reduce fracture manually
13

14. Sternal fractures
Open reduction
Unstable fracture
Displacement >1cm
Associated lower extremity injury
For flail sternum:
Internal or external
14

15. Flail chest
• At least two fractures per rib, in at least two ribs
• Creating one floating segment comprised of several
rib sections and the soft tissues between them
• Anterior and lateral are common
• Significant force required and associated with severe
lung injury
• Pathophysiology
– Paradoxical movement of the chest (diagnostic)
– Pain
15

16. Flail chest
• Unstable section of chest
wall exhibits paradoxical
motion (i.e, it moves in the
opposite direction of the
uninjured, normal-
functioning chest wall) with
breathing
• Is associated with
significant morbidity from
pulmonary contusion
16

17. Flail chest

18. Flail chest
Treatment
• Good analgesia
• Endotracheal intubation with continous positive
pressure ventilation for up to three weeks, until the
fracture becomes less mobile
Indications for endotracheal intubation
– Deterioration of pulmonary function
– Hypoxia
– Hypercarbia _PCO2 >45 mmHg
• Fracture fixation
18

19. Management of Flail chest
• Stabilize the flail segment
– Firm gentle manual pressure
– Apply IV bags
– Place patient with injured site down
– Traction
– Open fixation
• Insert a chest tube
19