Approach to Chest Trauma
Mary Osinga
Comprehensive Review
Fleming College
Traumatic Injuries
Airway injuries
 Chest and Breathing
 Circulation – shock
 Disability – neurological
 E- expose and extremity

Airway Problems
Problem in trauma is that the airway
may not look or behave as normal
 Forces onto the head and/or neck may
provide significant changes to the
anatomy of the airway
 Lets review normal airway anatomy

Normal
airway
Abnormal Airway




Edema
Presence of fluid
Loss of bony
structure integrity
Foreign objects
Airway management
Use a modified jaw thrust to avoid C
spine displacement
 Watch for nasal airway insertion in
patients with….?
 Oral airways in patients GCS<8
 Suction blood and secretions, remember
patients supine on board
 Watch for vomiting –beer and pizza

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 consequences:
-hypoxia, hypovolemia, 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

Deadly Dozen from ITLS
Airway obstruction
 Open Pneumo
 Flail Chest
 Tension Pneumo
 Massive Hemothorax
 Cardiac Tamponade

Detected in the primary survey
Deadly Dozen from ITLS
Myocardial contusion
 Traumatic aortic rupture
 Tracheal bronchial tear
 Diagphragmatic injury
 Esophageal injury
 Pulmonary contusion

Detected in the secondar
survey
Mechanism!
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
 2 or more ribs in 2 or more places
 Significant force required
 Palpate carefully and laterally
 Rx: ABCs and analgesia
 +/- splint the flail segment

Flail chest
Flail
Chest detail
Lung injury
Pulmonary contusion
 Pneumothorax
 Haemothorax
 Parenchymal injury
 Trachea and bronchial injuries
 Pneumomediastinum

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

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

Needle decompression required-ACP

In hospital-Either large bore cannula in
2nd ICS, MCL or insert chest tube

Reassess post needle
Hemothorax
Blunt or penetrating trauma
 Requires rapid decompression and fluid
resuscitation
 May require surgical intervention
 Clinically: hypovolemia
absence of breath sounds
dullness to percussion
 Can lose entire blood volume in chest

Knife wound
Some problems with Hemothorax
Significant blood loss-how much?
 Atelactasis
 V/Q Mismatch
 So what problems can your patients
have?

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, Beck’s triad:
distended neck veins
muffled heart sounds
hypotension
 Rx: Volume resuscitation
Pericardiocentesis

-
Cardiac tamponade
Aortic rupture
Usually blunt trauma involving
deceleration forces;
 ~90% die within minutes
 Most common site near ligamentum
arteriosum
 Treat like an aneurysm if still alive,
blunt trauma VSA if dead (?pronounce)
 Rx: surgical…poor prognosis

Aortic rupture
Ruptured Hemi diaphragm
Etiology?
 Side??
 Outcome
 Diagnosis- how can you tell??
 Treatment?

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

Chest Trauma
Identify early
 Rapid transport
 Auscultate frequently
 Consider tertiary care centre
 Watch for shock and treat

– IV fluids (bolus is…?)
– Large bore IV’s
– Trendelenberg