Chest trauma
Chest trauma

30 yo male

M: Driver in 80 kph head on collision
Restrained
I: Chest wall & sternal pain, leg injuries
S: 140/80 110bpm sats 90%
T: 15 mg IV morphine, Oxygen





Arrives in ED moaning, disorientated, splint on leg, hard
collar on neck
High flow oxygen
Chest
trauma
The key to effective trauma management is to minimize the time to



definitive management so the initial management should be focused
and abbreviated
List significant differential diagnosis in chest trauma
Inspection;




Palpation;







Chest wall tenderness
crepitus
Subcutaneous emphysema
Position trachea
Auscultation


Retractions
Symmetrical chest wall expansion
Wounds, flail segments
Very difficult in ED room; low sensitivity but good specificity
Determine absence / asymmetry of breath sounds
JVP (difficult to ascertain in neck collars and low in low volume states
Absence of pain, tenderness and auscultatory abnormalities in the
patient with normal mental status has a NPV near 100%
Chest trauma

Soon after arrival

100/70, PR 130, sats 92% on oxygen mask, skin dusky

What would you do and what are you looking for?
Chest trauma

Pneumothorax
how reliable is the clinical examination?
how reliable is the trauma CXR?
how is a tension pneumothorax treated?
what do we do with occult PTx on CT?
how do we treat stab wound to the chest?
Chest trauma
Pneumothorax
Cause
- simple
- open
- tension
- Sudden increase in intra thoracic pressure
- Rib fractures lacerate the lung
- Deceleration injury tears the lung
- Blunt force disrupts the alveoli
Examination
universal finding common (50-7% inconsistent(<25%)rare (10%)
chest pain. Respiratory distress
tachycardia, ipsilateral decreased air entry
low sats, tracheal dev, hypotension
- cyanosis, hyperresonance, drowsy
- ipsilateral; hyper-expansion, hypo-motility
Tracheal deviation is inconsistent and poorly predictive
In the ventilated patient; rapid onset drop in saturations and blood press
Chest trauma
CXR







supine misses 30 - 50%
the supine AP CXR is much less sensitive (75%)than the erect
CXR
Air accumulates in the anteromedial recess
abnormal hyperlucency in lower chest/upper abdomen as air
collects in the anterior costo-phrenic abscess
Sub-pulmonary air collection or hyperlucency
Deep sulcus sign; abnormally deep and lucent costophrenic
angle. Ant PTx
Unusually well defined mediastinal structures because of
postero-medial air
Depression of hemi-diaphragm
U/S (more sensitive than CXR >90%)
ultrasound
Chest trauma

Tension pneumothorax
Any patient you clinically suspect of having tension PTx
and in distress, is hypoxic or hypotensive
decompress urgently without radiologic confirmation
(sats < 92% on O2, syst < 90, RR < 10, drowsy, cardiac arrest)
mortality is 4 fold in intubated patients if thoracotomy is delayed waiting for CXR


Needle thoracotomy
14# cannula in 2/3 ICS MCL.
however, up to ⅓ patients have a thicker chest wall than cannula length
can use 4/5 ICS MAL if chest wall too thick
follow by insertion of a chest tube
Wait for CXR confirmation in stable patients (with PTx)
 Confirms diagnosis and may prevent unnecessary thoracostomy
 May reveal diaphragmatic rupture which would make thoracostomy
dangerous
what would happen if we inserted a L sided chest tube?
tension pneumothorax
Chest trauma

Occult pneumothorax;
diagnosed by CT in 2 – 8 %
20% will require tube thoracostomy

When do we treat occult pneumothorax?
guidelines for thoracostomy
1. > 5×80mm
2. associated rib fractures
3. requiring future positive pressure ventilation
4. multiple injuries, haemorrhagic shock, brain injury

What do you do if you elect to do nothing?
repeat CXR in 6 and 24 hours
stabbing





Most are clinically stable on arrival
15% require operative management
‘normal CXR’ require repeat in 6 hrs
Injury to ‘cardiac box’ =
clavicle-costal margin
between midclavicular lines
 Less than 25% make it to hospital; of which
 41% present haemodynamically stable
 CXR; 59% widened mediastinum
27% haemothorax
 CT; replacing angiogram, shows trajectory
10-30% involve the abdomen; when wound is below 4th nipple
Chest trauma



58 yo male motorbike rider hit by truck from
behind
Complaining of chest pain, no LOC
120 bpm, 140/90, RR 28, sats 94% on 8L O2
Chest trauma

Haemothorax
clinical Decreased chest expansion, decreased breath sounds (dull to percussion)
CXR (sens 50%, spec 90%)
moderate size: >400-500 mls blood to detect on supine CXR
diffuse non-segmental opacification through which lung markings can be seen,
large size >1500mls
ground glass appearance on CXR
haemodynamic compromise from blood loss and mediastinal shift
U/S ( sens 90%, spec 95%)
tube thoracostomy
lung re-expansion will tamponade bleed
place ICC posteriorly unless there is a pneumothorax as well
10-15% require thoracotomy
thoracotomy if stable and bleeds>200mls/hr or >1500ml in total
if unstable and bleeds>100mls/hr or > 100ml in total
no improvement in haemothorax will require a second ICC
antibiotics prob not required if adequate drainage of haemothorax and sterile
technique used
Chest trauma – rib#

Compression or shearing of the lung parenchyma leads to localized disruption
of the alveolar capillary membrane and lung interstitium. Blood leaking out into
the interstitium

50% rib fractures undetectable radiologically
Rib fractures cause severe pain, delayed morbidity and mortality that leads to
pneumonia
Chest wall injury; ⅓ have pulmonary complications
30% pneumonia
↑rib#s → ↑mortality esp>3-4 ribs (13% mortality)
age; > 65yo mortality (8 vs 61%)(Bulger) each additional rib# increases
mortalityby 19%
elderly patients with rib fractures should be admitted
concurrent ≥ 2 extra-thoracic injuries ↑↑ mortality
Blunt chest injury treatment;
 pain control (epidural analgesia better outcome, esp if > 4 rib# and > 65yo)
 chest physio
 mobilisation
 Unnecessary IV fluid administration should be meticulously avoided



Rib #



1st and 2nd rib# may indicate severe neurovasc injuries
most common in ejected MVA victims
Lower rib#s may indicate abdo injuries
diaphragmatic injuries
Admit ≥ 3 rib#s, underlying resp disease, complications (pneumo,
heamo, pul contusion), pain not controlled (must be able to deep
breathe and cough), unable to cope at home, elderly

Sternal fractures; ECG
troponin; not routinely required unless
haemo unstable
1.
2.
3.
4.
5.
Deep sulcus
Widened mediastinum, obscured aortic knuckle, opacified aorto-pul window
R side Contusion
L Haemothorax
7 – 10 R rib#
Chest trauma

52 yo male
Hit by car travelling at 70 kph
Brief LOC, chest pain
120 bpm, 100/70, sats 90%

You are the doctor completing the primary survey



Chest trauma

Flail chest





most severe form of blunt chest trauma; mortality 10-20%
Poor outcome is due to the underlying pulmonary contusion
Causes long term chest wall pain and exertional dyspnoea
Advances in knowledge and ICU techniques over the last 3
decades have not impacted on mortality
Management
Unnecessary IVF infusion should be avoided
 Obligatory mechanical ventilation should be avoided (Trinkle)
(intubate to improve gas exchange and not for mechanical correction)
 Optimal analgesia (epidural)
 Chest physio
 CPAP works (Tanaka, Gunduz)
 Surgical fixation worked in old studies not comparing new techniques

Cardiac echo
Blunt Cardiac Injury



Sustained from rapid deceleration with direct blow to the
chest
Suspect with mechanism or poor cardiovascular response to
their injury
Difficult diagnosis







Chest pain or SOB
Chest wall tenderness, flail, crepitus
Sinus tachy, arrhythmia, pump failure
No single or combination of test reliably diagnoses it
Normal ECG in stable patient with blunt chest trauma
essentially rules out significant risk of blunt myocardial injury
Cardiac echo for unexplained hypotension, ECG changes or
pump failure
Troponin has no important clinical value in diagnosis of BCI
Blunt aortic injury








Mainly MVA, pedestrian, falls, impact from any direction
Second most common cause of death in blunt injuries; 85% die pre-hospital
CXR can be used as a initial screening tool (98% NPV if normal)
 Widened mediastinum most common trigger for additional workup to exclude
BAI
 supine 10cm, PA 8cm and mediastinal/chest ratio 0.38 (at level or aortic arch)
 Other signs;
obscured or indistinct aortic knob
depression L main bronchus
deviation NGT
opacification aorto-pul window
displaced L parasternal stripe
fracture 1st rib, apical cap
 CXR may be normal in 25%
Screen with CTA; 100% NPV
Angiography; gold standard and may be used when CT equivocal
Requires immediate repair unless there are more urgent issues requiring
laparotomy or craniectomy
Endoluminal stent or surgical repair (complication; spinal cord ischaemia or renal
failure)
Treat hypertension to reduce shearing forces with b -blockers