Key features
- Thoracic injuries account for 25% of deaths from trauma.
- 50% of patients who die from multiple injuries also have a significant thoracic injury.
Managementprimary survey
Identify and treat major thoracic life-threatening injuries.
Tension pneumothorax
- A clinical diagnosis. There is no time for X-rays.
- Patient has respiratory distress, is tachycardic and hypotensive.
- Look for tracheal deviation, decreased movement, hyperresonant percussion note, and absent breath sounds over affected hemithorax.
- Treat with immediate decompression. Insert a 12G cannula into the second intercostal space in the midclavicular line. Follow this with insertion of an underwater seal chest drain into the fifth intercostal space between the anterior and midaxillary line.
Open pneumothorax
- Occlude with a three-sided dressing.
- Follow by immediate insertion of an intercostal drain through a separate incision.
Flail chest
- Results in paradoxical motion of the chest wall. Hypoxia is caused by restricted chest wall movement and underlying lung contusion.
- If the segment is small and respiration is not compromised, nurse patient in HDU with adequate analgesia. Encourage early ambulation and vigorous physiotherapy. Do regular blood gas analysis.
- In more severe cases, endotracheal intubation with positive-pressure ventilation is required.
Massive haemothorax
- Accumulation of more than 1500mL of blood in pleural cavity.
- Suspect when shock is associated with dull percussion note and absent breath sounds on one side of chest.
- Simultaneously restore blood volume and carry out decompression by inserting a wide bore chest drain.
- Consider need for urgent thoracotomy to control bleeding if there is continued brisk bleeding and need for persistent blood transfusion. Consult with a regional thoracic centre.
Cardiac tamponade
- Most commonly results from penetrating injuries but blood can also accumulate in pericardial sac after blunt trauma.
- Recognize by haemodynamic instability: hypotension, tachycardia, raised jugular venous pressure, pulsus paradoxus, and faint heart sounds.P.441
- If critically ill with suspected tamponade perform blind pericardiocentesis and call cardiothoracic or general surgeons to consider emergency thoracotomy.
- If unwell but responding to treatment arrange urgent transthoracic echo or focused abdominal ultrasound in A & E.
Managementsecondary survey
Perform a further in-depth examination: in stab injuries expose the patient fully and position them so that you can assess front, back, and sides of the chest for any wounds missed in the primary survey.
An erect chest X-ray looking for the following injuries.
Simple pneumo-lhaemothorax
Treat with a chest drain if large or symptomatic or in any patient likely to undergo a general anaesthetic.
Pulmonary contusion
Most common potentially lethal chest injury. Risk of worsening associated consolidation and local pulmonary oedema. Treat with analgesia, physiotherapy, and oxygenation. Consider respiratory support for a patient with significant hypoxia.
Tracheobronchial rupture
- Suspect when there is persistent large air leak after chest drain insertion. Seek immediate (cardiothoracic) surgical consultation.
- Thoracic CT scan usually diagnostic.
Blunt cardiac injury (myocardial contusion/traumatic infarction)
Suspect when there are significant abnormalities on ECG or echocardiography. Seek cardiological/cardiothoracic surgical advice.
Aortic disruption
- Patients survive immediate death because the haematoma is contained.
- Suspect when history of decelerating force and where there is widened mediastinum on chest X-ray.
- Thoracic CT scan is diagnostic.
- Consider cardiothoracic surgical referral.
Diaphragmatic rupture
- Usually secondary to blunt trauma in restrained car passengers (seat belt compression causes burst injury commonly on the left side).
- Suspect in patient with a suitable history and a raised left hemidiaphragm on CXR.
- Penetrating trauma below the fifth intercostal space can produce a perforation.
- Thoracoabdominal CT scan usually diagnostic.
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