CHEST TRAUMA

Overview
 Chest trauma (or thoracic trauma) is a serious
injury of the chest. Thoracic trauma is a
common cause of significant disability and
mortality, the leading cause of death from
physical trauma after head and spinal cord
injury. Blunt thoracic injuries are the primary or a
contributing cause of about a quarter of all
trauma-related deaths. The mortality rate is
about 10%.
 Thoracic injuries are a contributing factor in up
to 75% of all trauma-related deaths.
 Types of Chest Trauma
 Blunt Chest  Penetrating
Trauma Chest Trauma
BLUNT CHEST TRAUMA
 Blunt injury to the chest can affect any one
or all components of the chest wall and
thoracic cavity. These components include
the bony skeleton (ribs, clavicles, scapulae,
sternum), lungs and pleurae,
tracheobronchial tree, esophagus, heart,
great vessels of the chest, and the
diaphragm.
Clinical Presentation of Patients with
Blunt Chest Trauma
 The clinical presentation of patients with blunt chest trauma varies
widely and ranges from minor reports of pain to florid shock. The
presentation depends on the mechanism of injury and the organ
systems injured.

 Obtaining as detailed a clinical history as possible is extremely

important in the assessment of a patient with a blunt thoracic
trauma. The time of injury, mechanism of injury, estimates of
RTA velocity and deceleration, and evidence of associated
injury to other systems (eg, loss of consciousness) are all
salient features of an adequate clinical history.

 Information should be obtained directly from the patient whenever

possible and from other witnesses to the accident if available.
 Blunt Thoracic Injuries and their Treatment

1. Chest Wall Fractures, Dislocations,

and Barotrauma (Including
Diaphragmatic Injuries)

2. Blunt Injuries of the Pleurae, Lungs,

and Aerodigestive Tracts.
 Chest Wall Fractures,
Dislocations, and
Barotrauma (Including
Diaphragmatic Injuries)
 Chest Wall Fractures, Dislocations, and Barotrauma
(Including Diaphragmatic Injuries)

 Rib fractures
-Rib fractures are the most common blunt
thoracic injuries.
-Patients usually report inspiratory chest pain and
discomfort over the fractured rib or ribs. Physical
findings include local tenderness and crepitus
over the site of the fracture. If a pneumothorax is
present, breath sounds may be decreased and
resonance to percussion may be increased.
-Pain relief and the establishment of adequate
ventilation are the therapeutic goals for this injury.
 Chest Wall Fractures, Dislocations, and Barotrauma (Including
Diaphragmatic Injuries)

 Flail chest
-A flail chest, by definition, involves 3 or more consecutive rib fractures
in 2 or more places, which produces a free-floating, unstable segment
of chest wall.)
-Patients report pain at the fracture sites, pain upon inspiration, and,
frequently, dyspnea. Physical examination reveals paradoxical motion of
the flail segment. The chest wall moves inward with inspiration and
outward with expiration. Tenderness at the fracture sites is the rule.
Dyspnea, tachypnea, and tachycardia may be present. The patient may
overtly exhibit labored respiration due to the increased work of
breathing induced by the paradoxical motion of the flail segment.
-All of the treatment modalities for patients with rib fractures are
appropriate for those with flail chest.
Respiratory distress or insufficiency can ensue in some patients with
flail chest because of severe pain secondary to the multiple rib
fractures, the increased work of breathing, and the associated
pulmonary contusion. This may necessitate endotracheal intubation and
positive pressure mechanical ventilation
 Chest Wall Fractures, Dislocations, and
Barotrauma (Including Diaphragmatic Injuries)
 Clavicular fractures
-Primary treatment consists of immobilization with a
figure-of-eight dressing, clavicle strap, or similar
dressing or sling.
 Sternal fractures
- Most sternal fractures require no therapy specifically
directed at correcting the injury. Patients are treated
with analgesics and are advised to minimize activities
that involve the use of pectoral and shoulder girdle
muscles. The most important aspect of the care for
these patients is to exclude blunt myocardial and
other associated injuries.
Blunt Injuries of
the Pleurae,
Lungs, and
Aerodigestive
Tracts
 Blunt Injuries of the Pleurae, Lungs, and
Aerodigestive Tracts
 Pneumothorax
-Pneumothoraces in blunt thoracic trauma are. most
frequently caused when a fractured rib penetrates the lung
parenchyma This is not absolute. Pneumothoraces can
result from deceleration or barotrauma to the lung without
associated rib fractures.
-Patients report inspiratory pain or dyspnea and pain at
the sites of the rib fractures. Physical examination
demonstrates decreased breath sounds and
hyperresonance to percussion over the affected
hemithorax.
-All patients with pneumothoraces due to trauma need a
thoracostomy tube.
 Blunt Injuries of the Pleurae, Lungs, and
Aerodigestive Tracts
 Hemothorax
-The accumulation of blood within the pleural space can be due
to bleeding from the chest wall (eg, lacerations of the intercostal
or internal mammary vessels attributable to fractures of chest
wall elements) or to hemorrhage from the lung parenchyma or
major thoracic vessels. Patients report pain and dyspnea.
-Physical examination findings vary with the extent of the
hemothorax. Most hemothoraces are associated with a
decrease in breath sounds and dullness to percussion over the
affected area. Massive hemothoraces due to major vascular
injuries manifest with the aforementioned physical findings and
varying degrees of hemodynamic instability.
-Hemothoraces are evacuated using thoracostomy tube.
Multiple chest tubes may be required.
PENETRATING CHEST TRAUMA
 The mechanism of injury may be categorized as low, medium, or high
velocity.
-Low-velocity injuries include impalement (eg, knife wounds), which
disrupts only the structures penetrated.

-Medium-velocity injuries include bullet wounds from most types of

handguns and air-powered pellet guns and are characterized by much
less primary tissue destruction than wounds caused by high-velocity
forces.

-High-velocity injuries include bullet wounds caused by rifles and

wounds resulting from military weapons.
Shotgun injuries, despite being caused by medium-velocity projectiles,
are sometimes included within management discussions for high-
velocity projectile injuries.
Laboratory Studies

 Laboratory examinations are rarely required in the acute

treatment of patients with penetrating chest injuries.
Hemoglobin or hematocrit values and arterial blood gas
determinations offer the most useful information for
treating these patients; however, tests may be temporarily
delayed until patients are stabilized. Blood chemistry
results, serum electrolyte values, and WBC and platelet
counts add little information for initial treatment but can
establish a baseline by which to follow the course of the
patient through his or her therapy. Underlying medical
conditions (eg, diabetes, chronic renal insufficiency), either
known or discovered via the laboratory examinations,
should be noted and treated when appropriate.
Treatment

 Surgical Therapy
-Any organ within the chest is potentially susceptible
to penetrating trauma, and each should be considered
when evaluating a patient with thoracic injury. These
organs include the chest wall; the lung and pleura; the
tracheobronchial system, including the esophagus,
diaphragm, thoracic blood vessels, and thoracic duct;
and the heart and mediastinal structures.
 Chest wall injury
The primary treatment of chest wall
injuries is a combination of pain control,
aggressive pulmonary and physical
therapy, selective use of intubation and
ventilation, and close observation for
respiratory decompensation.
 Lung injuries
Injuries related to the pleural space can
generally be divided into pneumothorax
or hemothorax. Most patients with such
injuries can be cared for with a simple
tube thoracostomy
 Cardiac injuries
-Traumatic cardiac penetration is highly lethal, with case
fatality rates of 70-80%. The degree of anatomic injury and
occurrence of cardiac standstill, both related to the
mechanism of injury, determine survival probability.
Patients who reach the hospital before cardiac arrest
occurs usually survive. Those patients surviving
penetrating injury to the heart without coronary or valvular
injury can be expected to regain normal cardiac function
on long-term follow up.
-Pericardiocentesis can be both diagnostic and
therapeutic.
-Stable patients with cardiac wounds may be diagnosed
using a subxiphoid pericardial window. Bleeding must be
rapidly controlled using finger occlusion, sutures, or
staples. Inflow occlusion and cardiopulmonary bypass are
rarely necessary.
THE END