Trauma to Chest - Emergency Management

Trauma to Chest

Tension Pneumothorax

·        Signs:

o   Apex beat lost 

o   Blocks IVC ® ¯venous return ® ­JVP

o   ¯Vocal fremitus

o   Hyper-resonance

o   Displaced trachea (maybe)

o   US may help with diagnosis

·        On X-ray must have both of no peripheral vascular markings and a visceral pleural line

·        Types: 

o   Primary/spontaneous: apical sub-pleural blebs are common and occasionally rupture. Especially tall, thin, young males. Can occur at rest. Recurrence 20%

o   Secondary: in any lung disease

·        Treatment:

o   Insert 14g iv cannula into midaxillary line at level of nipple (any lower and may get diaphragm)

o   Hissing of air is diagnostic

·        Remove needle and leave cannula in place.  Attach tubing and put other end under water

·        PP ventilation will help reinflate the lung

·        Insertion where there wasn‟t a pneumothorax will cause one!

Open Pneumothorax

·        Sucking wound Þ can‟t create –ive intrathoracic pressure

·        Occlusive dressing and positive pressure

Massive Haemothorax

·        1500 ml in thorax or > 200 ml per hour 

·        Mainly penetrating wounds of pulmonary vessels (e.g. intercostals). If great vessels affected usually don‟t survive 

·        Significant amount of blood needs surgical removal ® thoracotomy

Flail Chest

·        Needs lots of force – so suspect pulmonary contusion as well 

·        Independent segment of chest wall ® paradoxical movement.  Requires two breaks

·        Treat with IPPV for at least a week

Cardiac Tamponade

·        Commonly results from penetrating injury

·        Commonly confused with a pneumothorax – think pneumo-thorax first – more common

·        Signs: 

o  Impaired diastolic filing ® ¯stroke volume. Initially tachycardia and vasoconstriction maintain cardiac output and BP. Eventually hypotension and shock 

o  Cardinal signs: Beck‟s triad – hypotension, ­venous pressure (­JVP), small quiet heart

o  Pulsus paradoxus: > 10 mmHg ¯ in systolic BP with normal inspiration

·        Treatment:

o  ?Emergency pericardiocentesis (either via xyphisternum or into apical area).  Surgery essential 

o  Colloid fluid infusion ® ­filling pressure and stroke volume

Pulmonary Contusion

·        Leads to non-compliance: V/Q mismatch, shunting ® ¯ PO2

·        Ventilate

Myocardial Contusion

·        Suspect if fractured sternum (requires big force)

·        There will be a current of injury on ECF and cardiac enzymes 

·        Causes arrhythmias and ¯CO

·        Treatment: 24 hours observation under ECG – can be arrhythmias

Rib Fracture

·        Commonest injury: pain impairs ventilation 

·        Complications: atelectasis, pneumonia, contusion, pneumothorax, secondary pleural effusion 2 – 3 weeks later

·        Treatment: pain relief

Traumatic Rupture of Aorta

·        Results from rapid deceleration, usually at ligamentum arteriosum

·        Immediately fatal in 90% of cases.  50% further mortality per 24 hours thereafter untreated

·        Diagnosis suspected on CXR: widened mediastinum, 1^st & 2^nd rib fracture, obliteration of aortic knob, deviation of trachea. Definitive diagnosis by aortogram

·        Treatment: repair 

·        Complications: paraplegia due to ¯blood flow to spine