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Thoracic traumas 

1. BLUNT TRAUMA

Rib fracture

  • Ribs 4-9 are most frequently fractured
  • Fracture of rib 1 – more injury to great vessels and brachial plexus
  • If ribs 8, 10, 11, 12 involved – check for injuries of liver, spleen, kidneys
  • Clinical features – pleuritic chest pain, rapid shallow breathing, Atelectasis , hypoxemia
  • Investigations – CXR
  • Treatment – strong analgesia, intercostal nerve block
    • Pulmonary toilet – patient asked to cough and breathe deeply to remove secretions (reduces atelectasis)
    • Severe injury – internal fixation with plates and screws

Flail chest

  • From double fractures of >2 adjacent ribs in >2 different places
  • Flail segment moves inward during inspiration
  • Clinical features
    • Painful breathing, paradoxical chest movements, crepitus
    • Rapid shallow breathing, dyspnea, tachypnea, bruising/swelling
  • Investigations – CXR, pulse oximetry, blood gases, chest CT
  • Treatment – high flow oxygen, intra-pleural local anaesthesia, analgesia, ORIF

Pneumothorax

  • Air in pleural space as a result of partial/complete collapse of lung space ( 3 types )

Simple/closed pneumothorax

  • Chest wall is intact, air enters the pleural space from lung surface
    • Opening in lung tissue – leaks air into chest cavity (usually self-limiting)
  • Pleural cavity pressure is LESS THAN atmospheric pressure
  • Clinical features – chest pain, dyspnea, tachypnea, decreased breath sounds on affected side
  • Treatment – airway assistance, monitor for development of tension pneumothorax

Open pneumothorax (life threatening, rapid deterioration)

  • Opening in chest cavity that allows air to enter the pleural cavity
    • Causes lung collapse due to increased pressure in pleural cavity
  • Pleural cavity pressure is EQUAL TO atmospheric pressure
  • Clinical features – dyspnea, sharp pain, subcutaneous emphysema, decreased breath sounds, hyper-resonance
  • Investigations – CXR
  • Treatment
    • Observe if pneumothorax is small
    • Aspiration
    • Chest tube – between 4th and 5th intercostals space, mid-axillary line
    • Pleurectomy, thoracotomy

Tension pneumothorax

  • Air builds into pleural space with no way for air to escape
  • Caused by – penetrating trauma, blunt trauma, iatrogenic injury
  • Pleural cavity pressure is MORE THAN atmospheric pressure
  • Results in lung collapse on affected side
    • Causes increased pressure on mediastinum, the other lung, great vessels
    • Leads to decreased venous return and shock
  • With each inhalation – lung collapses further
    • Trachea deviates to the opposite side – causes compressed heart and depressed hemidiaphragm
  • Clinical features
    • Anxiety, panic, poor colour
    • Absent breath sounds on affected side, accessory muscle use
    • Hypotension, tachypnea and tachycardia, tracheal deviation
  • Treatment
    •  Needle decompression – large bore needle in 2nd intercostal space, mid-clavicular line
    • Chest tube – between 4th and 5th intercostal space, mid-axillary line
  • Complications – haemorrhage, infection, trauma (liver, spleen, diaphragm, aorta, heart)

Haemothorax

  • Free blood in pleural cavity – lacerated blood vessels in thorax
    • As blood increases, there is more pressure on the heart and other vessels in chest cavity
  • Clinical features – often asymptomatic
    • Dyspnea, tachypnea, hypovolemia, flat neck veins, decreased breath sound
  • Investigations
    • CXR
    • CT to distinguish haemothorax from a lung contusion
  • Treatment
    • Chest drain
    • Transfusion for blood loss (urgent thoracotomy if 1-2L lost)
    • Thrombolytic therapy (Streptokinase)

Pulmonary contusion

  • Interstitial and/or alveolar lung injury without any frank laceration
  • Usually occurs secondary to non-penetrating trauma
    • Direct blunt trauma, deceleration, concussive/compressive force
  • Natural progression of pulmonary contusion – worsening hypoxemia within 24-48hrs
  • Clinical features – hemoptysis, dyspnea, cough, chest wall abrasion, ecchymosis, respiratory failure
  • Investigations
    • CXR – well localised opacification
    • Pulse oximetry, ABG
    • CT
  • Treatment
    • Antibioitcs
    • Oxygen mask, pulmonary toilet
    • Thoracotomy
    • Mechanical ventilation

Subcutaneous emphysema

  • Air collects in subcutaneous tissue from pressure of air in pulmonary cavity
  • Feels like rice crispies when overlying skin is touched
  • Seen from neck to groin area – chest, neck, face (travels along fascia)
  • Clinical features – neck swelling, chest pain, dysphagia, wheezing, dyspnea
  • Treatment – if massive, cut into skin and place catheters to release air

Blunt cardiac trauma

  • Cardiac contusion can cause full cardiac rupture – leading to death
    • E.g. direct blow over pericardium, rapid deceleration accidents
  • Investigations – FAST scan
  • Treatment
    • Observation and bed rest – for patients with normal ECG + troponins
    • Anti-arrhythmics
    • Ionotropes in cardiogenic shock

Rupture of thoracic aorta

  • Usually occurs distal to left subclavian artery
  • Cause – road traffic accidents, rapid deceleration
  • Clinical features
    • Burning/tearing feeling in chest, rapid loss of consciousness
    • Increased pulse, sudden hypotension, wide pulse pressure
    • Systolic murmur over precordium
    • Hoarseness – compression of recurrent laryngeal nerve
    • Hypertension in arms and hypotension in legs
  • Investigations
    • CXR – wide upper mediastinum, tracheal deviation
    • CT, aortic angiogram, trans-oesophageal echocardiogram (TOE)
  • Treatment – resuscitation, surgical repair

2. PENETRATING TRAUMAS

Pericardial tamponade

  • Compression of heart due to fluid accumulation within pericardium
    • Once pericardial sac cant expand anymore, there is increased pressure on the heart
      • Heart cannot pump properly
    • Leads to decreased BP and increased heart rate to compensate – can cause cardiac arrest
  • Clinical features
    • Beck’s triad – low BP, increased JVP, muffled heart sounds
    • Increased respiratory rate and heart rate
    • Poor skin colour
  • Investigations
    • CXR – enlarged globular heart
    • ECHO – shows fluid in pericardial sac
    • ECG – inverted T wave, ST elevation, low QRS voltage
  • Treatment
    • High flow oxygen
    • Treat clinical features of shock
    • Pericardiocentesis – insert at angle of xiphoid cartilage at 7th rib
    • Sternotomy/thoracotomy

Oesophageal injury

  • Damage to oesophagus
    • Bacteria – leads to mediastinitis, causes abscess
    • Air – leads to pneumothorax and emphysema
    • Gastric juice – causes oesophageal burns, which leads to fluid and electrolyte imbalance
  • The above mechanisms all eventually lead to sepsis and pneumonia, followed by cardiovascular collapse
  • Clinical features
    • Pain with swallowing
    • Unexplained fever which lasts for over 24 hours
    • Subcutaneous emphysema
  • Pleural effusion
  • Investigations – oesophagoscopy, CT
  • Treatment – drainage and operative repair
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