Definition
A.Any mechanism that causes injury to the bony or soft tissue in the thorax.
B.Any of these injuries alone or in combination can be devastating and life-threatening to the patient, in a very short period of time.
Incidence
A.Account for up to 25% of all trauma-related deaths.
B.Approximately 80% to 85% of patients with chest trauma will experience at least one rib fracture.
C.Gunshot wounds to the chest tend to be more fatal.
D.Approximately 5% to 10% of chest trauma will involve sternal fractures.
Pathogenesis
A.Related to mechanism of injury.
B.Common mechanisms: Blunt chest trauma, penetrating trauma (gunshot wounds, stab wounds, impalements, acceleration–deceleration shearing forces, and compressive forces).
Predisposing Factors
A.Chest trauma can occur in anyone, but there is a higher incidence in younger males who may engage in high risk behaviors.
Subjective Data
A.Common complaints/symptoms.
1.Chest wall and back pain, worse with movement, coughing, breathing.
2.Shortness of breath.
3.Increased pain with palpation.
B.Common/typical scenario.
1.Other signs and symptoms.
a.Crepitus in the presence of fractures.
b.Splinting or shallow breathing.
c.Decreased breath sounds on the affected side (pneumothorax).
d.Beck’s triad: Muffled, distant heart sounds (cardiac tamponade), jugular venous distention, and narrowed pulse pressures.
C.Subjective data/review of systems.
1.Ask the patient about the events surrounding the injury. With falls, ask if the patient tripped or passed out. Determine if syncope needs to be ruled out.
2.If motor vehicle collisions (MVC) occur, ask the patient about restraints. Was there a steering wheel deformity?
3.Assess for chest pain. Location? Characteristics? Reproducible?
Physical Examination
A.Aimed at identifying the most life-threatening injury first.
B.Advanced trauma life support (ATLS) guidelines provide a quick but thorough approach to patient assessment.
Diagnostic Tests
A.FAST examination: May show cardiac tamponade and can be used to determine the presence of a pneumothorax without the use of chest x-ray.
B.Plain radiograph of the chest to identify fractures, atelectasis, pneumothorax, or widened mediastinum (possible aorta injury).
C.CT and CT angiogram help to identify specific bony, organ, and vascular injuries.
D.ECG.
E.Arterial blood gas: May show respiratory acidosis related to hypoventilation as a result of pain and splinting.
F.Cardiac enzymes.
Differential Diagnosis
A.Common traumatic chest injuries.
1.Bony injuries.
a.Rib fractures.
i.Definition: Fractures of one or more ribs. Can be located bilaterally, or may be displaced and can stand alone or result in injury to underlying structures such as the lungs, subclavian vessels, or organs such as the spleen and liver.
1)Flail chest: Occurs when at least two adjacent ribs are broken in multiple places, creating a free moving segment allowing that segment of the chest wall to move independently. If fractures are near the sternum, there can be a free-floating segment of the sternum, as well as rib. This can be a life-threatening condition.
b.Sternal fractures.
i.Definition: Fractures of the manubrium or sternal body. Persons older than 65 years will have increased risk of death (10%–12%) with one rib fracture. The rate increases by 5% with each additional rib fracture.
ii.Management.
1)Rule out underlying injury to other tissues or organs.
2)Cardiac echo will determine if there is a cardiac contusion or other heart-related injury.
3)Pain management.
4)Aggressive pulmonary hygiene. Encourage incentive spirometer.
5)Supplemental oxygen.
6)Displaced rib fractures or flail segments may require operative intervention for stabilization.
2.Lung injuries.
a.Pulmonary contusion.
i.Definition.
1)Bruising to the lung parenchyma.
2)Clinical course: Tend to worsen in the first 24 to 48 hours. Can lead to atelectasis, infiltrate, effusions, or empyema.
3)Frequently associated with rib fractures.
ii.Management.
1)Supplemental oxygen.
2)May require intubation and supported ventilation.
3)Analgesia.
4)Chest physiotherapy.
b.Pneumothorax.
i.Definition.
1)Accumulation of air in the pleural space, resulting in partial or complete collapse of the lung.
2)Tension pneumothorax: Life-threatening condition. As air accumulates in the pleural space, it exerts an increased pressure on the heart; mediastinal shift to the unaffected side can lead to circulatory collapse.
c.Hemothorax.
i.Definition.
1)Blood accumulates in the pleural space.
2)Considered massive hemothorax
when drainage exceeds 1.5 L in less than 2 hours after injury, necessitating emergent thoracotomy.
ii.Physical examination findings of pneumothorax or hemothorax.
1)Decreased breath sounds on the affected side.
2)Deviated trachea is a late sign.
3)Respiratory distress, hypoxia, tachycardia, or hypotension may be present.
iii.Other physical findings.
1)Cyanosis.
2)Diaphoresis.
3)Chest pain.
4)Altered mental status.
iv.Management.
1)Small pneumothorax or hemothorax can be managed conservatively by observation and repeat chest x-ray (CXR).
2)Pneumothorax greater than 20% requires thoracostomy tube (chest tube) insertion.
3)Massive hemothorax with drainage of more than 1.5 L in 2 hours may require thoracotomy and repair of lung injury.
d.Cardiac tamponade.
i.Definition: Accumulation of blood or fluid in the pericardial sac, causing a compression of the heart muscles. This leads to decreased cardiac output, which is life-threatening.
ii.Physical examination findings.
1)Beck’s triad: A constellation of findings suggestive of tamponade.
a)Jugular vein distention.
b)Hypotension with narrowing pulse pressures.
c)Distant or muffled heart sounds.
iii.Other physical findings.
1)Tachycardia.
2)Pulsus paradoxus.
3)Altered mentation.
4)Oliguria.
5)Signs of impending shock.
iv.Management.
1)Pericardiocentesis.
2)Management of shock.
e.Great vessel injuries.
i.Definition.
1)Interruption of the wall of any of the great vessels is a life-threatening event. Injuries to the aorta, internal vena cava, or subclavian vessels can be the result of laceration from bony segments or shearing or compressive forces. These require operative intervention.
2)Physical findings.
a)Chest or back pain, shortness of breath, weakness.
b)Hypotension.
c)Variations in blood pressure (BP) in both upper extremities.
d)Shock.
3)Management.
a)Thoracotomy with repair to affected vessels; may require cardiopulmonary bypass.
b)Mechanical ventilation.
c)Replacement of blood volume with transfusion, may require massive transfusion protocols.
d)May require hemodynamic support with vasopressors and volume resuscitation.
Evaluation and Management Plan
A.General plan.
1.Identify specific injuries and treat accordingly.
2.Primary goals of therapy.
a.Pain management.
b.Prevention of atelectasis and pneumonia.
c.Supplemental oxygen.
3.Explain expectant course with patient and family.
4.Consider adding cardiac enzymes to workup to rule out underlying stress to heart.
5.May require multiple radiographs to evaluate course of healing.
6.For patients with chest tubes, document the output and consistency of drainage and whether or not an air leak is present.
B.Patient/family teaching points.
1.Cough and deep breathing exercises.
2.Incentive spirometry or other airway clearance devices.
3.Incisional wound care.
C.Pharmacotherapy.
1.When indicated, vasopressors to support hemodynamics.