Chest Trauma

Published on 14/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

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15

Chest Trauma

In the wilderness environment, blunt thoracic injuries usually result from falls or direct blows to the chest. Penetrating injuries result from gun, knife, or arrow wounds; impalement after a fall; or a rib fracture. Immediate, life-threatening thoracic injuries include flail chest, pneumothorax/hemothorax, tension pneumothorax, open (“sucking”) chest wound, and pericardial tamponade.

Disorders

Rib Fracture

Treatment

1. Care for any open chest wounds.

2. Treat an isolated rib fracture.

3. Treat multiple rib fractures.

Flail Chest

Treatment

1. Immediately arrange for evacuation of the patient. A small or moderate flail segment can be tolerated for 24 to 48 hours, after which it may need to be managed with mechanical ventilation.

2. Administer intercostal nerve block(s) (Fig. 15-1) to assist in short-term management of pain and pulmonary toilet.

3. Place a bulky pad of dressings, rolled-up extra clothing, or a small pillow gently over the site, or have the patient splint the arm against the injury to stabilize the flail segment and relieve some of the pain.

4. If the patient is unable to walk, transport him or her lying on the back or injured side.

5. If the patient is severely short of breath, assist with mouth-to-mouth rescue breathing. Time your breaths with those of the patient, and breathe gently to provide added air during the patient’s inspirations.

Tension Pneumothorax

Treatment

Use rapid pleural decompression if the patient appears to be decompensating (Box 15-1; Fig. 15-2). Possible complications include infection and profound bleeding from puncture of the heart, lung, major blood vessel, liver, or spleen.

Box 15-1   How to Perform Pleural Decompression

1. Swab the entire chest with povidone–iodine or other antiseptic, such as chlorhexidine.

2. If sterile surgical gloves are available, put them on after washing hands.

3. If local anesthesia is available, infiltrate the puncture site down to the rib and over its upper border.

4. Insert a large-bore (14-gauge) intravenous catheter, needle, or improvised pointed, sharp object into the chest just above the third rib in the midclavicular line (midway between the top of the shoulder and the nipple in a line with the nipple approximates this location) (see Fig. 15-2, A). If you hit the rib, move the needle or knife upward slightly until it passes over the top of the rib, thus avoiding the intercostal blood vessels that course along the lower edge of every rib (see Fig. 15-2, B). The chest wall is 3.8 to 6.4 cm (1.5 to 2.5 inches) thick, depending on the individual’s muscularity and the amount of fat present. A gush of air signals that you have entered the pleural space; do not push the penetrating object in any further. Releasing the tension converts the tension pneumothorax into an open pneumothorax.

5. Leave the needle or catheter in place (see Fig. 15-2, C), and place the cut-out finger portion of a surgical glove with a slit cut into the end over the external opening to create a unidirectional flutter valve that allows continuous egress of air from the pleural space (see Fig. 15-2, D and E).

Open (“Sucking”) Chest Wound

Treatment

1. Place a petrolatum-impregnated gauze pad on top of the wound, cover it with a 4 × 4 inch gauze pad, and tape it on all four sides (Fig. 15-3).

2. Observe closely for signs of tension pneumothorax, and treat as described earlier, with pleural decompression.

3. If a penetrating object remains impaled in the chest, do not remove it. If necessary, carefully shorten the external portion of the penetrating object (e.g., break off the arrow). Place a petrolatum gauze dressing next to the skin around the object, and stabilize it with layers of bulky dressings or pads.

4. A patient with an open chest wound below the nipple line may also have an injury to an intra-abdominal organ (see Chapter 16).

Pericardial Tamponade

Blunt or penetrating cardiac injury leading to pericardial tamponade is uncommon but life threatening. A small amount of intrapericardial blood can severely restrict diastolic function.

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