Chest Trauma

Published on 14/03/2015 by admin

Filed under Emergency Medicine

Last modified 22/04/2025

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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

Signs and Symptoms

1. Pain in the chest after blunt chest trauma

2. Pain that worsens with inspiration

3. Point tenderness over the fractured rib(s)

4. Crepitus and deformity, occasionally detected on palpation

5. Fractured ribs usually occur along the side of the chest. Pushing on the sternum while the patient lies supine will produce pain at the fracture site, instead of at the point of contact

Treatment

1. Care for any open chest wounds.

a. Cover the wound quickly, especially if there is air bubbling, to avoid “sucking” chest wound (see Open [“Sucking”] Chest Wound, later).

b. Use a petrolatum-impregnated gauze, heavy cloth, or adhesive tape for the dressing.

2. Treat an isolated rib fracture.

a. Administer an oral analgesic, and instruct the patient to rest.

b. Note that thoracic taping and splinting are contraindicated so that the patient can take full unimpeded inspirations.

c. Encourage the patient to cough or deep-breathe at least 10 times per hour to prevent atelectasis.

3. Treat multiple rib fractures.

a. Be aware that multiple fractures are associated with higher risk for serious underlying injuries.

b. Cushion the patient in a position of comfort, and frequently reevaluate the patient’s ability to breathe.

c. Do not tape or tightly wrap the ribs because this might prevent complete reexpansion of the lung with inspiration, leading the patient to take only shallow, inadequate breaths and possibly leading to atelectasis and pneumonia. Provide analgesics so that the patient may take at least 10 deep breaths or give one good cough every hour.

d. Evacuate the patient as soon as possible. If the chest injury is on one side, transport the patient with the injured side down to facilitate lung expansion and oxygenation of the blood on the uninjured side.

Flail Chest

Signs and Symptoms

1. A portion of the chest wall that is mechanically unstable, indicating that a series of three or more ribs is fractured in both the anterior and posterior planes

2. Unstable segment that paradoxically moves inward during inspiration, thereby inhibiting ventilation

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.

FIGURE 15-1 Technique for intercostal nerve block. With the patient seated or lying prone, skin prepped ideally using sterile technique, identify the posterior angle of the rib (6 to 8 cm [2.4 to 3.1 inches] from the spinous processes). The 25-gauge needle is advanced with 20 degrees of cephalad angulation and to the inferior margin of the rib. The needle is then walked off the inferior rib margin while maintaining cephalad angulation and advanced 2 to 3 mm to lie adjacent to the intercostal nerve. The intercostal nerve lies inferior to the intercostal vein and artery. Inject 3 to 5 mL bupivacaine 0.25% to 0.5%, lidocaine 1% to 2% with epinephrine 1:200,000 to 1:400,000, or ropivacaine 0.5% to 0.75%.

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.

a. Use soft and lightweight materials.

b. Use large strips of tape to hold the pad in place.

c. Do not tape entirely around the chest because this will restrict breathing efforts.

d. Do not allow the object to restrict breathing in any manner.

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.

Pneumothorax/Hemothorax

Signs and Symptoms

1. Pain that worsens with inspiration

3. Unilateral decreased or absent breath sounds

4. Resonance on percussion with a pneumothorax; flat or dull on percussion with a hemothorax

5. Subcutaneous emphysema (in the case of pneumothorax)

6. Pneumothorax can be identified by loss of the “comet tails” or loss of pleural sliding on ultrasound examination.

Treatment

1. Evacuate the patient immediately.

2. Monitor closely for the development of a tension pneumothorax.

Tension Pneumothorax

Signs and Symptoms

1. Distended neck veins (may not be present if patient is hypovolemic)

2. Tracheal deviation away from the side of the pneumothorax

3. Unilateral, absent, or grossly diminished breath sounds

4. Hyperresonant hemithorax to percussion

5. Subcutaneous emphysema

6. Respiratory distress, cyanosis, cardiovascular collapse

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).

FIGURE 15-2 Pleural decompression. A, Insertion point for pleural decompression. B, “Walk” needle over the top of the rib to avoid intercostal vessels. C, Catheter in place. D, Finger of a glove is attached to the needle or catheter to create a flutter valve. E, Flutter valve allows air to escape but collapses to prevent air entry.

Open (“Sucking”) Chest Wound

Signs and Symptoms

A chest wound in which air is sucked into the pleura on inspiration; usually caused by penetrating injury.

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).

FIGURE 15-3 Treatment of sucking chest wound. Sealing the wound with a gel defibrillator pad works best because this pad adheres to wet or dry skin. Petrolatum gauze or plastic wrap also works well.

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.

Signs and Symptoms

1. The triad of distended neck veins, hypotension, and muffled heart sounds is present in only one-third of patients.

2. Pulsus paradoxus, an increase in the normal physiologic decrease in blood pressure with inspiration, may be present.

Treatment

1. The only temporizing measure pending evacuation is pericardiocentesis. This procedure should be done in the wilderness only if there is a high index of suspicion, coupled with shock (and impending death) unresponsive to other resuscitative efforts.

2. Advance a long (≈15 cm [5.9 inches]), 16- to 18-gauge needle with an overlying catheter through the skin 1 to 2 cm (0.4 to 0.8 inches) below and to the left of the xiphoid. The needle is advanced at a 45-degree angle with the tip directed at the tip of the left scapula.

3. After the pericardial sac is entered, aspirate blood with a syringe until the patient’s condition improves. Repeat aspiration as the patient’s condition warrants.

4. Immediately evacuate the patient.

Related

Field Guide to Wilderness Medicine