Types of chest injuries

Crush injuries involving lung, pleura, ribs.

Single rib fracture.
Two or more rib fractures.
Steering wheel injury-causes multiple rib fractures, bilaterally
often with flail chest, with fracture dislocation of upper end of
sternum.
Stove in chest or flail chest.
Traumatic pneumothorax.
Haemothorax, haemopneumothorax, with fracture ribs.
Tension pneumothorax.
Pericardia!, cardiac injuries and rupture of bronchus.
Associated injuries in liver, spleen, diaphragm, major vessels.
Causes
Road traffic accidents.
Industrial accidents.
Blast injuries.
Crush injuries.
Stab injuries.
In children, ribs are malleable and so fracture ribs are rare.
In elderly because of rig id ribs fracture is common.
First and second ribs are protected by clavicle and so their
fracture is uncommon.
11th and 12th ribs are floating ribs and so their fracture ais
rare.
Classification of Chest Injuries
As per the American College of Surgeons Committee on Trauma
chest injuries are classified as (deadly dozen):
1. Immediately life-threatening injuries.
2. Potentially life-threatening injuries .
mmediately life-threatening
Injuries
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive pneumothorax
• Cardiac tamponade
• Flial chest
injuries
• Tracheobronchial disruption
• Aortic disruption
• Diaphragmatic disruption
• Esophageal disruption
• Cardiac contusion
• Pulmonary contusion
Pathological Effects of Chest Injuries
Immediate
Hypoxia
Hypercarbia
Acidosis
Hypovolemic shock
Bronchospasm
Late
Empyema, fibrothorax
Lung abscess
Mediastinitis
Cardiac arrhythmias
Clinical Features of Thoracic Injuries
History of trauma, painful breathing, cough, haemoptysis,
pain in the chest wall, sometimes external wound may be
present (in communicating wounds).
Features of shock when major vessels are involved, i.e .
tachycard ia, hypotension, cold periphery.
Respiratory distress-tachypnoea, cyanosis, respiratory
difficulties.
Tenderness over the fracture site.
Dullness on percussion with decreased breath sounds
signifies haemothorax. Resonant with decreased breath
sound confirms pneumothorax.
Surgical emphysema with palpable crepitus may be
present.
Investigations
Chest X-ray shows haemothorax, pneumothorax,
fracture ribs.
Hb%, PCV to assess blood loss.
Blood grouping and cross matching.
Blood gas analysis, i.e. P02 and PC02.
Ultrasound abdomen to look fo r associated
abdominal injuries.
FAST (Focused abdominal sonar trauma).
CT chest and CT abdomen.
Treatment
Initial First Aid
Airway: Prevention of aspiration, plastic airway,
intubation, tracheostomy.
Breathing: ICT placement, supportive measures.
Circulation: Fluid therapy, CVP line, blood transfusion.
Look for disability.
Expose the patient properly for proper breathing and
assisting.
Assess the patient properly.
Examine the patient thoroughly.
Evaluate the patient for associated injuries like of head,
abdomen, fracture limbs, spine.
Further Treatment
Fracture rib without complication is treated with analgesics
and rest.
Haemothorax, pneumothorax should be treated with inter-
- costal tube drainage (ICT) with underwater seal.
Flail segment should be treated accordingly.
Blood transfusion is done whenever required.
Antibiotics like penicillin, cefotaxime, etc. to prevent infection.
Nasal oxygen, throat suction.
Ventilator support with IPPV (Intermittent positive pressure
ventilation), with regular monitoring of blood gas.
Tracheostomy/endotracheal intubation is done whenever
required.
Antibiotics , bronchodilators, often steroids are other supportive
measures required .
Trauma

The approach to treatment must be methodical and exact because

the signs, particularly in the presence of other injury, may easily be
missed. The guidelines produced by the American College of
Surgeons Advanced Trauma Life Support (ATLS®) Group provide
a thorough and unambiguous approach to trauma. Thoracic trauma
is responsible for over 70 per cent of all deaths following road
traffic accidents. Blunt trauma to the chest in isolation is fatal in 10
per cent of cases, rising to 30 per cent if other injuries are present.
An increasing number of penetrating thoracic wounds is also seen
from domestic and civil violence, with a mortality rate of 3 per cent
for simple stabbing to 15 per cent for gunshot wounds.
Initial management
Early deaths after thoracic trauma are caused by
hypoxemia, hypovolaemia and tamponade. The first steps
in treating these patients should be to diagnose and treat
these problems as early as possible because they may be
readily corrected. Young patients have a large
physiological reserve and serious injury may be
overlooked until this reserve is used up; then the situation
is critical and may be irretrievable. The best approach is to
maintain a high index of suspicion and suspect the worst if
life-threatening conditions are to be anticipated and
treated. Early consultation with a regional thoracic centre
is advised in cases of doubt. In an emergency it is
essential that experienced help is summoned immediately.
The basic principles of resuscitation are
securing the airway and restoring the
circulating volume. Blood and secretions
are removed from the oropharynx by
suction. If the patient is unable to
maintain his or her airway then an
oropharyngeal airway followed by
tracheal intubation (once a cervical spine
injury is excluded) may be necessary.
A thorough inspection of the chest wall includes
noting the frequency and pattern of breathing,
external evidence of trauma and structural defects
of the thorax. Palpation will detect surgical
emphysema, paradoxical movement and a stove-in
chest. Auscultation and percussion should reveal
the existence of a pneumothorax (there is decreased
movement on the affected side with a hyperresonant
percussion note, reduced breath sounds in the axilla
and shift of the trachea to the opposite side) which
requires emergency drainage
Once the patient has been stabilised then radiographs of the
chest should be taken and further treatment decided on the
basis of the patient’s condition and the radiographic result.
It is rarely necessary to perform a thoracotomy in the
resuscitation room but, in the case of tamponade from a
penetrating injury, it might be life saving. However, the fact
is that, even in experienced hands, the yield in terms of
survival in this group of patients is very small. If there is
profound hypotension as a result of cardiac tamponade,
needle aspiration of the pericardium is life saving and may
hold the situation long enough for more controlled surgery
to be performed.
The components of chest injury in blunt
trauma
Any combination of structures may be
involved in varying degrees of severity. If the
skeletal injuries are severe, underlying
parenchymal injuries are likely to be in
proportion; however, in young flexible chests,
or those restrained by seat belts, there may be
little external evidence of the severity of
internal damage.
Chest wall
Localised rib fracture due to direct trauma. A simple rib fracture may
be serious in elderly people or in those with chronic lung disease who
have little pulmonary reserve. Uncomplicated fractures require
sufficient analgesia to encourage a normal respiratory pattern and
effective coughing. Oral analgesia may suffice but intercostal nerve
blockade with local anaesthesia may be very helpful. Chest strapping
or bed rest is no longer advised and early ambulation with vigorous
physiotherapy (and oral antibiotics if necessary) is encouraged. A
chest radiograph is always taken to exclude an underlying
pneumothorax. It is useful to confirm the skeletal injuries but routine
chest radiography may miss rib fractures. However, once a
pneumothorax and major skeletal injuries are excluded, the
management is the same — the local control of chest pain.
Major chest wall trauma.
Flail chest
This occurs when several adjacent ribs are fractured in two places either on one
side of the chest or either side of the sternum. The flail segment moves
paradoxically, that is, inwards during inspiration and outwards during expiration,
thereby reducing effective gas exchange. The net result is poor oxygenation from
injury to the underlying lung parenchyma and paradoxical movement of the flail
segment. The underlying lung injury with loss of alveolar function may result in
deoxygenated blood passing into the systemic circulation. This creates a right-to-
left shunt and prevents full saturation of arterial blood. In the absence of any other
injuries and, if the segment is small and not embarrassing respiration, the patient
may be nursed on a high-dependency unit with regular blood gas analysis and
good analgesia until the flail segment stabilises. In the more severe case,
endotracheal intubation is required with positive pressure ventilation for up to 3
weeks, until the fractures become less mobile. Thoracotomy with fracture fixation
is occasionally appropriate if there is an underlying lung injury to be treated at the
same time. An anterior flail segment with the sternum moving paradoxically with
respiration can be stabilised by internal fixation but operative management is not
usual for either.
First rib fracture. Fracture of the first rib should
alert the clinician to a potentially serious chest
injury. This rib is well protected and requires a
considerable force to fracture and associated injuries
to the great vessels, abdomen, head and neck are
common. The mortality rate associated with a
fracture of the first rib exceeds 30 per cent. Similar
suspicions are raised when fractures of the sternum
and scapula are seen. Fractures of the lower ribs
may involve underlying abdominal viscera (spleen
on the left and liver on the right). Intercostal artery
bleeding may still be severe, resulting in
haemothorax.
Fractures of the sternum.This injury is now seen as a
result of deceleration on to seat belts. Steering wheel
injuries are now much less common. The injury is very
painful even in the mild case where only the external
plate of the sternum is fractured. However, there is a real
risk of underlying myocardial damage and the patient
should be observed in hospital with constant
electrocardiogram (ECG) monitoring, analgesia and serial
cardiac enzymes. Rupture of the aorta and associated
cervical spine injuries also need to be excluded. Most
cases need no specific treatment but paradoxical
movement or instability of the chest may need more
active management. It should be remembered that sternal
fracture may occur during closed cardiac massage.
Pleura.
If the visceral pleura is breached (most commonly by a rib
fracture) pneumothorax follows. Generation of positive
pressure in the airways by coughing, straining, groaning
or positive pressure ventilation will result in tension
pneumo-thorax. The pleural space may also fill with blood
as a result of injury anywhere in its vicinity. Remember
that an erect chest radiograph is the only sure way to
confirm or exclude the diagnosis of pneumothorax and
should be obtained if at all possible. Early management of
tension pneumothorax is life saving. Good management of
the pleural space preempts many later complications from
clotted haemothorax, constriction of the lung and
empyema.
Types of pneumothorax
1.Spontaneous
2. Traumatic
a.Simple
b.Tension
c.Open
Traumatic pneumothorax. Blunt trauma to the chest wall may result
in a lung laceration from a rib fracture. All traumatic
pneumothoraces require drainage through an under-water seal drain
because of the possibility that they may become a tension
pneumothorax with mediastinal shift and circulatory collapse. There
is decreased air entry on the affected side and the trachea may be
pushed over to the opposite side. There is an increased percussion
note and reduced breath sounds. If a tension pneumothorax is
suspected on clinical grounds, treatment is necessary before
radiographs can be taken. A wide-bore needle introduced into the
affected hemithorax will release any air undertension and is life
saving. A wide-bore intercostal rube is introduced laterally and
directed to the apex of the pleural cavity. A second drain may be
introduced basally to drain blood.
Chest drain insertion. Insertion of a chest drain is indicated when
there is air or fluid in the pleural cavity