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Up to half of all trauma patients sustain some degree of thoracic injury. Twenty to twenty-five percent of all trauma deaths are directly attributable to chest trauma. Thoracic trauma is a contributing factor in another 25% of trauma deaths.
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1This chapter is a revision of Chapter 22 in the 6th edition by Seth Stearley, MD, and L. Richard Boggs, MD.
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The ABCs should be addressed as previously outlined in Chapters 9 and 10. There are specific considerations in evaluating the ABCs in the patient with blunt or penetrating chest trauma. The airway can be obstructed at any level from the pharynx to the trachea. Abnormalities in breathing can be caused by one or more of the following mechanisms: (1) impairments in the chest wall or musculature, eg, secondary to pain or because the chest wall motion is not coordinated; (2) impairments in gas exchange, secondary to atelectasis, contusion, or disruption of the respiratory tract; and (3) CNS impairments secondary to drugs or head trauma. Hypoxia is the most important feature of chest injury. Early interventions should attempt to insure that an adequate amount of oxygen is delivered to the portions of the lung capable of normal ventilation and perfusion. Abnormalities in circulation can be caused by blood loss, increased intrapleural pressure, blood in the pericardial sac, vascular disruption, or myocardial dysfunction. Since shock will most often be caused by blood loss, the first step should be to ensure adequate fluid resuscitation.
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Pain may impair chest wall expansion and impede oxygenation. Pain should be relieved with small frequent doses of narcotic medications, eg, 2–8 mg of morphine or 50–100 μg of fentanyl every 30 minutes as needed. The pain level should be constantly reassessed to ensure adequate analgesia.
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Several entities need to be considered in the patient with chest trauma. They can cause severe hypoxia and/or shock. The diagnoses are made clinically and need to be addressed without waiting for any diagnostic testing. Any patient presenting with any one of these entities should be treated as outlined and admitted to the hospital for further care.
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Tension pneumothorax develops when a one-way valve air leak occurs from either the lung or chest wall. Air enters the pleural space but cannot escape, leading to increased intrapleural pressure, collapse of the lung, and shift of the mediastinal contents to the opposite side. Tension pneumothorax can result from blunt chest injury with resultant parenchymal lung injury, but can also be secondary to positive-pressure ventilation. Occasionally a small penetrating wound can cause a valve-like effect that allows air to enter the pleural space on inspiration but not exit on expiration. The collapse of the lung leads to right to left pulmonary shunting and resultant hypoxia. In addition, increased intrathoracic pressure and pressure on the vena cava can reduce ...