Amongst injuries associated with blunt chest trauma are tension pneumothorax, hemothorax, and cardiac tamponade, for which bedside diagnosis and immediate intervention by the emergency provider may be lifesaving.
Initial assessment and management of airway, breathing, circulation, and disability should follow the Advanced Trauma Life Support (ATLS) primary survey guidelines. Intubate patients in respiratory distress (Table 164-1). Maintaining good oxygenation is especially important in preventing secondary injury in head-injured patients. Investigate for tension pneumothorax and cardiac tamponade during the primary survey for all patients in shock after chest trauma.
++ Table Graphic Jump Location Table 164-1 Considerations for Early Ventilatory Assistance after Thoracic Trauma ||Download (.pdf)
Table 164-1 Considerations for Early Ventilatory Assistance after Thoracic Trauma
Altered mental status
Multiple blood transfusions
Preexisting pulmonary disease
Respiratory rate >30 to 35 breaths/min
Vital capacity <10 to 15 mL/kg
Negative inspiratory force <25 to 30 cm of water
Physical examination should include assessment for tracheal deviation, unequal chest rise, abnormal breath sounds, visible trauma to the chest wall, subcutaneous emphysema (suggestive of pneumothorax), open chest wounds, and bowel sounds in the chest (suggestive of diaphragmatic injury).
In the hemodynamically unstable, polytrauma patient who requires immediate operation without CT imaging, exclude immediate threats to life with rapid bedside tests (physical examination, chest radiograph, ultrasound, and chest tube, as needed). Excessive fluid administration may worsen edema in patients with pulmonary contusions. Administer fluids judiciously with crystalloids to maintain perfusion, and use blood products early in resuscitation.
If subclavian venous cannulization is attempted, it should be done on the side of suspected injury so that an iatrogenic pneumothorax does not result in bilateral pneumothoraces. Check for a tension pneumothorax or tube displacement in any patient who suddenly decompensates while on mechanical ventilation.
A small open (sucking) chest wound can progress to a tension pneumothorax through a one-way valve effect. Cover the wound with sterile petroleum gauze taped on 3 sides to allow air to exit but not enter. Immediately insert a chest tube at another site and not through the wound.
Flail chest occurs when fracture of a section of ribs in multiple places allows instability of a section of the chest wall. Intubation and positive pressure ventilation will stabilize the flail segment, so intubate patients with respiratory compromise, along with those with evidence of shock, severe head injury, preexisting pulmonary disease, fracture of eight or more ribs, and age >65 years. Insert a chest tube to relieve an identified or suspected pneumothorax. Surgical fixation may be needed.
Rib fractures may suggest other injuries or cause morbidity in themselves. Fractures of the first and second ribs require great force, and should therefore cause high suspicion and evaluation for other major thoracic injuries including myocardial, vascular, and bronchial injuries. Multiple lower rib fractures should raise suspicion for liver or splenic ...