Chapter 24: Chest Trauma

INTRODUCTION

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.

IMMEDIATE MANAGEMENT OF LIFE-THREATENING PROBLEMS

ESTABLISH ABCs

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, for example, 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) central nervous system (CNS) impairments secondary to drugs or head trauma. Hypoxia is the most important feature of chest injury. Early interventions should attempt to ensure 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.

PAIN CONTROL

Pain may impair chest wall expansion and impede oxygenation. It may also result in decreased tidal volume and cough, resulting in greater risk for developing nosocomial pneumonia. Pain should be relieved with small frequent doses of narcotic medications, for example, 4–8 mg of morphine or 50–200 μg of fentanyl every 30 minutes as needed. The pain level should be constantly reassessed to ensure adequate analgesia. Some studies have shown that early epidural analgesia provides more effective pain relief in comparison with other analgesic modalities, and it is most applicable to patients with functional respiratory compromise secondary to pain.

IMMEDIATELY LIFE-THREATENING THORACIC INJURIES IDENTIFIED ON THE PRIMARY SURVEY

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.

TENSION PNEUMOTHORAX

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 ...