When a patient arrives with traumatic injuries
to the chest, you must be vigilant.
Life threatening injuries are quite possible.
Always assume the worst.
The chest can be injured with blunt force,
penetrating force, or both.
Here are four specific injuries that you cannot
afford to miss.
1 – Pneumothorax
A pneumothorax is air in the pleural space
– the space defined by the pleura that covers
the organs of the chest, including lungs and
reflects back to line the underside of the
chest wall.
Think of this condition in someone who has
had either blunt or penetrating trauma to
the chest.
Subcutaneous emphysema – or air under the
skin, reduced breath sounds, and respiratory
distress are signs and symptoms associated
with this condition.
A tension pneumothorax is a particularly important
type of pneumothorax to identify.
There is so much air in the pleural space
that the mediastinum is pushed over and it
impedes venous return.
This causes shock.
You must identify this condition.
The signs of a regular pneumothorax will be
present but the patient will be hypotensive
and you may see tracheal deviation away from
the side of the pneumothorax.
Chest x-ray or CT scanning can confirm the
diagnosis of
a pneumothorax.
In most cases, a chest tube will be required
to drain the air out of the pleural space.
If you think the patient has a tension pneumothorax,
then you must decompress the air immediately,
usually by placing a small needle angiocatheter
in the pleural space.
This should be done before the chest radiograph
is done.
2 – Hemothorax
A hemothorax is blood in the pleural space.
This blood can come from the chest wall or
the lung tissue itself.
A hemothorax can be caused by blunt or penetrating
trauma to the chest.
You must suspect this condition when there
is respiratory distress, shock, or reduced
breath sounds.
Chest X-ray or CT Scanning can confirm this
diagnosis as well.
Like pneumothorax, a hemothorax will generally
require a chest tube to drain the blood out
of the pleural space.
3 – Flail Chest
A flail chest is a result of blunt trauma
to the chest.
A flail chest is a section of the chest wall
that is moving independently of the rest of
the thoracic cage.
This happens when there are multiple adjacent
ribs that are broken in multiple places.
Think of this when you see paradoxical motion.
Paradoxical motion of the chest is when a
section of the chest moves in the opposite
direction as the majority of the chest wall
on inspiration and expiration.
So as one inspires and expands the ribcage
the flail segment is paradoxically drawn in
further.
In addition to paradoxical movement, the patient
will have chest pain and some degree of respiratory
distress.
There is usually an underlying pulmonary contusion.
Treatment of this condition is usually positive
pressure ventilation.
4 – Hemopericardium
A patient can rapidly die from this condition.
Think of this in penetrating trauma to the
anterior chest.
Blood is leaking from a hole in the heart
wall and accumulating in the closed pericardial
space.
The patient may experience signs of hemodynamic
failure – with a rapid loss of blood pressure,
a rise in heartbeat, and loss of consciousness.
Diagnosis should be made by bedside echocardiography.
The blood will need to be released and the
hole repaired in the operating room.
