Wednesday, October 15, 2014

For doctors and paramedics, a brief about chest injury

Chest injury and breathing

Why is it important to understand Chest Trauma?

It is important to understand Chest Trauma since it affects both the breathing and Circulation in trauma patients

Is it a common problem and how significant is it in trauma?

It is very significant as it a common cause of death in trauma patients

Why is it relevant to me as I am not a cardio thoracic surgeon?

Chest trauma does not need surgery in majority of patients. Less than 10% patients need surgery in chest trauma. Majority of them need simple procedures such as giving oxygen, chest drain insertion etc which often saves a patient from dying.

Can you explain about chest trauma in simple terms so that i can understand?

We need to understand the anatomy to understand the chest injury and the different types of the injury

The injuries may not be obvious at first as normal chest x ray does not rule out chest trauma.  Hence it is essential to understand the physiology.

Explain to me in simple terms about the anatomy behind the chest trauma.

Essential anatomy:       1. Lungs with the airways and blood vessels with a cavity                                          around called pleural cavity

                                       2. Heart with a cavity around called peritoneal cavity

                                       3.  Mediastinum which has all the major vessels and the airways                                            and the oesophagus

        4. the chest is covered with bones [ribs and                                              clavicle], muscles [intercostal vessels] and separated from the abdomen by  diaphragm.

 How do i remember all this Anatomy when i see a patient and read a chest x ray

                                as simple as ABC…….

        1. A   Airway: Trachea

        2. B   Breathing: lungs, pleural cavity, chest wall

        3. C   Circulation: Heart, pericardial cavity, major vessels

        4. D   Diaphragm

        5. E   Everything else: includes Esophagus, Entered tubes & lines

Essential physiology

                                Chest has the gas exchange chamber

The chamber itself with the air in and the exhaust:     trachea and airways
the motor :                  Chest wall with the ribs, muscles and diaphragm
the current which is needed to operate the motor for gas                                        exchange chamber : the intercostal nerves  and the phrenic nerve

Chest has the main pump of the body namely the heart and the main vessels

how do i remember all this physiology when i am confronted with a patient

              As simple as what is taught in your MBBS

                                assess the patient with

                                Oxygen saturation : oxygen delivery to skin

                                alertness                :  oxygen delivery to brain and  CO2                clearance

                                Pulse              : heart rate

                                blood pressure  : heart output and resistance to the flow of blood

                                urine output   : heart function to keep the kidneys working well

I understand all this. Now tell me a way to assess and manage a patient with chest trauma.

                        When faced a patient with chest trauma, always and always
                                Go back to airway
                                ensure a patient airway
                                       talk to the patient
                                       check his nose, mouth, teeth, tongue, throat and larynx      area are normal.
                                       make sure that his cervical spine is protected if injury cannot be excluded.

                                then follow what you have been taught at medical school


                                and then measure

Inpect and palpate  for         breathless ness and tachypnoea

                                               open wounds and abnormal chest wall movements

                                               trachea position and neck swelling

                                               tenderness and crepitus
percuss and ausculate        resonance to percussion
                                               air entry

                                               heart sounds

measure and assess           Oxygen sauration

                                               blood pressure

                                               and all parameters for shock including urine output
                                               be liberal with chest x ray

i have all done all the assessments as above, how do i manage the patient with chest injury

                                Identify life threatening injury and manage then and there

                                identify any non life threatening injury and come back to its management after completing the primary survey and management

Life threatening injuries

                                characterised by what you find in your assessment

                during inspection and palpation

                                1. air hunger and cyanosis
                                2. open chest wall wounds
                                3. abnormal chest wall movements
                                4. tracheal deviation

                during percussion and auscultation

                                absent breath sounds & either no or hyper resonant on percussion

                during measurement
                                low oxygen saturation

if you find any of these, patient may die with the following injuries if you do not act now

                Airway obstruciton

                tension pneumothorax

                open pneumothorax

                massive hemothorax

                cardiac tamponade
                flail chest

how do one recognise these conditions and how do i treat them as i detect them

airway obstruction       

        air hunger, cyanosis    
        patient not talking and unable to talk                                                                                                                         
        Treatment: Oxygen, manual clearance, suction and secure airway

Tension pneumothorax
        Trachea deviated to one side                    
        Hyperresonant chest with no air entry                      
        Engorged veins and shock

                Airway first and
                needle decompression and                                                                          chest drain
Massive hemothorax
        Engorged veins and shock
        Trachea deviated
        Dull chest and no air entry

        Airway first and
        IV access and fluids and Blood transfusion
        ICD chest drain insertion
Open pneumothorax

        Open wound in chest
        Pneumothorax features

        Airway first and
        Three way dressing
        Chest drain insertion
Cardiac tamponade


        Engorged veins and shock
        Muffled heart sounds

        Airway first and
        Needle drainage
        ECG monitoring

Flail chest
        Paradoxical breathing
        With multiple rib fractures

        Pain relief
        Ready to intubate and internal splinting


Chest trauma is common, can kill a patient if not recognized and treated promptly. Majority of treatment in chest trauma is ensuring a patent airway, oxygen, simple measures such as chest drain.