Breathing and Chest Trauma
Dr S Chockalingam
One of the major killer injuries is Chest Trauma. In fact the chest trauma is the commonest killer for a driver behind a steering wheel especially when not wearing a seat belt. Chest trauma is one of the injuries, which is treatable in a patient who can reach a hospital alive. Appropriate treatment can save many lives if recognised promptly. This appropriate treatment is often a simple intervention as opposed to a thoracotomy. Any doctor irrespective of their specialist interest should safely perform these simple interventions.
The following content focuses briefly on the essential anatomy, physiology of the chest. The main focus is then on recognising these injuries and acting swiftly to save one’s life. Early recognition of these injuries will also help in preventing late deaths.
Essential Anatomy:
The Chest is comprised of the lungs and pleural cavity, heart and pericardium, mediastinum and its contents, chest wall with the ribs and the muscles, diaphragm.
Essential Physiology:
The function of the chest is mainly two fold, gas exchange chamber and a safe haven for the heart and major vessels.
1.The lungs with the bronchial tree and alveoli function as gas exchange chamber. Oxygen gets in to the circulation and CO2 is excreted. The Chest Wall with the pleural cavity and the diaphragm acts as the motor behind to facilitate the gas exchange.
2. A safe place to keep the important organ, the heart and the main blood vessels.
Recognition and treatment of the chest injuries:
In our Medical School, we are taught the art of clinical Medicine. These would be taking a detailed history, thorough examination and ordering appropriate investigations before instituting treatment. The management of trauma is a clear exception to this approach. Hence we have to recognise the injuries and treatment the life threatening injuries before proceeding to the next step. This is most appropriate in chest trauma.
Recognition of Chest Injuries:
A patient who had trauma should always have the primary survey starting with
Ensuring a patent Airway with Cervical Spine Protection before moving on to the chest injuries. The injuries to the airway presents with similar features to the chest injuries. Airway obstruction with
1. Strider
2. Inability to talk
3. Broken tooth
4. Secretions in the pharynx
5. Gross swelling of the neck
Should be managed before moving on to the chest injuries.
The recognition of the chest injuries is essentially two fold.
1. Assess the breathing
2. Assess the cardiac function
These are done by
1. Look
2. Feel
3. Percuss
4. Auscultate
5. Use adjuncts
Look:
1. Equal chest wall movements
2. Engorged veins in the neck
3. For open wounds
4. Abnormal chest wall movements
Feel:
1. Tenderness
2. Crepitus
3. For equal chest wall movements
4. Pulse rate
5. Tracheal position, midline or deviated
Percuss:
1. Hyper resonance
2. Dull note on percussion
Auscultate:
1. Air entry on both sides
2. Heart sounds
3. Abnormal sounds suggesting obstruction
4. Blood pressure
Adjuncts:
1. Pulse oximetry, Pulse, Blood Pressure assessments
2. Chest X ray
3. ECG
Serious Injuries to be recognised promptly:
1. Conditions which affect mainly breathing
a. Massive air collection around the lungs: massive pneumothorax
b. Massive blood collection around the lungs: massive hemothorax
c. Chest wall injuries leading to flail chest
d. Open chest wound with pneumothorax
2. Conditions which affect the heart and circulation
a. Massive blood collection around the heart: Cardiac Tamponade
b. Massive blood collection around the lungs: massive hemothorax
Treatment as you recognise these serious injuries
1. Needle decompression and chest drain for massive pneumothorax
2. Cover open wounds with air tight dressings immediately
3. Resuscitate with oxygen and blood prior to
4. Chest Drain for massive hemothorax
5. Ventilate with oxygen, ambo bag for flail chest before intubation
6. Needle decompression of pericardium in rare instances
The rest of the chest injuries can wait until we complete the primary survey and management of other major injuries.
Other Injuries, which will become life threatening in due course and hence should be recognised and treatment started. These are
1. Pneumothorax which is not massive
2. Hemothorax which is not massive
3. Major airway injury of tracheobronchial tree
4. Blunt injury to the heart
5. Major vessel injury such as aorta
6. Mediastinal often open injury
7. Injury to the diaphragm
8. Multiple rib fractures
Please remember the power cable for chest wall function is “the intercostals nerves and the phrenic nerve and the brain” ultimately. Hence any injury to the spinal cord, brain and the phrenic nerve will affect breathing even when the chest wall is not injured.
Summary
We have to be familiar with understanding of the following features associated with major chest injuries
When observing the patient
1. Chest pain and air hunger
2. Distress in breathing
3. Sucking open, but often-small wounds in the chest wall.
4. Flail chest
When eliciting the signs
5. Absent breath sounds
6. Engorged neck veins
7. Subcutaneous emphysema
8. Tachycardia and Hypotension
9. Deviated trachea
10. Muffled heart sounds
11. Cyanosis
When assessing with
12. Abnormal saturation with Pulse oximetry
13. Chest x ray abnormalities in trauma
14. ECG changes of blunt cardiac injury
The key message of this review on Chest Trauma is never underestimate these injuries as often these injuries kill a patient within few hours of injury and if not will adversely affect the outcome in the first few days of admission to the hospital
