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
inspect
palpate
percuss
auscultate
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
pulse
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
Diagnosis:
air
hunger, cyanosis
stridor
patient
not talking and unable to talk
Treatment:
Oxygen, manual clearance, suction and secure airway
Tension pneumothorax
Diagnosis:
Trachea
deviated to one side
Hyperresonant
chest with no air entry
Engorged
veins and shock
Treatment
Airway
first and
needle
decompression and chest drain
Massive hemothorax
Diagnosis:
Engorged
veins and shock
Trachea
deviated
Dull
chest and no air entry
Treatment:
Airway
first and
IV
access and fluids and Blood transfusion
ICD
chest drain insertion
Open pneumothorax
Diagnosis
Open
wound in chest
Pneumothorax
features
Treatment
Airway
first and
Three
way dressing
Chest
drain insertion
Cardiac tamponade
Diagnosis
Engorged
veins and shock
Muffled
heart sounds
Treatment
Airway
first and
Needle
drainage
ECG
monitoring
Flail chest
Diagnosis:
Paradoxical
breathing
With
multiple rib fractures
Treatment
Pain
relief
ICD
Ready
to intubate and internal splinting
Summary:
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.
