Thoracic Injuries

• • Simple rib fracture is most common thoracic injury

  • Spectrum from simple rib fracture to fracture with hemothorax to flail chest with associated pulmonary contusion

  • Flail chest occurs when a portion of the chest wall becomes separated from the rib cage by multiple fractures and moves opposite to the rib cage with rib inspiration and expiration decreasing respiratory efficiency

  • Early deaths commonly due to:

  • -Airway obstruction

    -Flail chest

    -Open pneumothorax

    -Massive hemothorax

    -Tension pneumothorax

    -Cardiac tamponade

  • Late deaths are due to:

  • -Respiratory failure

    -Sepsis

    -Unrecognized injuries

  • 85% of chest injuries do NOT require open thoracotomy

Epidemiology

• • Accounts directly or contributes to 50% of deaths from trauma

  • 80% of blunt thoracic injuries are related to motor vehicle accidents

  • Penetrating injury nearly as frequent as blunt injury

Symptoms and Signs

• • Pain on inspiration

  • Decreased ventilation

  • Cyanosis, ashen or gray facies may indicate upper airway obstruction

  • Stridor

  • Poor respiratory excursion

  • Retraction of supraclavicular, suprasternal, intercostal, or epigastric regions

  • Paradoxic chest wall movement indicates flail chest

  • Tracheal shift, dullness to percussion and absence of breath sounds unilaterally with flat neck veins can indicate massive hemothorax

  • Tracheal shift, tympany to percussion and absence of breath sounds unilaterally with distended neck veins may indicate tension pneumothorax

Laboratory Findings

• • Hypoxemia

  • Hypercapnea

Imaging Findings

• • Chest film or CT scan:

  • -Rib fractures

    -Pneumothorax

    -Hemothorax

    -Tension pneumothorax (does not need chest film to diagnose)

    -Wide mediastinum

• • Associated injuries in abdomen may dictate therapy

Rule Out

• • Airway obstruction

  • Tension pneumothorax

  • Flail chest

  • Massive hemothorax

  • Cardiac tamponade

  • Open pneumothorax

• • Physical exam

  • Chest x-ray

• • Adequate analgesia

  • Intubation and mechanical ventilation as needed

Surgery

• • Rarely, external fixation of chest wall

  • Operative repair specific for injury

Treatment Monitoring

• • Serial ABG measurements

Complications

• • Atelectasis

  • Hypercapnea

  • Hypoxia

Prognosis

• • Hospital mortality of isolated thoracic injury is 4-8%, but rises to 10-15% with 1 other organ system involved and to 35% if multiple organs involved

Prevention

• • Seatbelt use

References