Related Subjects:
|Initial Trauma Assessment and Management
|Thoracic Trauma Assessment and Management
|Flail Chest Rib fractures
|Resuscitative Thoracotomy
|Haemorrhage control
|Traumatic Head/Brain Injury
|Traumatic Cardiac Arrest
|Abdominal trauma
|Tranexamic Acid
|Silver Trauma
|Cauda Equina
🚑 Introduction
- Thoracic trauma accounts for ~25% of trauma deaths.
- In the UK, 90% follow blunt trauma (often MVCs). Penetrating injuries (e.g. gunshot wounds) are more common in the USA.
- Blunt vs penetrating injuries → very different courses. Penetrating injuries more often require surgery.
⚡ Mechanisms of Injury
- Direct blunt force: steering wheel, bat, fist.
- Acceleration/deceleration: sudden kinetic change (e.g. RTC).
- Shear forces: torsional in RTCs.
- Compression: crush by wall/tree/building.
- Blast wave injury: concussive wave from explosion.
🩺 Clinical Features
- Breathlessness & pain: fractures, flail chest, lung contusion.
- Hypotension & shock: causes include haemorrhage, tension pneumothorax, tamponade.
- Chest pain: rib fractures → need strong analgesia.
- Vascular damage: check major pulses & capillary refill.
- Raised JVP: tamponade, tension PTX, or heart failure.
- Subcutaneous emphysema: pneumothorax or oesophageal rupture.
🫁 Life-Threatening Injuries (ATLS priorities)
- External haemorrhage: direct pressure, dressings.
- Airway obstruction: suction, adjuncts, intubation; consider surgical airway if needed.
- Simple pneumothorax: air in pleural space → chest drain.
- Rib fractures (≥3): high risk of deterioration, esp. elderly → admit & monitor.
- Flail chest: paradoxical rib movement; suggests major injury with contusions & haemopneumothorax.
- Diaphragmatic rupture: blunt/penetrating; L > R; may be missed on CXR.
- Blunt aortic injury: deceleration force → suspect with shock not responding; may need endovascular repair.
- Oesophageal injury: subtle signs; requires surgical repair.
- Open pneumothorax: cover with 3-sided dressing, insert chest tube away from wound, then close definitively.
- Tension pneumothorax: one-way valve effect → tachypnoea, hypoxia, shock, tracheal deviation.
- Needle decompression: 5th ICS mid-axillary line (preferred) or 2nd ICS MCL → then chest drain.
- NICE: consider open thoracostomy if expertise available.
- Massive haemothorax: >1500 mL blood in chest → shock. Chest drain, blood products, likely thoracotomy.
- Cardiac tamponade: Beck’s triad (hypotension, muffled heart sounds, raised JVP).
- Definitive: thoracotomy & repair.
- Emergency pericardiocentesis if no surgical option.
🔬 Investigations
- FBC, clotting, U&E, glucose, lactate, amylase.
- Group & crossmatch 6–10 units blood.
- CT Traumogram.
- POCUS/Echo → pericardial fluid, cardiac trauma.
- Toxicology screen if indicated.
🛠️ Management
- ABC resuscitation, oxygen, IV fluids (prefer blood to crystalloids), analgesia, massive transfusion protocol if needed.
- Insert chest drain for PTX/HTX; consider resuscitative thoracotomy in penetrating trauma with tamponade.
- Ventilate carefully in contusions → low tidal volume, avoid barotrauma.
- ≥3 rib fractures, flail chest, age >65, ventilator need, or comorbidities → transfer to Major Trauma Centre.
- Needle decompression can fail (blocked/kinked) → finger thoracostomy more reliable.
- Chest tubes 28–32F are effective for draining haemothorax.
🩻 FAST & Imaging
- eFAST can rapidly detect PTX/HTX; negative scan doesn’t exclude PTX.
- Thoracic CTA → used for blunt aortic injury; stable partial tears often managed endovascularly.
- Medical management of aortic injury: beta-blockers → HR <80 bpm, MAP 60–70 mmHg.
📚 References
