On successfully completing this topic, you will be able to:
identify life-threatening injuries in the chest
identify potentially life-threatening injuries in the chest
be aware of the skills required to manage these life-threatening injuries.
Medical emergencies, including cardiac disease, are discussed in Chapter 22. This chapter focuses on intrathoracic emergencies, mainly caused by trauma but occasionally arising spontaneously, as in the case of spontaneous pneumothorax or aortic aneurysm dissection.
Introduction
In the 2006–08 report of the Confidential Enquiries into Maternal Deaths in the UK, 29 women died from traumatic causes (17 road traffic accidents, 11 murders and one house fire).
Chest injuries are common in patients with major trauma and they are responsible for around one-quarter of trauma deaths. Many of these deaths can be prevented by the prompt recognition of life-threatening conditions and the early initiation of simple methods of treatment. Few patients will require surgery. Most are treated by the simple methods demonstrated on the MOET course of needle thoracocentesis and chest drain placement. Prompt and effective resuscitation of the mother, including the avoidance of aortocaval compression is the most effective way of ensuring good fetoplacental perfusion.
Types of injury to the chest
Chest injuries are usually classified as penetrating, blunt or both. When there are external signs of thoracic injury, intra-abdominal organs, including the gravid uterus, may also have been damaged, particularly in the later stages of pregnancy. The reverse is also true, in that obvious abdominal trauma may extend into the chest.
Initial assessment and management
An accurate history of the incident is vital. For example, the driver of a car in collision with a tree would be at risk of a traumatic brain injury, cervical spine trauma, traumatic aortic rupture, lung and myocardial contusion and abdominal trauma, in addition to many other bony and soft-tissue injuries.
The principles of management are:
primary survey and resuscitation: life-threatening injuries discovered during the primary survey should be dealt with immediately
assessment of fetal wellbeing and viability
secondary survey: careful head-to-toe examination should identify any other injuries sustained
definitive care.
Life-threatening injuries to identify and treat
Mnemonic for life-threatening injuries in the chest:
Tension pneumothorax
The diagnosis should be considered in any trauma patient with severe respiratory distress and also, in some cases, shock. There is usually reduced air entry and reduced chest expansion but hyper-resonance on the affected side. The classic signs of tracheal deviation and distended neck veins may be very late or absent, the latter especially in those with concurrent hypovolaemic shock.
If there is any doubt, needle thoracocentesis to decompress the air, and subsequent intercostal drain placement, should be performed without delay and are very safe when performed correctly.
Open pneumothorax (sucking chest wound)
A large chest-wall defect will suck air through it with each inspiration and cause a progressive decline in pulmonary function.
The principle of management is to cover the defect in such a way as to prevent air being sucked in, but allow accumulated air to escape. An Asherman seal will be effective for small wounds or a dressing, taped securely on three sides only, for larger wounds. An intercostal drain should be placed remote to the site of injury.
Massive haemothorax
Massive haemothoraces are usually caused by damage to a systemic or pulmonary vessel. Clinical signs include evidence of hypovolaemia, decreased air entry and dullness to percussion.
The drainage of a large collection, without wide-bore intravenous access for fluid replacement, can lead to circulatory collapse when the tamponade effect is acutely lost, so intravenous access should be secured prior to drainage. Most haemothoraces are managed conservatively, but if after the placement of an intercostal drain the initial loss is greater than 1500 ml, or continuing losses exceed 200 ml/hour, operative intervention may be needed.
Flail chest
When a segment of the chest wall loses continuity with the rest of the thoracic cage from multiple rib fractures, that segment moves paradoxically with respiration and the segment is called a flail segment. Hypoxia is caused by trauma to the underlying lung, which can be severe. The bony injury can be extremely painful and this impairs oxygenation further. The principles of management include high concentration oxygen, insertion of an intercostal drain, careful fluid management and effective analgesia often with a thoracic epidural. A period of mechanical ventilation may be required in severe cases.
Cardiac tamponade
This occurs, infrequently, with blunt or penetrating trauma to the chest. It can be difficult to detect. It may also be seen in association with spontaneous rupture of the aorta, a well- recognised feature of women with Marfan’s syndrome. In the 2006–08 maternal mortality report, seven women died from spontaneous dissection of the aorta leading to cardiac tamponade.
Signs include tachycardia, arterial hypotension, shock, distended neck veins and muffled heart sounds. It should be suspected in a hypotensive patient with a penetrating injury to the chest over the cardiac outline, either anteriorly or posteriorly. Ultrasound can quickly confirm the diagnosis. The treatment is urgent surgical exploration, but needle pericardiocentesis can be performed, under ultrasound and ECG control, if the patient is deteriorating.
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
