Visits: 18
also known as: chest trauma, thoracic injury, thoracic trauma
Thoracic / chest trauma is the leading cause of death from physical trauma after head and spinal cord injury and a common cause of significant disability and mortality. Blunt chest (thoracic) injuries are the primary or a contributing cause of about a quarter of all trauma-related deaths. The mortality rate is about 10%. Chest injuries were first described in detail in around 1600 BC in the ancient Egyptian Edwin Smith Papyrus.
Classification: Chest trauma can be classified generally as blunt or penetrating, having different patho-physiological features and clinical courses.
Specific types of chest trauma include:
• Injuries to the chest wall
o Chest wall contusions or hematomas.
o Rib fractures
o Flail chest
o Sternal fractures
o Fractures of the clavicle and shoulder girdle
• Pulmonary injury (injury to the lung) & injuries involving the pleural space
o Pulmonary contusion
o Pulmonary laceration
o Pneumothorax
o Haemothorax
o Haemopneumothorax
• Injury to the airways
o Tracheobronchial tear
• Cardiac injury
o Pericardial tamponade
o Myocardial contusion
• Blood vessel injuries
o Traumatic aortic rupture, thoracic aorta injury
• Injuries to other structures within the torso
o Oesophageal injury (Boerhaave syndrome)
o The Diaphragm injury
Diagnosis
Most blunt injuries are managed with relatively simple interventions like intubation and mechanical ventilation and chest tube insertion. Diagnosis of blunt injuries may be more difficult and require additional investigations such as CT scanning. Penetrating injuries often require surgery, and complex investigations are usually not needed to come to a diagnosis. Patients with penetrating trauma may deteriorate rapidly, but may also recover much faster than patients with blunt injury.
Primary survey: Look for –
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• Massive haemothorax
• Pericardial tamponade
Secondary survey: Look for –
• Pulmonary contusion
• Myocardial contusion
• Aortic disruption
• Traumatic diaphragmatic hernia
• Tracheobronchial disruption
• Oesophageal disruption
Indications for emergency room thoracotomy
• Acute pericardial tamponade unresponsive to cardiac massage
• Exsanguinating intra-thoracic haemorrhage
• Intra-abdominal haemorrhage requiring aortic cross clamping
• Need for internal cardiac massage
Indications for urgent thoracotomy
• Chest drainage >1500 ml or >200 ml per hour
• Large unevacuated clotted haemothorax
• Developing cardiac tamponade
• Chest wall defect
• Massive air leak despite adequate drainage
• Proven great vessel injury on angiography
• Proven oesophageal injury
• Proven diaphragmatic laceration
• Traumatic sepal or valvular injury of the heart