CHEST TRAUMA THE DEADLY DOZEN OF CHEST TRAUMA

With interpersonal violence remaining on epidemic levels in South Africa thoracic trauma is frequently encountered and managed by our general practitioners, particularly in remote areas.

Approximately 85% of all thoracic trauma can be treated without specialised surgical intervention; probably the most common presentation is related to rib fractures. The patient complains of pain aggravated by breathing or coughing. Compression of the rib cage elicits pain and fractures are seen on chest or rib X- rays. Chest X-rays are of paramount importance and should be obtained as early as possible. In all penetrating wounds radio- opaque markers should be placed to facilitate estimation of the wounding trajectory. Associated injuries such as , haemothorax or pulmonary contusion must be excluded. Spinal injuries should be considered in the appropriate scenario. The treatment is oral analgesics in mild to moderate pain, and HERBERT CUBASCH ELIAS DEGIANNIS consideration of opioids, nerve block, epidural or intrapleural MD, FCS (SA) MD, PhD, FRCS (Glasg), analgesia in the presence of severe pain. The complications of Specialist Surgeon FCS (SA), FACS pneumothorax or haemothorax are treated with insertion of an Department of Surgery Principal Surgeon and intercostal drain, placed at the level of the fifth intercostal space in the anterior axillary line. Chris Hani Baragwanath Director of Trauma

Hospital Department of Surgery Severe chest injuries are responsible for 25% of all trauma Johannesburg Chris Hani Baragwanath deaths, and in a further 25% they are a contributing cause of Hospital mortality. Life-threatening injuries can be remembered as the Herbert Cubasch is a junior Johannesburg deadly dozen — six are immediately life threatening and should lecturer in surgery at the be sought during the primary survey and six are potentially life threatening and should be detected during the secondary survey. University of the Elias Degiannis is Associate A reproducible and safe approach in their diagnosis and Witwatersrand, and currently Professor of Surgery in the management is taught by the Advanced Trauma Life Support a Consultant General Department of General (ATLS) course. Surgeon at Chris Hani Surgery at the University of IMMEDIATE LIFE-THREATENING INJURIES Baragwanath Hospital. His the Witwatersrand. He is special interests are in the Trauma Director and a 1. Airway obstruction breast surgery and trauma Unit Head at Chris Hani Early preventable trauma deaths are often due to lack of or surgery. Baragwanath Hospital. He delay in airway control. The most common cause in the publishes actively in the unconscious patient is obstruction caused by the tongue. Dentures, teeth, secretions and blood can contribute to airway trauma field. He is an ATLS obstruction in trauma. Bilateral mandibular fracture, expanding instructor, and instructs neck haematoma producing deviation of the pharynx and courses for the International mechanical compression of the , laryngeal trauma such Association for the Surgery as thyroid or cricoid fractures and tracheal injury include other of Trauma and Surgical causes of airway obstruction. Intensive Care. These patients need intubation (with simultaneous protection of the cervical spine). Early intubation is very important, particularly in cases of neck haematomas or possible airway oedema. Airway oedema can be insidious and progressive and can make delayed intubation more difficult if not impossible.

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Approximately 85% of all pneumothorax is a clinical diagnosis thoracic trauma can be and treatment should not be delayed treated without specialised by waiting for radiological confirmation. surgical intervention; probably the most common Treatment consists of immediate presentation is related to decompression and is managed rib fractures. initially by rapidly inserting a large- bore needle into the second intercostal space in the midclavicular line of the Severe chest injuries are affected hemithorax. This is responsible for 25% of all immediately followed with a Fig. 1. Chest radiograph: A stabbed trauma deaths, and in a insertion. heart with a haemopericardium and right-sided haemothorax. further 25% they are a 3. Pericardial tamponade contributing cause of Pericardial tamponade needs to be 4. Open pneumothorax mortality. differentiated from tension pneumo- (‘sucking chest wound’) thorax in the shocked patient with This is due to a large open defect in distended neck veins. It is most the chest (> 3 cm), leading to Tension pneumothorax is a commonly the result of penetrating equilibration between intrathoracic clinical diagnosis and trauma. Accumulation of a relatively and atmospheric pressure. Air treatment should not be small amount of blood into the non- accumulates in the hemithorax with distendable pericardial sac can delayed by waiting for each inspiration, leading to profound produce tamponade physiology. The radiological confirmation. hypoventilation and hypoxia. Signs clinical diagnosis can be and symptoms are usually straightforward or very difficult. All proportionate to the size of the defect. patients with penetrating injury anywhere near the heart plus shock 2. Tension pneumothorax Initial management consists of must be considered to have cardiac A tension pneumothorax develops promptly closing the defect with a injury until proven otherwise. The when a ‘one-way-valve’ air leak sterile occlusive dressing taped on classic diagnostic Beck’s triad consists occurs, either from the or through three sides to act as a flutter-type of venous pressure elevation, decline the chest wall. Air is forced into the valve. If the patient is not intubated a in arterial pressure and muffled heart without any means of chest tube is inserted as soon as sounds. Pulsus paradoxus and escape, completely collapsing the possible in a site remote to the injury Kussmaul’s sign could further suggest affected lung. The mediastinum gets site. Definitive treatment may warrant pericardial tamponade. High index of displaced to the opposite side, formal debridement and closure, suspicion and further diagnostic decreasing venous return and preferably in the operating room, and investigations (chest X-ray, showing compressing the opposite lung. all such patients should be referred enlarged heart shadow or cardiac early. echo showing fluid in the pericardial The most common causes are sac) are required for the subclinical penetrating chest trauma, blunt chest 5. Massive haemothorax case. In cases where major bleeding trauma with parenchymal lung injury Accumulation of blood in a from other sites has taken place, the that did not spontaneously close, hemithorax can significantly neck veins may be flat. Pericardio- iatrogenic lung punctures and compromise respiratory efforts by centesis has a high potential for mechanical positive pressure compressing the lung and preventing iatrogenic injury to the heart and it ventilation. adequate ventilation. Such massive should, at the most, be applied as a accumulation of blood presents as desperate temporising measure in a The clinical presentation is dramatic. haemorrhagic shock, unilateral transport situation (under ECG The patient is panicky, with absence of breath sounds, dullness to control). The correct immediate tachypnoea, dyspnoea and distended percussion, and flat neck veins. The treatment of tamponade is operative neck veins (similar to pericardial treatment consists of correcting the (sternotomy or left thoracotomy) with tamponade). Clinical examination can hypovolaemic shock, insertion of an repair of the heart, if time allows it in reveal tracheal deviation (a late intercostal drain, and in some cases an operating theatre, otherwise in the finding — not necessary to clinically intubation. emergency room. confirm diagnosis), hyper-resonance and absent breath sounds over the Blood in the pleural space should be affected hemithorax. Tension removed as completely and rapidly as

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Traumatic aortic rupture is respiratory cycles and during consisting of control of the systolic a common cause of sudden coughing. Voluntary splinting due to arterial blood pressure (~ 100 mg Hg) death after an automobile pain, mechanically impaired chest and postponement of the operation is wall movement and the associated advisable in patients who are collision or fall from a lung contusion all cause hypoxia. The physiologically unstable due to trauma great height. For the patient is also at high risk for in other anatomical areas. subgroup of immediate immediate or delayed pneumothorax survivors salvage is or haemothorax. 2. Tracheobronchial injuries frequently possible if aortic Severe subcutaneous emphysema with respiratory compromise can suggest rupture is identified and Traditional treatment consisted of mechanical ventilation to ‘internally tracheobronchial disruption. The chest treated early. splint’ the chest until fibrous union of drain placed on the affected side will the broken ribs occurred. The price for reveal a large air leak, and the collapsed lung may fail to re-expand. Significant blunt cardiac that was considerable in terms of ICU resources and ventilation-dependent If after insertion of two drains the lung injury that causes morbidity. Currently the treatment fails to re-expand the peripheral haemodynamic instability is consists of oxygen administration, doctor should arrange referral to a rare. Blunt myocardial adequate analgesia and trauma centre. injury should be suspected physiotherapy. Ventilation is reserved in any patient with for patients developing respiratory Bronchoscopy is diagnostic. Treatment involves intubation of the unaffected significant blunt trauma failure. Operation is another treatment option for flail chest, after having followed by operative repair. who develops ECG been discarded in the past due to the abnormalities in the view that underlying pulmonary 3. Blunt myocardial injury resuscitation room. contusion was the dominant Significant blunt cardiac injury that pathology. Now a selected group with causes haemodynamic instability is isolated, severe chest injury and flail rare. Blunt myocardial injury should segments has been shown to benefit be suspected in any patient with possible in order to prevent ongoing from internal operative fixation. significant blunt trauma who develops bleeding, empyema or late ECG abnormalities in the resuscitation POTENTIALLY LIFE- . Clamping a chest drain to room. THREATENING INJURIES tamponade a massive haemothorax is Diagnostic tools are 12-lead ECG usually not helpful. 1. Thoracic aortic disruption tracings and two-dimensional Traumatic aortic rupture is a common Initial drainage of more than 1 500 ml echocardiography that can show wall cause of sudden death after an of blood or ongoing haemorrhage of motion abnormalities. automobile collision or fall from a more than 200 ml/h over 3 - 4 hours great height. For the subgroup of are generally considered indications There is no evidence that enzyme immediate survivors salvage is for urgent thoracotomy. Caution is studies have a place in diagnosis or frequently possible if aortic rupture is required in the case of a patient who management. identified and treated early. It should drains 500 ml into the drain bottle, be clinically suspected in patients with but has persistent dullness or All patients with myocardial contusion a discrepancy of the blood pressure radiographic opacification. diagnosed by conduction between left and right arm or between abnormalities are at risk for sudden 6. Flail chest upper and lower limbs, a widened dysrhythmias and should be monitored pulse pressure and chest wall A flail chest occurs when a segment of for the first 24 hours. After this interval contusion. Erect chest X-ray can also the chest wall does not have bony the risk for sudden dysrhythmias suggest thoracic aortic disruption, the continuity with the rest of the thoracic decreases substantially, unless most common radiological finding cage. This condition usually results significant stress like a general being a widened mediastinum. The from blunt trauma associated with anaesthetic is added. diagnosis is confirmed by multiple rib fractures, i.e. two or more aortography, or contrast spiral CT 4. Diaphragmatic injuries ribs fractured in two or more places. scan of the mediastinum and to a The blunt force required to disrupt the A high index of suspicion is needed in lesser extent by transoesophageal integrity of the thoracic cage typically stab wounds below the nipple line as echocardiography. produces an underlying pulmonary in normal expiration the diaphragm contusion. The diagnosis is clinical, rises up to the fifth intercostal space. The treatment is immediate open not radiographic. The chest wall must Diagnosis of blunt diaphragmatic operative intervention. In selective be observed for paradoxical motion of rupture is missed even more often in cases conservative management a chest wall segment for several the acute phase due to associated

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injuries. There is no single gold segment or fractured ribs. This is a IN A NUTSHELL standard of investigation. Chest very common potentially lethal chest radiography after placement of a injury and the major cause of A significant proportion of deaths nasogastric tube, contrast studies of hypoxaemia after blunt trauma. It is an from thoracic trauma occur virtually upper or lower gastrointestinal tract, independent risk factor for pneumonia immediately (i.e. at the time of CT scan, and diagnostic peritoneal and adult respiratory distress injury), for example rapid lavage have an only limited positive syndrome (ARDS). The natural exsanguination following traumatic or negative predictive value. Most progression of pulmonary contusion rupture of the aorta, or major accurate evaluation is by video- manifests as worsening hypoxaemia vascular disruption after penetrating assisted thoracoscopy or laparoscopy, for the first 24 - 48 hours. The chest X- injury. the latter offering the advantage of ray findings are typically delayed and Of survivors with thoracic injury easier repair and additional non-segmental. Contrast CT scan can who reach hospital, a significant evaluation of the abdominal organs. be confirmatory. If abnormalities are proportion die in hospital as the seen on the admission chest X-ray, the result of mis-assessment or delay in Operative repair is recommended in pulmonary contusion is severe. the institution of treatment. These all cases. Haemoptysis or blood in the deaths occur early as a endotracheal tube is a sign of consequence of shock, or late as pulmonary contusion. In mild contusion the result of ARDS and sepsis. the treatment is oxygen administration, aggressive pulmonary toilet and Most life-threatening thoracic adequate analgesia. In more severe injuries can be simply and promptly cases mechanical ventilation is treated after identification, by necessary. While one should avoid needle or tube placement for fluid-overloading these patients to drainage. These are simple and counteract a trend to pulmonary effective techniques that can be oedema, establishment of performed by any medical normovolaemia is critical for adequate practitioner. tissue perfusion and fluid restriction is Fig. 2. Chest radiograph: Blunt Emergency room thoracotomy (ERT) not advised. trauma, left-sided diaphragmatic has distinct and specific rupture and haemothorax and right- CONCLUSION indications. Indiscriminate use will sided pneumothorax. not alter the morbidity or mortality, Chest injuries are often life but will increase the risk of 5. Oesophageal injury threatening, either in their own right or communicable disease transmission in conjunction with other system in health workers. Most injuries result from penetrating injuries. Efficient initial assessment trauma; blunt injury is rare. A high Injuries to the chest wall and according to the ATLS principles index of suspicion is required. The thoracic viscera can directly impair should focus on identifying and patient can present with odynophagia, oxygen transport mechanisms. The correcting the immediate threats to subcutaneous or mediastinal hypoxia and hypoxaemia that life. A high index of suspicion must be emphysema, , retro- results may cause secondary injury, maintained thereafter to diagnose the oesophageal air, and unexplained especially to the brain. potential threats to life as their fever within 24 hours of injury. The symptoms and signs can be very Brain injury can secondarily mortality rises exponentially if subtle. Early consultation and referral aggravate thoracic injuries by treatment is delayed more than 12 - to a trauma centre is advised in cases disrupting normal ventilatory 24 hours. Mediastinal and deep of doubt. patterns. In addition, the lung is a cervical emphysema must be seen as target organ for secondary injury evidence of an aero-digestive injury Further reading following shock and remote injury. until proven otherwise! Combination of oesophagogram in decubitus Advanced Trauma Life Support Course Manual. Chicago: American College of position and oesophagoscopy confirm Surgeons, 1997. the diagnosis in the great majority of Guidelines for Practice Management: Blunt cases. The treatment is operative. Myocardial Injury. The Eastern Association for the Surgery of Trauma (EAST). Online: http//:www.east.org (2004) 6. Pulmonary contusion Guidelines for Practice Management: Pulmonary contusion is caused by Prophylactic Antibiotics in Tube Thoracostomy. The Eastern Association for the Surgery of haemorrhage into the lung Trauma (EAST). Online: parenchyma, usually underneath a flail http//:www.east.org (2004)

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