Chapter : Chest Trauma 5 Contact Hours Author: Jassin M. Jouri Jr., MD Learning objectives Describe the common etiology of chest trauma. Describe diagnosis strategies for blunt chest injuries. Explain the pathophysiology of chest trauma. Identify common treatments for blunt chest injuries. List common injuries to the chest wall. Explain common treatment strategies for penetrating chest injuries. Identify common types of pulmonary and pleural space injuries. Describe recovery procedures for chest injuries. Recognize the impact of chest trauma on the tracheobronchial Identify the most common cause of penetrating chest injuries. region. Explain pain management strategies for chest injuries. Define common types of cardiac injury. Describe the purpose of intubation and ventilation in patients with Identify the two categories of chest injury. cardiac injury. Recognize the visual signs of a blunt chest injury. Introduction Chest trauma is ranked 3rd highest cause of morbidity and mortality positive pressure imposed on the chest wall. [13] These are typically in the USA after head and extremity trauma. [2] An accident or caused by accidents and fall injury. Blunt injury can affect all the areas premeditated penetration of a foreign object into the chest is the usual of the chest wall, thoracic cage and its contents. These components cause of chest trauma or injury. This type of injury may further result may range from the bony structures like ribs, clavicles, scapulae, and in bruises, fracture of ribs or severe injury to the chest wall such as sternum and viscera like lungs and pleurae, trachea-bronchial tree, lung or heart contusions. Furthermore, major chest trauma may occur esophagus, heart, great vascular structures, and the diaphragm. [2] alone or in combination with multiple other injuries. [1] Here we While on the other hand, when a foreign object breaks through the have discussed the approach to chest trauma in detail to get complete chest wall, Penetrating trauma occurs. It usually enters the tissue of understanding in terms of etiopathology, various types of injuries and the body, creating an open wound. Stabbing, gunshot wound, arrow their effective management. through the heart and such, are the major cause of penetrating trauma, Chest traumas are classified into two types: blunt or penetrating [5] [13] which will be further discussed. trauma. Blunt chest trauma occurs due to sudden compression or I.ETIOLOGY A. Motor vehicle accidents By far, the most vital cause of major blunt chest trauma is motor over a short distance, or what we called deceleration, are the cause vehicle accidents (MVAs). [2] Due to the increasing occurrence of motor vehicle accidents. Severity of the injury depends on energy of traffic and vehicular accidents, blunt chest injuries are the most transferred during deceleration as a result of the crash. Motor vehicle common problems in civil practice. Motor vehicular accidents report accidents accounts for half of the death, usually with unintentional for 70-80% of such injuries. According to statistics from Peitzman’s causes, and the risk of having major injury incidence can increase from The Trauma Manual, motor vehicle accidents are the leading cause 300% to 500% if the victim is ejected from the vehicle. [1] of injury death, accounting for 44, 800 deaths in 2003 or 15.4 deaths One of the determinants of injury caused by motor vehicle accidents is in 100,000 populations. Over 3.5 million sustained nonfatal injuries by magnitude of force, or the strength or measurement of the amount secondary to motor vehicle crashes in 2003. Despite these, the death of an applied force, equals to mass times acceleration (force=mass x rate per vehicle miles traveled (VMT) has gradually declined over a acceleration). [1] Although the body tries to stand still after it hits an period of century from 18 deaths per 100 million per VMT in 1925 to object, the internal organs continue to move until they hit something, approximately 5 per 100 million VMT in 1960 to as low as 1.56 per such as the lungs hit the ribs, or the heart strikes the sternum, or the 100 million VMT in 2003. In the 2005 National Trauma Data Bank aorta presses against the spine. All of these adverse events following (NTDB), motor vehicle crashes accounted for 43.1% of cases and 47% accidents lead to contusion, bleeding, and rupture within the thoracic of mortalities. Motor vehicle crash-related deaths occurred in 4.9% of cage. We can also determine the extent of injury by the location of NTDB cases. [1] the victim from the vehicle. It depends where the victim was seated, Incidence of different vehicular collisions, or accidents that happened in the front seat or the back, or he or she was the passenger in the with pedestrians are reported almost every day. These kinds of mishaps vehicle, or the driver itself. Furthermore, vehicle restraint devices frequently cause a person’s injury, mild to severe cases, and even are also identified for the extent of damages to the victim, may it worse, death. Injuries that are produced by a rapid decrease in velocity be used or not, or the kind of restraint that are worn or applied. Of Nursing.EliteCME.com Page 1 course, it is obvious that injuries to the unrestrained are at greatest twice the mortality of frontal impacts, causing the occupant to project risk. On the other hand, the use of Lap belts may reduce injury by to the next compartment. Meanwhile, rear-end impact collisions do 50%, that should be worn correctly (designed to fit across the pelvis). not usually cause severe injury, but a usual extension-flexion injury is Meanwhile, optimal protection can be provided when three-port common. [1] constraints plus airbags are used, especially applicable in front-end Motorcycle vehicles are at more risk in accidents, with the fact that collisions. Still with the use of the three-point restraint, secondary the driver usually absorbs the impact and the associated kinetic collision of the occupant with the vehicle is reduced. Ejection is also energy, though the majority of deaths are because of cranial injuries, prevented and mortality is substantially decreased, though with the use and extremity fractures are much more common. In the meantime, of these restraints, injury to the extremities are not prevented. On the pedestrian-automobile incidents are accountable for two percent of other hand, the use of shoulder belts that are worn but without the lap the injuries, but they still account for the 13% of the traffic-related component may associate with multiple vascular injuries that include deaths. Six percent holds the prevalence of trauma to the torso internal damage or thrombosis of major arteries. [1] (including chest, abdomen and pelvis), though musculoskeletal and As stated earlier, there is greater damage and injury to a victim that is intra-abdominal injuries are more common. Children, elderly, and unrestrained. The majority of injuries in frontal crashes are the result intoxicated victims are more common in this kind of impact. [1] of impact in the steering wheel, windshield, dashboard or floorboards. With its frequent association with motor vehicle accidents, chest At least 46% causes the injury and trauma to the major thoracic area. trauma typically occurs in connection with injuries to other major On the other hand, thoracic and abdominal injuries are more prevalent systems like the head and abdomen. It is said that at least 86% of in a lateral crash. [1] Because of the limited space between the driver victims with thoracic injuries has involvement of one or more other and the colliding vehicle, it results to the direct impact between the bodily system. This is good enough to have an idea regarding the high vehicle and the occupant. Lateral impact collisions are associated with level of force involved in chest trauma. B. Falls There are a variety of definitions about falls, one of which differs from mostly occurs in children. These measurements are still not enough its origin. According to the World Health Organization, Fall is defined to highlight the impact of disabilities related to afall for elderly as an event which results in a person coming to rest inadvertently on people having fewer life years to lose. In addition to this, the elderly the ground or floor or other lower level, [3] while to Tinetti, Speechley, individuals who suffer a fall related disability are at a high risk for and Ginter, a fall in the non-hospitalized geriatric population is defined subsequent long-term care and hospitalization care. It is proven as “an event which results in a person coming to rest unintentionally globally that falls are one major public health problem. [3] on the ground or lower level, not as a result of a major intrinsic event Falls are classified into a variety of means. One of which is the use of (such as a stroke) or overwhelming hazard.”[3] Another definition by International Classification of Diseases published by the World Health Agostini, Baker, and Bogardus, which was adapted for the inpatient, Organization. [41] The code is widely used for the analysis of the acute, and long-term care areas to define it as “unintentionally coming general health situation of a particular population group. This includes to rest on the ground, floor, or other lower level, but not as a result the classification of disease and other health problems, depending of syncope or overwhelming external force.” Other meanings are on the incidence and nature that appear on the health record or death extensive and include falls related to intrinsic events such as syncope certificate of a victim. This helps in the monitoring of incidence, or stroke. Just like Nevitt’s definition of a fall is “falling all the way mortality and morbidity of a particular health problem.