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 pneumothorax, 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 trachea, 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. July 2004 Vol.22 No.7 CME 369 CHEST TRAUMA 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 chest tube 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 lung 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 thoracic cavity 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 370 CME July 2004 Vol.22 No.7 CHEST TRAUMA 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