Chest Trauma

The chest is surrounded by a cell or bone box that protects some of the most important vital organs: the heart and lungs along with the great vessels (aorta and vena cava) and the airway. It accounts for approximately 25% of all injuries and can have serious complications, leading to up to 40% of deaths.

There are two mechanisms for injury to the chest, blunt and penetrating, the first being the most common. In my personal experience, I have often seen both blunt and penetrating chest trauma, and the concern is always to quickly diagnose any damage in these patients because when the injury is mild, it can take hours to develop the symptoms. As with any other type of trauma, the time it takes to diagnose and treat is crucial to the patient’s prognosis. Although the mechanisms of trauma are different for the blunt and for the penetrating as well as the treatments, in which the penetrating enters surgery with more frequency, the mortality rate is basically the same.

a) What to Do When Facing a Chest Trauma

The SAFE approach is a practical way of being methodical and efficient in the face of such an emergency: • Shout for help (call) • Assess the scene • Free from danger? • Evaluate the casualty

REMEMBER:

• Find out the mechanism of the trauma. • The airway has to be clear. Sometimes polytrauma patients have contents in their mouth that have to be cleared with gauze. • The patient with many wounds may be bleeding from many places. It is important to focus on the life-threatening damage, mainly vascular and pulmonary. • Vascular damage is the first thing you need to control BEFORE the airway. If you see any massive bleeding, STOP THE BLEEDING FIRST. • The neck must be stabilized because there may have been damage to the trachea. To stabilize the neck before the emergency help arrives, take the patient’s head with both your hands and keep it in a straight position. If you have a cervical collar, you can use it. If you are alone and must continue to assess the patient, place two pillows or rolled towels on each side of the injured person’s head. • Make sure you ask as many details as you can about the accident. All that information helps the paramedics think of diagnostic possibilities.

b) Physical Exam

• Take vital signs, pulse, and respiration rate for one minute. • Use a blood pressure monitor to measure their blood pressure from time to time. Take note as a decrease is a sign of alarm. • Observe that the breathing movements of the chest are rhythmic and symmetrical. When there is no synchronization between the movements and the breathing of the patient, there is a flail chest. Flail chest is when a segment of the rib cage breaks due to trauma and becomes detached

from the rest of the chest wall. It occurs when multiple adjacent ribs are broken in multiple places, separating a segment so a part of the chest wall moves independently. • When the patient breathes, see if one side of the chest is more inflated than the other. It may be a sign of a pneumothorax, which is the penetration of air out of the lung. It can be caused by trauma that punctures the lining of the lung, such as a broken rib or a knife. • Check for penetrating wounds in the chest, and take note of the number and location.

c) Help May Take Time to Come, but You Have to Act

Chest wounds are not worth suturing if the paramedic hasn’t examined them, but you should cover them up with gauze while you wait. It’s a different technique than usual. It is practical, easy, and very useful. It is based on the principle that all the wounds we see in the chest are penetrating until it is proved otherwise; therefore the air may be coming in through those wounds, aggravating the patient’s condition. Cover all the wounds in the chest with gauze, but leave a free edge without adhesive. That way the air can get out, but when it tries to get in, the gauze will collapse and prevent it. This is a temporary solution until help arrives. It is not a treatment. Take vital signs every ten minutes: pulse, respirations per minute, and blood pressure. If you see that the patient is decompensating, heart rate is increasing, breathing is shallow, and blood pressure is dropping but don’t see any bleeding or any reason for that to be happening, the patient may be having a tension pneumothorax. This is an absolute emergency that you must deal with as that person can die within minutes.

d) Needle Thoracostomy for Tension Pneumothorax: Emergency

Procedure that Can Save a Life

A pneumothorax is the entry of air into the pleural space; this is outside the lung. Normally that space has a specific pressure that allows the lung to expand and contract with breathing. When air enters this space, either from a penetrating injury that passes through it or from an internal injury, such as a broken rib that passes through the lung, the air is trapped in that area, and the lung collapses and does not perform its function of ventilating. When the pressure inside the chest increases so much that it begins to compress the heart, there are physical manifestations, such as a drop in blood pressure and an increase in the heartbeat and number of breaths. This phenomenon is called tension pneumothorax and is life threatening.

BruceBlaus, Own work, CC BY 3.0

You can give the patient temporary relief by letting the air out of the lung with a procedure called needle thoracostomy. This can be done with a relatively simple surgical procedure that will help get the air out and the lung and heart back into place.

Materials:

• A 14-gauge needle • Gloves and mask • Isopropilic alcohol

Technique:

1. Locate the second intercostal space in the mid-clavicular line on the affected side.

2. Pass the needle you’re going to use through the finger of a glove. This acts as a valve that lets air out but doesn’t let it in. 3. Clean the area at and around the insertion site using 70% isopropyl alcohol. 4. Insert the needle into the indicated place, piercing the skin over the rib and below the target interspace. Keep going with the needle until the pleura is punctured (usually indicated by a pop and/or sudden decrease in resistance). This procedure is temporary. It relieves the patient’s symptoms and removes the threat until help arrives and a chest tube can be inserted.

Petr Menzel, CC BY-SA 3.0