10. Chest injuries: types, diagnosis and treatment

OVERVIEW

• Thoracic trauma may be blunt or penetrating and can rapidly impair ventilation, oxygenation or circulation.
• Immediate lethal conditions include airway obstruction, tension pneumothorax, open pneumothorax, massive haemothorax, flail chest with respiratory failure and cardiac tamponade.
• Associated injuries include pulmonary contusion, rib/sternal fractures, tracheobronchial injury, blunt cardiac injury, aortic injury and diaphragmatic rupture.

ANATOMY AND MECHANISMS

• The thoracic cage protects lungs, heart and great vessels.
• The pleura has visceral and parietal layers; the pleural space is normally a potential space.
• The mediastinum contains heart, great vessels, trachea, oesophagus and major nerves.
• Blunt deceleration can tear the aorta near the ligamentum arteriosum; compression can cause pulmonary contusion or cardiac injury.
• Penetrating injuries may damage lung, heart, intercostal vessels or great vessels.
• Rib fractures can lacerate pleura or lung and pain causes splinting, atelectasis and secretion retention.

CLINICAL PRIORITIES

• Use ATLS primary survey.
• Assess airway patency, respiratory rate, work of breathing, chest expansion, oxygen saturation, tracheal position, percussion, breath sounds, neck veins, perfusion and mental state.
• Look for open wounds, sucking chest wounds, flail segments, bruising, subcutaneous emphysema and seat-belt marks.
• Do not wait for imaging to treat a clinically obvious tension pneumothorax or other immediately life-threatening injury.