See also : Westmead Guidelines
Primary survey threats
Secondary survey threats
Other manifestations of chest injury
Second leading cause of trauma death behind head / brain
- follows hypovolaemia, ventilation/perfusion mismatch and
intrathoracic pressure changes.
--> the most serious feature and early interventions must correct
- inadequate ventilation due to intrathoracic pressure changes and
- results from shock.
Airway in Chest Trauma
Laryngeal injury can
accompany chest trauma.
Posterior dislocation of the SC jt
can cause obstruction if the displaced fragment rests on the trachea
- this may also cause vascular injury as the aortic arch branches
- seen as stridor, voice change and obvious base-of-neck trauma.
- establish a patent airway (try ETT; may need to reduce #: grasp
clavicle with a pointed clamp (eg towel clip) and manually reduce it
--> then usually stable).
Completely expose the chest and neck.
- observe, palpate. percuss, auscultate.
Look for subtle signs of compromise
- progressively more shallow resps.
- cyanosis is late and its absence is not sensitive.
- observe wall asymmetry, deformity, lacs, cuts, abrasions etc.
Major thoracic injuries are:
- tension pneumothorax
- open pneumothorax (sucking
- flail chest
- massive haemothorax
Perform circulation check as per primary
Attach an ECG and pulse oximeter to the chest-injured pt.
- pts with sternal or rapid deceleration injury are prone to
myocardial injury and dysrhythmia.
- hypoxia and acidosis enhance this possibility.
- lidocaine may be required for premature contractions.
PEA may be present in tamponade, tension pneumothorax, profound
hypovolaemia or cardiac rupture.
- massive haemothorax
- cardiac tamponade
ABG = useful.
Perform usual secondary survey.
Consider 8 lethal injuries:
- simple pneumothorax
- pulmonary contusion
- tracheobronchial tree injury
- blunt cardiac injury
- aortic disruption
- diaphragmatic injury
- mediastinal traversing wounds
Unlike the immediately life-threatening injuries of the primary
survey, these are rarely obvious.
- have a high index of suspicion
Manifestations of Chest Injury
Indicates an underlying injury that needs attention.
If PPV is required, consider tube to prevent tension pneumo
Look for upper torso/face/arm plethora and
- relates to acute, temporary compression of the superior vena cava.
Massive swelling and cerebral oedema may be present.
Treat associated injuries
Ribs: splinting due to pain impairs ventilation, oxygenation and
- atelectasis and pneumonia are risks.
Primary survey AP XRs will miss up to 70% of all rib #s.
Childrens' ribs are highly pliable; can have significant
intrathoracic injuries without rib #
Ribs 1-3 are protected by bony framework of upper limb.
- #s of upper two ribs, sternum, scapula suggests major force
magnitude, places head, neck, spine and intrathoracic contents at
- associated higher mortality
- a result of a direct blow; associated rib # common
- cardiac and pulmonary contusion can accompany sternal #s
- provide adequate analgesia, rarely operative repair if marked
displacement / instability.
Rarely, posterior sternoclavicular dislocation can result in
mediastinal displacement of clavicular heads with SVC obstruction
--> immediately reduce via CTx surgery.
Middle ribs 4-9
- commonly #'d, and blow out in AP compression of the thorax.
- direct force tends to drive ends of bones in, causing pneumothorax
- the younger the pt, less likely to suffer rib #s
- multiple rib #s in young pts = great force
Lower ribs #
- consider spleen / liver trauma.
What to do:
1. Detect with exam
2. CXR / CT for associated injury (finding XR evidence for rib #s is
- CT for contusion, flail, associated intrathoracic injury.
3. Relieve pain.
4. Chest physiotherapy
5. Do not tape, splint etc.
Scapula / clavicle
Generally manageable non-operatively.
- increasing enthusiasm for fixation with severe displacement or
Scapula #s associated with substantial energy transmission to thorax
See flail chest
Very rare but possibly lethal.
--> Boerhaave's syndrome
- with a L pneumo/haemothorax without rib #s
- a severe blow to lower sternum / epigastrium and is in pain /
shock out of proportion
- particular matter in chest tube after blood clears.
Wide drainage and repair is indicated, preferably within a few
1. As above
2. Suspected severe lung injury being transferred, undergoing
anaesthesia or PPV.
1. Don't overlook a simple pneumothorax
2. Evacuate simple haemothorax else lung entrapment or empyema may
3. Diaphragm injuries are notorious for being overlooked.
4. Don't delay evaluation of the wide mediastinum and transfer to
facility capable of treating for evaluation
5. Don't underestimate rib #s, especially at extremes of age, and
aggressively control pain without resp depression.
6. Don't underestimate pulmonary contusion - may deteriorate and
need careful monitoring / mechanical ventilation for several days.
7. Geriatric patients tolerate chest trauma poorly due to poor
reserves and comorbidities.