Chest Trauma

The early killer

Brain death can occur after <10 minutes of oxygen deprivation, so the first priority in trauma is always the airway (A in ABCs).

Five immediate life-threatening chest injuries

1. Tension pneumothorax.
2. Open pneumothorax.
3. Cardiac tamponade.
4. Massive hemothorax.
5. Flail chest.

Air enters the pleural space and cannot escape → rising intrathoracic pressure → lung collapse + decreased venous return → obstructive shock.

Classic findings

• Severe dyspnea.
• Hypotension/hypoperfusion.
• Distended neck veins (JVD).
• Absent or decreased breath sounds on the affected side.
• Hyperresonance to percussion.
• Tracheal deviation away from the affected side (late finding).

Immediate treatment

1. Needle thoracostomy.
2. Then a chest tube (tube thoracostomy).

The “sucking chest wound”

An open defect in the chest wall allows air movement between the atmosphere and pleural space.

Findings

• Obvious chest wall wound.
• Respiratory distress.
• A “sucking” sound.
• Often associated with hemothorax.

Treatment

1. Cover with a three-sided occlusive dressing: prevents air entry and allows air to escape.
2. Chest tube placement.

Blood accumulates in the pericardial sac → impaired ventricular filling → obstructive shock.

Common after penetrating trauma (stab wounds) and blunt trauma to the anterior chest.

Beck triad

• Hypotension.
• JVD.
• Muffled heart sounds.

Distinguish tamponade from tension pneumothorax

Both cause hypotension, JVD, and shock.

• Tamponade: muffled heart sounds.
• Tension pneumothorax: absent breath sounds.

Very small amounts of blood (150–200 mL) can cause tamponade, so a normal chest X-ray does NOT exclude it.

Treatment

• Initial: pericardiocentesis.
• Definitive: surgical repair/thoracotomy.

A large accumulation of blood in the pleural cavity.

Definition: ≥1500 mL of blood in one hemithorax. Each hemithorax can hold up to 40–50% of blood volume.

Causes

• Lung injury.
• Intercostal artery injury.
• Internal mammary artery injury.

Why it kills

1. Hypovolemic shock: loss of preload.
2. Hypoxia: collapsed lung → V/Q mismatch.
3. Compression: pressure impairs venous return and lung expansion.

Findings

Shock, dullness to percussion, decreased breath sounds, and respiratory distress.

Treatment

1. Immediate chest tube.
2. Thoracotomy if continued bleeding.

Surgical indications

Persistent bleeding: 1500 mL initially OR 200 mL/hour for several hours.

Multiple rib fractures cause a free-floating chest wall segment.

Definition: ≥3 adjacent ribs fractured, each in ≥2 places. Usually associated with pulmonary contusion.

Paradoxical movement

• During inspiration, the flail segment moves inward.
• During expiration, it moves outward.

Main problem

Pulmonary contusion → hypoxemia, not the rib fractures themselves.

Complications: increased work of breathing, respiratory fatigue, and respiratory arrest.

Treatment: mild cases

• Pain control.
• Pulmonary hygiene.
• Incentive spirometry.
• Restrict excess IV fluids.

Treatment: severe cases

Ventilatory support if:

• Persistent hypoxemia.
• Shock.
• Severe associated injuries.
• Elderly patients.
• Many rib fractures.

Must-know associations

• Hyperresonance → pneumothorax.
• Dullness to percussion → hemothorax.
• Beck triad (hypotension + JVD + muffled heart sounds) → cardiac tamponade.
• Paradoxical chest wall movement → flail chest.
• Tracheal deviation away from the lesion → tension pneumothorax.

When given a trauma patient:

1. Assess the airway first.
2. Determine whether the problem is obstructive shock, hypovolemic shock, or respiratory failure.
3. Use percussion findings: hyperresonance = air; dullness = blood.
4. If unstable, treat clinically before imaging.

One-line memory tricks

• Tension pneumothorax: “Air under pressure shifts the mediastinum.”
• Tamponade: “Heart squeezed by blood.”
• Massive hemothorax: “Chest fills with blood.”
• Flail chest: “Broken ribs move backward.”
• Open pneumothorax: “Hole in chest wall sucks air.”