Approximately a quarter of deaths due to trauma are attributed to thoracic injury. Immediate deaths are essentially due to major disruption of the heart or of great vessels. Early deaths due to thoracic trauma include airway obstruction, cardiac tamponade or aspiration.

The majority of patients with thoracic trauma can be managed by simple manoeuvres and do not require surgical treatment.

RESPIRATORY DISTRESS

Respiratory distress may be caused by:

HAEMORRHAGIC SHOCK

Haemorrhagic shock may be due to:

RIB FRACTURES

Fractured ribs may occur at the point of impact and damage to the underlying lung may produce lung bruising or puncture. In the elderly patient, fractured ribs may result from simple trauma. The ribs usually become fairly stable within 10 days to two weeks. Firm healing with callus formation is seen after about six weeks.

FLAIL CHEST

The unstable segment moves separately and in an opposite direction from the rest of the thoracic cage during the respiration cycle. Severe respiratory distress may ensue. This is a medical emergency and can be treated with positive pressure ventilation and analgesia.

TENSION PNEUMOTHORAX

Tension pneumothorax develops when air enters the pleural space but cannot leave. The consequence is progressively increasing intrathoracic pressure in the affected side resulting in mediastinal shift. The patient will become short of breath and hypoxic.

Urgent needle decompression is required prior to the insertion of an intercostal drain. The trachea may be displaced (late sign) and is pushed away from the midline by the air under tension. Immediate decompression can be achieved by needle decompression, as described above, but a definitive chest drain should be inserted as soon as possible.

The extent of internal injuries cannot be judged by the appearance of a skin wound.

HAEMOTHORAX

Haemothorax is more common in penetrating than in non-penetrating injures to the chest. If the haemorrhage is severe hypovolaemic shock will occur as well as respiratory distress due to compression of the lung on the involved side.

Optimal therapy consists of the placement of a large chest tube.

PULMONARY CONTUSION

Pulmonary contusion (bruising) is common after chest trauma. It is a potentially life-threatening condition. The onset of symptoms may be slow and may progress over 24 hours post injury. It is likely to occur in cases of high-speed accidents and falls from great heights.

Symptoms and signs include:

OPEN CHEST WOUNDS

In open or “sucking” wounds of the chest wall, the lung on the affected side is exposed to atmospheric pressure with lung collapse and a shift of the mediastinum to the uninvolved side. This must be treated rapidly. A seal, such as a plastic packet, is sufficient to stop the sucking, and can be applied until reaching hospital. In compromised patients intercostal drains, intubation and positive pressure ventilation is often required.

OTHER INJURIES

The injuries listed below are also possible in trauma, but carry a high mortality risk even in regional centres. They are mentioned for educational purposes.

MYOCARDIAL CONTUSION

Myocardial contusion is associated, in chest blunt trauma, with fractures of the sternum or ribs. The diagnosis is supported by abnormalities on ECG and elevation of serial cardiac enzymes, if these are available. Cardiac contusion can simulate a myocardial infarction. The patient must be submitted to observation with cardiac monitoring, if available. This type of injury is more common than generally realized and may be a cause of sudden death well after the accident.

Beware pulmonary contusion and delay in deterioration of respiratory state

PERICARDIAL TAMPONADE

Penetrating cardiac injuries (for example, following stab wounds) are a leading cause of death in urban areas. It is rare to have pericardial tamponade with blunt trauma. Pericardiocentesis must be undertaken early if this injury is considered likely. Look for it in patients with:

Treatment is pericardiocentesis which is potentially hazardous and should only be undertaken by experienced clinicians.

THORACIC GREAT VESSEL INJURIES

Injury to the pulmonary veins and arteries is often fatal, and is one of the major causes of on-site death.

RUPTURE OF TRACHEA OR MAJOR BRONCHI

Rupture of the trachea or major bronchi is a serious injury with an overall estimated mortality of at least 50%. The majority (80%) of ruptures of bronchi are within 2.5 cm of the carina. The usual signs of tracheobronchial disruption are the following:

TRAUMA TO THE OESOPHAGUS

Trauma to the oesophagus is rare in patients following blunt trauma injury. Perforation of the oesophagus is more frequently caused by penetrating injury. It is lethal if unrecognized because of mediastinitis. Patients often complain
of sudden sharp pain in the epigastrium and chest with radiation to the back. Dyspnoea, cyanosis and shock occur, but these may be late symptoms.

DIAPHRAGMATIC INJURIES

Diaphragmatic injuries occur more frequently in blunt chest trauma, paralleling the rise in frequency of car accidents. The diagnosis is often missed. Diaphragmatic injuries should be suspected in any penetrating thoracic wound.

THORACIC AORTA RUPTURE

Thoracic aorta rupture occurs following severe decelerating forces such as high speed car accidents or falls from great heights. Patients have high mortality as the cardiac output is 5 litres/minute and the total blood volume in an adult is 5 litres.

Beware pericardial tamponade in penetrating chest trauma.