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Related Subjects: |Initial Trauma Assessment and Management |Thoracic Trauma Assessment and Management |Flail Chest Rib fractures |Resuscitative Thoracotomy |Haemorrhage control |Traumatic Head/Brain Injury |Traumatic Cardiac Arrest |Abdominal trauma |Tranexamic Acid |Silver Trauma |Cauda Equina

Cadaver studies have shown improved success in reaching the thoracic cavity when the fourth or fifth intercostal space mid-axillary line is used instead of the second intercostal space mid-clavicular line in adult patients. ATLS now recommends this location for needle decompression in adult patients.

Introduction

• Thoracic trauma causes 1/4 trauma deaths.
• In UK 90% is secondary to blunt injury and most are MVC
• Penetrating Gunshot wounds commoner in USA
• Blunt vs Penetrating injuries different clinical courses
• Penetrating injuries more likely to need operative intervention.

Different modalities

• Direct blunt force: plastic bullet, fist or bat, steering wheel
• Acceleration or deceleration: sudden changes in kinetic energy seen in RTC
• Shear force: torsional forces may be seen in RTC.
• Compression: crush injury e.g. wall, building, tree
• Blasts: bomb explosion with concussive wave

Clinical

• Observation: difficulty breathing - pain or fractures, may see moveable section of ribs which move in with inspiration and out with expiration - this is a flail chest. Bruising over the chest wall.
• Hypotension and shock - Bleeding, Tension PTX, Tamponade. Gte good IV access and consider needle decompression if compromised and tension PTX suspected.
• Chest Pain - Rib fractures and look for flail chest and pain limiting breathing needs good analgesia
• Major vessel damage: Palpate major pulses on all 4 extremities and assess capillary refill on extremities
• Breathlessness and cyanosis - Lung contusion, Tension PTX
• Raised JVP - Heart failure, Tamponade or Tension PTX
• Subcutaneous emphysema - Pneumothorax or Oesophageal rupture and air in mediastinum

Life threatening injuries

• External Haemorrhage
  • Use simple dressings with direct pressure to control external haemorrhage
• Airway obstruction
  • Direct removal of any obstruction where possible, suction. basic airway management, including oral or nasal airway, suction and bag–valve–mask. Be aware of any suspected neck injuries.
  • High flow Oxygen, remove obstruction. Intubation where needed.
  • Consider front of neck airway - cricothyroidotomy
• Simple pneumothorax
  • Air collecting between the visceral and parietal pleura as a result of blunt or penetrating trauma. Results in lung collapse and altered ventilation/perfusion. Needs chest drain insertion
  • Use clinical assessment to diagnose pneumothorax for the purpose of triage or intervention. Consider using eFAST (extended focused assessment with sonography for trauma) to augment clinical assessment but a negative eFAST of the chest does not exclude a pneumothorax.
• Rib fractures
  • Patients with significant chest injury, including 3 or more rib fractures are at high risk of deterioration
  • Patients with co-morbidities including prior poor chest wall compliance as well as the elderly are particularly at risk of hypoventilation in the setting of chest trauma and may deteriorate rapidly.
• Older Patients
  • Some of the most common injuries in the elderly and those >65 years are twice as likely to develop pneumonia.
  • Should be admitted to a trauma centre.
• Flail Chest
  • Flail chest injury represents a particularly severe form of chest trauma and is an immediate threat to life.
  • Suggests a significant chest injury and is associated with contusions and haemopneumothorax
  • Patients develop a degree of mechanical ventilatory failure
• Diaphragm injury
  • Diaphragm needed for effective ventilation. Injury from penetrating mechanism or blunt trauma to abdomen. May be associated lung and abdominal injuries
  • Results in pulmonary compromise and complications to peritoneal contents and may be associated with other significant injuries.
  • Left sided ruptures are seen more commonly that the right possibly due to protection by the liver. May be missed on CXR.
• Blunt aortic injury
  • Damage can cause massive exsanguination and death. They are fixed and so susceptible to sudden decelerative forces in trauma.
  • Suspected aortic injury who do not respond to resuscitative measures may require rapid diagnosis and preparation for surgical intervention if available.
• Oesophageal injury
  • Oesophageal injuries are more commonly associated with penetrating trauma and may have concomitant injuries to adjacent structures. Evidence of oesophageal injury may be subtle, but delay in diagnosis can result in associated sepsis. These injuries need to be managed by specialist surgical intervention.
• Open Pneumothorax
  • If an opening in the chest wall is approximately 2/3rd of the diameter of the trachea or greater, air will pass through the chest wall defect with each respiratory effort, rather than down the trachea.
  • Close the opening in the chest with a sterile dressing, occluded on 3 (of four) sides which allows air to escape during expiration but not enter in inspiration.
  • Next insert a chest tube at a site away from the wound. Once the intercostal catheter is in place, then the dressing can be converted to a 4-sided, occlusive dressing. These sorts of wounds will likely require definitive surgical closure.
  • 3-sided occlusive dressing: large enough to overlap the wounds edges and then taped securely on 3 sides to provide a flutter type valve effect.
  • As the patient breathes in the dressing prevents air from entering but in expiration allows air to escape.
• Tension pneumothorax
  • The recognition of tension pneumothorax, its primary treatment by needle thoracostomy and definitive treatment by tube thoracostomy are essential at all hospital-level facilities that handle trauma
  • New progressive tachypnoea, low O₂, tachycardia, hypotension, decreased breath sounds, hyper expansion, when late pushes trachea way, subcutaneous emphysema and desaturation. Raised JVP
  • Seen with injury to pleural parenchyma creates a one-way valve defect allowing air to enter the pleural space but not leave. Rise in intra-thoracic pressure impedes ventilation, while the collapsed lung impairs gas exchange, both resulting in tachypnoea and hypoxia.
  • Raised intra-thoracic pressure also impedes venous return both from the IVC and SVC, as well as increasing afterload on the heart. Obstructive shock soon develops.
  • Only perform chest decompression in a patient with suspected tension pneumothorax if there is haemodynamic instability or severe respiratory compromise.
  • Needle decompression in either 5th ICS mid axillary line (with the arm in the abducted position) or 2nd ICS MCL using a large bore IV Cannula (14 or 16G) with a 10ml syringe attached is inserted, and air is drawn.
  • Once needle decompressed then insert chest drain usually with a tube. An incision is made through skin, dermis and fascia at the fourth or fifth intercostal space, just anterior to the mid axillary line. (Prior infiltration of local anaesthetic is required if the patient is conscious).
  • The intercostal space is then traversed using a curved forceps via blunt dissection and decompression through the pleura, completed with a sweep with a sterile gloved finger. The site is then covered with a three way dressing, or a valve-bag. Re-sweeping of the site can also be performed if the patient deteriorates.
  • NICE: Use open thoracostomy instead of needle decompression if the expertise is available, followed by a chest drain via the thoracostomy in patients who are breathing spontaneously. Observe patients after chest decompression for signs of recurrence of the tension pneumothorax
• Massive haemothorax
  • Accumulation of blood and fluid in the hemi thorax compromises ventilation and compresses the lung, especially when there is >1500mls or 1/3 the patients’ blood volume in the chest cavity.
  • Seen mostly after penetrating trauma but can also be present in blunt trauma. Bleeding can be from lungs, major vessels, intercostal vessels or the heart. Can lead to respiratory failure, hypotension and shock.
  • ABC and resuscitation and insertion of a chest drain. Large bore IV cannulas or intraosseous access for volume resuscitation commenced.
  • Damage control resuscitation techniques should be employed until there is definitive control of bleeding. Use minimal crystalloid and early use of blood products. Aim for an adequate (though not normal) systolic blood pressure.
  • An intercostal catheter allows for measurement of blood loss, as well as some tamponade effect when allowing the lung to re-expand against the chest wall. This will have some effect on intercostal bleeding and parenchymal bleeding.
  • Where >1,500ml is drained, thoracotomy is likely required. Activate the massive transfusion protocol as the patient is likely to require large amounts of blood to restore perfusion.
• Cardiac tamponade
  • Occurs when blood, fluid or air enters the pericardium, restricting cardiac activity and interfering with filling.
  • Primarily penetrating trauma but some severe blunt chest trauma that results in right heart injury.
  • Progressive symptoms and signs evolve over minutes. May detect Becks Triad (hypotension, raised JVP, muffled heart sounds)
  • What is often seen is the plethoric face and neck that results from inflow obstruction. This tends to be more pronounced than when seen in tension pneumothorax, and is a distinctive sign.
  • Needs decompression of the pericardial sac and repair of the myocardial defect. Permissive hypotension and minimal volume resuscitation should be employed until decompression is achieved.
  • If the patient is in shock, and a surgeon is available, the patient should undergo a resuscitative thoracotomy. Preferably this should be in theatre (operative thoracotomy) if time allows, however if the patient loses output it will need to be performed in the emergency department.
  • If no surgical services are available, nor anyone trained in the procedure of resuscitative thoracotomy and cardiac repair, then the patient should be transferred as a matter of urgency.
  • If the patient is in severe shock (or has lost output), with tamponade confirmed on ultrasound, and all other causes have been eliminated or treated, then a pericardiocentesis can be performed.
• Deteriorating patient
  • Hypoxia may develop as injuries evolve. Maybe due to Hypoventilation due to pain or fatigue from increased work of breathing as well as side effects of opiate analgesia.
  • Other causes include the development of a tension pneumothorax, atelectasis and pneumonia
  • Needs escalation, good analgesia and respiratory support and possibly physio

Investigations

• FBC, Clotting, Amylase, U&E, glucose, lactate
• Group and cross match 6-10 units.
• CT Traumogram
• Toxicology screen
• POCUS or Cardiac echo for blood in pericardial sac and heart trauma

Management

• ABC, Oxygenation, IV fluids - give blood, Analgesia. Activate Massive Transfusion protocol. Treat Tension PTX. Intubation and ventilation for respiratory failure. Ongoing pulse oximetry and ECG monitoring.
• Patients with significant chest injury, including 3 or more rib fractures, flail chest injury, a need for ventilator support, patients > 65 years of age and with any significant co-morbidities should be transferred to a major trauma service for definitive care.
• Resuscitative Thoracotomy (RT) in penetrating trauma may be considered for patients who arrive pulseless but with electrical activity or with tamponade despite treatment and resuscitation.
• Ventilatory support in patients with pulmonary contusions and poor lung compliance requires ventilation at lower tidal volumes and low inspiratory pressure in order to reduce barotrauma and secondary lung injury.
• Studies of both prehospital and hospital providers have demonstrated that though landmarks can be appropriately recited, they are not always accurately identified.
• Needle decompression can fail to improve clinical decompensation in patients who have haemothorax or in whom the angiocatheter has kinked.
• Performing a finger thoracostomy can ensure adequate decompression of the chest and eliminate tension pneumothorax as the cause of decompensation.
• Evidence-based research and clinical experience indicate that size matters with respect to the optimal size chest tube required to drain a haemothorax.
• Prospective analysis has shown 28-32 F to effectively drain haemothorax without resulting in increased retained haemothorax.

Focused abdominal sonography for trauma (also known as FAST) technique

• Can evaluate the thoracic cavity for the presence of air. It can aid in the rapid diagnosis of pneumothorax in the emergency department.
• The presentation and treatment of blunt aortic injury has evolved with the use of thoracic CTA to evaluate for blunt aortic injury.
• Haemodynamically normal patients with partial injury are now managed with endovascular techniques.
• The injury is medically managed by decreasing the heart rate (<80 bpm) and mean arterial pressure (60-70 mm Hg) through the use of beta-blockers.

References

• MAJOR TRAUMA GUIDELINES & EDUCATION
• NICE guidelines on Trauma