Chest injuries, blunt
One-fourth of all trauma deaths in the United States result from chest injuries. Many are blunt chest injuries, which include myocardial contusion and rib and sternal fractures; these may be simple, multiple, displaced, or jagged. Such fractures may cause potentially fatal complications, such as hemothorax, pneumothorax, hemorrhagic shock, and diaphragmatic rupture.
Causes
Most blunt chest injuries result from motor vehicle accidents. Other common causes include sports and blast injuries.
Signs and symptoms
Rib fractures produce tenderness, slight edema over the fracture site, and pain that worsens with deep breathing and movement; this painful breathing causes the patient to display shallow, splinted respirations that may lead to hypoventilation.
Sternal fractures, which are usually transverse and located in the middle or upper sternum, produce persistent chest pain, even at rest. If a fractured rib tears the pleura and punctures a lung, it causes pneumothorax, which usually produces severe dyspnea, cyanosis, agitation, extreme pain and, when air escapes into chest tissue, subcutaneous emphysema.
Multiple rib fractures
Multiple rib fractures may cause flail chest: a portion of the chest wall “caves” in, which causes a loss of chest wall integrity and prevents adequate lung inflation. Bruised skin, extreme pain caused by rib fracture and disfigurement, paradoxical chest movements, and rapid, shallow respirations are all signs and symptoms of flail chest, as are tachycardia, hypotension, respiratory acidosis, and cyanosis.
Flail chest can also cause tension pneumothorax, a condition in which air enters the chest but can’t be ejected during exhalation; life-threatening thoracic pressure buildup causes lung collapse and subsequent mediastinal shift. The cardinal signs and symptoms of tension pneumothorax include tracheal deviation (away from the affected side), cyanosis, severe dyspnea, absent breath sounds (on the affected side), agitation, jugular vein distention, and shock.
Hemothorax
When a rib lacerates lung tissue or an intercostal artery, hemothorax occurs, causing blood to collect in the pleural cavity, thereby compressing the lung and limiting respiratory capacity. It can also result from rupture of large or small pulmonary vessels.
Massive hemothorax is the most common cause of shock following chest trauma. Although slight bleeding occurs even with mild pneumothorax, such bleeding resolves very quickly, usually without changing the patient’s condition.
Rib fractures may also cause pulmonary contusion (resulting in hemoptysis, hypoxia, dyspnea and, possibly, obstruction), large myocardial tears (which can be rapidly fatal), and small myocardial tears (which can cause pericardial effusion).
Further complications
Myocardial contusions produce electrocardiogram (ECG) abnormalities. Laceration or rupture of the aorta is nearly always immediately fatal. In rare cases, aortic laceration may develop 24 hours after blunt injury, so patient observation is critical.
Diaphragmatic rupture (usually on the left side) causes severe respiratory distress. Unless treated early, abdominal viscera may herniate through the rupture into the thorax, compromising both circulation and the vital capacity of the lungs.
Other complications of blunt chest trauma include cardiac tamponade, pulmonary artery tears, ventricular rupture, and bronchial, tracheal, or esophageal tears or rupture.
Diagnosis
A history of trauma with dyspnea, chest pain, and other typical symptoms suggest a blunt chest injury. A physical examination and diagnostic tests determine the extent of injury.
❑ Percussion reveals dullness in hemothorax and tympany in tension pneumothorax.
❑ Auscultation may reveal a change in position of the loudest heart sound in tension pneumothorax or muffled heart tones in cardiac tamponade.
❑ Chest X-rays may be used to confirm rib and sternal fractures, pneumothorax, flail chest, pulmonary contusions, lacerated or ruptured aorta, tension pneumothorax, diaphragmatic rupture, lung compression, or atelectasis with hemothorax.
❑ ECG may show abnormalities with cardiac damage, including multiple premature ventricular contractions, unexplained tachycardias, atrial fibrillation, bundle-branch heart block (usually right), and ST-segment changes.
❑ Serial aspartate aminotransferase, alanine aminotransferase, lactate dehydrogenase, creatine kinase (CK), and CK-MB levels are elevated.
❑ Retrograde aortography and transesophageal echocardiography reveal aortic laceration or rupture.
❑ Contrast studies and liver and spleen scans help detect diaphragmatic rupture.
❑ Echocardiography, computed tomography scans, and cardiac and lung scans show the extent of the injury.
Treatment
Clinical tip Blunt chest injuries call for immediate physical assessment, control of bleeding, maintenance of a patent airway, adequate ventilation, and fluid and electrolyte balance.
❑ Check all pulses and level of consciousness. Also, evaluate color and temperature of skin, depth of respiration, use of accessory muscles, and length of inhalation compared with exhalation.
❑ Check pulse oximetry values for adequate oxygenation.
❑ Observe tracheal position. Look for jugular vein distention and paradoxical chest motion. Listen to heart and breath sounds carefully; palpate for subcutaneous emphysema (crepitation) and a lack of structural integrity in the ribs.
❑ Obtain a history of the injury. Unless severe dyspnea is present, ask the patient to locate the pain, and ask if he’s having trouble breathing. Obtain an order for laboratory studies (arterial blood gas analysis, cardiac enzyme levels, complete blood count, and typing and crossmatching).
❑ For simple rib fractures, give a mild analgesic, encourage bed rest, and apply heat. To prevent atelectasis, instruct the patient on incentive spirometry and deep breathing, coughing, and splinting. Don’t strap or tape his chest.
❑ For more severe fractures, intercostal nerve blocks may be needed. Obtain X-rays before and after the nerve blocks to rule out pneumothorax.
❑ If the patient has excessive bleeding or hemopneumothorax, intubate him. Chest tubes may be inserted to treat hemothorax and to assess the need for thoracotomy. To prevent atelectasis, turn the patient frequently and encourage coughing and deep breathing.
❑ If the patient has pneumothorax, he may need a chest tube placed anteriorly to the midaxillary line at the fifth intercostal space, to aspirate as much air as possible from the pleural cavity and to reexpand the lungs. Insert chest tubes attached to water-seal drainage and suction.
❑ If the patient has flail chest, place him in semi-Fowler’s position. Reexpansion of the lung is the first definitive care measure. Administer oxygen at a high flow rate under positive pressure. Suction the patient frequently, as completely as possible. Carefully observe the patient for signs of tension pneumothorax.
❑ The patient with flail chest will also need I.V. therapy started. Use lactated Ringer’s solution or normal saline solution. Beware of both excessive and insufficient fluid resuscitation.
❑ For hemothorax, treat shock with I.V. infusions of lactated Ringer’s solution or normal saline solution. Administer packed red blood cells for blood losses greater than 1,500 ml or circulating blood volume losses exceeding 30%. Autotransfusion is an option. Administer oxygen.
❑ The patient with hemothorax will also need insertion of chest tubes in the fifth or sixth intercostal space anterior to the midaxillary line to remove blood. Monitor and document vital signs and blood loss. Watch for falling blood pressure, rising pulse rate, and hemorrhage —all require thoracotomy to stop bleeding.
❑ For pulmonary contusions, give limited amounts of colloids (for example, salt-poor albumin, whole blood, or plasma) to replace volume and maintain oncotic pressure. Administer an analgesic, a diuretic and, if necessary, a corticosteroid, as needed. Monitor arterial blood gas values to ensure adequate ventilation; provide oxygen therapy, mechanical ventilation, and chest tube care.
❑ For suspected cardiac damage, close intensive care or telemetry may detect arrhythmias and prevent cardiogenic shock. Impose bed rest in semi-Fowler’s position (unless the patient requires shock position); as needed, administer oxygen, an analgesic, and other supportive drugs to control heart failure or supraventricular arrhythmia.
❑ Watch for cardiac tamponade, which calls for pericardiocentesis. Essentially, provide the same care as for a patient who has suffered myocardial infarction.
❑ If the patient has myocardial rupture, septal perforation, or another cardiac laceration, immediate surgical repair is mandatory; less severe ventricular wounds require use of a digital or balloon catheter; atrial wounds require a clamp or balloon catheter.
❑ For the few patients with aortic rupture or laceration who reach the facility alive, immediate surgery is mandatory, using synthetic grafts or anastomosis to repair the damage. Give large volumes of I.V. fluids (lactated Ringer’s or normal saline solution) and whole blood, along with oxygen at very high flow rates; then transport the patient promptly to the operating room.
❑ If the patient has tension pneumothorax, insertion of a spinal or 14G to 16G needle into the second intercostal space at the midclavicular line is necessary to release pressure in the chest. After that, insert a chest tube to normalize pressure and reexpand the lung. Administer oxygen under positive pressure, along with I.V. fluids.
❑ For a diaphragmatic rupture, insert a nasogastric tube to temporarily decompress the stomach, and prepare the patient for surgical repair.
Book Source Details
- Book Title: Handbook of Diseases
- Author(s): Springhouse
- Year of Publication: 2003
- Copyright Details: Handbook of Diseases, Copyright © 2003 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Diseases, Copyright © 2008 Williams & Wilkins.
More About Causes of Chest symptoms
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More About This Book:
Title: Handbook of Diseases
Authors: Springhouse
Publisher: Lippincott Williams & Wilkins
Copyright: 2003
ISBN: 1-58255-266-5
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Chest wounds, penetrating (Handbook of Diseases)
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