Chest wounds, penetrating
Depending on their size, penetrating chest wounds may cause varying degrees of damage to bones, soft tissue, blood vessels, and nerves. Mortality and morbidity from a chest wound depend on the size and severity of the wound.
Gunshot wounds are usually more serious than stab wounds, both because they cause more severe lacerations and rapid blood loss and because ricochet commonly damages large areas and multiple organs. Patients require prompt, aggressive treatment to increase survival.
Causes
Stab wounds from a knife or ice pick are the most common penetrating chest wounds; gunshot wounds are a close second. Wartime explosions or firearms fired at close range are the usual source of large, gaping wounds.
Signs and symptoms
In addition to the obvious chest injuries, penetrating chest wounds can also cause several other effects:
❑ A sucking sound occurs as the diaphragm contracts and air enters the chest cavity through the opening in the chest wall.
❑ Level of consciousness varies, depending on the extent of the injury. If the patient is awake and alert, he may be in severe pain, which will make him splint his respirations, thereby reducing his vital capacity.
❑ Tachycardia stems from anxiety and blood loss.
❑ A weak, thready pulse results from massive blood loss and hypovolemic shock.
Penetrating chest wounds may also cause lung lacerations (bleeding and substantial air leakage through the chest tube), arterial lacerations (loss of more than 100 ml of blood/hour through the chest tube), and exsanguination. Pneumothorax (air in the pleural space causing loss of negative intrathoracic pressure and lung collapse), tension pneumothorax (intrapleural air accumulation causing potentially fatal mediastinal shift), and hemothorax can also result.
Other effects include arrhythmias, cardiac tamponade, mediastinitis, subcutaneous emphysema, esophageal perforation, and bronchopleural fistula. Tracheobronchial, abdominal, or diaphragmatic injuries can also occur.
Diagnosis
An obvious chest wound and a sucking sound during breathing confirm the diagnosis. Consider any lower thoracic chest injury a thoracicoabdominal injury until proved otherwise.
Further tests to provide baseline data include:
❑ pulse oximetry and arterial blood gas analysis to assess respiratory status
❑ chest X-rays before and after chest tube placement to evaluate the injury and tube placement (In an emergency, don’t wait for chest X-ray results before inserting the chest tube.)
❑ complete blood count, including hemoglobin (Hb) level, hematocrit, and differential (Low Hb level and hematocrit reflect severe blood loss; in early blood loss, these values may be normal.)
❑ palpation and auscultation of the chest and abdomen to evaluate damage to adjacent organs and structures.
Treatment
Clinical tip Penetrating chest wounds require immediate support of respiration and circulation, prompt surgical repair, and measures to prevent complications.
❑ Immediately assess airway, breathing, and circulation. Establish a patent airway, support ventilation, and monitor pulses frequently.
❑ Place an occlusive dressing over the sucking wound. Monitor patient for signs of tension pneumothorax (tracheal shift, respiratory distress, tachycardia, tachypnea, diminished or absent breath sounds on the affected side); if tension pneumothorax develops, temporarily remove the occlusive dressing to create a simple pneumothorax.
❑ Control blood loss (also remember to look under the patient to estimate loss), type and crossmatch blood, and replace blood and fluids as necessary.
❑ Prepare the patient for chest X-rays and placement of chest tubes (using water-seal drainage) to reestablish intrathoracic pressure and to drain blood in hemothorax. A second X-ray will evaluate the position of tubes and their functions.
❑ Emergency surgery may be needed to repair the damage caused by the wound.
Special considerations
❑ Throughout treatment, monitor central venous pressure and blood pressure to detect hypovolemia, and assess vital signs. Provide an analgesic, if needed. Tetanus and antibiotic prophylaxis may be necessary.
❑ Reassure the patient, especially if he has been the victim of a violent crime. Report the incident to the police in accordance with local laws. Help contact the patient’s family, and offer them reassurance as well.
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.
Other Book Chapters Related to Chest symptoms
Read excerpts from these other book chapters related to Chest symptoms:
Medical Books Excerpts
- CHEST PAIN
- "Algorithmic Diagnosis of Symptoms and Signs" (2003)
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- Chest pain
- "Handbook of Signs & Symptoms (Third Edition)" (2006)
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- Chest Pain
- "A Pocket Manual of Differential Diagnosis" (1999)
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- Chest pain
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Barrel chest
- "Professional Guide to Signs & Symptoms (Fifth Edition)" (2006)
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- Chest pain
- "Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series" (2007)
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- Chest pain
- "Signs & Symptoms: A 2-in-1 Reference for Nurses" (2007)
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- Chest Pain
- "The Diagnostic Approach to Symptoms and Signs in Pediatrics" (2006)
- [ read ]
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 expansion, asymmetrical (Alarming Signs and Symptoms: Lippincott Manual of Nursing Practice Series)
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