Emergency Medicine - Chest Injuries: By Ramesh Reddy M.D.
When a patient arrives with traumatic injuries to the chest, you must be vigilant. Life threatening injuries are quite possible. Always assume the worst. The chest can be injured with blunt force, penetrating force, or both. Here are four specific injuries that you cannot afford to miss.
1 – Pneumothorax A pneumothorax is air in the pleural space – the space defined by the pleura that covers the organs of the chest, including lungs and reflects back to line the underside of the chest wall. Think of this condition in someone who has had either blunt or penetrating trauma to the chest. Subcutaneous emphysema – or air under the skin, reduced breath sounds, and respiratory distress are signs and symptoms associated with this condition.
A tension pneumothorax is a particularly important type of pneumothorax to identify. There is so much air in the pleural space that the mediastinum is pushed over and it impedes venous return. This causes shock. You must identify this condition.
The signs of a regular pneumothorax will be present but the patient will be hypotensive and you may see tracheal deviation away from the side of the pneumothorax. Chest x-ray or CT scanning can confirm the diagnosis of a pneumothorax. In most cases, a chest tube will be required to drain the air out of the pleural space. If you think the patient has a tension pneumothorax, then you must decompress the air immediately, usually by placing a small needle angiocatheter in the pleural space.
This should be done before the chest radiograph is done. 2 – Hemothorax A hemothorax is blood in the pleural space. This blood can come from the chest wall or the lung tissue itself. A hemothorax can be caused by blunt or penetrating trauma to the chest. You must suspect this condition when there is respiratory distress, shock, or reduced breath sounds. Chest X-ray or CT Scanning can confirm this diagnosis as well.
Like pneumothorax, a hemothorax will generally require a chest tube to drain the blood out of the pleural space. 3 – Flail Chest A flail chest is a result of blunt trauma to the chest. A flail chest is a section of the chest wall that is moving independently of the rest of the thoracic cage. This happens when there are multiple adjacent ribs that are broken in multiple places. Think of this when you see paradoxical motion. Paradoxical motion of the chest is when a section of the chest moves in the opposite direction as the majority of the chest wall on inspiration and expiration. So as one inspires and expands the ribcage the flail segment is paradoxically drawn in further. In addition to paradoxical movement, the patient will have chest pain and some degree of respiratory distress.
There is usually an underlying pulmonary contusion. Treatment of this condition is usually positive pressure ventilation. 4 – Hemopericardium A patient can rapidly die from this condition. Think of this in penetrating trauma to the anterior chest. Blood is leaking from a hole in the heart wall and accumulating in the closed pericardial space.
The patient may experience signs of hemodynamic failure – with a rapid loss of blood pressure, a rise in heartbeat, and loss of consciousness. Diagnosis should be made by bedside echocardiography. The blood will need to be released and the hole repaired in the operating room.
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