Chest Wall Injuries
Rib fractures: 50% of single rib fx missed on CXR. Main reason for considering rib fracture to assessing for other problems: hemopneumothorax, pulmonary contusion, intraabdominal injury. Main treatment is pain control. Usually break at point of impact or posterior angle/posterolateral due to weakest point of rib. Multiple rib fractures may need observation to assess pulmonary function in 1-2 days. Usually heal in 3-6 weeks.
NEXUS Chest CT Criteria for blunt trauma: Have to not have any of these to not need chest CT: abnormal CXR, rapid decal > 20 foot fall, MVC > 40mph, distracting painful injury, chest wall tenderness, sternal tenderness, thoracic spine tenderness, scapular tenderness. So basically every patient can’t be ruled out for chest CT.
Flail chest: free-floating segment of ribs.
Sternum fracture: usually body or manubrium. Very low incident of dysrythmias with mortality < 1%. If EKG and stable vital signs for 6 hours, no further cardiac workup.
Pulmonary Contusion: usually high speed MVC. Due to direct injury to lung parenchyma and secondary associated with resuscitation with edema/hemorrhage. CXR may show patchy ground glass opacities in mild/moderate contusion. 70% won’t be seen on initial CXR. Contusion > 20% of lung are up to 80% risk of developing acute lung injury. Main treatment is pain control to maintain ventilation. If intubated, place non-injured lung down by turning patient to decubitus position. Also high-frequency oscillating ventilation.
Pulmonary hematomas: usually dissolve, though can be infected.
Pneumothorax: If asymptomatic thoracic stab wound and has no pneumothorax, observe an repeat in 4-6 hours and if no pneumothorax, can discharge home. If patient needs intubation, air or long transportation, consider chest tube or small pleural catheter. If small pneumothorax < 1 cm width (confined to 1/3 chest), and unchanged at 4-6 hours and otherwise healthy, treat with observation. Ultrasound: M-mode over most superior portion of chest wall – look between ribs. “Seashore sign” is normal lung movement; “stratosphere sign” is abnormal sign or pneumothorax.
Chest tube placement: Anterior axillary line at level of nipple or infrmammory line in women (5th intercostal space). Oblique skin incision 1-2cm below interspace and go above rib to avoid nerve/artery. Oblique tunnel is to allow good closure of incision when tube removed preventing recurrent pneumothorax. Open rib 1.5-2cm, use finger when puncturing through on top of clamp and inspect to make sure lung isn’t attached to rib wall. If suspecting hemothorax, go large with 32-40Fr chest tube. Advance tube until 2.5-5cm past last hole in chest tube. Water suction at 20-30cm H20. If leaving ED, never clamp chest tube (can convert to tension pneumothorax). If unclamped, water seal bottle kept at 1-2 feet lower than patient’s chest. Chest tubes have been thought to may need prophylactic IV abx afterward.
Tension pneumothorax: clinical diagnosis with distended neck veins, hypotension/hypoperfusion, deviated trachea, decreased breath sounds. If suspected, immediate needle decompression with 14g need catheter into either midclavicular line above rib on 2nd intercostal space or laterally in same region as chest tube due to fall chest walls (study showing smaller depth on lateral aspect). ATLS will now recommend 5th IC space anterior axillary line over 2nd IC space in next edition (Laan, 2016) Need large bore chest tube after needle decompression.
Open pneumothorax: ‘sucking chest wound’ or even GSW. Do not pack (may have lung ‘inhale’ contents. Cover wound with 3-sided dressing so air can escape but cannot enter wound. Avoid complete occlusion which may cause tension pneumothorax.
Pneumomediastinum: look for Hamman sign: crunching sound over heart in diastole. Usually secondary to alveolar rupture with bronchioalveolar sheath dissection. Very often only require observation.
Rapid decel injuries. Occurs usually within 2cm of carina. Can cause hemoptysis, subcutaneous empysema, SOB. All lacerations of branch > 1/3 circumference will likely require surgical repair. Most usually require bronchoscopy.
Blunt trauma usually 3/4 left sided, 1/4 right sided. bowel can herniate and get strangulated/ischemia called a ‘tension enterothorax.’ Treatment always laparotomy.
Tintinalli, Seventh Edition, Chapter 258: Pulmonary Trauma
Rosens, Second Edition, Chapter 38: Thoracic Trauma
Reimagining your Approach to Tension PTX, Zag Qasim, AAEM 2017