Chest Trauma

Chest Trauma: Initial Rx - Life Savers First

• Primary Survey (ABCDE): Address life threats.
  • Airway & C-Spine: Ensure patency, protect spine.
  • Breathing: Address lethal six! (📌 ATOM-FC: Airway obstruction, Tension pneumo, Open pneumo, Massive hemo, Flail chest, Cardiac tamponade)
    • Tension Pneumothorax: Needle decompress (2nd ICS MCL / 5th ICS AAL) → chest tube.
    • Open Pneumothorax: Three-sided occlusive dressing.
    • Massive Hemothorax: Chest tube. >1500mL initial / >200mL/hr (2-4h) → Thoracotomy.
    • Flail Chest: Paradoxical motion. Analgesia, O2; PPV if resp. failure.
    • Cardiac Tamponade: Beck's triad (↓BP, ↑JVP, muffled sounds). Pericardiocentesis.
  • Circulation: 2 large IVs, fluids; control hemorrhage.
  • Disability: GCS, pupils.
  • Exposure & Environment: Prevent hypothermia.

⭐ In tension pneumothorax, immediate needle decompression is life-saving before chest X-ray. Preferred site: 5th ICS AAL.

Pleural Space Invaders - Air & Blood Battles

Pneumothorax (Air)

• Types: Simple; Tension (mediastinal shift, ↓CO ⚠️); Open (sucking wound).
• Dx: ↓BS, hyperresonant. CXR: pleural line, no lung marks. Tension: mediastinal shift. eFAST: no lung slide.
• Rx:
  • Tension: Needle decompress (14G, 2nd ICS MCL / 5th ICS MAL) → ICD.
  • Open: 3-sided dressing → ICD.
  • Other: ICD (5th ICS, Triangle of Safety). Small: observe.

Hemothorax (Blood)

• Dx: ↓BS, dull. CXR: blunted CPA (>200mL), opacity.
• Rx:
  • ICD (28-32F) drainage.
  • Thoracotomy indications:

    ⭐ Initial drain >1500mL; OR >200mL/hr x 2-4hr; OR persistent shock.

  • Retained clot (>300-500mL): VATS/Thoracotomy.

Chest Wall & Cardiac Hits - Beat & Breathe Blues

• Rib Fractures: Common. Pain → splinting → atelectasis/pneumonia.
  • Ribs 1-2: Suspect major vascular/bronchial injury.
  • Ribs 9-11: Suspect diaphragmatic/hepatic/splenic injury.
• Flail Chest: ≥3 consecutive ribs fractured in ≥2 places. Paradoxical motion. Underlying pulmonary contusion is key.
  • Rx: Pain control, O2, PPV if respiratory failure.
• Sternal Fracture: High energy. Screen for myocardial contusion, aortic injury.
• Pulmonary Contusion: Lung bruising. Hypoxia. CXR: infiltrates. Worsens 24-48 hrs.
  • Rx: Supportive, O2, PEEP.
• Myocardial Contusion (BCI): ECG (arrhythmias, ST changes), ↑Troponin. Echo.
  • Rx: Monitor, supportive.
• Cardiac Tamponade: Beck's Triad (📌 3 D's: Decreased BP, Distant heart sounds, Distended neck veins). Pulsus paradoxus >10 mmHg.
  • Dx: FAST/Echo. Rx: Pericardiocentesis.

  ⭐ Electrical alternans on ECG is specific for large pericardial effusion/tamponade.

• Commotio Cordis: Sudden V-fib from chest blow. Structurally normal heart. Rx: Defibrillation.

Deep Thoracic Threats - Great Vessel & Pipe Perils

• Traumatic Aortic Rupture (TAR)
  • Mechanism: Deceleration (MVA, fall).
  • Site: Aortic isthmus (most common).
  • CXR: Widened mediastinum (>8 cm), left hemothorax.
  • Dx: CTA gold standard. TEE if unstable.
  • Rx: BP control (SBP 100-120 mmHg), TEVAR/open surgery.
  • ⭐ > Most common site of traumatic aortic rupture is the aortic isthmus.
• Other Great Vessel Injuries (SVC, IVC, Pulmonary vessels)
  • High mortality; often penetrating.
  • Dx: CTA. Rx: Surgical repair.
• Tracheobronchial Injury (TBI)
  • Site: Usually within 2.5 cm of carina.
  • Signs: Subcutaneous emphysema, persistent air leak, Hamman's sign, hemoptysis.
  • Dx: Bronchoscopy (gold standard).
  • Rx: Secure airway, surgical repair.
• Esophageal Perforation
  • Causes: Penetrating, Boerhaave's, iatrogenic.
  • Signs: Severe chest pain, Mackler's triad (Boerhaave's). Left pleural effusion common.
  • Dx: Contrast esophagogram (Gastrografin then barium), CT.
  • Rx: NPO, IV antibiotics, surgical repair.

High‑Yield Points - ⚡ Biggest Takeaways

• Tension pneumothorax: immediate needle decompression, then chest tube.
• Massive hemothorax: >1500 mL or >200 mL/hr drainage; requires thoracotomy.
• Flail chest: ≥3 ribs fractured in ≥2 places; paradoxical breathing.
• Cardiac tamponade (Beck's triad): hypotension, JVD, muffled heart sounds; needs pericardiocentesis.
• Aortic rupture: common at ligamentum arteriosum; widened mediastinum on CXR.
• Open pneumothorax: sucking chest wound; manage with three-sided occlusive dressing.
• Tracheobronchial injury: suspect with persistent pneumothorax, subcutaneous emphysema, hemoptysis.