Chest injury as part of major trauma, can range from painful to life threatening so prompt treatment and recognition is vital. Esp. in ‘Silver Trauma’ when ‘minor’ injuries may have devastating consequences – the full guidance can be found @WYMTN – HERE
Initial Management
- High flow oxygen
- Drainage? – of any associated pneumothorax or haemothorax, if indicated.
- Assessment by the anaesthetist present at the trauma call regarding need for mechanical ventilation.
- Fluid resuscitation
- Resuscitate with blood products if hypotensive due to haemorrhage.
- Consider risks and benefits of permissive hypotension as part of damage control resuscitation.
- Balance against risk of fluid overload and development of ARDS in a lung with contusions.
- Early, good quality pain relief
- Paracetamol
- NSAIDs (if no contra-indication)
- IV morphine and/or IV ketamine
- Regional anaesthetic techniques
- Consider discussing chest trauma with thoracic surgeons if any of the following are present:
- Any case that may require surgical intervention to the chest
- Pneumomediastinum
- Subcutaneous emphysema
- Significant symptom burden
- Failure of pain control
- Inability to cough effectively / clear pulmonary secretions
- Ventilatory compromise
NOTES:
- These are relative indications and not absolute, particularly in the case of subcutaneous emphysema)
- CT scan of the chest should generally be obtained prior to referral and should be strongly considered in any patient requiring admission because of chest wall injuries.
Severity
- Minor: general managed at TU (i.e. local)
- < 4 rib fractures
- Lung contusions without an oxygen requirement or < 40% oxygen requirement
- Small haemothorax (< 500 ml from ICD)
- Pneumothorax +/- ICD
- Moderate: generally requires transfer to MTC
- First & Second rib fractures
- B/L rib fractures (> 3 rib fractures on each side)
- Moderate haemothorax (1L of blood from ICD)
- Lung contusions with > 40% oxygen requirement
- Persistent chest wall pain despite analgesia as per WYMTN guideline recommendations
- Pneumomediastinum with concerns of a possible tracheobronchial or oesophageal injury
- Severe: generally requires transfer to MTC
- Deformity of chest wall/ thoracic cavity
- Flail chest (radiological flail segment with paradoxical chest wall movements on clinical examination)
- Persistent air leak at 48 hours
- Massive haemothorax (> 1.5L of blood from ICD)
- Rib 1-2 fractures with underlying vascular injury
- Lung contusions with progressive respiratory failure requiring ventilation.
- Sternal fracture with a mediastinal haematoma and abnormal ECG suggestive of potential mediastinal vessel injury or cardiac contusion.
