Chest Injury

PENETRATING INJURY

Common objects causing injury are knives, arrows, spears,and bullets.The objective of the management is to restore normal anatomy or physiology resulting from the stab injury.

 

Investigations

1. For the majority of cases, the chest radiograph alone is adequate.
2. Specialized investigations are ordered where more detail is required.

Management

1. Clean wounds and apply clean dressing to wounds. Tetanus toxoid 0.5 ml STAT.
2. Make sure resuscitation measures continue during transportation.
3. If the instrument used during stabbing is still in situ, DO NOT remove.Advisable this one removed only in a controlled setting like in theatre. For referral, stabilize this by surrounding with heavy dressing or other cloth like material.
4. If available, insert chest tube.Drain pleural collections using chest tube, which will suffice for most injuries. Conduct surgical intervention to stop bleeding that continues, or correct significant anatomical or physiological anomalies.NB: (This is applicable for only about 5%of cases).

SIMPLE RIB FRACTURES

This is a break in the continuity of a rib(s). Could be traumatic or pathological.Types of fractures can be crack fracture(s), single or multiple fractures with fragment displacement,and segmental fracture(s).

Clinical Features

1. There is a history of trauma. Pain on breathing or movement. Evidence of chest trauma. Crepitus at the fracture site or tenderness. May have signs of associated haemo-pneumothorax, subcutaneous emphysema.
2. Caution: The chest injury may be associated with splenic or liver injury especially with higher and lower rib fractures.

Investigations

1. Physical examination
2. Chest radiograph;oblique views may be necessary.

Management

1. Oxygen: Supplementation if signs of respiratory distress are present.
2. Analgesia: Administer pethidine and 2%lidocaine 2-5ml directly into fracture site;repeat once daily or after 3 days.
3. Chest drainage: Insert tube as indicated. Admit the patient for observation if fractures of the first rib and those of the 8th rib and below are present.
4. Antibiotics:Give flucloxacillin 500mg QDS. For children less than 2 years give a quarter adult dose;for older children, half adult dose. Antibiotics given because of the associated atelectasis. Mucolytic drugs, e.g.,carbocisteine 750mg TDS for adults;children 2-5 years 62.5-125mg QID, while 6-12 years 250mg TDS.
5. Manage associated conditions.
6. Initiate chest physiotherapy.

FLAIL CHEST

 

This occurs when multiple fractures are sustained with more than one site per rib. The main danger is that the patient may lapse into respiratory failure.

Clinical Features

The features include the following:

1. Chest pain
2. Paradoxical chest movement
3. Dyspnoea may be present
4. Evidence of fractured ribs
5. Haemothorax and pneumothorax or both

Investigations

• Chest radiograph

Management

1. Splint flail segment.
2. Administer analgesia. Make sure no neurological deficit is present.
3. Restrict fluids to avoid development of adult respiratory distress syndrome.
4. Observe for respiratory failure: If it develops, transfer the patient to ICU. If no respiratory failure results, continue with conservative management in general wards.
5. At referral center if referred to ICU: Cary out intubation with positive end expiratory pressure(PEEP)applied.
6. Best facility to refer: Best managed at level 5 and above where possible use of ICU will be available.

 

PNEUMOTHORAX

This occurs when air enters the pleural space, causing lung collapse on the affected side. Causes include spontaneous development following staphylococcal pneumonia due to chronic obstructive pulmonary disease. Pneumothorax may also be caused by blunt trauma with rib fractures and or lung contusion,penetrating injuries, stab wounds, and missiles.

Clinical Features

There is shortness of breath, tightness of the affected chest, tachypnoea, and tachycardia. Sweating and Cyanosis may be present. Reduced chest excursion also occurs, with reduced air entry on auscultation. Hyper-resonant chest is noted on percussion.

Investigations

Chest radiograph: Shows various degrees of lung collapse.

Management

1. If more than 5% pneumothorax, institute tube thoracostomy drainage(underwater seal drainage); IMPORTANT: maintain absolute sterility while performing this procedure.
2. Chest tube may be removed when the lung is fully expanded and remains fully expanded after test clamping the test tube for a number of hours.
3. Tension pneumothorax needs more rapid treatment with immediate insertion of a wide bore cannula drainage or underwater seal drainage under local anaesthesia.

 

Nota Bene:Tension pneumothorax is a clinical diagnosis and not a radiological diagnosis. Ordering a chest radiograph may result in patient death before active treatment can be implemented.

 

1. An associated flail chest leads to paradoxical breathing and may require assisted ventilation (i.e., intermittent positive pressure ventilation),if features of respiratory failure develop.

 

HAEMOTHORAX

This occurs when blood collects in the pleural space. Haemothorax may vary in amount from small to massive collections. Causes include trauma, post surgical bleeding, and tumours of the chest cavity and chest wall.

Clinical Features

Depending on the magnitude of the blood collection, there could be hypovolemic  shock for massive bleeding, or symptoms similar to those associated with pneumothorax, except for the percussion note, which is dull for haemothorax. However,haemopneomothorax is the more common presentation following chest trauma.

Investigation

1. Chest radiograph
2. Erect posteroanterior view and lateral
3. Look for fractured ribs,collapsed lung(s), fluid collection in the pleural space(air-fluid level),position of mediasternum,and diaphragm.
4. Specialized tests as needed.
5. Other tests relevant to the primary underlying cause of haemothorax.

Management

1. Resuscitation if needed
2. Small heamothorax(blunting of the costophrenic angle), will resolve spontaneously. Conservative management with daily reviews.
3. Largetyhaemothorax will require underwater seal drainage.
4. Physiotherapy as needed.
5. For large clotted haemothorax, perform thoracotomy to drain clot or refer to a more specialized unit.
6. Look at the primary problem

• For a fracture of rib, inject 2% lidocaine about 2-5 ml intercostal block.
• Advanced  malignant disease, coagulopathy, etc., will need to be appropriately managed.