Chest trauma

Tension Pneumothorax

• Clinical diagnosis
• Treatment precedes radiology in clear-cut or unstable cases
• Can occur in ventilated patients with a simple pneumothorax (undiagnosed or if no chest drain)
• Symptoms / signs:
  • Tracheal deviation away from affected side (not always easily identifiable)
  • Hypoxia
  • Decreased air entry/movement, hyper-resonance/expansion (affected side)
  • Tachycardia
  • Hypotension (late sign)

 Resuscitation

• Oxygen 15 L/min via nonrebreather mask
• Analgesia
• If patient is in cardiac arrest or peri-arrest: immediate needle decompression / needle thoracentesis (temporary measure). Refer to Appendix 1: Immediate Needle Decompression / Needle Thoracentesis Procedure for procedure details.
• For needle thoracostomy refer to Appendix 2: Needle Thoracostomy Procedure

 Open Pneumothorax

• Penetrating chest wall injury with associated open pneumothorax
• Sucking air through the pleural space rather than the trachea during respiration.
• Symptoms / signs:
  • Respiratory distress/failure
  • Decreased air entry and chest wall movement
  • Hyper-resonant to percussion
  • Chest wall wound - air might be heard passing through with respiration.

 Resuscitation

• Oxygen 15 L/min via nonrebreather mask.
• Analgesia
• In hospital
  • Small wound: cover with occlusive dressing.
  • Larger wound: suture/staple.
  • Immediate formal intercostal catheter placed away from wound.
• Out of hospital
  • 3-sided occlusive dressing (creating a one-way valve) – this is no longer recommended in a hospital setting.
  • Consider use of 3-sided occlusive dressing in the Pre-hospital settings where there is a delay or chest drain insertion is not possible
  • A bleeding or large wound could make this hard to apply
• An intercostal catheter should be placed away from wound when possible

 Massive Haemothorax

• A hemithorax can hold up to 40% of a child’s blood volume
• Symptoms / signs:
  • Signs of shock – tachycardia, hypotension, cold peripheries.
  • Respiratory failure reduced air entry, chest wall movement and dullness to percussion.

Indications for urgent thoracotomy:^{1, 5}

• Initial blood drainage >15-50 mL/kg of blood via chest drain.
• Continued bleeding > 2-3 mL/kg/hour continual.
• Significant residual haemothorax post-tube drainage.

 Resuscitation

• Oxygen 15 L/min via nonrebreather mask
• Analgesia
• Insert 2 wide bore intravenous cannulas and commence intravascular volume resuscitation.
• May require Critical Bleeding and Rotem algorithm.
• Chest Drain Management
• Intercostal Catheter and Needle Thoracentesis
• Request urgent surgical review for possible thoracostomy if ongoing haemorrhage and ongoing haemodynamic instability despite critical major haemorrhage protocol.

 Flail Chest (chest wall instability or deformity)

• Paradoxical movement – the flail segment collapses with inspiration and bulge with expiration while the rest of the chest wall moves in the opposite way.
• Symptoms / signs:
  • Respiratory distress.
  • Possible decreased air entry due to associated pulmonary contusion and splinting.
  • Possible subcutaneous emphysema.⁷

 Resuscitation

• Oxygen 15 L/min via nonrebreather mask.
• Analgesia
• Stabilisation of flail segment – may be placed injured side down.
  • Positive pressure ventilation.
  • Improve ventilation.
  • Intubation may be necessary to help with analgesic demands.
• Referral to Cardiothoracic surgeons for consideration of rib fixation.

 Cardiac Tamponade

• Bleeding into the pericardium secondary to blunt or penetrating injury
• Blood may originate from cardiac chamber, a great vessel or from the myocardium in the presence of a myocardial contusion
• This results in decreased filling of the heart and thus reduced stroke volume and shock

Symptoms /signs

• Respiratory distress
• Hypotension
• Narrow pulse pressure
• Distended neck veins
• Soft heart sounds
• Refractory shock

Investigations

• Electrocardiogram (ECG) – generally small complexes.
• Bedside ultrasound/eFAST for confirmation if patient is stable and an accredited clinician is available.

Cardiac arrest due to suspected traumatic cardiac tamponade: treat as per Traumatic Cardiac Arrest Guideline

 Resuscitation

• Oxygen 15 L/min via nonrebreather mask
• ECG + ECG monitoring
• Fluid resuscitation (increase preload and minimise right ventricular collapse)
• Gold standard: Open surgical drainage in theatre

In severe shock / no surgical facilities available:

• Needle pericardiocentesis as a temporising measure.
• A long needle inserted at a left sub-xiphoid position, directed posteriorly at a 45° angle and towards the left shoulder.
• Best performed under ultrasound guidance where skills and equipment permit.

 Chest wall / Pulmonary 

 Rib Fractures

Rib fractures may be a marker of potential severe underlying injuries, especially if multiple or 1st rib fractures.

• Flail chest injuries are rare in children.
• Rib fractures in 0- to 3-year-old: consider non-accidental injury
  
  

 Management

• Analgesia

Oxygen supplementation in severe cases

 Simple Pneumothorax

• Clinical signs: possible spectrum from no symptoms to decrease air entry and hyper resonance.
• Chest X-Ray: small pneumothorax may not be visible. Suspect if: increased radiolucency, deep sulcus sign.
  
  

 Management

• Intercostal Catheter
• Chest Drain Management
• Pigtail catheter as effective as above in simple pneumothorax with reduced pain.

 Pulmonary Contusion

• Can occur in the absence of rib fractures or other external signs.
• Chest X-Ray: increased pulmonary opacity, changes may evolve over time.
• CT scan: may reveal contusion not evident on initial Chest X-Ray

 Management

• Oxygen Supplementation
• May require non-invasive or invasive ventilation.
• Analgesia
• Avoid excessive IV fluids.
  
  

 Pulmonary Lacerations

• Penetrating injuries or associated with rib fractures.
• Cause haemothorax or pneumothorax and rarely, air embolism

 Management

• Oxygen supplementation
• Management of concurrent injury
• Cardiothoracic surgical consultation

 Tracheobronchial Injury

• Uncommon
• Clinical signs: subcutaneous emphysema, tension pneumothorax, haemoptysis, ongoing air leak
• Failure of lung expansion on chest X-Ray

 Management

• Cardiothoracic surgical consultation
• Consider second intercostal catheter

 Mediastinal injury

• Most are rapidly fatal at the scene.
• Suspect based on mechanism of injury, physical signs (often absent) and chest X-Ray findings.

Chest X-Ray signs of aortic injury

• Widened mediastinum (mediastinum to chest radio >0.25)
• Loss or abnormal contour of aortic knob
• Depression of left mainstem bronchus
• Deviation of the trachea to the right
• Deviation of the oesophagus, nasogastric or orogastric tube to the right
• Left pleural cap.
• Left haemothorax
• Upper rib fractures

 Management

• CT, angiography, aortogram or transoesophageal echocardiography
• Urgent cardiothoracic surgical referral

 Cardiac Injuries

• Uncommon
• Pericardial tamponade / Myocardial contusion
• Tachycardia
• Elevation of jugular vein pressure (distended neck veins)
• Hypotension
• Arrest with pulseless electrical activity.

 Management

• ECG
• Electrocardiography (echo)
• Urgent cardiothoracic surgical involvement
• Pericardiocentesis in arrested or unstable patient.

 Oesophageal Trauma

• In penetrating trauma – high index of suspicion.
• Chest X-Ray – mediastinal air (early clue).
• With time (hours), an evolving sepsis with pleural effusion (usually left-sided) and mediastinitis ensue.

 Management

• Gastrograffin study, Oesophagoscopy or both.
• Broad-spectrum antibiotics and urgent surgical review.
  
  

 Diaphragmatic rupture

• Rare blunt injury
• More acknowledged now with penetrating injuries as occult injuries.
• Clinical signs: hypoxia.
• Chest X-Ray: show signs of herniated stomach or bowel.
• Laparotomy can confirm diagnosis.

 Management

• CT scan – may miss small tears whilst magnetic resonance imaging has greater accuracy.
• Suspect occult diaphragmatic lacerations in penetrating trauma.
• Laparoscopy or thoracoscopy.