Following head trauma and spinal trauma, chest trauma is the third commonest cause of death due to trauma. It is responsible for about 20 percent of all deaths in the US and is a major factor when it comes to death from other causes about 50 percent of the time.What is Chest Trauma?
Chest trauma causes a great many cases of morbidity and mortality in the US. Chest trauma can be blunt chest trauma from, say, a car accident. It can also be from penetrating trauma from a knife or a gunshot injury. Blunt force trauma can affect the bony skeleton such as the ribs, the sternum, the clavicles and the scapulae. It can also affect the lungs and the tracheobronchial tree, the heart, the esophagus and the great vessels of the chest.
Trauma alone is the leading cause of death from age 1 year to about age 45 years. There are more than 100,000 cases of accidental death in the US. Thoracic injuries occur in about 12 persons per million per day and about a third of these injuries need a hospital admission. Blunt trauma to the chest accounts for a quarter of all these injuries.
The pathophysiology involved in blunt force trauma to the chest involves some kind of damage to the flow of blood, the flow of air, or both functions. Sepsis can happen when there is an esophageal perforation, leading to leakage of food contents into the bloodstream.
Many cases of blunt trauma lead to rib fractures. Rib fragments can puncture a portion of the lung and it can make it too painful to breathe properly. The traumatic injury can impact the lungs and can cause pulmonary contusions. The presence of pulmonary contusions means that the lung capacity is diminished.
The heart or major vessels can be damaged, causing hemorrhaging and resulting in a decrease in cardiac output. If severe, it can lead to death.
Penetrating injuries can be low velocity, medium velocity or high velocity. Low velocity injuries include knife wounds that only disrupt the areas in contact with the instrument. Medium velocity wounds come from handguns and air-powered pellet guns. They have a moderate amount of tissue destruction. High velocity weapons like rifles and military weapons do the most damage. Trauma related to the latest combat battles over the last 20 years has been 40 percent penetrating chest trauma injuries.Symptoms of Chest Trauma
Symptoms of chest trauma can be roughly the same, regardless of whether the trauma was blunt force or penetrating. These symptoms include:
- Difficulty breathing
- Hypotension from blood loss
- Failure of the lungs to expand properly
- Crunching sounds when palpating the rib cage
- Bruising of the chest wall
- Coughing up blood
- Flail chest, when a section of the chest wall sucks in when the patient is inhaling
- Puncture wound to the chest that sucks air
Chest trauma has several causes, usually related to high forces. For example:
- Motor vehicle accidents account for up to 70 percent of blunt force chest trauma
- Motorcycle accidents
- ATV accidents
- Falls from a great height
- Sports-related injuries
- Gunshot wounds
- Knife injuries
- Combat blast injuries
The vast majority of chest injuries are related to motor vehicle, motorcycle and ATV trauma. This is why it is important to get EMS on the scene to these types of accidents because chest trauma can often be managed if managed correctly.Diagnosis of Chest Injuries
In some cases, plain film x-ray is all that is needed to show chest trauma. This test, using a PA and Lateral view, can show rib fractures, sternal fractures, clavicle fractures and sternal fractures. It can also show if the lung has collapsed or partially collapsed and can tell if any metallic foreign bodies reside in the chest cavity.
Sometimes more needs to be looked at. The doctor orders the giving of IV contrast dye to show the contours of the arteries and veins. Then an x-ray machine attached to a computer is used to give cross-sectional images of the chest cavity, including the lungs, bones, and heart. It is a good test to look for areas of bleeding or for damage to the heart and great vessels.
In some cases, an MRI examination is done. MRI machines are particularly good at picking up soft tissue injuries, even without contrast. They give cross-sectional images just like CT scanners but receive their images using a strong magnet and radio waves.
The various imaging techniques are looking for broken bones, collapsed lungs, foreign bodies, bleeding outside the heart (a pericardial hemorrhage), and for the structure of the major vessels of the chest cavity.Treatment of Chest Injuries
The treatment of chest injuries begins in the field because rapid treatment at the scene of the accident can save lives. Here are the treatment techniques and pearls to consider:
- If there is an object in the chest, such as a knife, it should not be removed. Doing so could cause external or internal hemorrhage.
- An airtight plastic or metallic dressing should be placed over any hole that goes into part of the chest activity.
- The injured person needs to be positioned with the injured side facing down. This pool the blood in an area already injured.
- The injured person should be given pure oxygen to breathe. This helps in cases of blood loss or ventilator dysfunction.
- The neck and back of the patient should be immobilized as soon as possible to avoid dislocating any possible fractures of the c-spine, t-spine or l-spine.
- CPR may be indicated if the patient is not breathing adequately or has no pulse or blood pressure.
Internal chest trauma requires emergency evacuation for x-rays and definitive treatment. The ABCs of trauma therapy always apply as the patient is being transported and when they are in the hospital.
The emergency department will need to treat rib fractures. The first and second ribs are the most dangerous as they can cause large vessel damage to the vessels that travel from the chest to the arms. Fractures are painful on deep breathing and, as long as they are not causing a pulmonary laceration, they can be kept as still as possible until they heal.
If a rib is fractured in two or more places and is accompanied by nearby ribs also fractured in two or more places, you get a flail chest. This involves a paradoxical collapse inward of the section of chest wall not connected to any other part of the body through bony connections. When the patient inhales, the flail chest part of the chest sucks inward paradoxically. It often involves having a pulmonary contusion underneath. It needs to be stabilized by binding the segment and having the patient lie on the affected side with padding applied.
If there is a sudden force on the chest as seen on high speed collisions, falls from great heights or being pinned under a rock, there is a sudden increase in the pressure in the chest. Blood won’t move properly through the heart and the patient may be cyanotic. In such a case, elevate the head of the bed to 30 degrees to reduce the excess pressure to the head. Supplemental oxygen is necessary until surgery can be done to fix the damaged heart.
In a pulmonary contusion, the lung tissue is damaged and the alveoli become blood filled and lung oxygen exchange is blocked. It is commonly seen in flail chest conditions and is treated by watchful waiting.
A pericardial tamponade, blood fills up the pericardial space. It prevents the heart from expanding completely as it pumps. The pulses become diminished and the pulse pressure will become less. The treatment is to insert a needle into the pericardial space and draw out the excess blood.
There is a condition called commotio cordis, in which a healthy person goes into sudden cardiac arrest from ventricular fibrillation. It is caused by a sudden force striking the middle of the chest. It has to happen at the right moment during the heart beat to cause it. It is best treated with CPR and defibrillation.
If you or a loved one has suffered chest trauma as a result of someone else's negligence and would like to discuss your legal options with an experienced Sacramento Personal Injury Attorney, contact us online or call us at 916.921.6400 to set up a FREE consultation.