1. Rib fracture
1.1. Therapeutic intervention
1.1.1. For simple fracture
1.1.1.1. Rest, Apply ice intermittently for the first 24 hours (to decrease swelling)
1.1.1.2. Administer systemic analgesics or regional anesthesia
1.1.1.3. Apply heat after the first 24 hours ( to promote blood flow and healing)
1.1.2. Pain that increases with inspiration
1.2. Assessment of rib fractures
1.2.1. Point tenderness (the patient can identify the site of pain precisely)
1.2.2. Assess palpable deformity ( step-off defect) if the fracture is displaced
1.2.3. Ecchymosis or abrasions at the site of injury
1.2.4. Splinting of the chest muscles ( to reduce chest wall movement)
1.2.5. Subcutaneous emphysema ( if there is associated lung or tracheobronchial injury)
1.2.6. Bony crepitus ( palpable bone motion) at the fracture site
1.3. For displaced fractures in the elderly
1.3.1. Hospital admission
1.3.2. Regional anesthesia for severe pain , intercostal nerve blocks
1.3.3. Epidural analgesia
1.3.4. Incentives spirometer
1.3.5. Close monitoring of respiratory status
2. Flail chest
2.1. Causes
2.1.1. Most commonly from crush injury
2.2. Assessment of flail chest
2.2.1. Severe chest pain
2.2.2. Difficult breathing
2.2.3. Tachypnea, shallow breathing
2.2.4. Hypoxemia " skin color , oxygen saturation , ABG "
2.2.5. Paradoxical chest movement may be masked by splinting created by chest wall muscle spasms
2.2.6. Crepitus
2.3. Management of flail chest
2.3.1. Continuous positive airway pressure (CPAP) may be indicated for some patients
2.3.2. High flow oxygen using reservoir mask
2.3.3. Adequate pain control : the method of choice is an intercostal nerve block
3. Pneumothorax
3.1. Classification of pneumothorax
3.1.1. Open pneumothorax
3.1.2. Simple/ closed
3.1.3. Tension pneumothorax
3.2. Causes
3.2.1. Open pneumothorax
3.2.1.1. Penetrating injury
3.2.2. Simple/ closed
3.2.2.1. Occurs spontaneously as a result of chest trauma
3.2.3. Tension pneumothorax
3.2.3.1. It result from blunt or penetrating trauma
3.2.3.2. Complications of simple pneumothorax
3.2.3.3. Mechanical ventilation
3.3. Immediate management
3.3.1. Management of tension pneumothorax
3.3.1.1. Remove tension by needle thoracentesis at the second intercostal space mid clavicular line or chest drain insertion at the fifth intercostal space
3.3.1.2. Maintain oxygenation by high flow oxygen mask
3.3.2. Management of open pneumothorax
3.3.2.1. High flow oxygen using reservoir mask and mechanical ventilation
3.3.2.2. Sterile ecclusive wound dressing tapped down on three sides to create flutter valve
3.3.2.3. Establish first IV access
3.3.2.4. Insert chest drain through a surgically created hole
3.3.2.5. Stabilize an impaled object in place until removal in OR because removal may cause respiratory compromise and circulatory collapse
3.3.2.6. Prophylactic antibiotics and anti-tetanus
3.3.2.7. Prepare for surgical closure of wounds and removal of impaled object
3.4. Assessment
3.4.1. Assessment of open pneumothorax
3.4.1.1. Mechanism of injury
3.4.1.2. Penetrating object
3.4.1.3. Tachypnea, decreased or absent air entry at the affected side
3.4.1.4. Audible suction sound during spontaneous inspiration
3.4.1.5. Bubbles around the wound
3.4.1.6. Tachycardia and hypotension
3.4.2. Assessment of tension pneumothorax
3.4.2.1. Diminished air entry at the affected side
3.4.2.2. Hyper resonance
3.4.2.3. Tracheal deviation to the unaffected side, cyanosis
3.4.2.4. Distended neck vein if patient is not hypovolemic
3.4.2.5. Tachycardia, tachypnea,shock
3.4.2.6. If patient conscious
3.4.2.6.1. Very distressed, very rapid worsening dyspnea, hypoxia manifested by confusion, agitation, restlessness
4. Massive haemothorax
4.1. Causes
4.1.1. Penetrating or blunt trauma to the intercostal vessel internal mammary artery
4.2. Assessment of massive haemothorax
4.2.1. Tachypnea, hypovolemic shock, and diminished or absent breath sound on the affected side
4.2.2. The JVP may be elevated as a result of pressure accumulated blood, other associated injuries
4.2.3. On percussion there will be dullness
4.2.4. The neck veins may be collapsed as result of hypovolemia
4.3. Immediate management of massive haemothorax
4.3.1. High flow oxygen using reservoir mask
4.3.2. Simultaneous restoration of blood volume and decompression of the chest cavity
4.3.3. Prepare thoracotomy if immediate drainage was 1500 ml or if drainage was 200 ml/ hour for 2 to 4 hours
4.3.4. Insert chest drain using blunt dissection so that herniated abdominal organs can be palpated by fingers before chest drain insertion
5. Cardiac tamponad
5.1. Causes
5.1.1. It result from penetrating injury primarily stab wound to the chest or upper abdomen
5.2. Assessment of cardiac tamponade
5.2.1. Assess the mechanism of injury
5.2.2. Shock and falling arterial pressure
5.2.3. Increase venous pressure which can be assessed by venous distension but absent of venous distension does not exclude cardiac tamponade
5.2.4. Kussmaul's sign is a paradoxical increase in JVP on inspiration
5.2.5. Air hunger, agitation, Altered LOC , ECG change& ST segment elevation
5.2.6. Beck's triad
5.2.6.1. Decreased muffled heart sound due to fluid in pericardial cavity
5.2.6.2. Raised CVP due to impaired venous return because of cardiac compression
5.2.6.3. Hypotension because of poor cardiac output
5.3. Immediate management of cardiac tamponade
5.3.1. • pericardiocentesis
5.3.1.1. High flow oxygen using reservoir mask
5.3.1.2. Blunt trauma if the heart and vessels have been damaged
5.3.1.3. Continuous cardiac monitoring is essential during the procedure if aspirate contains blood clot
5.3.1.4. Prepare for urgent exploration
5.3.1.5. Circulatory resuscitation to correct hypovolemia
6. Airway& breathing
6.1. Initiate or maintain spinal immobilization
6.2. Assess and secure airway
6.2.1. Chest response
6.2.2. Look for chest movement and listen to breathe sound over 10 seconds
6.3. Indicators of airway obstruction
6.3.1. Apnea, tachypnea,increase respiratory effort,intercostal retraction
6.3.2. Use accessory muscles, noisy respiration, pallor, and cyanosis
6.4. Prepare for pericardiocentesis and thoracotomy
6.5. If airway is compromised
6.5.1. Head tilt chin lift or jaw thrust
6.5.2. Cover wound
6.5.3. Insert airway and start ventilation
6.5.4. Needle thoracotomy
6.5.5. Insert chest tube
7. Manifestations indecating chest trauma
7.1. Palpation
7.1.1. Crepitus
7.1.2. Pulsation, apex beat
7.1.3. Subcutaneous emphysema
7.1.4. Tracheal deviation
7.1.5. Swelling, and pain
7.1.6. Masses
7.2. Percussion
7.2.1. Hyper resonance
7.2.2. Resonant sound
7.2.3. Dullness
7.3. Inspection
7.3.1. Rate,rhythm,depth,respiration
7.3.2. Paradoxical chest movement
7.3.3. Use accessory muscles
7.3.4. Wound, bruises, surface trauma
7.3.5. Jugular vein pressure
7.3.6. Intercostal retraction
7.3.7. A symmetry of chest movement
7.4. Auscultation
7.4.1. Breathe sound
7.4.2. Heart sound
7.4.3. Bowel sound in chest
8. Classification of chest trauma
8.1. Mechanism of injury
8.1.1. Blunt thoracic injury (large area)
8.1.2. Penetrating thoracic trauma(small area)
8.2. Sites of injury
8.2.1. Diaphragmatic injury
8.2.2. Skeletal injury
8.2.3. Heart and great vessel injury
8.2.4. Pulmonary injury
8.3. Injury pattern
8.3.1. Open injury
8.3.2. Close injury
9. Assessment of chest injury
9.1. Primary survey
9.1.1. Identify and treat immediate life threatening conditions
9.1.1.1. Tensions pneumothorax
9.1.1.2. Open pneumothorax
9.1.1.3. Massive heamothorax
9.1.1.4. Flail chest
9.1.1.5. Cardiac tamponade
9.2. Secondary survey
9.2.1. Carried out to identify other injuries
9.3. Ongoing assessment
9.3.1. Ultrasound, Echo, CBC , CKMB
9.3.2. LOC , blood pressure, pulse, urinary output and pain
9.3.3. RR, depth,PO2,chest wall movement
9.3.4. Cardiac monitoring, ECG, ABG , X-ray
10. Intial management of chest injury
10.1. Circulation
10.1.1. Obtain a minimum of 2 IV lines
10.1.2. Assess circulation "Responsiveness, pulse, skin color, skin temperature,capillary refill Time,bleeding"
10.1.3. Send for blood group & cross match
10.1.4. Administer blood
10.2. Disability
10.2.1. Assess LOC , pupils size, retraction
10.3. Exposure and environmental control
10.3.1. Keep the patient warm with blanket and warm IV fluid and blood
10.3.2. Expose patient to detect missed injuries if traumatized
10.3.3. Keep patient skin clean
10.4. Diagnostic procedures for chest injuries
10.4.1. Chest x-ray
10.4.2. Bronchoscopy
10.4.3. Arterial blood gases
10.4.4. CT scan