Chest/Rib Fractures and Trauma (Smarty PANCE)

What is flail chest?

Flail chest is defined as two or more contiguous rib fractures with two or more breaks per rib — is one of the most serious of these injuries and is often associated with considerable morbidity and mortality. It occurs when a portion of the chest wall is destabilized, usually from severe blunt force trauma

How is flail chest diagnosed?

Flail segment of chest wall that moves paradoxically (sucks in with inspiration and pushes out with expiration opposite the rest of the chest wall)

What is the major cause of respiratory compromise with flail chest?

Underlying pulmonary contusion

What is the treatment of flail chest?

Intubation with positive pressure ventilation and PEEP PRN (let ribs heal on their own)

What is the treatment of most rib fractures?

The majority heal uneventfully with rest, analgesia, cessation of inciting activity for ~4-6 weeks

What is a pneumothorax?

A pneumothorax is a collapsed lung. A pneumothorax occurs when air leaks into the space between the lung and chest wall.

What are the four types of pneumothorax?

There are four types of pneumothorax:

● Traumatic pneumothorax: This occurs when an injury to the chest (as from a car wreck or gun or knife wound) rips through the parietal pleura, allowing air to enter from the outside, directly into the pleural space

● Tension pneumothorax: can develop similarly to a spontaneous pneumothorax or a traumatic pneumothorax - with the one difference being that it creates a one-way valve for air to flow into the pleural space - air can enter, but cannot leave.

● Primary spontaneous pneumothorax: This happens when a small air bubble on the lung ruptures. These may happen for no obvious reason or while undergoing changes in air pressure (like when scuba diving or mountain climbing).

● Secondary spontaneous pneumothorax: This typically happens to those who already have lung disease. As the lung is already compromised by disease and may have diminished capacity, this can be a serious complication.

What are the symptoms of a tension pneumothorax?

Tension pneumothorax develops when a lung or chest wall injury is such that it allows air into the pleural space but not out of it (a one-way valve). As a result, air accumulates and compresses the lung, eventually shifting the mediastinum, compressing the contralateral lung, and increasing intrathoracic pressure enough to decrease venous return to the heart, causing shock. Symptoms include dyspnea, jugular venous distention, tachypnea, anxiety, pleuritic chest pain, unilateral decreased or absent breath sounds, tracheal shift away from the affected side, hyperresonance on the affected side

How is pneumothorax diagnosed?

A pneumothorax is generally diagnosed using a chest X-ray. In some cases, a computerized tomography (CT) scan may be needed to provide more-detailed images. Ultrasound imaging also may be used to identify a pneumothorax.

Open vs. closed traumatic pneumothorax?

Closed pneumothorax: blunt trauma → lung damage → air flows from the lung into the pleural space

Open pneumothorax: penetrating trauma to the chest wall → pathway for air directly into pleural space

What is the treatment of a tension pneumothorax?

Rapid thoracostomy incision or immediate decompression by needle thoracostomy in the second intercostal space midclavicular line, followed by tube thoracostomy placed in the anterior/ midaxillary line in the fourth intercostal space (level of the nipple in men)

What is the medical term for a "sucking chest wound"?

Open pneumothorax

What is a tube *thoracostomy*

Chest tube

How is an open pneumothorax diagnosed and treated?

Diagnosis: usually obvious, with air movement through a chest wall defect and pneumothorax on CXR . Treatment in the ER: tube thoracostomy (chest tube), occlusive dressing over chest wall defect

What does a pneumothorax look like on chest X-ray?

Loss of lung markings (Figure shows a right-sided pneumothorax; arrows point out edge of lung-air interface)

What is a *hemothorax*?

Accumulation of blood in the pleural space from an intercostal blood vessel, the internal mammary artery, the lung, the heart, or the great vessels.

How is hemothorax diagnosed?

*Unilaterally* decreased or absent breath sounds; dullness to percussion; CXR, CT scan, chest tube output

What is the treatment of hemothorax?

Volume replacement

*Tube thoracostomy (chest tube)*

Removal of the blood (which will allow apposition of the parietal and visceral pleura, sealing the defect and slowing the bleeding)

What are indications for emergent thoracotomy for hemothorax?

Massive hemothorax =

1. > 1500 cc of blood on initial placement of chest tube

2. Persistent > 200 cc of bleeding via chest tube per hour x 4 hours

What is *cardiac tamponade*?

Bleeding into the pericardial sac, resulting in constriction of heart, decreasing inflow and resulting in decreased cardiac output (the pericardium does not stretch!)

What are the signs and symptoms of cardiac tamponade?

Tachycardia/shock with Beck's triad, pulsus paradoxus, Kussmaul's sign

Define Beck's triad

1. Hypotension

2. Muffled heart sounds

3. JVD Kussmaul's sign JVD with inspiration

How is cardiac tamponade diagnosed?

Ultrasound (echocardiogram)

What is the treatment of cardiac tamponade?

Pericardial window—if blood returns then median sternotomy to rule out and treat cardiac injury