You have a new patient!
A fifty-year-old male patient is brought into the resuscitation room following a motor vehicle accident. The patient is a motorcyclist who was hit on his left side by a lorry moving at 40mph (64.4 kph). He was flung 3 metres, and his helmet remained intact, while the motorcycle was badly damaged. Vital signs are as follows: T 36.5, BP 168/98, HR 112, RR 32, and SpO2 95% on 10L facemask. A cervical collar has been applied by paramedics on scene. On arrival, the patient appears to be in respiratory distress, using his accessory muscles of respiration.
What do you need to know?
Chest trauma occurs in approximately one-third [1] of trauma patients and causes up to 25% mortality [2] in a multiply injured patient. More than 80% of thoracic injuries were blunt [1] rather than penetrating, and 70% of blunt injuries were a result of road traffic accidents [2,3,4], with drivers and front-seat passengers being placed at highest risk [2].
Pathophysiology | Example of injuries (non-exhaustive) |
Airway | Tracheobronchial injury |
Breathing (a) V/Q mismatch
(b) Gas exchange abnormalities |
Sternal or rib fractures +/– flail chest Pneumothorax +/– hemothorax Diaphragmatic injury Pulmonary vascular injury or thrombosis Pulmonary contusion or laceration |
Circulation (a) Hemorrhagic shock (b) Cardiogenic shock (c) Obstructive shock |
Great vessel (e.g. aortic) disruption Cardiac contusion or laceration Tension pneumothorax Cardiac tamponade |
Medical History
The mnemonic “AMPLE” highlights several critical aspects of a patient’s history that should be gathered from all trauma patients: Allergies, Medications currently used, Past illnesses and pregnancy, Last meal, and Events related to the injury [5]. Alert patients can often provide details about the mechanism of their injury and the level of force or impact experienced. They may also report symptoms such as pain in the chest, back, or abdomen, dyspnoea, noisy breathing, hemoptysis, hematemesis, syncope or pre-syncope. Eyewitness accounts from passers-by and paramedics may be helpful in supplementing an overall picture of the scene, particularly if the patient is unable to provide a history at this point in time. The ATMIST template, which includes age, time, mechanism, injuries, signs and symptoms, and treatment, is an effective tool for guiding handovers from prehospital teams [6].
Physical Examination
A comprehensive physical examination is crucial to detect major thoracic injuries early to facilitate timely intervention. The patient’s vital signs often help identify patients who are decompensating or at higher risk of deterioration. These include abnormalities such as tachycardia, bradycardia, tachypnea, bradypnea, hypotension, and hypoxemia.
Inspection
On inspection, assess the patient for:
(a) Airway obstruction, respiratory distress, or decompensation:
- Stridor
- Use of accessory muscles
- Asterixis, drowsiness, or obtundation
(b) Chest wall injuries:
- Steering wheel or seatbelt imprints
- Chest wall contusions, deformities, or wounds
- Asymmetric and paradoxical chest wall movements
- For penetrating injuries, always check for exit wounds, and assume involvement of adjacent body cavities e.g. abdomen
(c) Peripheral signs of shock or major thoracic injury:
- Cold and clammy peripheries (most types of shock)
- Jugular venous distension (tension pneumothorax or cardiac tamponade)
Palpation
On palpation, assess the patient for:
(a) Pneumothorax, hemothorax, or lung collapse:
- Tracheal deviation
- Subcutaneous emphysema
(b) Rib fractures and associated complications:
- Bony tenderness
- Step deformities
- Flail segments
(c) Pulses:
- Irregular heart rhythm (arrhythmia from cardiac injury)
- Pulse delay or differential (aortic dissection)
Percussion
On percussion, assess the patient for:
(a) Hyperresonance: pneumothorax
(b) Dullness: hemothorax, lung collapse
Auscultation
On auscultation, assess the patient for:
(a) Stridor or wheeze: airway obstruction
(b) Reduced breath sounds: pneumothorax or hemothorax
(c) Muffled heart sounds or pericardial rub: pericardial effusion
As patients with thoracic injuries often present with concomitant abdominal and shoulder injuries, complete your examination with a thorough evaluation of the abdomen and shoulder girdles (including the clavicle and scapula).
Alternative diagnoses
The important injuries to assess all patients with chest trauma are summarised in literature as the ‘Deadly Dozen’, as listed in Table 2 [7]. The first six (‘Lethal Six’) are immediately life-threatening and ought to be detected during the primary survey, while the next six (‘Hidden Six’) may not be immediately apparent but are potentially life-threatening and should be picked up during the secondary survey.
Table 2: ‘Deadly Dozen’ in Thoracic Trauma
‘Lethal Six’ | ‘Hidden Six’ |
1. Airway obstruction | 1. Thoracic aortic disruption |
2. Tension pneumothorax | 2. Tracheobronchial disruption |
3. Cardiac tamponade | 3. Myocardial contusion |
4. Open pneumothorax | 4. Traumatic diaphragmatic tear |
5. Massive hemothorax | 5. Esophageal disruption |
6. Flail chest | 6. Pulmonary contusion |
Diagnostic testing
Apart from the ‘Lethal Six’ pathologies, early diagnostic testing can aid in the detection of life-threatening pathologies, including but not limited to the ‘Hidden Six’. A combination of point-of-care tests (POCT), chest imaging, and laboratory tests can help physicians make critical decisions in the assessment of a patient with chest trauma.
POCT
- Arterial or venous blood gas (ABG/VBG):
- When to do it: Signs and symptoms of respiratory distress or decompensation, or when there is a clinical suspicion of shock.
- Findings to look for: A low PaO2:FiO2 (P/F) ratio indicates degree of respiratory failure; an elevated PaCO2level suggests hypoventilation and respiratory decompensation; an elevated serum lactate level indicates poor end-organ perfusion and shock.
- Electrocardiogram (ECG)
- When to do it: Mechanism suggests major chest trauma, signs and symptoms of chest wall injury, or features of active ongoing cardiac disease [8].
- Findings to look for: Arrhythmias and ischemic changes may suggest cardiac injury; small or alternating QRS complexes may indicate pericardial effusion.
- Point-of-care ultrasonography (POCUS):
- When to do it: Mechanism suggests major polytrauma or chest trauma, hemodynamic instability[9,10]
- Findings to look for: Reduced cardiac contractility or wall rupture, pericardial effusion, absence of lung sliding or presence of lung point, sternal or rib fractures [11]
- Pitfalls: Due to poor sensitivity and operator dependence, normal findings do not exclude cardiac, pulmonary, aortic, or musculoskeletal injury [9,10]; serial assessments are recommended to improve sensitivity.
Imaging
- Plain chest radiograph (CXR):
- When to do it: Mechanism suggests major polytrauma or chest trauma [9,10]; unable to exclude significant thoracic injury by NEXUS Chest Radiography Rule (Table 3) [12,13].
- Findings to look for: Pneumothorax, pneumomediastinum, subcutaneous emphysema, hemothorax, widened mediastinum, abnormal aortic contour, sternal and rib fractures, flail segments, raised hemidiaphragm, gastrointestinal herniation into thoracic cavity, foreign bodies.
- Pitfalls: Due to poor sensitivity (40% of patients with normal CXR had CT-proven thoracic injuries), normal findings do not exclude cardiac, pulmonary, aortic, or musculoskeletal injuries [9,10].
Table 3: NEXUS Chest Radiography Rule [12] This applies to patients 15 years or older who sustained blunt trauma within the last 24 hours. No thoracic imaging is required if none of the following criteria are met:
|
- Computer tomography of thorax or aortogram (CT Thorax / Aortogram):
- When to do it: Mechanism suggests major polytrauma or chest trauma [9,10]; suspicion of thoracic injury based on clinical findings or CXR / POCUS; unable to exclude significant thoracic injury by NEXUS Chest CT Decision Instrument (Table 4) [14].
- Findings to look for: Cardiac, pulmonary, aortic, or musculoskeletal injuries.
- Pitfalls: Risk-benefit ratio needs to be assessed and possibly discussed with the patient and/or their next-of-kin in patients at risk of contrast-induced nephropathy or who are pregnant.
Table 4: NEXUS Chest CT Decision Instrument [14] This applies to patients with stable vital signs, 15 years or older. No chest CT is required if none of the following criteria are met:
|
Laboratory tests
- Cardiac enzymes:
- When to do it: Hemodynamic instability, ECG abnormalities
- Pitfalls: Prognostic yield remains unclear
Risk stratification
The two useful clinical tools in the emergency department are the NEXUS rules above, which both have 99% sensitivity in excluding significant thoracic injuries in the absence of all criteria, and hence may guide the judicious use of chest imaging.
There are several risk stratification tools developed to predict poorer outcomes (e.g. mortality, pneumonia, acute respiratory distress syndrome) in patients with chest trauma, including the Thoracic Trauma Severity Score (TTSS) [15,16], Chest Trauma Score (CTS)[17,18], and Rib Fracture Score (RFS)[19]. However, none are routinely used in the emergency department setting given that they do not affect clinical management in the ED and typically require advanced imaging as part of the risk stratification process.
Management
Patients with chest trauma are managed according to Advanced Trauma Life Support (ATLS) [20] principles in order to detect and address ‘ABCDE’ issues in a timely fashion.
(a) Airway
- Establish definitive airway (intubation, front-of-neck access) if partial or complete airway obstruction is identified.
(b) Breathing
- Administer 100% O2 if hypoxemic.
- Apply one-way seal to open chest wounds.
- Intubate for mechanical ventilation if there is respiratory failure (oxygenation, ventilation).
- Finger and tube thoracostomy if there is suspicion of pneumothorax or hemothorax.
(c) Circulation
- Administer IV crystalloids if there are signs of shock and end-organ hypoperfusion.
- Transfuse blood products and consider activating the massive transfusion protocol if suspecting hemorrhagic shock.
- Consider pericardiocentesis if in cardiac tamponade and no surgeon is readily available.
- If the patient goes into traumatic circulatory arrest, there may be a role for emergency department thoracotomy (EDT), unless (1) there were no signs of life on scene, (2) the injuries are unsurvivable, or (3) prolonged downtime exceeding 15 minutes.
(d) Disability
- Consider early intubation if the patient is drowsy (which could be a result of shock, hypercarbia, hypoxemia, or concomitant head injury).
- Check for concomitant thoracic spine injury.
(e) Environment / Exposure
- Assess for injuries across the chest, back, and adjacent areas such as the shoulder girdles and abdomen.
- Keep the patient warm.
Urgent surgical consultation is often warranted in all cases of penetrating chest trauma and if there is suspicion of any of the ‘Deadly Dozen’ pathologies.
Medications
- Analgesia is crucial for relieving pain and preventing atelectasis, but when using opioids, careful dosing is necessary to avoid hypoventilation.
- Tranexamic acid stabilises blood clots and reduces mortality in patients with significant ongoing bleeding presenting within 3 hours of injury [21].
- Prophylactic antibiotics and the tetanus vaccine are used to prevent infection, particularly in patients with penetrating chest trauma, significant hollow viscus injuries, or those undergoing invasive procedures. The use of these medications should follow institutional guidelines.
Special patient groups
- Paediatric patients: Children have more compliant chest walls and hence may sustain significant intrathoracic injuries without obvious chest wall abnormalities. In addition, multiple chest wall injuries or a mechanism of injury that is incompatible with the child’s developmental milestones should raise suspicion for non-accidental injury. A careful evaluation and a high index of suspicion are required in this patient group.
- Geriatric patients: Older adults, due to reduced pulmonary reserves, are at an increased risk of developing respiratory complications. This patient group should be counselled on the increased risks of atelectasis, pneumonia, and acute respiratory distress syndrome. Adequate analgesia and incentive spirometry may help to reduce the risk of these complications.
When to admit the patient
- All patients with penetrating chest trauma or blunt trauma with suspicion of significant intrathoracic injury should be admitted for evaluation and monitoring.
- Patients who remain symptomatic despite a normal initial evaluation can be observed for 8 hours, with serial physical examinations or chest radiographs scheduled.
- Most other patients can be safely discharged with appropriate advice (to return to the ED if developing pain, dyspnoea, fever, haemoptysis, or hematemesis, which may suggest missed injuries or complications such as chest infection).
Revisiting your patient
The patient is managed according to ATLS [20] principles.
Airway: There is no stridor or obvious facial injury. The cervical spine has been immobilised.
Breathing: He is tachypnoeic and hypoxaemic. The trachea is deviated to the right. There is a left chest wall deformity with bruising, asymmetric chest wall movements, and left-sided paradoxical movements. There is no obvious penetrating injury. Crepitus and step deformities are palpated on the left chest wall. Breath sounds are reduced on the left. Tension pneumothorax and flail chest are suspected. POCUS demonstrates absent lung sliding on the left. An arterial blood gas demonstrates hypoventilation with a PaCO2 of 42 mm Hg despite the patient’s tachypnoea (PaCO2 is expected to be low). Left finger thoracostomy is performed, with a gush of air noted upon entry into the pleural cavity, and a large-bore chest tube is inserted. Intubation with manual in-line stabilisation is performed in view of impending type 2 respiratory failure.
Circulation: The patient is tachycardic and has borderline low blood pressure. His peripheries are cold and clammy. Pulses are regular and there is no pulse delay or differential. An initial FAST scan is negative for free fluid in the abdomen or pericardial sac. Heart sounds are normal. Two large-bore intravenous cannulas are inserted for crystalloid administration.
The rest of the primary survey and adjuncts: The rest of the primary survey is normal. A plain chest radiograph confirms the presence of a left pneumothorax with subcutaneous emphysema and multiple left-sided rib fractures constituting a flail segment (see example videos below). There is no obvious hemothorax, widened mediastinum, or raised hemidiaphragm. Analgesia, prophylactic antibiotics, and the tetanus vaccine are administered.
Disposition: The patient is admitted to the surgical intensive care unit and planned for further advanced imaging and operative interventions by the surgical team.
Authors
Ivan Low
Ivan Low is a Resident in Emergency Medicine in Singapore's public healthcare system. He graduated from the National University of Singapore (NUS) in 2018, and is currently working as a military doctor in the Republic of Singapore Navy. He is a Designated Workplace Doctor (Compressed Air Works) and is trained in Diving and Hyperbaric Medicine. He is actively involved in medical education, particularly in the Singapore Medical Association. He has been awarded the NUS Junior Doctor Teaching Award several times in recognition of his work.
Jeremy Wee Choon Peng
Dr Jeremy Wee serves as a Senior Consultant at the Department of Emergency Medicine at the Singapore General Hospital. Besides being actively involved in the care of patients at the Emergency Department, Dr Wee has a special interest in Trauma care as well as Medical Education. This led to his completion of the Masters of Science in Health Professions Education and the Masters in Trauma Sciences. He is currently the Program Director of the Singhealth Emergency Medicine Residency Program and is actively involved in undergraduate education as an Adjunct Assistant Professor Duke-NUS Graduate Medical School, Clinical Senior Lecturer with Yong Loo Lin School of Medicine.
Listen to the chapter
References
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Reviewed By
Arif Alper Cevik, MD, FEMAT, FIFEM
Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.
