65.1 The general method for a thoracic injury

A severe chest injury is terrifying for a conscious patient. You can usually save the patient’s life, but you must have a logical approach worked out in advance. His injury can be a blunt one from a road accident, or a penetrating one from a bullet, a spear, or an arrow. Often, his chest injury is only one of several other injuries. The procedure that he is likely to need most urgently is to have blood and air drained from a pleural cavity—rapidly and, if necessary, on both sides. This is the critical procedure in thoracic surgery, and is often not done when it should be. A patient may have any of the following chest injuries:

(1) Broken ribs. A thoracic injury usually breaks the ribs of an older patient. But if a patient is young, his ribs may be so elastic that he can have severe internal injuries without breaking them. By themselves broken ribs are not important and soon heal.

(2) A haemothorax. The blood in a patient’s pleural cavity can come from his chest wall, or from his lungs.

(3) A pneumothorax. Air in a pleural cavity usually comes from a patient’s lungs, but it can come from his trachea, his bronchi, or his chest wall. A small pneumothorax is usually harmless and resolves spontaneously.

(4) A haemopneumothorax. He may have both blood and air in a pleural cavity.

(5) A tension pneumothorax. The air in a patient’s pleural cavity may be under pressure when a wound of his lung, or (rarely) an open chest wound, acts as a valve and allows air to get in but not out. More air is trapped each time he breathes. The lung on the injured side collapses, his mediastinum moves towards the normal side, and restricts the movement of that lung too. His bronchi may kink and make his breathing even more difficult. Unless you rapidly let out the air, he dies.

(6) A flail chest. Multiple fractures of a patient’s ribs can cause a large part of his chest wall to move independently of the rest of it, or allow it to be pushed inwards (stove-in chest). The danger of a flail chest is that the loose piece, which should be moving outwards during inspiration, may be sucked inwards (paradoxical movement), and greatly impede his breathing. His mediastinum can also move paradoxically as he breathes. The result is that air, which should be replaced with each respiration, merely moves from one lung to the other (paradoxical breathing).

(7) A sucking chest wound allows a pleural cavity to communicate with the outside air, with the result that the lung on the injured side collapses, the patient’s mediastinum moves paradoxically, and he has paradoxical breathing. Closing his open wound may save his life.

(8) Surgical emphysema is the result of air escaping into the tissues, usually under the skin. Air in the mediastinum is much more serious and may indicate the rupture of a bronchus.

(9) Shocked lung is the result of contusion by a shock wave. This is common and causes haemoptysis.

(10) Other injuries in a patient’s thorax or abdomen include injuries to his aorta, his diaphragm, his heart, his liver, his spleen, or his thoracic spine. Aortic tears are a common cause of death in road accidents.

Here are some of the ways you can help a patient. The purpose of most of them is to make sure that his lungs are normally ventilated: (1) You can secure his airway, and encourage him to cough and clear it. It is easily obstructed, especially if he is a child, and he can only too easily inhale blood, secretions, or the contents of his stomach. He may need bronchoscopy, suction, tracheal intubation, or occasionally tracheostomy. This will reduce his dead space and make a tracheal toilet easier. (2) You can remove air from the top of his pleural cavities or blood from the bottom using a drain with an underwater seal. (3) You can close his open chest wound, particularly a sucking one. (4) You can stabilize his flail chest. (5) You can assist his ventilation with a self–inflating bag. (6) You can transfuse him. (7) You can prevent infection. (8) You can relieve cardiac tamponade by aspirating blood from his pericardial cavity. Last and certainly not least, you can provide physiotherapy which will help him to cough. The great danger with all chest injuries is that retained secretions will cause infection, collapse of a lung, and death. Only active physiotherapy will prevent this.

In more severe injuries a patient’s chest must be opened and the organs inside it repaired (thoracotomy). This major procedure is beyond our scope here, but fortunately only about 5% of the chest injuries which need a drain need a thoracotom. Ideally, if a patient has anything but the mildest degree of flail chest, he should be connected to an intermittent positive pressure respirator (IPPR), and have his blood gases monitored. This too is unlikely to be possible.

If you don’t have a respirator, you can keep a patient inflated with a self inflating bag while you refer him. If this is impossible, we describe other ways of treating a flail chest (65.6).

Don’t be too optimistic. Chest injuries can be as deceptive as abdominal ones—although a patient may seem to be in fair condition to start with, he can deteriorate rapidly.

ABDULLA (41) was hit in the left flank by a passing car. He had a cold nose, a fast weak pulse, and a normal blood pressure. His left flank and lower left ribs were tender. An X-ray film showed gut in his chest. He was in the theatre in 20 minutes, by which time two intravenous drips had improved him considerably. A right upper paramedian incision was made and a hand passed up to his diaphragm. This revealed a hole. The skin incision was therefore extended up into his eighth left intercostal space. It was now seen that his spleen, although not actively bleeding, had been badly bruised. Splenectomy was easy through the enlarged incision. His diaphragm was repaired with interrupted figure–of–eight sutures in one layer, and his chest closed with two layers of continuous monofilament. He recovered. LESSONS (1) Opening the chest, when you have to, may make surgery much easier. (2) It will also be easier if you do it early.