THE GENERAL METHOD FOR A CHEST INJURY

This extends Section 51.3 on the care of a severely injured patient.

THE RAPID ASSESSMENT OF A CHEST INJURY

If a patient’s airway is blocked, clear it as in Section 52.1.

If air is going in and out, but his breathing is distressed, he may have multiple fractured ribs or severe abdominal pain.

If he is making great respiratory efforts, but is still hungry for air, think of a flail chest or a pneumothorax.

If he is cyanosed in the presence of an adequate airway, he may have a badly damaged lung, a flail chest, or a pneumothorax. Give him oxygen.

Many patients with chest injuries breathe much more easily as soon as they are intubated.

THE HISTORY OF A CHEST INJURY

Assess the force of the patient’s injury carefully. The greater the force, the greater the chances that he has a severe injury.

THE EXAMINATION OF A CHEST INJURY

If a patient is conscious, and is now breathing easily, strip him to the waist, and ask him to describe the pain and show you exactly where it is. if unconscious, remove his clothes and examine his chest carefully.

INSPECTION Assess the rate and depth of the patient’s breathing, while he is breathing normally. Ask him to take a deep breath. If his ribs are broken, his attempts to do so will soon be stopped by sharp pain.

Mediastinal shift

Is his apex beat in its normal place? Feel in his suprasternal notch to find out if his trachea is displaced.

Do both sides of his chest expand equally?

Look carefully for any areas of diminished chest movement. This may be in one area only, or involve the whole of one side. Look at him from the sides and from the top and bottom of the trolley.

CAUTION! Look carefully for paradoxical movement. Look at the movement of a normal area, then compare this with the possibily abnormal one. Paradoxical movement may be difficult to see when a patient is shocked and his respiratory movements are small; it may only come on later, when he is resuscitated. Don’t be confused by the indrawing of his lower costal margin that is common in mild respiratory obstruction, especially in children.

Are his intercostal spaces distended on one side compared with the other? (tension pneumothorax).

Is he cyanosed? Look at his mucous membranes and his finger nails.

CAUTION! Anaemic patients do not become cyanosed, and may die of anoxia without showing it. There must be 5 g/dl of reduced haemoglobin in a patient’s circulation before you can observe cyanosis.

Look carefully for any bruises on his chest caused by a steering wheel or a safety belt, or by the imprint of his clothes.

Are the patient’s jugular veins abnormally distended? (anything which impedes the venous return to the heart, a tension pneumothorax, mediastinal shift, and especially cardiac tamponade).

PALPATION If a patient is conscious, start by feeling a pain–free area, and then move towards the injured one. Feel for: (1) Tenderness. (2) Crepitus when fractured ribs move with respiration. (3) The crackly feeling of surgical emphysema.

Feel his abdomen for rigidity, tenderness, and distension.

PERCUSSION Do this gently. Don’t fail to turn him or sit him up so that you can examine his back. Dullness may indicate blood or the collapse of a lung, and hyper–resonance may be caused by a tension pneumothorax.

ASCULTATION Can you hear the patient’s breath sounds all over his chest, or are they diminished? Note especially: (1) Clicking sounds from fractured ribs. (2) The coarse crepitations of surgical emphysema. (3) Reduced or absent breath sounds on one side indicating fluid, or air in a pleural cavity, or the collapse of a lung. Listen for this sign while he is supine, as in Fig. 65-7. (4) High pitched breath sounds suggesting a tension pneumothorax.

The two coin test Place a coin on the patient’s chest and tap it with another coin. A bell–like note (combined with other signs) suggests a tension pneumothorax.

OTHER SIGNS OF A CHEST INJURY

ABDOMEN Examine this carefully. Note any tenderness, rigidity or distension. If a patient’s lower left ribs are fractured posteriorly, think of a ruptured spleen. If he is tender in his right upper abdomen, suspect a ruptured liver. Fractures of the lower 6 ribs can cause abdominal tenderness without there being any injured abdominal viscera.

FRACTURED RIBS If a patient is not too ill, gently spring his chest from front to back, or from side to side, between your hands. If this causes severe pain he has probably broken some ribs. Feel for the tender fracture sites. They will be easier to feel than to see on an X–ray.

PULSE Is this stronger on inspiration than on expiration? Is his jugular venous pressure raised? These are both signs of cardiac tamponade (65.9).

X–RAY all patients you suspect of having a serious chest injury. X–rays are not necessary to diagnose fractured ribs (which are difficult to see), but are a useful way of making sure that a patient’s lungs and pleural cavities are normal. Unless other injuries prevent it, try to take an erect x–ray. if he cannot stand, you may be able to support him sitting up on a trolley for the very short period that is necessary for a film to be taken.

Examine the films systematically noting first his rib cage and other bones, then his trachea and lungs, and finally his heart and mediastinum. Look for rib fractures by holding the film obliquely, and looking along each rib.

If you have to X–ray him lying flat on a trolley, try to give the table a slight head up tilt. The films may show a large pneumothorax or a haemothorax, fractured ribs, or surgical emphysema. They will not show a small pneumothorax, or a fluid level in a haemopneumothorax.

Haemothorax

A diffuse opacity in a lower lung field, which is more easily seen in an erect film. A haemothorax may not be easy to diagnose radiologically, so rely on your stethoscope.

Pneumothorax

(1) The lung markings do not reach all the way out to the edge of the thoracic cage. (2) You can see the pleura as a faint line. (3) The apices look different.

Contusion of the lung

Diffuse mottling with dense patches in places. These intensify in the next few days and then clear.

Aortic injury

If the patient’s mediastinum is significantly widened, check the pulses in each of his arms and in each side of his neck. He may have injured his aorta or the great vessels at the root of his neck.

Cardiac tamponade

A wide heart shadow.

THREE MAJOR DIFFERENTIAL DIAGNOSES IN A CHEST INJURY

If a patient has a large haemothorax, he will be sweaty and clammy, have a rapid, thready pulse, collapsed neck veins, an apex beat in its normal place, and a chest which is stony dull to percussion. Sometimes even a large haemothorax causes very few signs.

If a patient has a tension pneumothorax, he will have increasing difficulty breathing, a rapid pulse which may be of good volume, perhaps slightly distended neck veins, an apex beat and trachea displaced to the other side, and a tympanitic note on percussion.

If he has cardiac tamponade, he will be severely distressed and shocked, he will have a rapid weak pulse, grossly distended neck veins, an apex beat you can neither feel nor see, and a normal percussion note.

PHYSIOTHERAPY is very important to prevent collapse of a lung. There are these possibilities; (2) and (3) are not suitable for patients with severe rib injuries. (1) Try deep breathing and coughing every 2 to 4 hours, accompanied by suction if necessary. (2) Vibration to the chest wall. (3) Slapping the chest wall.

PARTICULAR INJURIES Read on for methods of draining a patient’s chest (65.2), managing uncomplicated fractures of his ribs and sternum (65.3), and treating a haemothorax (65.4), a pneumothorax (65.5), a flail chest (63.5), open chest injuries (65.7), and stab wounds (65.8).

If you are in doubt how to manage a patient, admit him and observe him. A haemothorax may take some days to form.

DON’T OVERLOOK A HAEMOTHORAX