If a whole lobe of a patient’s LUNG FAILS TO EXPAND when you insert an underwater seal drain, he is suffering from PULMONARY COLLAPSE. This is partly due to retained secretions, which is why trying to get a patient with a chest injury to cough is so important, painful although this may be. If he will not cough out retained secretions, aspirate them.
If you have failed to prevent collapse, first try physiotherapy (65.1). Encourage him to breathe deeply and cough. If this fails, bronchoscope him within an hour. If you cannot do this, pass a sterile rubber catheter or bougie into his unanaesthetized larynx to start him coughing. if he has to be bronchoscoped more than twice, do a tracheostomy, so that you can aspirate secretions regularly with a fine catheter. Oxygen and antibiotics are only of minor value. Collapse of a lung is common and can complicate any severe chest injury.
If a patient’s whole head and arms are COVERED WITH PETECHIAE, he is suffering from TRAUMATIC ASPHYXA. In this rare syndrome violent compression of his chest forces blood into the veins of his head, neck, and arms. Small blood vessels burst and cover his skin with petechiae. He may also have retinal and conjunctival haemorrhages, and become unconscious. Provided he recovers from any other injuries he may have, traumatic asphyxia is not in itself serious. Sit him up in bed and give him oxygen.
If his FACE SWELLS ALARMINGLY, as in Fig. 65-1, and there is a crepitant swelling under the skin and muscles of his neck, he is suffering from SURGICAL EMPHYSEMA. This is common, but it is seldom serious in itself, and soon disappears. He may swell from his pelvis to his forehead. If his eyelids are swollen and he has difficulty seeing, show him how he can milk the air out of them. Where necessary, treat the underlying cause. This may be a leak from a lung that requires an underwater seal. You can remove small quantities of air by massaging it into a few pockets, and then aspirating it with a syringe and needle. If surgical emphysema spreads or threatens his life, do a tracheostomy. This abolishes coughing and the large rises in intrathoracic pressure it causes.
If air escapes into his mediastinium and pleura from tears in his trachea, oesophagus, or bronchi, it may press on the veins at the base of his neck and congest the veins of his head. Insert an underwater drain and seal and remove the air trapped in his pleura. This may cure him.
