creation date: 2025-11-03 15:51
tags: Workups
Chest Trauma
Background
Chest trauma refers injury to the thoracic area that can result in a number of life-threatening conditions including:
- Pneumothorax
- Hemothorax
- Pulmonary contusions
- Rib fractures
- Cardiac tamponade
- Diaphragmatic rupture
Downstream complications from delayed diagnosis and treatment include respiratory failure, shock, or multiorgan dysfunction.
Motor vehicle accidents (MVAs) are the leading cause of chest trauma owing to crushing or deceleration. Gunshot injuries are associated with open pneumothorax.
Pathophysiology
The thoracic cage comprises of the sternum, ribs, and thoracic vertebrae, which is important for protecting the vital organs within the chest cavity. Vital structures within the mediastinum includes the heart, great vessels, trachea, esophagus, and lymph nodes. The lungs are also within the thoracic cavity.
Chest trauma can result from penetrating or blunt trauma. Blunt trauma imparts kinetic energy to the point of impact which then directly damages the chest and dispersing to more distant sites. Penetrating trauma transfers energy into the tissues penetrated and is related to the projectile velocity.
Damage to the chest wall, musculature, or gas exchange surfaces influence breathing. Collection of air can result in pneumothorax should an the pleura connect to adjacent tissue.
Traumatic injuries can also result in the accumulation of blood within the pleural cavity (hemothorax). Accumulation of chyle (lipid-rich lymphatic fluid) characterizes chylothorax which can result in respiratory, nutritional, and immunosuppressive complications.
It should be noted that due to the more compliant and compressible chest walls of pediatric patients, compensation may be robust enough to mask hypotension until mechanisms are exhausted before manifesting as shock.
Differential Diagnosis
Diagnoses associated with chest trauma primary relate to damage done from the trauma.
Initial Evaluation
Patients can present with a variety of signs and symptoms varying in severity. A rapid primary assessment must be made following ATLS guidelines (ABCDE).
If necessary resuscitation should be started immediately, with secondary survey completed after stabilization.
History
Patients who are conscious may report symptoms such as:
- Chest pain
- Dyspnea
- Hemoptysis
- Palpitations
- Sensation of pressure/tightness in the chest
Dizziness, nausea, and diaphoresis may be reported in cases of significant bleeding or cardiac injury.
Reports of pain, deformity, or loss of function in other sites may be present in cases of polytrauma. For example, flank or abdominal pain may be reported with concomitant abdominal injury.
History can also elucidate the mechanism of injury. Common inciting events include MVAs, falls, assaults, and penetrating injuries. In cases of MVAs, the extent of the accident, such as airbag deployment, time needed for extrication, and level of damage to the vehicle may guide management.
Assessment of comorbid medical conditions can impact interventional approaches. These conditions include:
- Diabetes mellitus
- Cardiovascular disease
- Coagulopathies
- Chronic lung disease
- Immunosuppression
- Renal impairment
Physical Exam
Physical findings should focus on early recognition of life-threatening injuries. These include:
- Airway obstruction or rupture
- Tension pneumothorax
- Cardiac tamponade
- Massive hemothorax
- Flail chest
Secondary survey can focus on:
- Rib fractures
- Small hemothorax
- Small pneumothorax
- Pulmonary contusion
- Chest wall contusion
In should be noted that several injuries can be hidden and clinical suspicion should be maintained:
- Tracheobronchial injury
- Aortic injury
- Myocardial contusion
- Pulmonary contusion
- Diaphragmatic rupture
- Esophageal rupture
A comprehensive assessment should be made for bruising, abrasions, and penetrating wounds.
In cases of MVAs, the “seat belt sign” can indicate internal injury.
Investigations
Immediate evaluation with a Extended Focused Assessment with Sonography in Trauma (eFAST) should be performed.
Chest radiography and CT is often used for evaluation of structures once patient is stable.
Blood work is typically completed which includes:
- CBC (anemia may indicate acute blood loss)
- Coagulation panel
- Blood typing (should transfusion be necessary)
- Arterial blood gas (for patients with hypoxemia or shock)
- Cardiac enzymes (if cardiac injury is suspected)
- Blood glucose (if patient has history of DM or is unconscious)
An ECG may be indicated if potential cardiac involvement is suspected. This can find new onset ischemia or dysrhythmias.
In cases where injury is near the esophagus, bronchoscopy may be indicated following a CT scan.