Critical Alerts

• Tension pneumothorax - clinical diagnosis; decompress immediately (don't wait for X-ray)
• Massive hemothorax - >1500 mL blood or >200 mL/hr output = likely thoracotomy
• Cardiac tamponade - Beck's triad; pericardiocentesis if unstable
• Open pneumothorax - seal with occlusive dressing (3-sided)
• Flail chest = paradoxical movement; worry about underlying pulmonary contusion

Key Diagnostics

• Chest X-ray (initial)
• FAST/eFAST (pericardial effusion, pneumo/hemothorax)
• CT chest with contrast (stable patients)
• ABG if respiratory distress
• Type and crossmatch

Emergency Treatments

• Tension pneumothorax: Needle decompression → chest tube
• Hemothorax: Chest tube 32-36 Fr
• Tamponade: Pericardiocentesis or ED thoracotomy
• Flail chest: Pain control, may need intubation
• Massive transfusion: 1:1:1 for hemorrhagic shock

Chest trauma refers to injury to the thoracic cavity and its contents, including the chest wall, lungs, heart, great vessels, esophagus, and diaphragm. It accounts for 25% of trauma deaths and contributes to another 25% of trauma mortality.

Classification

Anatomical Zones

Epidemiology

• Incidence: 10-15% of all trauma admissions
• Mortality: 10-20% overall; higher in penetrating
• Common mechanisms: MVA (most common blunt), assault (most common penetrating)

Immediate Intervention Required

Indications for ED Thoracotomy

Penetrating Trauma

• Pulseless with witnessed arrest <15 minutes
• Profound refractory hypotension with tamponade

Blunt Trauma

• Generally not indicated except:
• Witnessed arrest <10 minutes
• Signs of tamponade

Causes of Hypotension in Chest Trauma

Causes of Respiratory Distress

Primary Survey (ATLS)

A-B-C-D-E Approach

• Identify and treat life-threatening injuries during primary survey
• Don't delay treatment for diagnostics

eFAST (Extended FAST)

Sensitivity for Pneumothorax: 60-90% Better than CXR for occult pneumothorax

Chest X-ray

Standard initial imaging for all chest trauma

CT Chest

Gold standard for stable patients

CT Angiography

• Indicated for suspected aortic injury
• Widened mediastinum, apical cap, rib fractures 1-2
• Loss of aortic knob

ICU Admission Criteria

• Hemodynamic instability
• Respiratory failure or high oxygen requirement
• Chest tube with significant output
• Flail chest
• Pulmonary contusion
• Post-thoracotomy
• Aortic injury
• Myocardial contusion with arrhythmia
• Multiple rib fractures in elderly

Floor/Monitored Bed

• Stable rib fractures with adequate pain control
• Small resolved pneumothorax post-chest tube
• Stable contusion with normal oxygenation

Discharge Criteria

• Pain controlled with oral medications
• Adequate oxygenation on room air
• Chest tube removed (if applicable)
• Ambulatory
• Follow-up arranged
• Understands return precautions

Follow-up Considerations

Understanding Chest Trauma

• Chest injuries can range from minor bruises to life-threatening conditions
• Even minor rib fractures are painful and take weeks to heal
• Pain control is important to prevent complications like pneumonia

Activity Restrictions

• Avoid strenuous activity until cleared
• Incentive spirometry 10 times per hour while awake
• Deep breathing despite pain to prevent pneumonia

Warning Signs to Return

• Increasing shortness of breath
• Worsening chest pain
• Fever
• Coughing up blood
• Dizziness or fainting
• Rapid heart rate

Elderly Patients

• Higher mortality from same injuries
• Pre-existing cardiac/pulmonary disease
• Lower threshold for admission
• Consider rib fixation
• Aggressive pain control (epidural)

Anticoagulated Patients

• Higher risk from rib fractures
• Delayed hemothorax
• Reverse anticoagulation if significant injury
• Lower threshold for CT imaging

Pediatric

• More pliable chest wall
• Significant injury can occur without rib fractures
• Mediastinum more mobile
• Higher risk of tracheobronchial injury

Pregnancy

• Displaced diaphragm in third trimester
• Fetal monitoring after trauma
• Kleihauer-Betke test for Rh-negative
• Left lateral positioning

Performance Indicators

Documentation Requirements

• Mechanism with details
• Primary and secondary survey findings
• FAST results
• Imaging interpretations
• Procedures performed (chest tube site, size, output)
• Response to interventions
• Disposition rationale

Diagnostic Pearls

1. Tension pneumothorax is clinical diagnosis - treat, don't image
2. eFAST for pneumothorax - more sensitive than supine CXR
3. Widened mediastinum on CXR - needs CT angiography
4. Pulmonary contusion worsens over 24-72 hours - anticipate
5. First rib fracture = high-energy mechanism; thorough workup

Treatment Pearls

1. Needle decompression is temporizing - always follow with chest tube
2. Chest tube: large for blood, any size for air
3. 3-sided dressing for open pneumothorax - valve effect
4. Pain control for rib fractures - epidural reduces complications
5. Damage control resuscitation - 1:1:1, permissive hypotension

Disposition Pearls

1. Elderly + multiple rib fractures = admit - high complication rate
2. Pulmonary contusion = monitor closely for deterioration
3. Chest tube removal when output <150-200 mL/24h and no air leak
4. Delayed hemothorax can occur - warn patients
5. Follow-up CXR to confirm resolution