Chest Trauma - Blunt

Assessment
Management
Disposition

Assessment

Life Threatening Consequences of Blunt Chest Trauma

1. Cardiac Injury
2. Vascular Injury
3. Lung Injury
4. Flail Chest
5. Diaphragmatic Rupture

Early Surgical Referral

Blunt injury to the chest with any of the following:

• Haemodynamic Instability
• Vascular Injury
• Pulmonary Contusion/Flail Chest
• Immediate drainage of > 1500 ml blood in chest drain
• > 200ml blood per hour in chest drain

Chest injuries frequently accompany multiple other injuries: ALWAYS look for co-existing injuries

Use a standard ATLS approach

Assess – Intervene – Reassess: Assessment and Management occur in tandem

The goal is to determine whether there is significant intra-abdominal trauma

DMIST Handover from Ambulance

• Triage patient using SATS
• Measure and Record Vital Signs
• Finger prick Haemoglobin

Examination

Primary: Assess ABC’s then secondary Head to Toe examination

Specifically for Blunt Chest Trauma

• Check haemodynamic status and Hb
• Look for potential sites of occult blood loss
• Screen for internal bleeding (Chest; Abdomen)
• Chest Examination: Chest movement; Discolouration; Tenderness; Air Entry; Trachea; Surgical Emphysema

Be aware of tracts extending to the neck and abdomen.

Take a SAMPLE History

• Signs and Symptoms: Shortness of Breath; Haemoptysis
• Allergies
• Medications
• Past Medical history
• Last Meal
• Events: Mechanism and Type of Injury

Investigations

• Hb and Glucose
• Oxygen Saturation
• Bloods: Formal Hb, XMatch, Arterial Blood Gas may be indicated
• Chest X-Ray (erect is best, lateral decubitus for suspected small haemothorax)
• Other X-Rays as Indicated

Point of Care EFAST scan

• Look for intra-abdominal, pleural and pericardial fluid
• Look for pneumothorax
• If stable, consider CT scan of chest

Management

Stabilise the ABC’s

Airway:

• Tension pneumothorax may compromise trachea

Breathing:

• Treat haemo/pneumothorax
• Decompress and treat tension pneumothorax
• Cover sucking chest wounds
• Assess for pulmonary contusion; rib fractures and flail segments

Circulation:

• Insert at least one large bore (14G preferable) on the opposite side of the injury
• Thoracotomy is not indicated in blunt chest trauma
• Consider cardiac injury in the absence of significant visible bleeding

Monitor the Patient:

• Attach monitors (ECG, SpO2, BP)
• Urinary catheter
• Nasogastric tube (not with BOS fracture)

IV Analgesia

Morphine Sulphate

Constitute 10mg in 10 ml of sterile water (10 ml total)

Loading dose: 0.1 to 0.15 mg/kg (use less for elderly and frail) then bolus 0.05 mg/kg every

15 minutes. Titrate to effect.

Beware drop in BP and respiration.

Disposition

Discharge:

• Normal vital signs after 4 hours and
• No admission criteria

Discharge all patients with a Chest Injury Discharge Advice form.

Admit:

Level 2:

• Any blunt chest injury requiring intervention OR
• Pulmonary Contusion OR
• Needs admission for other injuries

Provided no criteria for Level 3 hospital admission

Level 3:

(See Direct Trauma Referral Criteria)

• Poly-trauma
• Pregnant
• Haemophilia
• Injuries requiring advanced imaging (CT scan/Fluoroscopy/Bronchoscopy)
• Injuries requiring specialist care (e.g cardio-thoracic surgery)