Chest Trauma - Penetrating

Assessment
Management
Disposition

Assessment

1. Cardiac Injury
2. Vascular Injury
3. Lung Injury
4. Diaphragmatic Rupture

Early Surgical Referral

Penetrating injury to the chest with any of the following:

• Haemodynamic Instability
• Vascular Injury
• Peritoneal Signs
• 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
• Fingerprick Haemoglobin

Examination

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

Specifically for Penetrating Chest Trauma

• Check haemodynamic status and Hb
• Look for potential sites of blood loss (front and back)
• Screen for external bleeding (Chest; Neck; Abdomen)
• Screen for internal bleeding (Chest; Abdomen; Neck)
• Chest Examination: Chest movement; Discolouration; Tenderness; Air Entry; Trachea; Surgical Emphysema
• Assess wound tract carefully but do NOT do a blind finger exploration

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:

• Injury extending to neck may cause pressure on airway
• Tension pneumothorax may compromise trachea

Breathing:

• Treat haemo/pneumothorax
• Decompress and treat tension pneumothorax
• Cover sucking chest wounds

Circulation:

• Insert at least one large bore (14G preferable) on the opposite side of the injury
• Thoracotomy indicated in the event of massive haemo-thorax (emergency) or no cardiac output (emergency center)
• 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:

• Wound judged to be non-penetrating and
• Normal vital signs after 4 hours and
• Repeat CXR normal after 4 hours
• No admission criteria

Discharge all patients with a Chest Injury Discharge Advice form.

Admit:

Level 2:

• Any penetrating chest injury 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)