Chest trauma

The most common causes of chest injuries in peacetime are considered to be car accidents, falls from heights, blunt force trauma, and penetrating chest wounds. In wartime, gunshot wounds, which are penetrating in nature, predominate in the structure of chest injuries.

Closed chest trauma in combat conditions is represented by mine-explosive wounds, which, as a rule, have a combined nature of damage.

ICD-10 code

• S20 Superficial injury of chest
• S21 Open wound of chest
• S22 Fracture of rib(s), sternum and thoracic spine
• S23 Dislocation, strain and injury of joints and capsular-ligamentous apparatus of the thoracic cage
• S24 Injury of nerves and spinal cord in thoracic region
• S25 Injury of blood vessels of thoracic region
• S26 Injury of the heart
• S27 Injury of other and unspecified thoracic organs
• S28 Crushing injury of thorax and traumatic amputation of part of thorax
• S29 Other and unspecified injuries of chest

Epidemiology of chest trauma

According to the N. V. Sklifosovsky Research Institute of Emergency Care, chest injuries account for every third case of all injuries. In peaceful conditions, severe chest injuries, along with skull injuries, are the leading causes of death among victims. These are mainly people of working age, under 40 years of age. Chest injuries are considered the cause of every fourth fatality.

According to data from domestic forensic medical examination bureaus (the analysis is based on expert opinions and forensic medical examination reports of corpses), closed chest trauma ranks second among injuries to other anatomical and physiological areas as the immediate cause of death.

Knowledge of the etiology and pathophysiology of chest organ injuries and protocols for providing care are necessary for optimal and timely provision of care.

[ 1 ], [ 2 ], [ 3 ], [ 4 ], [ 5 ], [ 6 ], [ 7 ]

Classification of chest injuries

Closed injuries

Without damage to internal organs

• No bone damage
• With bone damage (without paradoxical or with paradoxical chest movements)

With damage to internal organs

• No bone damage
• With bone damage (without paradoxical or with paradoxical chest movements)

Injuries

• Non-penetrating wounds (blind and penetrating)
  • without damaging the bones,
  • with bone damage
• Penetrating wounds (through and through, blind)
  • With injury to the pleura and lung (without hemothorax, with small, medium and large hemothorax)
    • without open pneumothorax,
    • with open pneumothorax,
    • with valve pneumothorax
  • With anterior mediastinal injury
    • without damage to organs,
    • with heart damage,
    • with damage to large vessels
  • With injury to the posterior mediastinum
    • without damage to organs,
    • with damage to the trachea,
    • with damage to the esophagus,
    • with damage to the aorta,
    • with damage to the mediastinal organs in various combinations

[ 8 ], [ 9 ], [ 10 ], [ 11 ], [ 12 ]

The influence of injury mechanisms

The mechanism of chest trauma is of great importance, since closed and penetrating wounds have different pathophysiological and anatomical features. Most blunt traumas do not require active surgical care, but rather conservative treatment (oxygen therapy and/or auxiliary non-invasive mechanical ventilation, pleural drainage).

The diagnosis of "closed chest injury" may be difficult, requiring additional examinations (chest CT). In case of open chest injury, emergency care is required, with additional diagnostic examinations performed according to strict indications.

Diagnosis of chest injuries

In some cases, chest trauma is easy to diagnose, in others, if anamnesis cannot be collected, diagnosis is difficult. Severity is assessed using the ISS scale. The prognosis for open and closed injuries is determined using the TRISS system.

Penetrating chest wounds are often accompanied by damage to the diaphragm and abdominal organs. Thoracoabdominal trauma is assumed if the wound is at the level of the nipples or lower. Damage to the diaphragm and abdominal organs is also possible with a higher entry wound, if the wound is inflicted by a long object, and with gunshot wounds due to the unpredictability of the bullet's movement. With a closed chest injury, structures located at a significant distance from the point of impact (large vessel, bronchus, diaphragm) can be damaged. Even minor injuries (for example, an isolated rib fracture) are dangerous. With all these injuries, serious complications are possible: bleeding, pneumothorax, infectious complications, pneumonia.

A high-quality examination helps to clarify the diagnosis, as well as the extent and nature of the injury.

[ 13 ], [ 14 ], [ 15 ], [ 16 ], [ 17 ], [ 18 ]

Indications for hospitalization

All chest injuries, including superficial ones, require medical attention. Late treatment will lead to increased disability and complications.

Survey

The main goal of the initial examination is to detect life-threatening disorders:

• tension pneumothorax,
• massive hemothorax,
• open pneumothorax,
• cardiac tamponade,
• presence of a costal valve.

[ 19 ], [ 20 ], [ 21 ], [ 22 ]

Monitoring

• Saturation of hemoglobin with oxygen (essential component).
• CO2 in the final portion of the exhaled mixture (if the patient is intubated).

Interventions

• Drainage of the pleural cavity.
• Thoracotomy.

Detailed inspection

A more complete examination is carried out to diagnose all injuries and plan further treatment. During the examination, the following is determined:

• rib fractures and costal valve,
• pulmonary contusion, the clinical manifestation of which is possible after 24-72 hours,
• pneumothorax,
• hemothorax,
• aortic damage,
• heart contusion.

[ 23 ], [ 24 ], [ 25 ], [ 26 ]

Physical examination

With proper organization of the examination and certain skills, a physical examination takes about 5 minutes.

During the inspection, pay attention to:

• Cyanosis is a sign of increasing hypoxemia caused by respiratory failure. If only the face, neck and upper chest ("décolleté") are bluish, it is necessary to suspect traumatic asphyxia, which occurs when the chest is compressed. It is characterized by pinpoint hemorrhages in the skin and mucous membranes.
• Spontaneous breathing - presence or absence, intercostal space retraction during inhalation (respiratory failure, airway obstruction), paradoxical breathing (final rib fracture with chest wall flotation), unilateral respiratory movements (bronchial rupture, pneumothorax, unilateral hemothorax), stridor (damage to the upper respiratory tract).
• Swelling of soft tissues, especially the eyelids and neck (subcutaneous emphysema) is a sign of damage to the lung or main bronchus.
• Pay attention to unusual breathing noises, stridor, and “sucking” wounds of the chest wall.
• In case of penetrating wounds, it is necessary to examine the front and back surfaces of the body (the exit wound may be located on the back).

On palpation:

• Determine the deviation of the trachea.
• They evaluate the uniform participation of the chest in the act of breathing.
• Pain in the chest wall (sometimes rib fractures) is diagnosed.
• The presence of subcutaneous emphysema (“snow crunch”) is determined.

On auscultation:

• The conduction of auscultatory respiratory sounds during the act of breathing is assessed.
• They determine the conduction of respiratory sounds and their characteristics at all listening points (considered to have maximum diagnostic value with correct auscultation).

On percussion:

• Percussion on both sides of the chest may reveal dullness or resonance (if the examination is performed in a noisy room, the results may be distorted).

Classic lung examination data

Syndrome	Trachea	Border	Auscultation	Percussion
Tension pneumothorax	Displaced	Reduced Breasts can be fixed in a state	Noises are reduced or absent	Dullness and tympanic sound
Hemothorax	Middle line	Reduced	Noise reduction at high and normal at moderate	Dullness, especially on the basal surface
Lung contusion	Middle line	Normal	Normal noises may have crepitations.	Normal
Collapsed lung	Towards the collapsed lung	Reduced	Most likely reduced	Tympanic sound
Simple pneumothorax	Middle line	Reduced	May be weakened	Tympanic sound

Laboratory research

• Complete blood count (hematocrit, hemoglobin content, leukocytes with formula calculation).
• ACS, blood gas composition (oxygenation index, CO2 content).
• For intubated victims - monitoring of CO2 in the final expired air.

Instrumental research

A chest X-ray is performed (if the patient's condition allows) in two projections and preferably in a vertical position.

An ultrasound is performed (it is possible to detect hemo-, hydrothorax with a quantitative assessment of the size and determination of the puncture point).

The following methods are considered to be promisingly developed (not excluding the above methods and techniques, but only supplementing them):

• spectral analysis of auscultatory phenomena (does not replace traditional auscultation),
• Electron beam computer tomography (EBCT), which allows assessment of pulmonary perfusion,
• computerized assessment of pulmonary perfusion using computed rheography,
• assessment of pulmonary hemodynamics using an invasive method using the PICCO method.

Indications for consultation with other specialists

Successful treatment and diagnostic tactics require joint work of teams from intensive care units, thoracic and abdominal surgery, as well as diagnostic units (ultrasound, CT, angiosurgery, endoscopic rooms). Thus, when treating chest trauma, a comprehensive approach with a predominance of intensive care tactics is necessary.

Treatment of chest trauma

Treatment of chest trauma begins immediately in accordance with the general principles of intensive care (infusion therapy with reliable vascular access, restoration of airway patency, stabilization of hemodynamics). Associated injuries, of which fractures, head and abdominal injuries are most common, are combined in nature and are more dangerous than chest trauma. Therefore, priorities in treatment tactics should be determined from the very beginning.

After resuscitation measures (if necessary) and diagnosis, the treatment tactics are determined. There are three possible treatment tactics for chest injuries - conservative therapy, drainage of the pleural cavity and surgery. In most cases, with closed trauma and penetrating chest wounds, conservative treatment is sufficient (according to literature, up to 80%), alone or in combination with the installation of drains. The number of emergency surgical interventions in the volume of thoracotomies does not exceed 5%.

Drug treatment

According to a systematic review by the Eastern Association for the Surgery of Trauma, a meta-analysis of 91 sources, Medline, Embase, Pubmed, and Cochrane Community data for the period from 1966 to 2005 was performed, the results were published in June 2006.

Level of evidence I

• No information sources were found that meet this criterion.

Level of evidence II

• In victims with chest trauma (pulmonary contusion), proper volume status is maintained. In order to ensure correct volume loading, it is recommended to use a Swan-Ganz catheter for invasive hemodynamic monitoring.
• The use of pain relief and physical therapy reduces the likelihood of respiratory failure and subsequent prolonged mechanical ventilation. Epidural analgesia is an adequate way to provide pain relief in severe trauma.
• Respiratory support for victims is provided with the obligatory condition of using a respirator in the shortest possible time. PEEP/CPAP should be included in the ventilation protocol.
• Steroids should not be used in the treatment of pulmonary contusion.

Evidence level III

• The use of non-invasive mask assisted ventilation in CPAP mode is the method of choice in conscious victims with severe respiratory failure.
• One-lung ventilation is used in cases of severe unilateral lung contusion, when it is impossible to eliminate shunting in another way due to severe uneven ventilation.
• Diuretics (furosemide) are used to achieve the required volume status under the control of the DZLK.
• The indication for respiratory therapy is not the injury itself, but arterial hypoxemia due to respiratory failure.

Essential Components of Treatment for Chest Trauma Victims

• Pain relief and analgesics. Inadequate pain relief often leads (up to 65% in the elderly) to the development of pulmonary complications, while mortality can reach 15%. For adequate analgesia, patients, if there are no contraindications, undergo epidural analgesia (evidence level I). Its use reduces the length of hospital stay (evidence level II). Some sources (evidence level I) indicate that paravertebral blocks and extrapleural analgesia reduce the subjective perception of pain and improve lung function (evidence level II). With the combined use of epidural analgesia and intravenous administration of narcotic drugs (fentanyl, morphine), maximum analgesia is achieved. Reducing the dose by the type of synergism reduces the severity of side effects of each drug (evidence level II),
• Anxiolytics (benzodiazepines, haloperidol) have limited use. They are prescribed for anxiety, development of psychotic states. The use is predetermined by the protocol of sedation and analgesia in patients in the intensive care unit,
• antibacterial drugs,
• muscle relaxants are prescribed in situations where relaxation is necessary against the background of sedative therapy to ensure adequate ventilation (among the drugs, non-depolarizing muscle relaxants are recommended),
• respiratory therapy. There is no proven advantage over choosing one or another mode of mechanical ventilation in patients with chest trauma, with the exception of the ARDS network study protocol in the development of ARDS (see Appendix). In victims of this category, with hypovolemia, the use of high levels of PEEP is not recommended (level D). Other methods of correcting gas exchange (prone position) are of limited use, especially in patients with an unstable chest.

Other groups of drugs are used for symptomatic therapy. It should be noted that many traditionally used drugs have not proven their effectiveness in studies.

The issue of the timing of tracheostomy and indications for its implementation in different categories of victims with chest trauma has not been resolved.

Recommendations for antibacterial therapy (The EAST Practice Management Guidelines Work Group)

A Level I

Based on the available evidence (Class I and II), preoperative prophylaxis with broad-spectrum (aerobic and anaerobic) antibacterial agents is recommended as standard for patients with penetrating injuries. In the absence of visceral injury, no further administration is necessary.

In Level II

Based on the available evidence (class I and II), prophylactic administration of antibacterial drugs for various internal organ injuries is recommended for 24 hours.

Class I prospective, randomized, double-blind study. Class II prospective, randomized, uncontrolled study. Class III retrospective case study or meta-analysis.

C Level III

There are insufficient clinical studies to develop guidelines for reducing the risk of infection in patients with hemorrhagic shock. Vasospasm alters the normal distribution of antibiotics, reducing their penetration into tissues. To solve this problem, it is suggested to increase the antibiotic dose by 2-3 times until bleeding stops. Once hemostasis is achieved, antibacterial agents with high activity against facultative anaerobic bacteria are prescribed for a certain period, depending on the degree of wound infection. For this purpose, aminoglycosides are used, which have shown suboptimal activity in victims with severe trauma, which is probably due to the pharmacokinetics of the drug.

Anesthetic support

Anesthetic care is performed according to all the rules of anesthesiology, observing the criteria of safety and effectiveness. It is recommended to install an epidural catheter at the required level (depending on the injury) for subsequent analgesia in the postoperative period.

[ 27 ], [ 28 ], [ 29 ], [ 30 ], [ 31 ], [ 32 ], [ 33 ], [ 34 ], [ 35 ]

Surgical treatment of chest trauma

Selecting operational access

In case of damage to the heart and great vessels, a longitudinal sternotomy is performed. The left-sided anterolateral approach is also convenient; the incision is made in the fourth or fifth intercostal space and (if necessary) extended laterally. However, this approach makes it difficult to reach the mouth of the great vessels. In case of damage to the brachiocephalic trunk, a sternotomy is performed with a transition to the neck along the sternocleidomastoid muscle or clavicle. In case of unilateral total hemothorax, an anterolateral or posterolateral thoracotomy is used on the side of the injury. In case of right-sided hemothorax, the patient's supine position is preferred, since CPR, if necessary, is extremely difficult in the left lateral position. The optimal approach to the thoracic aorta is a left-sided posterolateral thoracotomy in the fourth intercostal space (the aortic arch is usually located here). If spinal injury cannot be ruled out, an anterior approach is used, and the thoracic aorta is identified by retracting the apex of the lung or using a single-lumen endotracheal tube with a bronchial blocker, which can be a large-diameter Fogarty catheter.

If hemopericardium is suspected, a diagnostic subxiphoid pericardiotomy is performed (as an independent intervention or during surgery on the abdominal organs). A 5-7.5 cm long skin incision is made above the xiphoid process and the aponeurosis is dissected along the white line of the abdomen. The xiphoid process is excised, the mediastinal tissues are bluntly peeled off, a section of the pericardium is exposed and dissected. If blood is detected in the pericardial cavity, a sternotomy is performed, bleeding is stopped, and the wound of the heart or main vessel is sutured. All this must be taken into account when preparing for surgery. Subxiphoid access is used only for diagnostic purposes; it is not used for specialized operations.

Indications for surgical intervention:

Indications for surgery for chest injuries:

• cardiac tamponade,
• a large gaping wound in the chest wall,
• penetrating wounds of the anterior and superior mediastinum,
• penetrating wound of the mediastinum,
• ongoing or profuse bleeding into the pleural cavity (bleeding through drains),
• the release of a large amount of air through the drainage systems,
• rupture of the trachea or main bronchus,
• diaphragm rupture,
• aortic rupture,
• esophageal perforation,
• foreign bodies in the chest cavity.

Life-threatening conditions that occur with chest trauma and require emergency care include:

• Cardiac tamponade as a result of bleeding into the pericardial cavity (wound, rupture or contusion of the heart, damage to the mouth of the main vessel).
• Total hemothorax (damage to the heart or lung, rupture of a major vessel, bleeding from intercostal vessels, abdominal trauma with damage to the diaphragm and bleeding into the pleural cavity).
• Tension pneumothorax (lung rupture, extensive damage to the bronchi, damage to the trachea).
• Rupture of the aorta or its major branch (blunt trauma as a result of impact during sudden braking, less commonly - penetrating chest wound).
• Terminal rib fracture (or rib and sternum fracture) with chest wall flotation (often accompanied by respiratory failure and hemothorax).
• Rupture of the diaphragm (blunt trauma is often accompanied by an extensive rupture of the diaphragm with the prolapse of abdominal organs into the chest cavity and breathing problems).

Prevention of pulmonary complications (pneumonia and atelectasis)

The goal is to ensure the patency of the airways from sputum and deep breathing. Sputum aspiration through the tracheal tube, percussion and vibration massage, postural drainage, and a spirotrainer are performed. Moistened oxygen breathing (ultrasonic nebulizers) and adequate pain relief are prescribed (see above in this section). All these measures are considered not mutually exclusive, but complementary. Bronchoscopy can be of significant help in the sanitation of the airways from sputum and blood after injury.

Chest trauma prognosis

According to world data, the level of points on the TRISS scale is considered prognostic. The degree of disability, the length of the hospital stay will be determined directly by the nature of the injury and the development of complications, both pulmonary and extrapulmonary. Adequate and timely therapy is the key to successful treatment of this category of victims.

[ 36 ], [ 37 ]