# Immediate life-threatening injuries Immediate life-threatening injuries Airway obstruction Early intubation is very important, particularly in cases of neck haematoma or possible airway oedema. Airway distortion can be insidious and progressive and can make delayed intubation more di ffi cult if not impossible. Tension pneumothorax A tension pneumothorax develops when a ‘one-way valve’ air leak occurs either from the lung or through the chest wall. Air is sucked into the thoracic cavity without any means of escape, completely collapsing and then compressing the a ff ected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung. The most common causes are penetrating chest trauma, blunt chest trauma with a parenchymal lung injury and air leak that did not spontaneously close, iatrogenic lung injury (e.g. due to central venepuncture) and mechanical positiv e-pressure ventilation. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The clinical presentation is dramatic. The patient is increas ingly restless with tachypnoea, dyspnoea and distended neck veins (similar to pericardial tamponade). Clinical examination may reveal tracheal deviation; this is a late finding and is not - necessary to clinically confirm diagnosis. There will also be hyper-resonance and decreased or absent breath sounds over the a ff ected hemithorax. Tension pneumothorax is a clinical diagnosis and treatment should never be delayed by waiting for radiological confirmation. Always treat it with a high index of suspicion of being present ( Figure 29.3 ). Treatment consists of immediate decompression. This was historically taught by rapid insertion of a large-bore cannula into the second intercostal space in the mid-clavicular line of the a ff ected side, follo wed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line. However, current teaching advocates undertaking decompression in the safe triangle – defined posteriorly by latissimus dorsi, anteriorly by the lateral border of pectoralis major and inferiorly by a line perpendicular to the nipple going to the back, just anterior to the mid-axillary line – or, in extremis, a finger thoracostomy at the same location. Pericardial tamponade Pericardial tamponade needs to be di ff erentiated from a tension pneumothorax in the shocked patient with distended neck veins. It is most commonly the result of penetrating trauma. Accumulation of a relatively small amount of blood (50 /uni00A0 mL) into the non-distensible pericardial sac can produce compression of the heart and obstruction of the venous return, leading to decreased filling of the cardiac chambers during diastole. All patients with penetrating injury anywhere near the - heart plus shock must be considered to have a cardiac injury until proven otherwise. Classically , the presentation consists of central venous pressure elevation, a decline in arterial pressure with tachycardia and mu ffl ed heart sounds. However, in cases TABLE 29.3 The ‘deadly dozen’ threats to life from chest injury. Immediately life- Airway obstruction threatening Tension pneumothorax Pericardial tamponade Open pneumothorax Massive haemothorax Flail chest Potentially life- Aortic injuries threatening Tracheobronchial injuries Myocardial contusion Rupture of the diaphragm Oesophageal injuries Pulmonary contusion Figure 29.3 Radiological appearance of a tension pneumothorax (courtesy of Dr Elizabeth Dick, Consultant Radiologist, Imperial College Healthcare NHS Trust, London, UK). neck veins may be flat. A high index of suspicion and further diagnostic investigations will be needed to make the diagnosis is those cases that are not clinically obvious. These include an eFAST showing fluid in the pericardial sac, which is the most expeditious and reliable diagnostic tool, or chest radiography , looking for an enlarged heart shadow . In penetrating injury to the heart there is usually a sub stantial clot in the pericardium, which may prevent aspiration. Pericardiocentesis has no role in the management of cardiac tamponade secondary to penetrating myocardial injury . The correct immediate treatment of tamponade is operative, either via a subxiphoid window or by open surgery (sternotomy or left anterolateral thoracotomy), with repair of the heart in the operating theatre if time allows or otherwise in the emergency department. Summary box 29.4 Pericardial tamponade /uni25CF /uni25CF /uni25CF Open pneumothorax (‘sucking chest wound’) This is due to a large open defect in the chest (>3 /uni00A0 cm), lead ing to immediate equilibration between intrathoracic and atmospheric pressure. If the opening in the chest wall exceeds about two-thirds of the diameter of the trachea, then with each inspiratory cycle air will be pr eferentially drawn through the defect rather than through the trachea. Air accumulates in the hemithorax (rather than in the lung) with each inspiration, leading to profound hypoventilation on the a ff ected side and hypoxia. If there is a valvular e ff ect, increasing amounts of air in the pleura will result in a tension pneumothorax (see Tension pneumothorax ). Initial management consists of promptly closing the defect ◊ with a sterile occlusive plastic dressing (e.g. OPSITE or similar product), taped on three sides to act as a flutter-type valve. A chest tube is inserted as soon as possible in a site remote from the injury site. Massive haemothorax The most common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally from the internal mammary artery secondary to fractures of the ribs. In penetrating injury , a variety of viscera, both thoracic and abdominal (with blood leaking through a hole in the diaphragm from the positive pressure abdomen into the negative pressure thorax), may be involved. ◊ Trademark of Smith+Nephew. compromise respiratory e ff orts, compressing the lung and preventing adequate ventilation. Presenta tion is with haemorrhagic shock, flat neck veins, unilateral absence of breath sounds and dullness to percussion. The initial treatment consists of correcting the hypovolaemic shock, insertion of an intercostal drain and, in some cases, intubation. Initial drainage - of more than 1500 /uni00A0 mL of blood or ongoing haemorrhage of more than 200 /uni00A0 mL/h over 3–4 hours is generally considered an indication for urgent thoracotomy . Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding, an empy - There is no role for clamping a ema or fibr othorax later. chest tube to tamponade a massive haemothorax . The following points are important in the management of an open pneumothorax/haemothorax: /uni25CF if the lung does not reinflate, the drain should be placed on low-pressure (5 /uni00A0 cmH O) suction; 2 /uni25CF clot occlusion of a chest drainage tube may result in ‘no’ drainage, even in the presence of ongoing bleeding; /uni25CF a second drain is sometimes necessary (but see Tracheobronchial injuries ); /uni25CF a chest radiograph or eFAST can help identify the pres - ence of blood; /uni25CF physiotherapy and active mobilisation should begin as soon as possible. Flail chest This condition usually results from blunt trauma associated with multiple rib fractures, and is defined as three or more ribs fractured in two or more places. The blunt force typically - also produces an underlying pulmonary contusion. The diagnosis is made clinically in patients who are not ventilated, not by radiography . To confirm the diagnosis the chest wall can be observed for paradoxical motion of a chest wall segment. On inspiration, the loose segment of the chest wall is displaced inwards and therefore less air moves into the lungs. On expiration, the segment moves outwards (paradoxical respiration). V oluntary splinting of the chest wall occurs as a result of pain, so mechanically impaired chest wall movement and the associated lung contusion all contribute to the hypoxia. There is a high risk of developing a pneumothorax or haemothorax. The CT scan remains the gold standard for diagnosis of this condition. Traditionally , mechanical ventilation was used to ‘internally splint’ the chest but had a price in terms of intensive care unit (ICU) resources and ventilation-dependent morbidity . Currently , treatment consists of oxygen administration, adequate analgesia (including opiates) and physiotherapy . If a chest tube is in place, topical intrapleural local analgesia introduced via the tube can also be used. V entilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen. Surgery to stabilise the flail segment using internal fixation of the ribs may be useful in a selected group of patients with isolated or severe chest injury and pulmonary contusion. The presentation is similar to a tension pneumothorax – deteriorating cyanosis, tachycardia and agitation eFAST is diagnostic and may also detect free /f_l uid in the abdomen or pericardium There is no role for pericardiocentesis in traumatic cardiac tamponade. A left anterolateral thoracotomy or sternotomy should be performed with evacuation of the haematoma and repair of the myocardium Figure 29.4 Chest radiograph showing a widened mediastinum (courtesy of Dr Elizabeth Dick, Consultant Radiologist, Imperial College Healthcare NHS Trust, London, UK). Immediate life-threatening injuries Airway obstruction Early intubation is very important, particularly in cases of neck haematoma or possible airway oedema. Airway distortion can be insidious and progressive and can make delayed intubation more di ffi cult if not impossible. Tension pneumothorax A tension pneumothorax develops when a ‘one-way valve’ air leak occurs either from the lung or through the chest wall. Air is sucked into the thoracic cavity without any means of escape, completely collapsing and then compressing the a ff ected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung. The most common causes are penetrating chest trauma, blunt chest trauma with a parenchymal lung injury and air leak that did not spontaneously close, iatrogenic lung injury (e.g. due to central venepuncture) and mechanical positiv e-pressure ventilation. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The clinical presentation is dramatic. The patient is increas ingly restless with tachypnoea, dyspnoea and distended neck veins (similar to pericardial tamponade). Clinical examination may reveal tracheal deviation; this is a late finding and is not - necessary to clinically confirm diagnosis. There will also be hyper-resonance and decreased or absent breath sounds over the a ff ected hemithorax. Tension pneumothorax is a clinical diagnosis and treatment should never be delayed by waiting for radiological confirmation. Always treat it with a high index of suspicion of being present ( Figure 29.3 ). Treatment consists of immediate decompression. This was historically taught by rapid insertion of a large-bore cannula into the second intercostal space in the mid-clavicular line of the a ff ected side, follo wed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line. However, current teaching advocates undertaking decompression in the safe triangle – defined posteriorly by latissimus dorsi, anteriorly by the lateral border of pectoralis major and inferiorly by a line perpendicular to the nipple going to the back, just anterior to the mid-axillary line – or, in extremis, a finger thoracostomy at the same location. Pericardial tamponade Pericardial tamponade needs to be di ff erentiated from a tension pneumothorax in the shocked patient with distended neck veins. It is most commonly the result of penetrating trauma. Accumulation of a relatively small amount of blood (50 /uni00A0 mL) into the non-distensible pericardial sac can produce compression of the heart and obstruction of the venous return, leading to decreased filling of the cardiac chambers during diastole. All patients with penetrating injury anywhere near the - heart plus shock must be considered to have a cardiac injury until proven otherwise. Classically , the presentation consists of central venous pressure elevation, a decline in arterial pressure with tachycardia and mu ffl ed heart sounds. However, in cases TABLE 29.3 The ‘deadly dozen’ threats to life from chest injury. Immediately life- Airway obstruction threatening Tension pneumothorax Pericardial tamponade Open pneumothorax Massive haemothorax Flail chest Potentially life- Aortic injuries threatening Tracheobronchial injuries Myocardial contusion Rupture of the diaphragm Oesophageal injuries Pulmonary contusion Figure 29.3 Radiological appearance of a tension pneumothorax (courtesy of Dr Elizabeth Dick, Consultant Radiologist, Imperial College Healthcare NHS Trust, London, UK). neck veins may be flat. A high index of suspicion and further diagnostic investigations will be needed to make the diagnosis is those cases that are not clinically obvious. These include an eFAST showing fluid in the pericardial sac, which is the most expeditious and reliable diagnostic tool, or chest radiography , looking for an enlarged heart shadow . In penetrating injury to the heart there is usually a sub stantial clot in the pericardium, which may prevent aspiration. Pericardiocentesis has no role in the management of cardiac tamponade secondary to penetrating myocardial injury . The correct immediate treatment of tamponade is operative, either via a subxiphoid window or by open surgery (sternotomy or left anterolateral thoracotomy), with repair of the heart in the operating theatre if time allows or otherwise in the emergency department. Summary box 29.4 Pericardial tamponade /uni25CF /uni25CF /uni25CF Open pneumothorax (‘sucking chest wound’) This is due to a large open defect in the chest (>3 /uni00A0 cm), lead ing to immediate equilibration between intrathoracic and atmospheric pressure. If the opening in the chest wall exceeds about two-thirds of the diameter of the trachea, then with each inspiratory cycle air will be pr eferentially drawn through the defect rather than through the trachea. Air accumulates in the hemithorax (rather than in the lung) with each inspiration, leading to profound hypoventilation on the a ff ected side and hypoxia. If there is a valvular e ff ect, increasing amounts of air in the pleura will result in a tension pneumothorax (see Tension pneumothorax ). Initial management consists of promptly closing the defect ◊ with a sterile occlusive plastic dressing (e.g. OPSITE or similar product), taped on three sides to act as a flutter-type valve. A chest tube is inserted as soon as possible in a site remote from the injury site. Massive haemothorax The most common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally from the internal mammary artery secondary to fractures of the ribs. In penetrating injury , a variety of viscera, both thoracic and abdominal (with blood leaking through a hole in the diaphragm from the positive pressure abdomen into the negative pressure thorax), may be involved. ◊ Trademark of Smith+Nephew. compromise respiratory e ff orts, compressing the lung and preventing adequate ventilation. Presenta tion is with haemorrhagic shock, flat neck veins, unilateral absence of breath sounds and dullness to percussion. The initial treatment consists of correcting the hypovolaemic shock, insertion of an intercostal drain and, in some cases, intubation. Initial drainage - of more than 1500 /uni00A0 mL of blood or ongoing haemorrhage of more than 200 /uni00A0 mL/h over 3–4 hours is generally considered an indication for urgent thoracotomy . Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding, an empy - There is no role for clamping a ema or fibr othorax later. chest tube to tamponade a massive haemothorax . The following points are important in the management of an open pneumothorax/haemothorax: /uni25CF if the lung does not reinflate, the drain should be placed on low-pressure (5 /uni00A0 cmH O) suction; 2 /uni25CF clot occlusion of a chest drainage tube may result in ‘no’ drainage, even in the presence of ongoing bleeding; /uni25CF a second drain is sometimes necessary (but see Tracheobronchial injuries ); /uni25CF a chest radiograph or eFAST can help identify the pres - ence of blood; /uni25CF physiotherapy and active mobilisation should begin as soon as possible. Flail chest This condition usually results from blunt trauma associated with multiple rib fractures, and is defined as three or more ribs fractured in two or more places. The blunt force typically - also produces an underlying pulmonary contusion. The diagnosis is made clinically in patients who are not ventilated, not by radiography . To confirm the diagnosis the chest wall can be observed for paradoxical motion of a chest wall segment. On inspiration, the loose segment of the chest wall is displaced inwards and therefore less air moves into the lungs. On expiration, the segment moves outwards (paradoxical respiration). V oluntary splinting of the chest wall occurs as a result of pain, so mechanically impaired chest wall movement and the associated lung contusion all contribute to the hypoxia. There is a high risk of developing a pneumothorax or haemothorax. The CT scan remains the gold standard for diagnosis of this condition. Traditionally , mechanical ventilation was used to ‘internally splint’ the chest but had a price in terms of intensive care unit (ICU) resources and ventilation-dependent morbidity . Currently , treatment consists of oxygen administration, adequate analgesia (including opiates) and physiotherapy . If a chest tube is in place, topical intrapleural local analgesia introduced via the tube can also be used. V entilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen. Surgery to stabilise the flail segment using internal fixation of the ribs may be useful in a selected group of patients with isolated or severe chest injury and pulmonary contusion. The presentation is similar to a tension pneumothorax – deteriorating cyanosis, tachycardia and agitation eFAST is diagnostic and may also detect free /f_l uid in the abdomen or pericardium There is no role for pericardiocentesis in traumatic cardiac tamponade. A left anterolateral thoracotomy or sternotomy should be performed with evacuation of the haematoma and repair of the myocardium Figure 29.4 Chest radiograph showing a widened mediastinum (courtesy of Dr Elizabeth Dick, Consultant Radiologist, Imperial College Healthcare NHS Trust, London, UK). Immediate life-threatening injuries Airway obstruction Early intubation is very important, particularly in cases of neck haematoma or possible airway oedema. Airway distortion can be insidious and progressive and can make delayed intubation more di ffi cult if not impossible. Tension pneumothorax A tension pneumothorax develops when a ‘one-way valve’ air leak occurs either from the lung or through the chest wall. Air is sucked into the thoracic cavity without any means of escape, completely collapsing and then compressing the a ff ected lung. The mediastinum is displaced to the opposite side, decreasing venous return and compressing the opposite lung. The most common causes are penetrating chest trauma, blunt chest trauma with a parenchymal lung injury and air leak that did not spontaneously close, iatrogenic lung injury (e.g. due to central venepuncture) and mechanical positiv e-pressure ventilation. /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF /uni25CF The clinical presentation is dramatic. The patient is increas ingly restless with tachypnoea, dyspnoea and distended neck veins (similar to pericardial tamponade). Clinical examination may reveal tracheal deviation; this is a late finding and is not - necessary to clinically confirm diagnosis. There will also be hyper-resonance and decreased or absent breath sounds over the a ff ected hemithorax. Tension pneumothorax is a clinical diagnosis and treatment should never be delayed by waiting for radiological confirmation. Always treat it with a high index of suspicion of being present ( Figure 29.3 ). Treatment consists of immediate decompression. This was historically taught by rapid insertion of a large-bore cannula into the second intercostal space in the mid-clavicular line of the a ff ected side, follo wed by insertion of a chest tube through the fifth intercostal space in the anterior axillary line. However, current teaching advocates undertaking decompression in the safe triangle – defined posteriorly by latissimus dorsi, anteriorly by the lateral border of pectoralis major and inferiorly by a line perpendicular to the nipple going to the back, just anterior to the mid-axillary line – or, in extremis, a finger thoracostomy at the same location. Pericardial tamponade Pericardial tamponade needs to be di ff erentiated from a tension pneumothorax in the shocked patient with distended neck veins. It is most commonly the result of penetrating trauma. Accumulation of a relatively small amount of blood (50 /uni00A0 mL) into the non-distensible pericardial sac can produce compression of the heart and obstruction of the venous return, leading to decreased filling of the cardiac chambers during diastole. All patients with penetrating injury anywhere near the - heart plus shock must be considered to have a cardiac injury until proven otherwise. Classically , the presentation consists of central venous pressure elevation, a decline in arterial pressure with tachycardia and mu ffl ed heart sounds. However, in cases TABLE 29.3 The ‘deadly dozen’ threats to life from chest injury. Immediately life- Airway obstruction threatening Tension pneumothorax Pericardial tamponade Open pneumothorax Massive haemothorax Flail chest Potentially life- Aortic injuries threatening Tracheobronchial injuries Myocardial contusion Rupture of the diaphragm Oesophageal injuries Pulmonary contusion Figure 29.3 Radiological appearance of a tension pneumothorax (courtesy of Dr Elizabeth Dick, Consultant Radiologist, Imperial College Healthcare NHS Trust, London, UK). neck veins may be flat. A high index of suspicion and further diagnostic investigations will be needed to make the diagnosis is those cases that are not clinically obvious. These include an eFAST showing fluid in the pericardial sac, which is the most expeditious and reliable diagnostic tool, or chest radiography , looking for an enlarged heart shadow . In penetrating injury to the heart there is usually a sub stantial clot in the pericardium, which may prevent aspiration. Pericardiocentesis has no role in the management of cardiac tamponade secondary to penetrating myocardial injury . The correct immediate treatment of tamponade is operative, either via a subxiphoid window or by open surgery (sternotomy or left anterolateral thoracotomy), with repair of the heart in the operating theatre if time allows or otherwise in the emergency department. Summary box 29.4 Pericardial tamponade /uni25CF /uni25CF /uni25CF Open pneumothorax (‘sucking chest wound’) This is due to a large open defect in the chest (>3 /uni00A0 cm), lead ing to immediate equilibration between intrathoracic and atmospheric pressure. If the opening in the chest wall exceeds about two-thirds of the diameter of the trachea, then with each inspiratory cycle air will be pr eferentially drawn through the defect rather than through the trachea. Air accumulates in the hemithorax (rather than in the lung) with each inspiration, leading to profound hypoventilation on the a ff ected side and hypoxia. If there is a valvular e ff ect, increasing amounts of air in the pleura will result in a tension pneumothorax (see Tension pneumothorax ). Initial management consists of promptly closing the defect ◊ with a sterile occlusive plastic dressing (e.g. OPSITE or similar product), taped on three sides to act as a flutter-type valve. A chest tube is inserted as soon as possible in a site remote from the injury site. Massive haemothorax The most common cause of massive haemothorax in blunt injury is continuing bleeding from torn intercostal vessels or occasionally from the internal mammary artery secondary to fractures of the ribs. In penetrating injury , a variety of viscera, both thoracic and abdominal (with blood leaking through a hole in the diaphragm from the positive pressure abdomen into the negative pressure thorax), may be involved. ◊ Trademark of Smith+Nephew. compromise respiratory e ff orts, compressing the lung and preventing adequate ventilation. Presenta tion is with haemorrhagic shock, flat neck veins, unilateral absence of breath sounds and dullness to percussion. The initial treatment consists of correcting the hypovolaemic shock, insertion of an intercostal drain and, in some cases, intubation. Initial drainage - of more than 1500 /uni00A0 mL of blood or ongoing haemorrhage of more than 200 /uni00A0 mL/h over 3–4 hours is generally considered an indication for urgent thoracotomy . Blood in the pleural space should be removed as completely and rapidly as possible to prevent ongoing bleeding, an empy - There is no role for clamping a ema or fibr othorax later. chest tube to tamponade a massive haemothorax . The following points are important in the management of an open pneumothorax/haemothorax: /uni25CF if the lung does not reinflate, the drain should be placed on low-pressure (5 /uni00A0 cmH O) suction; 2 /uni25CF clot occlusion of a chest drainage tube may result in ‘no’ drainage, even in the presence of ongoing bleeding; /uni25CF a second drain is sometimes necessary (but see Tracheobronchial injuries ); /uni25CF a chest radiograph or eFAST can help identify the pres - ence of blood; /uni25CF physiotherapy and active mobilisation should begin as soon as possible. Flail chest This condition usually results from blunt trauma associated with multiple rib fractures, and is defined as three or more ribs fractured in two or more places. The blunt force typically - also produces an underlying pulmonary contusion. The diagnosis is made clinically in patients who are not ventilated, not by radiography . To confirm the diagnosis the chest wall can be observed for paradoxical motion of a chest wall segment. On inspiration, the loose segment of the chest wall is displaced inwards and therefore less air moves into the lungs. On expiration, the segment moves outwards (paradoxical respiration). V oluntary splinting of the chest wall occurs as a result of pain, so mechanically impaired chest wall movement and the associated lung contusion all contribute to the hypoxia. There is a high risk of developing a pneumothorax or haemothorax. The CT scan remains the gold standard for diagnosis of this condition. Traditionally , mechanical ventilation was used to ‘internally splint’ the chest but had a price in terms of intensive care unit (ICU) resources and ventilation-dependent morbidity . Currently , treatment consists of oxygen administration, adequate analgesia (including opiates) and physiotherapy . If a chest tube is in place, topical intrapleural local analgesia introduced via the tube can also be used. V entilation is reserved for patients developing respiratory failure despite adequate analgesia and oxygen. Surgery to stabilise the flail segment using internal fixation of the ribs may be useful in a selected group of patients with isolated or severe chest injury and pulmonary contusion. The presentation is similar to a tension pneumothorax – deteriorating cyanosis, tachycardia and agitation eFAST is diagnostic and may also detect free /f_l uid in the abdomen or pericardium There is no role for pericardiocentesis in traumatic cardiac tamponade. A left anterolateral thoracotomy or sternotomy should be performed with evacuation of the haematoma and repair of the myocardium Figure 29.4 Chest radiograph showing a widened mediastinum (courtesy of Dr Elizabeth Dick, Consultant Radiologist, Imperial College Healthcare NHS Trust, London, UK).