What is Thoracic Trauma (Chest Injury)?
Thoracic trauma, or injuries to the chest area, is responsible for up to 35% of trauma-related deaths in the United States. This category includes a wide variety of injuries that can lead to severe health issues or even death. It’s crucial to quickly assess these injuries during an initial trauma evaluation to identify those that pose an immediate threat to life and require fast treatment. Once life-threatening conditions have been checked and ruled out, less urgent chest injuries are often easily detected during a follow-up trauma check. Treating these injuries typically involves using basic principles of advanced trauma life support (ATLS).
What Causes Thoracic Trauma (Chest Injury)?
Thoracic trauma, or injuries to the chest, is generally caused by two types of events: blunt or penetrating trauma. Blunt trauma refers to injuries caused by an impact that doesn’t break the skin, while penetrating trauma involves injuries where an object pierces the skin and enters the body.
Car accidents are the main cause of blunt chest trauma, accounting for up to 80% of such injuries. Other reasons include falls, being hit by a vehicle as a pedestrian, violent acts, and injuries caused by explosions.
On the other hand, penetrating trauma is mainly caused by gunshot wounds or stabbings, which combined are responsible for 20% of all major injuries in the U.S.
Risk Factors and Frequency for Thoracic Trauma (Chest Injury)
Blunt trauma to the chest, as opposed to penetrating damage, is a major cause of trauma deaths, accounting for 20 to 25% of them. This is particularly a concern for people in high-speed vehicle crashes and those who don’t wear seatbelts. Older people and those with more severe injuries generally have worse outcomes. Despite its prevalence, less than one in ten people with blunt chest trauma need surgery, while for penetrating chest injuries, the number increases to 15 to 30%. Penetrating chest trauma, in general, has a higher death rate. The rate of these types of injuries often depends on where you live, with more occurring in urban areas, places with a lot of violence, and conflict zones.
- Blunt chest trauma accounts for 20 to 25% of trauma deaths.
- High-speed vehicle crashes and not wearing a seatbelt increase the risk.
- Older individuals and those with more severe injuries tend to have worse outcomes.
- Less than 10% of individuals with blunt chest trauma need surgery, but for penetrating chest injuries, that increases to 15 to 30%.
- Penetrating chest trauma usually has a higher death rate.
- The rate of chest trauma can be higher depending on location, such as urban areas, places with a lot of violence, and conflict zones.
Signs and Symptoms of Thoracic Trauma (Chest Injury)
When a patient comes in with trauma, healthcare professionals follow a protocol known as ATLS. This method first checks three crucial aspects: the patient’s airway, breathing, and circulation (often referred to as the ABCs). The goal is to quickly spot if the patient is experiencing a life-threatening condition such as a lung collapsing from air pressure (tension pneumothorax), fluid pressure around the heart (cardiac tamponade), injury to the main blood vessel from the heart (aortic injury), significant internal bleeding (massive hemothorax), or damage to the airways (tracheobronchial disruption).
In the trauma bay, doctors look closely at the patient’s appearance upon arrival. Quick signs like breathing difficulties, nervousness, excessive sweating, or resistance to lying flat might suggest severe heart or lung injuries like tension pneumothorax or cardiac tamponade. If these are suspected, the healthcare team would need to intervene quickly to address the patient’s breathing or circulation before checking the airway.
If the patient needs to be put on a breathing tube (intubation), the procedure may make their condition worse by adding pressure inside of the chest. So, if it’s possible, doctors would try to perform the necessary procedures to help the patient’s breathing and circulation before proceeding with intubation. Generally speaking, though, the assessment starts with making sure the airway is clear and figuring out if intubation is needed.
The breathing check begins with the trachea (the “windpipe”). The healthcare team looks and feels to make sure it’s centered and not shifted to one side. Next, they assess the chest wall for signs of unbalanced shape, listen for the breath sounds, and feel for pain, crackling sounds, or floppy sections. When they check circulation, low blood pressure in the patient suffering from chest trauma can be a sign of tension pneumothorax or tamponade. These conditions demand immediate attention before the medical team can continue to evaluate the patient further.
Testing for Thoracic Trauma (Chest Injury)
When dealing with an initial trauma assessment, an ultrasound of the abdomen and chest is a critical part of the process. This ultrasound, called the FAST exam, is usually done during the first physical check to quickly spot any issues with fluid in the chest, belly, or around the heart. These issues could indicate internal bleeding. An extended version of the FAST exam can also help spot a collapsed lung. The ultrasound uses a small probe to get a clear image of what’s happening inside the body. This exam focuses on seeing if the layers of the lung are sliding past each other properly – if they’re not, it could mean the lung has collapsed.
Besides ultrasound, a chest X-ray is another straightforward, quick, and cost-effective method of examining chest injuries. The person would have to retake the X-ray if any procedure is done in the trauma bay to make sure it was performed correctly. If you’ve had a minor accident, don’t have any signs of injury, are sober, and didn’t experience sudden deceleration, then a chest X-ray might not be necessary. But if you meet any of those criteria, then you should have one. On the other hand, a simple physical check isn’t enough to diagnose a pneumothorax, so anyone who has been through a penetration injury would need a chest x-ray.
CT scans are used more often these days to examine trauma patients. It’s more effective than a chest X-ray at detecting a hemothorax or pneumothorax and can also allow doctors to study the rib cage, lung tissue, the middle part of the chest, and the aorta. Doctors will decide to do a CT scan in cases of blunt trauma based on the physical examination, the type of injury, and their clinical judgment. However, CT scans should only be done when the mechanism of injury is substantial or when there are irregular chest x-ray findings, concerning symptoms, or high-risk injury patterns, such as a high-speed car crash, a fall from a significant height, or a direct blow to the chest.
Last but not least, for diagnosing esophageal injuries, techniques like esophagography, esophagoscopy, and bronchoscopy come in handy. Keep in mind, though, esophageal injuries are rare, don’t usually show specific symptoms, and are commonly associated with severe injuries. Chest X-rays may hint towards a problem with the esophagus, but the final diagnosis requires an esophagram or endoscopy. Usually, a water-soluble esophagram is performed first, followed by a barium esophagram if need be. Tracheobronchial injuries are also rare and usually occur under severe, high-risk conditions. In cases of penetrating injuries, often, the trachea and esophagus could both be injured and thus, have to be examined.
Treatment Options for Thoracic Trauma (Chest Injury)
During a trauma evaluation, life-threatening injuries should be quickly identified and addressed. The most common injuries from thoracic trauma, which refers to injury to the chest area, are pneumothorax (collapsed lung) and hemothorax (blood in the chest cavity). About 80% of these cases can be successfully managed with a procedure called tube thoracostomy, or a chest drain. The size of the tube depends on the severity and the type of injury, seen through a chest x-ray. If the condition is less severe, smaller tubes are appropriate, but larger ones may be better in more serious instances.
Occult pneumothorax is a condition where the lung collapse is visible on a CT scan, but not a typical chest x-ray. This condition is found in about 2 to 10% of trauma patients going through chest CT scans. It is recommended that patients having this condition should be closely monitored because it carries a risk of 5 to 10% of lung expansion. If the patient’s condition worsens or if they develop symptoms, a chest tube may be needed.
Chest wall injuries, which are quite common in thoracic trauma, typically occur due to car accidents, especially those involving seat belts or steering wheels impact. Rib fractures are present in up to 10% of all trauma patients, with fractures to the sternum (breastbone) and scapula (shoulder blade) being less common, 8% and 3.5% respectively. Mild cases with less than three rib fractures and no other injuries, can often be managed with pain medications outside of the hospital. However, each case needs to be evaluated individually, and some patients may need hospital admission for monitoring, especially if they are older or have issues maintaining oxygen levels.
Flail chest is a condition occurring when three or more ribs are broken in at least two places, causing a section of the ribs to move independently of the rest of the chest wall. It can potentially lead to respiratory failure due to underlying lung bruising. So, patients in this condition need careful monitoring as their symptoms may worsen over time.
Tension pneumothorax, which is a severe and life-threatening condition, happens when air builds up in the chest and puts pressure on the lung, causing it to collapse. It can be recognized from symptoms like shortness of breath, chest pain, and possibly life-threatening low blood pressure. It needs to be treated immediately, often by using a needle to release the built-up air.
In the case of massive blood build-up in the chest, it usually means there is severe bleeding from broken ribs or lung damage. If this is the case, it is usually treated with surgery. A condition called cardiac tamponade, where blood or fluid fills the sac around the heart, reducing its ability to pump blood, is also a critical condition requiring immediate action.
Penetrating trauma, where an object breaks into the chest cavity, is usually handled with surgery as well. The technique of surgery could vary depending on the injury’s location and severity. In many stable patients, a minimally invasive technique called Video-assisted thoracoscopic surgery (VATS) might be utilized.
Concerning resuscitative thoracotomies, emergency chest-opening procedures performed to manage life-threatening conditions in the chest, the outcomes often depend on the location of the injury as well as immediate signs of life on arrival. The procedure is generally recommended for patients who had a recent trauma and are showing signs of extreme distress or life-threatening injury.
What else can Thoracic Trauma (Chest Injury) be?
Injuries from blunt trauma, like a car accident or fall, can vary widely because many different parts of the chest might be hurt at the same time. These injuries can be caused by direct impact to the chest, a rapid change in speed, being crushed, or explosions. Sometimes, it’s hard to tell how severe the injury is just by looking at a person. Chest injuries, like broken ribs, are common and can usually be found with a physical examination or X-ray. However, some severe injuries might not show any clear signs on the outside, so doctors must be cautious when examining patients.
Things like high-speed car accidents, not wearing a seat belt, a lot of damage to the vehicle, injuries to the head, stomach, or major bones, chest wall bruising, and more can all increase the likelihood of a serious chest injury. On the other hand, penetrating trauma, where something breaks through the chest wall, results in damage based on the path of the object that caused the injury.
If a patient is unstable, meaning their heart rate and blood pressure may be too high or too low, it could be because of certain serious injuries. These might include a condition where blood fills the sac around the heart (cardiac tamponade), a large blood vessel has been damaged causing a large amount of blood in chest (massive hemothorax), or air builds up in the chest cavity causing pressure on the lungs (tension pneumothorax).
For stable patients, common injuries include having blood (hemothorax) or air (pneumothorax) in the chest. These should be quickly diagnosed. If doctors think that the windpipe (tracheobronchial) or food pipe (esophagus) might be injured, especially if there are wounds in specific areas of the chest around the heart (the “cardiac box”), they should do additional tests.
What to expect with Thoracic Trauma (Chest Injury)
The outlook for chest injuries can differ greatly, as they can cover everything from minor rib fractures to lung punctures, all the way to direct injuries to the heart caused by a penetrating object. The severity and type of injury, along with any existing health conditions a patient might have, ultimately decide the likely outcome for someone who has experienced a chest injury.
Possible Complications When Diagnosed with Thoracic Trauma (Chest Injury)
The likelihood of a severe complication after a rib fracture can vary greatly. It’s usually low for simple rib fractures, but it can be quite high if a big medical procedure is needed or if the injury is severe. The chest houses many vital organs and structures, so any complications can often be quite serious. This can include damage to important nerves like the vagus or phrenic nerves, the thoracic duct which carries lymph fluid, or crucial vascular structures that carry blood, which could lead to further issues. The type and seriousness of any complications depend on the extent and cause of the injury, as well as what medical procedures were done to treat it.
Preventing Thoracic Trauma (Chest Injury)
Many chest injuries are caused by incidents such as falls or car accidents. The best way to prevent these is through educating people about safety measures and providing the right preventive care. This can be achieved through public health initiatives and widespread awareness programs.
