Thoracic trauma is responsible for 25% of all trauma deaths and contributes to a further 25%. In Australasia and the UK, 90-95% of all chest trauma is secondary to blunt injury. (2) Motor vehicle crashes account for 70-80% of blunt chest trauma cases. (3) It is important to be aware of the mechanism of injury in chest trauma as blunt and penetrating injuries have different pathophysiology as well as clinical courses.
The initial assessment and management of patients presenting with chest trauma consists of the primary survey with appropriate interventions as per Advanced Trauma Life Support (ATLS)/Early Management of Severe Trauma (EMST) guidelines. Oxygenation should be optimised early, with consideration of ventilatory support for those patients in respiratory failure. In addition, the treating team must consider tension pneumothorax in all patients with signs of shock.(4)
Pulmonary contusions, pneumothorax and haemothorax occur in 30-50% of patients with severe blunt chest trauma. (2)Flail chest injury represents a particularly severe form of chest trauma, and is considered an immediate life threat. Flail chest injury is associated with contusions and haemopneumothorax, and these patients may also experience a degree of mechanical ventilatory failure. A number of factors contribute to morbidity and mortality in patients presenting with thoracic trauma these include failure or delay to perform pleural decompression, delayed or inadequate ventilatory resuscitation, inadequate management of shock, inadequate imaging and insufficient monitoring of arterial blood gases.
Approximately 10% of patients presenting with blunt thoracic trauma and 15 – 30% of patients with penetrating thoracic trauma require surgical intervention.(5)
A higher incidence of mortality is associated with penetrating trauma.(2)The majority of patients who do not require surgical intervention can be managed with supportive care and interventions which may include pleural decompression and drainage. (5)
Resuscitative Thoracotomy (RT) in penetrating trauma may be considered for patients who arrive within 10 minutes of becoming pulseless or with evidence of myocardial mechanical activity on ultrasound and/or electrical activity. (6)Other signs of life are respiratory effort or pupillary reaction. Similarly, patients who have sustained blunt chest trauma and display evidence of cardiac tamponade both clinically and on ultrasound examination, who remain severely hypotensive after chest decompression and volume resuscitation may also be candidates for RT.
Adjuncts to the primary survey include chest x-ray (CXR), extended focused assessment using sonography in trauma (eFAST), arterial blood gasses (ABGs), pulse oximetry and electrocardiogram (ECG) monitoring.
Delayed life-threatening complications are detected in the Secondary Survey where further in-depth examination can take place. Initially, hypoxia may be absent in the patient presentation however this may develop as the injuries evolve. Hypoventilation commonly develops due to pain, fatigue from increased work of breathing as well as side effects of opioid analgesia. Ventilatory support in patients with pulmonary contusions and poor lung compliance require ventilation at lower tidal volumes and low inspiratory pressure to reduce barotrauma and secondary lung injury.
Adequate analgesia is essential and many health services have a chest trauma pain management pathway that is followed to ensure analgesia is appropriately titrated. Any patient who is unable to deep breath and cough without pain should be referred to the hospital acute pain service for consideration for patient-controlled analgesia (PCA). Regional analgesia such as serratus anterior plane block (SAPB) or erector spinae block (ESB) should be considered as adjuncts.
Significant chest injury is rare in paediatric trauma, this is primarily due to the compliance of the chest wall which allows for greater deformation of the chest wall before the ribs fracture The mortality in paediatric patients with thoracic trauma is thought to be as high as 30%; death in paediatrics usually occurs soon after the injury whereas an adult with similar injuries tends to survive longer.(7)
The number of total rib fractures, bilateral rib fractures, and rib fractures in more than two areas are associated with increased complications. (8) Rib fractures are some of the most common injuries in the elderly and those >65 years are twice as likely to develop pneumonia. (9, 10). Patients with co-morbidities including prior poor chest wall compliance as well as the elderly are particularly at risk of hypoventilation in the setting of chest trauma and may deteriorate rapidly.
All patients with thoracic trauma must receive a rapid and systematic primary and secondary survey with appropriate interventions as required. The main goals are to detect and recognise potentially life-threatening injuries, stabilise the patient and manage all findings in a timely and appropriate manner. Patients with significant chest injury, including 3 or more rib fractures, flail chest injury or a need for ventilatory support should be transferred to an MTS.
Patients > 65 years of age, with any significant co-morbidities presenting with non-life threatening chest trauma should be treated with high suspicion and consultation with a MTS or Adult Retrieval Victoria (ARV) should be considered early, as often this cohort of patients can be appropriately managed in regional trauma center, which will avoid unnecessary transfers to a major trauma service for definitive care. If in doubt contact and discuss with receiving trauma team/consultant at the MTS or ARV.