Life threatening chest injuries need to be identified and managed early during the primary survey of major trauma patients. It is vital to actively search for these conditions, as they may not be apparent on initial presentation. Life threatening injuries may evolve over time, therefore it is important to emphasize the need for constant reassessment.
Use a systematic approach based on the ABCDE survey to assess and treat an acutely injured patient. The goal is to manage any life-threatening conditions and identify any emergent concerns. Clothing should be removed as soon as is possible to gain a thorough view of the patient.
Airway with cervical spine protection
Assess for airway stability and rapidly assess for major injuries affecting airway patency. Consider securing the airway with early intubation if there are any signs of:
Uncooperative/combative patient leading to distress and further risk of injury.
If the patient is already intubated, document the size and position of the endotracheal tube, including lip level, ETCO2 trace, cuff pressure, grade of view and any intubation difficulty (or Mallampati grade).
Maintain full spinal precautions if indicated - suspect spinal injuries in all poly-trauma patients. Ensure a cervical collar (where appropriate) and in-line stabilisation is maintained until appropriate clinical and/or radiological clearance.
For further detail please refer to the Primary Survey section of the Early Trauma Care guideline.
Auscultate chest for bilateral air entry, additional noises.
Rapid, shallow ventilation occurs in chest injury as well as developing hypoxia. All patients with chest injuries have a high oxygen demand and therefore supplemental oxygen should be supplied until injury is excluded or effectively managed. Make sure to check the back also as life threatening injuries may be otherwise undetected. Immediately after detection of any life-threatening injuries, interventions need to occur to prevent further deterioration.
Detecting life threatening injuries:
Tachypnoea, decreased or absent air entry to affected side, decreased chest movement, tracheal deviation (late sign) = Tension pneumothorax –> Finger thoracostomy followed by insertion of intercostal catheter.
Decreased or absent air entry or via eFAST or CXR = Massive Haemothorax ->Chest Tube Insertion
Open ‘sucking wound’, decreased air entry = Open pneumothorax - > 3 sided occlusive dressing, intercostal catheter insertion.
Paradoxical chest movement = Flail Chest & Pulmonary Contusions - >Adequate analgesia / regional block / oxygenation / consider early intubation and ventilation.
A chest x-ray should be performed in the resuscitation bay at the earliest opportunity (and performed with a pelvic x-ray as adjuncts to the primary survey).
Perform eFAST scan looking specifically for evidence of pericardial tamponade or pneumothorax.
Control bleeding if compressible source
Obtain IV access – x 2 large bore, take bloods.
IO access if unable to gain peripheral access.
Fluid replacement: early administration of blood products. If blood products are unavailable administer Normal Saline 0.9% to maintain permissive hypotension Systolic BP >70 to avoid haemodilution. Consult with ARV for further advice in the poorly perfused/bleeding major trauma patient.
eFAST: In experienced hands eFAST has a high sensitivity and specificity. (26) In the hypotensive patient, eFAST should be performed as part of the primary survey. In penetrating trauma to the torso an eFAST should be performed in all cases. In patients who are haemodynamically stable the eFAST may be delayed until the secondary survey if resources do not permit.
Assess level of consciousness, as a measure of end-organ oxygenation and perfusion.
GCS, Pupils, BSL.
Exposure and environmental control
By the end of the primary survey the patient should have been fully exposed to ensure no injuries posing an immediate life threat are overlooked. All patients should be exposed appropriately and sequentially, exposing one body region at a time whilst attempting to preserve patient dignity. Prior to exposing a patient, the patient should be informed and consent should be gained.
Trauma patients are prone to hypothermia, so upon completion of the primary survey deliberate measures to prevent this should be taken. Application of external warming devices such as Bair Huggers / warmed blankets are encouraged if the patient is even mildly hypothermic. Hypothermia in the trauma patient is associated with poorer outcomes and linked to deterioration of clotting abilities with increased blood loss. (27)
FBC, U&E’s, troponin, blood gas, coagulation studies and consider cross match/group and hold.
Titrated IV narcotic analgesia is the initial approach to pain management in trauma.
Ongoing pain from chest trauma decreases coughing, leads to shallow hyperventilation, reduced FRC and retention of sputum. This is of particular concern for the elderly trauma patient who is more prone to developing pneumonia.
Effective pain management may be achieved with the use of paracetamol, non-steroidal anti-inflammatory medicines, opioid analgesia, ketamine, as well as consideration of regional anaesthesia.
A chest wall block (e.g.: SAPB or ESB) should also be considered in this cohort of patients.