Emergency Medicine

CHEST INJURIES

232 Surgical Emergencies

4 Look for diffuse ground-glass haziness over one hemithorax if the CXR is

taken supine, which is easy to miss.

5 Alternatively, take a lateral decubitus CXR.

MANAGEMENT

1 Give high-dose oxygen and commence i.v. f luid, including blood.

2 Insert a large-bore 32- or 36-French gauge intercostal drain in the fifth or

sixth intercostal space in the mid-axillary line, using blunt dissection down

to and through the pleura (see p. 473).

3 A t horacotomy may be required if bleeding is severe and persists (see p. 238).

Rib and sternum fractures

DIAGNOSIS

1 These injuries are associated with direct trauma, including from a seat belt.

They cause localized pain and tenderness, worse on breathing or springing

the chest wall.

2 Associated injury may occur with fractures in the following areas:

(i) Clavicle, first and second ribs: damage to the subclavian vessels,

aorta, trachea, main bronchus, and spinal cord or brachial plexus.

(ii) Sternum: damage to the myocardium, great vessels and upper

thoracic spine.

(iii) Right lower ribs: damage to the liver and right kidney.

(iv) Left lower ribs: damage to the spleen and left kidney.

3 A f lail segment with paradoxical chest wall movement from multiple rib

fractures in two sites causes hypoxia, mainly from the underlying pulmon-

ary contusion.

4 Perform an ECG to exclude myocardial contusion (see below).

5 Request a CXR to look for the associated complications of pneumothorax,

haemothorax and a widened mediastinum, not simply to visualize the

fractures.

(i) A lateral sternal X-ray is indicated for a suspected sternal

fracture.

MANAGEMENT

1 Give the patient high-f low oxygen by face mask and aim for an oxygen

saturation of 94%.

2 Commence i.v. resuscitation as required, insert an intercostal drain if

indicated, and administer adequate analgesia such as increments of

morphine 2.5–5 mg i.v.