CHEST INJURIESSurgical Emergencies 2333 Refer the following patients to the surgical team for admission:
(i) Pneumothorax, haemothorax.
(ii) Fractured sternum with severe pain or ECG abnormalities.
(iii) Injury to other thoracic or abdominal organs.
(iv) Pre-existing lung disease with poor respiratory reserve.
(v) Rib fractures with significant pain. These patients may require a
thoracic epidural.
4 Discharge remaining patients with uncomplicated rib fractures or an
isolated sternal fracture with a normal ECG and CXR.
5 Provide an analgesic such as paracetamol 500 mg and codeine phosphate
8 mg two tablets orally q.d.s.
(i) Recommend regular deep-breathing exercises to prevent
atelectasis.
(ii) Contact the general practitioner (GP) by fax or letter.
6 Positive-pressure ventilation may be required for deteriorating respiratory
function, although an intercostal drain must be inserted first for any
pneumothorax, however small.
Myocardial contusion
DIAGNOSIS
1 This is due to blunt deceleration injury and is associated with rib fractures,
sternal fracture and chest wall contusion. It is difficult to diagnose as there is
no agreed gold standard.
2 It may be asymptomatic, but can cause chest pain or rarely cause transient
right ventricular dysfunction with distended neck veins, tachycardia and
hypotension.
3 Gain i.v. access and send blood for full blood count (FBC), U&Es, cardiac
biomarkers and group and save (G&S).
(i) Cardiac enzyme changes including creatine kinase (CK) and CK-
MB isoenzymes are unreliable, non-specific, and do not predict
the presence of contusion or its complications.
(ii) Troponins are a more reliable indicator of cardiac myocyte
damage, but do not quantify the potential risk, and may be falsely
normal:
(a) in addition they may diagnose antecedent myocardial
infarction, if raised.
4 Perform an ECG.
(i) Myocardial contusion may result in ventricular conduction
abnormalities and malignant arrhythmias.
(ii) ECG abnormalities range from sinus tachycardia, atrial
fibrillation, bundle branch block and ventricular extrasystoles to
non-specific ST and T wave abnormalities or ST elevation.