Emergency Medicine

CHEST INJURIES

Surgical Emergencies 237

Penetrating chest injury

DIAGNOSIS

1 Penetrating chest injury may be predicted by wounds:
(i) Medial to the nipple line anteriorly or tips of the scapulae
posteriorly – high risk of heart or great vessel injury.
(ii) Below the fourth intercostal space – injury to the abdominal
contents.
(iii) Above the umbilicus – injury to the lungs, heart or great vessels.

2 Patients usually present with pain and dyspnoea. However, some patients are
surprisingly undistressed.

3 The patient may become hypotensive due to blood loss from a haemothorax,
or the development of cardiac tamponade or tension pneumothorax.

4 Gain i.v. access and send bloods.

5 Request a CXR to look for any of the above complications.

6 Arrange an urgent focused bedside ultrasound if cardiac tamponade is
suspected, particularly in t he presence of a raised JVP.

MANAGEMENT

(^1) Assess and secure the airway, give high-f low oxygen, and perform needle
thoracocentesis if required. Commence f luid resuscitation.
2 80% of penetrating chest injuries are managed conservatively with the inser-
tion of an intercosta l drain (see p. 473).
3 Injuries involving the heart and great vessels require a thoracotomy, either in
t he ED or urgent ly in t heatre.
4 Emergency department thoracotomy
Patients in cardiac arrest secondary to trauma require an immediate thora-
cotomy in the resuscitation room:
(i) Optimum survival rates are found in patients with:
(a) palpable pulse and spontaneous respirations at the scene of
the incident
(b) elapsed time since cardiac arrest of <10 min
(c) penetrating trauma secondary to stab wound or low-velocity
bullet.
(ii) Conversely traumatic cardiac arrest is nearly always fatal in
patients with:
(a) blunt chest trauma or a high-velocity bullet wound
(b) absence of palpable pulse or respiratory effort at the scene of
the incident
(c) elapsed time without signs of life >15 min.