The Trauma Golden Hour by Unknown

Author:Unknown
Language: eng
Format: epub
ISBN: 9783030264437
Publisher: Springer International Publishing

17.2 Thoracic Lesions

Most common conditions related to thoracic trauma are pain, bleeding, mechanical instability of the chest wall, and defects of the chest wall.

17.3 Pain

Pain should be managed with careful and effective administration of analgesics. Although analgesics do not cause any direct effect on the stability of the wall or any functional alteration, their use can result in posterior ventilator imbalance by conscious decrease of thoracic mobility.

17.4 Pneumothorax

It is found in more than 20% of trauma in general and it is defined as an air collection in pleural space. It can be classified as simple, open, and hypertensive. Classical findings to all kinds of pneumothorax are respiratory discomfort, decrease of vesicular murmur on the affected side and hyperresonance on percussion. In hypertensive pneumothorax, there is also tracheal deviation to the opposite side of the injury, tachycardia, and jugular distention.

The size of the pneumothorax is not always related to the patient’s clinical presentation, which should be prioritized in the evaluation of the treatment. A closed-chest drainage can be performed in patients with a simple pneumothorax (20–22 French tube) in the fifth or sixth intercostal space in the anterior or midaxillary line. It is preferable to place the tube in the anterior axillary line due to more posterior comfort for the patient.

A simple pneumothorax can evolve to a hypertensive pneumothorax; therefore, the patient should be always carefully monitored. As the first management procedure of a hypertensive pneumothorax, a puncture with a gauge needle (10 to 16 gauge), sufficiently long to penetrate through the chest wall in the second or third intercostal space of the affected hemithorax, in the hemiclavicular line, to an immediate decompression, should be performed, transforming the hypertensive pneumothorax into an open pneumothorax. The next step is to perform a pleural drainage. Besides, patients should receive supplementary oxygen by a mask or undergo an orotracheal intubation with mechanical ventilation when necessary. A chest X-ray should be performed after the placement of the tube to verify if it is in place and if the drainage is effective.

During pre-hospital care, sucking chest wounds should be managed with a dressing that seals the wound in three sides to create a valve mechanism (allowing the exit of the air during expiration and preventing its entrance during inspiration). During hospitalar care, the chest drainage is preconized through a different site from the wound – which should be closed by occlusive dressing or synthesis of the skin by separated stitches – and orotracheal intubation when necessary. Bigger defects should be managed surgically by thoracotomy with correction of the lesion, closed-chest drainage, and mechanical ventilation with positive pressure.

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