Chest Trauma

PT Practice in Cardiorespiratory Conditions
LESSON : Chest Trauma
FACULTY OF HEALTH AND SPORT SCIENCES

Bachelor of Physiotherapy
Physiotherapy Practice in Cardiorespiratory Conditions - 6214
Chest Trauma
Learning objective
At the end students will be able to
• Discuss the different types type of chest wall injuries and its
management.
Introduction
• A chest injury, also known as chest trauma, is any form of
physical injury to the chest including the ribs, heart and
lungs. Chest injuries account for 25% of all deaths from
traumatic injury.
• Typically chest injuries are caused by blunt mechanisms such
as motor vehicle collisions or penetrating mechanisms such
as stabbings.
Anatomy of the chest

Two Lungs (right and left)
Heart
Diaphragm
Main Causes of Chest Trauma

• Blunt Trauma- Blunt force to chest.
• Penetrating Trauma- Projectile that enters chest causing

small or large hole.
• Compression Injury- Chest is caught between two objects

and chest is compressed.
Pneumothorax
• “Pneumothorax” is the
medical term for a collapsed
lung. Pneumothorax occurs
when air enters the space
around your lungs (the
pleural space). Air can find
its way into the pleural
space when there’s an open
injury in your chest wall or a
tear or rupture in your lung
tissue, disrupting the
pressure that keeps your
lungs inflated.
Types and causes of pneumothorax

• The two basic types of pneumothorax are traumatic pneumothorax
and nontraumatic pneumothorax.
Traumatic pneumothorax
• The trauma can damage chest structures and cause air to leak into
the pleural space.
Examples of injuries that can cause a traumatic pneumothorax include:

• trauma to the chest from a motor vehicle accident
• broken ribs
• a hard hit to the chest from a contact sport, such as from a football
tackle
• a stab wound or bullet wound to the chest
• medical procedures that can damage the lung, such as a central line
placement, ventilator use, lung biopsies, or CPR
Spontaneous Pneumothorax
There are two major types of spontaneous pneumothorax:
primary and secondary.
Primary spontaneous pneumothorax (PSP) occurs in people
who have no known lung disease, often affecting young males
who are tall and thin.
Secondary spontaneous pneumothorax (SSP) tends to occur in
older people with known lung problems.
• Some conditions that increase your risk of SSP include:
• chronic obstructive pulmonary disease (COPD), such as
emphysema or chronic bronchitis
• acute or chronic infection, such as tuberculosis or
pneumonia
• lung cancer
Simple/Closed Pneumothorax
• Opening in lung tissue that

leaks air into chest cavity
• Blunt trauma is main cause
• May be spontaneous
• Usually self correcting
Open Pneumothorax
• Opening in chest cavity that allows air to enter pleural
cavity
• Causes the lung to collapse due to increased pressure in
pleural cavity
• Can be life threatening and can deteriorate rapidly
Tension Pneumothorax
• Air builds in pleural space with no where for the air to escape
• Results in collapse of lung on affected side that results in pressure on
mediastium,the other lung, and great vessels
Clinical features of pneumothorax

• The onset of symptoms for a spontaneous pneumothorax normally
occurs at rest. A sudden attack of chest pain is often the first
symptom.
Other symptoms may include:
• a steady ache in the chest
• shortness of breath, or dyspnea
• breaking out in a cold sweat
• tightness in the chest
• turning blue, or cyanosis
• severe tachycardia, or a fast heart rate
Diagnosis
• Diagnosis is based on the presence of air in the space around the
lungs. A stethoscope may pick up changes in lungs sounds, but
detecting a small pneumothorax can be difficult. Some imaging tests
may be hard to interpret due to the air’s position between the chest
wall and lung.
Imaging tests commonly used to diagnose pneumothorax include:
• an upright posteroanterior chest radiograph

• a CT scan
• a thoracic ultrasound
Treatment for Open Pneumothorax
• High Flow oxygen

• Needle aspiration
• Pleurodesis
• Pleurectomy
• Apply occlusive dressing to wound
Occlusive Dressing
• Asherman Chest Seal

Hemothorax
• Hemothorax is the presence of blood in the pleural space.
• The source of blood may be the chest wall, lung
parenchyma, heart, or great vessels.
• Hematocrit value of at least 50% is necessary to differentiate
a hemothorax from a bloody pleural effusion.
Causes
• Hemothorax is usually a consequence of blunt or penetrating trauma.
Much less commonly, it may be a complication of disease, may be
iatrogenically induced, or may develop spontaneously
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax
Hemothorax
May put pressure on the heart

Hemothorax
Where does the blood come from.
Lots of blood vessels

S/S of Hemothorax
• Chest pain, especially when breathing.
• Cold, pale, or clammy skin.
• Rapid heart rate.
• Low blood pressure.
• Tense, rapid, or shallow breathing.
• Difficulty breathing.
• Feelings of restlessness.
• Anxiety.Diminished breath sounds on affected side
• Tachycardia
• Flat neck veins
Diagnosis
• Hemothorax are most commonly detected using a chest X-ray,
although ultrasound is sometimes used in an emergency setting.
• However, plain X-rays may miss smaller hemothorax while other
imaging modalities such as computed tomography (CT), or magnetic
resonance imaging may be more sensitive.
• In cases where the nature of an effusion is in doubt, a sample of fluid
can be aspirated and analysed in a procedure called thoracentesis.
Treatment for haemothorax
• High Flow oxygen

• Needle aspiration
• Thoracocentesis
Flail chest
• Flail chest is a life-threatening
medical condition that occurs
when a segment of the rib cage
breaks due to trauma and
becomes detached from the rest
of the chest wall.
Features of flail chest

• It occurs when multiple adjacent ribs are broken in multiple places,
separating a segment, so a part of the chest wall moves
independently.
• The number of ribs that must be broken varies by differing
definitions: some sources say at least two adjacent ribs are broken in
at least two places, some require three or more ribs in two or more
places.
• The flail segment moves in the opposite direction to the rest of the
chest wall: because of the ambient pressure in comparison to the
pressure inside the lungs, it goes in while the rest of the chest is
moving out, and vice versa. This so-called "paradoxical breathing"is
painful and increases the work involved in breathing.
S/S of Flail Chest

• Shortness of Breath
• Paradoxical Movement
• Bruising/Swelling
• Crepitus( Grinding of bone ends on palpation)
Diagnosis
• Diagnosis is by medical imaging with either plain X ray or CT scan.
Management:
• Treatment of the flail chest initially follows the principles of advanced
trauma life support. Further treatment includes:
• Good pain management includes intercostal blocks and avoiding
opioid pain medication as much as possible. This allows much better
ventilation, with improved tidal volume, and increased blood
oxygenation.
• Positive pressure ventilation, meticulously adjusting the ventilator
settings to avoid pulmonary barotrauma.
• Chest tubes as required.
• Adjustment of position to make the person most comfortable and
provide relief of pain.
• Aggressive pulmonary toilet
• Surgical fixation can help in significantly reducing the duration of
ventilatory support and in conserving the pulmonary function
Pericardial Tamponade
 Blood and fluids leak

into the pericardial sac
which surrounds the
heart.
 As the pericardial sac
fills, it causes the sac to
expand until it cannot
expand anymore
 Once the pericardial sac

can’t expand anymore,
the fluid starts putting
pressure on the heart
 Now the heart can’t
fully expand and can’t
pump effectively.
With poor pumping the
blood pressure starts to
drop.
 The heart rate starts to
increase to compensate but
is unable
 The patient’s level of
conscious drops, and
eventually the patient goes
in cardiac arrest
S/S of Pericardial Tamponade

• Distended Neck Veins
• Increased Heart Rate
• Respiratory Rate increases
• Poor skin color
• Narrowing Pulse Pressures
• Hypotension
• Death
Pericardiocentesis
• Using aseptic technique, Insert at least 3” needle at the
angle of the Xiphoid Cartilage at the 7th rib
• Advance needle at 45 degree towards the clavicle while
aspirating syringe till blood return is seen
• Continue to Aspirate till syringe is full then discard blood and
attempt again till signs of no more blood
• Closely monitor patient due to small about of blood
aspirated can cause a rapid change in blood pressure
Diaphragmatic Rupture
• A tear in the Diaphragm that allows the abdominal organs enter the
chest cavity
• More common on Left side due to liver helps protect the right side of
diaphragm
S/S of Diaphragmatic Rupture

• Abdominal Pain
• Shortness of Air
• Decreased Breath Sounds on side of rupture
• Bowel Sounds heard in chest cavity
Management
• Since the diaphragm is in constant motion with respiration, and
because it is under tension, lacerations will not heal on their own.
• Surgery is needed to repair a torn diaphragm.
• Most of the time, the injury is repaired during laparotomy.
Main references supporting the course:
1.Dean, E. & Frownfelter. K. (2012). Principles and practice of

cardiopulmonary physical Therapy. USA: Mosby. 5th edition.
2.Webber, B.A. & Pryor J.A. (1993). Physiotherapy for
respiratory and cardiac problems UK: Longman Group.
3.Patricia A. Downie. (1987). Cash's Textbook of Chest, Heart
and Vascular conditions for physiotherapists. Jaypee brothers,
New Delhi. 4th edition.

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PT Practice in Cardiorespiratory Conditions

LESSON : Chest Trauma

FACULTY OF HEALTH AND SPORT SCIENCES

Anatomy of the chest

Main Causes of Chest Trauma

• Penetrating Trauma- Projectile that enters chest causing

• Compression Injury- Chest is caught between two objects

Types and causes of pneumothorax

Examples of injuries that can cause a traumatic pneumothorax include:

• Opening in lung tissue that

Clinical features of pneumothorax

Imaging tests commonly used to diagnose pneumothorax include:

• an upright posteroanterior chest radiograph

Treatment for Open Pneumothorax

• High Flow oxygen

• Asherman Chest Seal

May put pressure on the heart

Lots of blood vessels

Treatment for haemothorax

• High Flow oxygen

Features of flail chest

S/S of Flail Chest

 Blood and fluids leak

 Once the pericardial sac

S/S of Pericardial Tamponade

S/S of Diaphragmatic Rupture

Main references supporting the course:

1.Dean, E. & Frownfelter. K. (2012). Principles and practice of

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