Chest and Abdominal Trauma

Blunt vs. penetrating chest trauma

Chest trauma is classified as blunt or penetrating, and the less dramatic of the two is not the safer one. Blunt chest trauma can carry a higher mortality than penetrating trauma, because minimal external evidence can mask massive internal damage. Rib fractures are the most common serious blunt injury. When 2 or more consecutive ribs are fractured in 2 or more places, the result is a flail chest: the fractured section becomes an unstable segment that moves paradoxically, in the direction opposite to the rest of the chest wall, as the patient breathes.

Penetrating trauma raises a different concern. Assume that all open chest wounds penetrate the chest cavity, and never probe a wound to check its depth. A sucking chest wound is a hole large enough that the negative pressure of normal breathing draws air directly through it into the chest.

Care for chest wounds

An open chest wound is sealed immediately. If no dressing is at hand, cover the wound with a gloved hand, then replace it with an occlusive dressing that extends at least 2 in beyond the wound on all sides. Give high-flow oxygen (O2), aiming for a saturation of 94–95%. Because of the risk of tension pneumothorax, request advanced life support (ALS) early, but do not delay transport waiting for them to arrive.

Transport the patient in a position of comfort. A patient with penetrating trauma to the chest or neck does not automatically need spinal immobilization; restrict spinal motion only if blunt trauma also occurred. In a flail chest, never restrict movement of the chest wall, even when paradoxical motion is plainly visible.

Injuries within the chest cavity

Several distinct injuries can develop inside the chest cavity, and each announces itself with a characteristic set of findings. The table below sets out the conditions you must recognize and the key signs of each.

Table 31.1Injuries within the chest cavity

Bear in mind that the chest cavity can hold more than 3 quarts (3 L) of blood with zero external sign of it, so a chest that looks unremarkable can be the site of a life-threatening hemorrhage.

Abdominal injuries

Evisceration is the protrusion of abdominal organs through an open wound. Among the solid organs, the liver, in the right upper quadrant (RUQ), and the spleen, in the left upper quadrant (LUQ), are the most commonly injured. Both are highly vascular, and injury to either can cause life-threatening bleeding. Hollow organs fail differently: when one ruptures, its contents spill into the abdominal cavity, the spilled contents cause peritonitis, and the abdomen becomes rigid.

Gunshot wounds to the abdomen are unpredictable because bullets deflect, fragment and tumble as they travel. Do not assume that only the structures directly beneath the entry wound are injured. A gunshot wound at the level of the lower ribs requires you to assume both a chest injury and an abdominal injury.

Care — open & closed abdominal trauma

Whether the abdominal injury is open or closed, the basic care is the same. Watch for vomiting and protect the airway. Position the patient supine with the knees flexed, which relaxes the abdominal muscles. Give O2 for hypoxia, treat for shock, and give nothing by mouth.

Open wounds call for additional steps. Control bleeding and dress the wounds. Never touch or attempt to replace eviscerated organs; cover them with a sterile dressing moistened with saline and re-moisten it as needed. Never use aluminum foil as an occlusive dressing, because it can cut the eviscerated organs. If an object is impaled, never remove it; stabilize it in place with bulky dressings and leave the patient's legs in the position in which they were found.