65. Thorax

From Primary Surgery

65.1 The general method for a thoracic injury

Fig. 65-1 A SEVERE CHEST INJURY. A, this patient has surgical emphysema-in spite of his alarming appearance, this part of his injury is benign. B, a broken rib has punctured his lung, air has collected under pressure in his right pleural cavity, compressed his right lung, and forced his mediastinum over to the left, impairing the ventilation of his left lung. Air has also escaped into his mediastinum and tracked up into his neck and face. Adapted from an original illustration by Frank H. Netter, M.D. from the CIBA collection of medical illustrations, copyright by CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation.

A severe chest injury is terrifying for a conscious patient. You can usually save the patient's life, but you must have a logical approach worked out in advance. His injury can be a blunt one from a road accident, or a penetrating one from a bullet, a spear, or an arrow. Often, his chest injury is only one of several other injuries. The procedure that he is likely to need most urgently is to have blood and air drained from a pleural cavity-rapidly and, if necessary, on both sides. This is the critical procedure in thoracic surgery, and is often not done when it should be. A patient may have any of the following chest injuries:

(1) Broken ribs. A thoracic injury usually breaks the ribs of an older patient. But if a patient is young, his ribs may be so elastic that he can have severe internal injuries without breaking them. By themselves broken ribs are not important and soon heal.

(2) A haemothorax. The blood in a patient's pleural cavity can come from his chest wall, or from his lungs.

(3) A pneumothorax. Air in a pleural cavity usually comes from a patient's lungs, but it can come from his trachea, his bronchi, or his chest wall. A small pneumothorax is usually harmless and resolves spontaneously.

(4) A haemopneumothorax. He may have both blood and air in a pleural cavity.

(5) A tension pneumothorax. The air in a patient's pleural cavity may be under pressure when a wound of his lung, or (rarely) an open chest wound, acts as a valve and allows air to get in but not out. More air is trapped each time he breathes. The lung on the injured side collapses, his mediastinum moves towards the normal side, and restricts the movement of that lung too. His bronchi may kink and make his breathing even more difficult. Unless you rapidly let out the air, he dies.

6) A flail chest. Multiple fractures of a patient's ribs can cause a large part of his chest wall to move independently of the rest of it, or allow it to be pushed inwards (stove-in chest). The danger of a flail chest is that the loose piece, which should be moving outwards during inspiration, may be sucked inwards (paradoxical movement), and greatly impede his breathing. His mediastinum can also move paradoxically as he breathes. The result is that air, which should be replaced with each respiration, merely moves from one lung to the other (paradoxical breathing).

(7) A sucking chest wound allows a pleural cavity to communicate with the outside air, with the result that the lung on the injured side collapses, the patient's mediastinum moves paradoxically, and he has paradoxical breathing. Closing his open wound may save his life.

(8) Surgical emphysema is the result of air escaping into the tissues, usually under the skin. Air in the mediastinum is much more serious and may indicate the rupture of a bronchus.

(9) Shocked lung is the result of contusion by a shock wave. This is common and causes haemoptysis.

(10) Other injuries in a patient's thorax or abdomen include injuries to his aorta, his diaphragm, his heart, his liver, his spleen, or his thoracic spine. Aortic tears are a common cause of death in road accidents.

Here are some of the ways you can help a patient. The purpose of most of them is to make sure that his lungs are normally ventilated: (1) You can secure his airway, and encourage him to cough and clear it. It is easily obstructed, especially if he is a child, and he can only too easily inhale blood, secretions, or the contents of his stomach. He may need bronchoscopy, suction, tracheal intubation, or occasionally tracheostomy. This will reduce his dead space and make a tracheal toilet easier. (2) You can remove air from the top of his pleural cavities or blood from the bottom using a drain with an underwater seal. (3) You can close his open chest wound, particularly a sucking one. (4) You can stabilize his flail chest. (5) You can assist his ventilation with a self-inflating bag. (6) You can transfuse him. (7) You can prevent infection. (8) You can relieve cardiac tamponade by aspirating blood from his pericardial cavity. Last and certainly not least, you can provide physiotherapy which will help him to cough. The great danger with all chest injuries is that retained secretions will cause infection, collapse of a lung, and death. Only active physiotherapy will prevent this.

In more severe injuries a patient's chest must be opened and the organs inside it repaired (thoracotomy). This major procedure is beyond our scope here, but fortunately only about 5% of the chest injuries which need a drain need a thoracotom . Ideally, if a patient has anything but the mildest degree of flail chest, he should be connected to an intermittent positive pressure respirator (IPPR), and have his blood gases monitored. This too is unlikely to be possible.

If you don't have a respirator, you can keep a patient inflated with a self inflating bag while you refer him. If this is impossible, we describe other ways of treating a flail chest (65.6).

Don't be too optimistic. Chest injuries can be as deceptive as abdominal ones-although a patient may seem to be in fair condition to start with, he can deteriorate rapidly.

THE GENERAL METHOD FOR A CHEST INJURY

This extends Section 51.3 on the care of a severely injured patient.

THE RAPID ASSESSMENT OF A CHEST INJURY

If a patient's airway is blocked, clear it as in Section 52.1 .

If air is going in and out, but his breathing is distressed, he may have multiple fractured ribs or severe abdominal pain .

If he is making great respiratory efforts, but is still hungry for air, think of a flail chest or a pneumothorax.

If he is cyanosed in the presence of an adequate airway, he may have a badly damaged lung, a flail chest, or a pneumothorax. Give him oxygen. Many patients with chest injuries breathe much more easily as soon as they are intubated.

THE HISTORY OF A CHEST INJURY

Assess the force of the patient's injury carefully. The greater the force, the greater the chances that he has a severe injury.

THE EXAMINATION OF A CHEST INJURY

If a patient is conscious, and is now breathing easily, strip him to the waist, and ask him to describe the pain and show you exactly where it is. if unconscious, remove his clothes and examine his chest carefully.

INSPECTION Assess the rate and depth of the patient's breathing, while he is breathing normally. Ask him to take a deep breath. If his ribs are broken, his attempts to do so will soon be stopped by sharp pain.

Mediastinal shift Is his apex beat in its normal place? Feel in his suprasternal notch to find out if his trachea is displaced.

Do both sides of his chest expand equally?

Look carefully for any areas of diminished chest movement. This may be in one area only, or involve the whole of one side. Look at him from the sides and from the top and bottom of the trolley.

CAUTION ! Look carefully for paradoxical movement. Look at the movement of a normal area, then compare this with the possibily abnormal one. Paradoxical movement may be difficult to see when a patient is shocked and his respiratory movements are small; it may only come on later, when he is resuscitated. Don't be confused by the indrawing of his lower costal margin that is common in mild respiratory obstruction, especially in children.

Are his intercostal spaces distended on one side compared with the other? (tension pneumothorax). Is he cyanosed? Look at his mucous membranes and his finger nails.

CAUTION ! Anaemic patients do not become cyanosed, and may die of anoxia without showing it. There must be 5 g/dl of reduced haemoglobin in a patient's circulation before you can observe cyanosis.

Look carefully for any bruises on his chest caused by a steering wheel or a safety belt, or by the imprint of his clothes.

Are the patient's jugular veins abnormally distended? (anything which impedes the venous return to the heart, a tension pneumothorax, mediastinal shift, and especially cardiac tamponade).

PALPATION If a patient is conscious, start by feeling a pain-free area, and then move towards the injured one. Feel for: (1) Tenderness. (2) Crepitus when fractured ribs move with respiration. (3) The crackly feeling of surgical emphysema. Feel his abdomen for rigidity, tenderness, and distension.

PERCUSSION Do this gently. Don't fail to turn him or sit him up so that you can examine his back. Dullness may indicate blood or the collapse of a lung, and hyper-resonance may be caused by a tension pneumothorax.

ASCULTATION Can you hear the patient's breath sounds all over his chest, or are they diminished? Note especially: (1) Clicking sounds from fractured ribs. (2) The coarse crepitations of surgical emphysema. (3) Reduced or absent breath sounds on one side indicating fluid, or air in a pleural cavity, or the collapse of a lung. Listen for this sign while he is supine, as in Fig. 65-7. (4) High pitched breath sounds suggesting a tension pneumothorax.

The two coin test Place a coin on the patient's chest and tap it with another coin. A bell-like note (combined with other signs) suggests a tension pneumothorax.

OTHER SIGNS OF A CHEST INJURY

ABDOMEN Examine this carefully. Note any tenderness, rigidity or distension. If a patient's lower left ribs are fractured posteriorly, think of a ruptured spleen. If he is tender in his right upper abdomen, suspect a ruptured liver. Fractures of the lower 6 ribs can cause abdominal tenderness without there being any injured abdominal viscera.

FRACTURED RIBS If a patient is not too ill, gently spring his chest from front to back, or from side to side, between your hands. If this causes severe pain he has probably broken some ribs. Feel for the tender fracture sites. They will be easier to feel than to see on an X-ray.

PULSE Is this stronger on inspiration than on expiration? Is his jugular venous pressure raised? These are both signs of cardiac tamponade (65.9).

X-RAY all patients you suspect of having a serious chest injury. X-rays are not necessary to diagnose fractured ribs ( which are difficult to see), but are a useful way of making sure that a patient's lungs and pleural cavities are normal. Unless other injuries prevent it, try to take an erect x-ray. if he cannot stand, you may be able to support him sitting up on a trolley for the very short period that is necessary fore fil m to be taken. Examine the films systematically noting first his rib cage and other bones, then his trachea and lungs, and finally his heart and mediastinum. Look for rib fractures by holding the film obliquely, and looking along each rib.

If you have to X-ray him lying flat on a trolley, try to give the table a slight head up tilt. The films may show a large pneumothorax or a haemothorax, fractured ribs, or surgical emphysema. They will not show a small pneumothorax, ora fluid level in a haemopneumothorax.

Haemothorax A diffuse opacity in a lower lung field, which is more easily seen in an erect film. A haemothorax may not 6e easy to diagnose radiologically, so rely on your stethoscope.

Pneumothorax (1) The lung markings do not reach all the way out to the edge of the thoracic cage. (2) You can see the pleura as a faint line. (3) The apices look different.

Contusion of the lung Diffuse mottling with dense patches in places. These intensify in the next few days and then clear.

Aortic injury If the patient's mediastinum is significantly widened, check the pulses in each of his arms and in each side of his neck. He may have injured his aorta or the great vessels at the root of his neck.

THREE MAJOR DIFFERENTIAL DIAGNOSES IN A CHEST INJURY

If a patient has a large haemothorax, he will be sweaty and clammy, have a rapid, thready pulse, collapsed neck veins, an apex beat in its normal place, and a chest which is stony dull to percussion. Sometimes even a large haemothorax causes very few signs .

If a patient has a tension pneumothorax, he will have increasing difficulty breathing, a rapid pulse which may be of good volume, perhaps slightly distended neck veins , an apex beat and trachea displaced to the other side, and a tympanitic note on percussion.

If he has cardiac tamponade, he will be severely distressed and shocked, he will have a rapid weak pulse, grossly distended neck veins, an apex beat you can neither feel nor see, and a normal percussion note.

PHYSIOTHERAPY is very important to prevent collapse of a l ung. There are these possibilities; (2) and (3) are not suitable for patients with severe rib injuries. (1) Try deep breathing and coughing every 2 to 4 hours, accompanied by suction if necessary. (2) Vibration to the chest wall. (3) Slapping the chest wall.

PARTICULAR INJURIES Read on for methods of draining a patient's chest (65.2), managing uncomplicated fractures of his ribs and sternum (65.3), and treating a haemothorax (65.4), a pneumothorax (65.5), a flail chest (63.5), open chest injuries (65.7), and stab wounds (65.8).

If you are in doubt how to manage a patient, admit him and observe him. A haemothorax may take some days to form.

DON'T OVERLOOK A HAEMOTHORAX

65.2 Draining the pleural cavity

Fig. 65-4 A CHEST SET. You will need this in a hurry, so always keep a chest drain set ready. As assembled by Sam Smith

Drainage is all that a patient with a chest injury usually needs. Remove air by putting a tube into the top of his pleural cavity, usually in his third intercostal space just lateral to his midclavicular line. Drain blood, fluid, or pus from the bottom, usually through his eighth or ninth space in his posterior axillary line. The easiest way to prevent air entering his chest is to lead the tubes from it under the surface of the water in a large bottle (Tudor-Edwards bottle). The principle of this is shown in A, Fig. 65-5. Air from his chest will bubble up from under the surface of the water, without allowing more air to enter. Any fluid in his chest will drip down the tube into the water. Provided the bottle is always well below the patient's bed, water from it cannot enter his chest. If he has both air and fluid in his pleural cavity, some surgeons would put one tube low in his chest and allow air and fluid to bubble out together as froth. Wiser ones insert two tubes.

Here is the equipment for a chest drain set. The life of one medical student was saved after an elephant had punctured his lung, because a tiny clinic had a chest drain set ready. Here is the equipment for it. Have it instantly ready, you will need it in a hurry.

• NEEDLES, hypodermic, large for chest aspiration, 1.6x100mm, 'Luer-lok' mount each, five only. This mount fits the three way stopcock listed below, and is a useful aspirating and exploring needle.

• STOPCOCK, for chest aspiration, `Luer-lok' male to 'Luer-lok' female, with side arm for tubing, two only. Use this for aspirating the chest.

• SYRINGES,. 5 m/ and 20 m/, both 'Luer-lok' These fit the stopcock.

• BOTTLE, Tudor-Edwards, 3 litres, chest drainage, including rubber bung and tubes, one only. This provides an underwater seal for closed drainage of the chest.

• CONNECTOR, for Tudor-Edwards chest drain, five only. This completes the equipment for an underwater chest drain.

• Alternatively, CHEST DRAIN SET, plastic, disposable, sterile, in packet complete, five only. You will not use a chest drain set very often, so the modest expense of a disposable one may be justified.

YOU WILL NEED A CHEST DRAINAGE SET IN A HURRY

SOME URGENT METHODS FOR CHEST INJURIES. A, releasing air from a tension pneumothorax (uncommon). B, aspirating blood from a pleural cavity, (common). C, aspirating the pericardium, (rare). After Naclerio with the kind permission of Grune and Stratton.

The first step is usually a diagnostic aspiration to make sure that a patient really does have fluid in his chest. After this, there are various ways you can put a tube in the chest. The easiest one is to push a large trocar and cannula between his ribs to remove the trocar, and then to push a plastic or rubber tube down the cannula. The cannula is then removed leaving the tube in place. If you don't have a suitable cannula, you can stab his chest wall with a scalpel and then use artery forceps to push a tube through an intercostal space. Always: (1) Take the strictest aseptic precautions. It is tragic to convert a haemothorax to pyohaemothorax, or to introduce new strains of bacteria into an empyema. (2) Prevent more than the minimum amount of air entering his pleural cavity. The alternatives described below do not include the use of a drip set to drain the chest, because: (1) the tube of a drip set is too narrow so that it is easily blocked, and (2) the needle is usually too short to reach the fluid.

DRAINING BLOOD OR AIR FROM THE CHEST

Fig. 65-2 DRAINING AIR AND BLOOD FROM THE CHEST is much the most valuable procedure in chest injuries, and all that most patients need. A, two drains are better than one drain, but, if you do use one drain, leave a sufficiently long length of tube inside the chest with holes near the entry of the tube through the chest wall. B, two tubes, upper and lower are better than one. The bottom tube must be low in the chest if blood is to drain properly. Kindly contributed by James Cairns.

DIAGNOSTIC ASPIRATION

EQUIPMENT A 10 or 20 ml 'Luer-lok' syringe and a 1.6 mm short bevel `Luer-lok' needle. A 5 ml syringe, a fine needle, a No.11 scalpel blade, and some local anaesthetic.

METHOD FOR BLOOD Find an assistant. Sedate the patient, sit him up, and lean him forwards over a bed table or a pile . of pillows.

Sit on a stool beside his bed, and percuss his chest to find the area of maximum dullness. This is usually over his sixth, seventh, or eighth rib in his posterior axillary line.

Use a fine needle to infiltrate a little local anaesthetic into the tissues at the site of the aspiration. Nick his skin with a scalpel blade parallel to his ribs. Push a large needle on the end of a 10 or 20 ml syringe slowly into his chest wall through the nick, pulling back the plunger as you do so.

Remove the syringe as soon as it fills with blood or flu, and put a swab on the hole. Record your findings and the site of the puncture accurately in his notes.

INSERTING A CLOSED INTERCOSTAL DRAIN

Fig. 65-6 INSERTING AN INTERCOSTAL DRAIN. You can also use a Malecot or de Pezzer catheter on an introducer. Kindly contributed by Peter Bewes.

A CHEST SET consists of: (1) A large trocar and cannula 8.3 mm (25 Ch). (2) A 24 to 30 Ch Malecot or de Pezzer catheter which just fits through the trocar. (3) A metre of 8 mm (24 Ch) plastic or rubber tube to join the catheter to the bottle, using a connector. if you don't have a suitable catheter, you can push the end of this tube through the trocar into the chest. if you do, the tube must be thick and stiff enough not to collapse when it goes through the chest. If convenient, you can use a thinner tube (5 mm, 16 Ch) for draining air. (4) A drainage bottle (Tudor-Edwards) complete with a cork and two tubes. Adjust the size of the bottle to the size of the patient. A child needs only a small bottle. (5) A needle holder. (6) Stout artery forceps to clamp the tube. (7) A No. 4 scalpel with a No. 23 blade. (8) Some No.1 monofilament. (9) Ordinary stitch scissors. (10) Gauze swabs and a gallipot.

Wrap all this equipment together in a green towel, put it i n a tray, tie it up with bandages, and autoclave it. Have it always ready sterile, as in Fig. 65-4.

USING A TROCAR AND CANNULA Position the patient, and find the point of maximum dullness as for aspiration.

Infiltrate the place where the tube is to go with anaesthetic solution as in A, Fig. 65-6. Push the needle down to the rib infiltrating as you go. Inject the solution in 1 ml portions, aspirating between each injection. Try to anaesthetize the patient's pleura without entering his pleural cavity. if necessary, anaesthetize one space above and one below the site of insertion of the tube.

Alternatively, block the intercostal nerve (A 6.7) 1 cm proximal to where you intend to introduce your cannula. Apply the first pair of artery forceps some way up the tube (B, Fig. 65-6). It will both clamp the tube, and serve as a gauge as to how much tube there is inside the chest. There must be at least 2 cm (for the free end of the tube in the pleural cavity), plus one chest wall thickness (which will vary with the patient's build), plus the length of the cannula, plus 4 cm spare.

Apply the second forceps to the distal end of the tube.

Nick the patient's skin with the scalpel blade (C), push the trocar and cannula through the infiltrated area into his pleural cavity (D).

Pull out the trocar (E) and quickly push the tube down the cannula (F) . Then pull out the cannula up as far as the first forceps, leaving the tube in his chest. The first pair of artery forceps ensures that the depth of tube inside his chest is just right. Apply the second pair of artery forceps close to his chest wall (G) and remove the cannula from the tube. Ask your assistant to connect the tube to an underwater seal drain as described below.

Release the artery forceps. Anchor the tube to his chest wall with a safety pin and adhesive strapping, or, better with a stitch. Alternatively, use strapping as in Fig. 65-8. Connect the catheter to an underwater seal drain.

CAUTION ! Don't let air get into his chest through the tube. Apply the artery forceps as above, and don't release them until the tube is connected to the underwater seal. if there is any delay in putting the tube into the cannula, plug it with your finger.

ALTERNATIVE USING A SCALPEL, ARTERY FORCEPS, AND A CATHETER

Use a scalpel with a No. 11 blade to make a 1 cm i ncision down to the upper edge of the rib and then through the intercostal space for about 3 mm. Avoid its lower edge, because the intercostal vessels run there. Push a pair of artery forceps or scissors down the incision, and by blunt dissection open up a track down to the pleura. Try not to enter it with the scalpel.

Clamp the catheter with artery forceps, hold the other end of it with another pair of artery forceps, and push it down the track into the pleura, as in H, Fig. 65-6. Alternatively, you can insert a Malecot or de Pezzer catheter on an introducer.

DRAINING AIR FROM THE PLEURAL CAVITY

Using any of the methods above, puncture the patient's third i ntercostal space well outside his midclavicular line, and lead the tube into an underwater seal drain.

MAKING AN UNDERWATER SEAL DRAIN FOR A CHEST INJURY

Fig. 65-5 DRAINING FLUID FROM THE CHEST. A, shows the principle, which is merely to lead a tube from the patient underwater. B, ifyou don't have the proper equipment, use any suitable bottle. C, the one bottle method. D, the two bottle method. Kindly contributed by Peter Bewes and James Cairns.

Take a 3 to 5 litre glass bottle with a large top, and a cork with two holes. Put a litre of water or dilute antiseptic into the bottle. Pass two glass tubes through cork and let one tube go down 5 cm below the level of the fluid. Connect the top end of the long glass tube to the rubber tube draining the patient's chest. Make sure the fit is airtight. The rubber tube must be long enough so that, if he moves about, he does not detach it from the bottle or raise it above the water level.

Ask him to cough. Blood or bubbles should come out of the tube.

Keep a pair of artery forceps near by, so that the rubber tube can be clamped if it becomes detached from the bottle. Fix a piece of strapping to the bottle, and mark the upper level of the fluid on it, so that you can measure how much blood or exudate is discharged.

When the bottle is changed, clamp the rubber tube with the forceps, and release them only when the bottle has been reconnected. if necessary, you can join the tubes from the top and bottom of the patient's chest with a Y-connector and drain them into one bottle.

Measure the volume of blood that drains and transfuse the patient as necessary.

CAUTION ! (1) The end of the tube must be 5 cm below the level of the water so that if the pressure in the chest rises above this, air or fluid will be blown off. I t is an undenvater seal. (2) Make sure that the nurses understand what the bottle is for and that nobody disturbs it. if anybody raises it above the level of the patient's chest, the water and antiseptic in the bottle may go into his pleural cavity!

Alternatively, arrange 2 bottles, as in D, Fig. 65-5. This will allow you to collect the exudate separately from the fluid.

DIFFICULTIES DRAINING THE CHEST

If you have NO SPECIAL BOTTLE, use any large bottle such as the plastic bottle in B, Fig. 65-5 and lead the tubing under the surface of the water. Hold it in place with adhesive strapping. If you want to see the water moving in the tube, fix a piece of glass tubing into the end of the plastic tube. You can use the narrow tube from a drip set, but this is not nearly so effective.

THE TUBE MUST NOT COME OUT ACCIDENTALLY

65.3 Uncomplicated fractures of the ribs and sternum

Fractured ribs are not important unless many are fractured, or unless there are serious injuries inside the patient's chest. The first three ribs are protected by the shoulder girdle in all but the most serious injuries, so it is usually the middle or lower ones that break. When many of a patient's ribs have been broken, the organs inside his chest are sure to have been injured also.

X-rays show only about half of the fractures that exist. They are not really necessary, if you are sure there is no pneumothorax, or least not a large one.

If there are no complications, fractures of the ribs need no treatment except for pain. Local anaesthesia properly done, especially with bupivacaine (A 6.7), can be very effective in relieving this.

Fracture of the sternum is another steering wheel injury. A patient's sternum fractures at the junction of its manubrium and body. Or, it can fracture in an acute flexion injury of his spine. Pain is severe and may interfere with breathing. Treatment is straightforward. Lie him flat in bed for 10 days, unless this interferes with breathing.

Sometimes, a patient's ribs break all round his sternum, so as to produce a 'flail sternum'. This is merely a variety of flail chest.

BROKEN RIBS AFTER A CHEST INJURY

LOCAL ANAESTHESIA FOR BROKEN RIBS Carefully feel the tender areas that indicate the patient's fractures. Mark them on his skin. Inject each fractured rib with 3 ml of 1.5% bupivacaine, or 1% lignocaine, making sure the tip of the needle is down on the rib in the subperiosteal space close to the fracture site. Often, pain relief lasts days, much longer than would be expected after a single dose of anaesthetic solution. The patient will be very grateful.

MANAGEMENT depends on how many ribs are broken and where they are broken.

If only a few of a patient's ribs are broken, (less than 4 fractures are visible on an X-ray, if you take one), and if there are no pulmonary signs, management depends on his age and activity. If he is young, treat him as an out-patient.

The main risk is infection in the underlying injured lung, especially in a frail oId person, and particularly in a heavy smoker, who is not physically active. Keep him moving, give him analgesics, and encourage deep breathing exercises. Warn him that pain may take 3 months to go away.

If a patient's sternum is fractured, lie him flat in bed for a few days, unless this interferes with his breathing.

If he has signs of a haemothorax or pneumothorax, admit him.

If his lower ribs are broken, consider the possibility of a rupture of his liver (66.7) or spleen (66.6).

65.4 Haemothorax and haemopneumothorax

Blood, or blood and air in a patient's pleural cavity, is the commonest complication of a chest injury. Bleeding can occur slowly over several days, so it is often overlooked, especially if a patient has multiple injuries. Detect it by: (1) Dullness to percussion. (2) Reduced breath sounds. Listen for these by sliding a flat stethoscope under his chest while he is, lying down. (3) A diffuse opacity in an X-ray, which is more clearly seen in an erect film. If there has been much bleeding, he will have all the usual signs of internal bleeding (53.2). He may also be cyanosed. If you don't remove blood urgently, it will clot, organize, and prevent his lung re-expanding. When this happens, it can only be made to expand again by decorticating it at thoracotomy. So make sure you diagnose haemothoraces, drain them immediatly, and keep a patient's injured pleura drained. Removing blood also removes the danger of leaving a fluid medium in his chest which may become infected.

DON'T MISS A HAEMOTHORAX

HAEMOTHORAX AND HAEMOPNEUMOTHORAX

Fig. 65-7 HAEMOPNEUMOTHORAX. A, when you examine for a haemothorax, slide your r stethscope under the patient while he is lying down, and listen for reduced air entry. B, this patient's lung has collapsed and he has a fluid level in his pleural cavity. C, if you drain a haemopneumothorax with a single tube, cut side holes in it and push it well up inside the pleural cavity. Kindly contributed by James Cairns and Peter Bewes.

HAEMOTHORAX Aspirate a patient's chest on the suspicion that there might be blood in it. If necessary, aspirate on both sides. If you find blood, insert an intercostal drain with an underwater seal bottle (65.2), on both sides if necessary. Leave the tube in until bleeding stops.

Replace the blood that he loses by transfusing an equal volume.

Examine his lungs several times daily. If drainage is successful, his breath sounds will gradually reappear and increase in strength. His pulse rate should fall and his blood pressure should rise.

If a patient's intercostal drain becomes blocked, reinsert it.

If his lungs fail to expand, refer him for decortication as soon as possible. The earlier you do this the easier the operation will be. If possible, refer him within 3 days.

HAEMOPNEUMOTHORAX Blood and air form a froth in the pleural cavity. Some blood will drain through a catheter i nserted high up anteriorly. But you will usually need to insert asecond one for blood lower down posteriorly. One tube may be enough; two tubes are better. If you decide to rely on a single tube, cut side holes in it and push it well up inside the pleural cavity.

DIFFICULTIES WITH BLOOD OR AIR IN THE CHEST

IF EARLY ASPIRATION FAILS TO WITHDRAW BLOOD, don't be put off. If you think blood is present, insert a drain. Sometimes the blood clots in the first few hours, after which the clot liquifies again before it finally organises a few days later. If the haemothorax is a large one, and clots continually block the tube, a thoracotomy may be necessary, so refer the patient rapidly.

If this is impractical, try resetting a rib and inserting an open drain (6.1).

Fig. 65-5 SOME MORE CHEST METHODS. A, B, and C, an emergency one way valve made from the finger of an old glove. D, to G, a method of making sure a chest drain is not pulled out. Cut nicks in two pieces of strapping, lay them round the tube, and overlap them. Stick two narrower pieces of strapping on top of them and twist these round the tube. H, to J, if you don't have a 3-way tap, drain the chest like this. Tie a piece of tube to two needles, aspirate the chest, and clamp the tube while you discharge the syringe . Kindly contributed by Peter Bewes and James Cairns.

If a patient has a severe chest injury and FAILS TO IMPROVE, (his pulse does not fall and his blood pressure does not rise), consider these possibilities:

(1) Has he any other injuries? X-ray him. You may see: (a) Broadening of his mediastinum suggesting an injury to his aorta. (b) The contents of his abdomen in his pleural cavity. (c) Patchy consolidation in one or both lung fields ('wet lung').

(2)Does he have an abdominal injury? Try peritoneal lavage (66.1). It will not interfere with treatment of his chest injury. If you are in any doubt, don't postpone laparotomy.

If BLOOD CONTINUES TO DRAIN from his pleural cavity, a large vessel has probably been injured, perhaps in his lung. Fortunately, this is rare. Replace blood as it is lost. If more than 500 ml drains during the second hour, thoracotomy is indicated. This is fortunately only necessary in about 5% of cases. If you can refer him for a thoracotomy, do so early.

If his HAEMOTHORAX BECOMES infected, treat it as an empyema (6.1).

DRAIN HAEMOTHORACES EARLY AND, IF NECESSARY, REPEATEDLY

65.5 Pneumothorax

A little air in a patient's pleural cavity causes no symptoms. It is slowly absorbed and needs no treatment. Larger pneumothoraces may cause his lung to collapse permanently, so you must drain them. If air enters through a valve-like injury, the pressure in his pleural cavity rises, displaces his mediastinum, and impairs both his respiration and his circulation. If he has dyspnoea, treatment is urgent, and life-saving. Mediastinal shift makes the diagnosis easy-provided you remember to look for it!

You can easily miss pneumothoraces if a patient has multiple injuries, and they can be fatal if you try to anaesthetize him without diagnosing them. So if there is any doubt, X-ray him first.

A pneumothorax can occasionally occur spontaneously, and complicate tuberculosis.

PNEUMOTHORAX

SIMPLE PNEUMOTHORAX

There is no need to insert an intercostal drain unless: (1) The patient is dyspnoeic. Or, (2) there is enough air in his pleural cavity to lower the apex of his lung about 3 cm below the top of his pleural cavity.

TENSION PNEUMOTHORAX

DIAGNOSIS The patient has severe chest pain, severe and increasing dyspnoea, and sometimes cyanosis. His chest on the side of the lesion is hyper-resonant with poor respiratory movements, and absent breath sounds. His trachea and apex beat are deviated to the other side. Sometimes he has severe abdominal pain which may confuse the diagnosis.

X-RAYS are characteristic, but you have no time to look for them. On the affected side there is: (1) collapse of the lung, (2) the absence of lung markings, (3) flattening of the patient's diaphragm, and (4) widening of his intercostal spaces.

EMERGENCY TREATMENT ANYWHERE Let out the air with a large needle, or with any convenient instrument. This may be life-saving, so don't wait for an X-ray. Take the largest needle you can find; in a real emergency there may not be time to sterilize it. Push it through the patient's third intercostal space in his midclavicular line. The air will hiss out of the needle, his trachea will return to the midline, and he will immediately breathe more easily. He will now live and you can move him. Sometimes this is the only treatment he needs. He usually needs an underwater seal drain.

LATER TREATMENT Follow this emergency treatment by connecting the needle to an underwater seal drain. If none is available, make a valve. Cut the finger off a rubber glove, make a slit in it, and fix it over the adaptor of the needle, as in Fig. 65-8. This valve will let air out, but not in. Don't use it if there is blood in the patient's chest, because it may become blocked. As soon as possible, insert an underwater seal drain.

If there is blood in the pleural cavity, drain this with a second tube through a lower intercostal space posteriorly, as for a haemothorax (65.2).

Deep breathing exercises will help the air to be absorbed.

DIFFICULTIES WITH A PNEUMOTHORAX

If AIR CONTINUES TO BUBBLE OUT OF THE UNDERWATER SEAL, i t may be coming from the patient's lungs, his trachea or his bronchi. X-rays may show that his lung is partly or totally collapsed. Bronchoscopy may show a blood clot in a bronchus and no lumen behind it. If air continues to bubble out of the underwater seal after 5 days, attach a high volume low pressure suction pump to the chest tube. This may expand his lung and bring it up against his chest wall where i t may seal itself. Adjust the pressure to produce bubbling only in expiration. If this fails, refer him for thoracotomy and repair of the tear.

If the patient's LUNG HAS STILL NOT EXPANDED weeks or months after the injury he may have an undiagnosed tear in his bronchus. if possible, refer him for bronchoscopy followed by repair of the tear, or lung resection.

IF YOU SUSPECT A TENSION PNEUMOTHORAX, DON'T WAIT FOR AN X-RAY

65.6 Flail chest

Fig. 65-9 THE MECHANISM OF A FLAIL CHEST. When the patient inspires and his chest expands, the flail section sinks in, and his mediastinum moves towards the normal side. When he expires, the flail section moves out and his mediastinum moves to the other side. The dotted lines show some air moving uselessly from one lung to the other. All this greatly impairs his ability to ventilate his lungs. Adapted from an original painting by Frank H. Netter, M.D. from THE CIBA COLLECTION OF MEDICAL ILLUSTRATIONS. Copyright by CIBA Pharmaceutical Company, Division of CIBA-GEIGY Corporation.

This is one of the really grave emergencies. If a patient is thrown forcefully onto the steering wheel of his car, it may push in part of his rib cage, and break several of his ribs at the front and the back. These fractures may be so aligned with one another that they isolate part of his chest wall. When he inspires, this part of his chest wall moves inwards also (paradoxical movement). He breathes with difficulty, because air can now move from one lung to another, instead of being exhaled. The result is dyspnoea, hypoxia, cyanosis, and carbon dioxide retention, which are especially dangerous if he is older or bronchitic. Multiple fractured ribs cause such great pain and muscle spasm that he tries not to cough. This encourages fluid to collect in his lungs and further spoils their function. Tragically, paradoxical respiration is often overlooked.

A patient's fractured ribs may be anywhere. Sometimes, the front or side of his chest moves paradoxically. Or, he may extensive fractures on either side of his spine, which allow large part of his chest wall to be pulled downwards by his diafra gm. Paradoxical movement is less severe when he has fracat the apex of his rib cage, or under his scapulae, because shoulder girdle can splint his broken ribs.

Many broken ribs bleed severely, and cause a large pneumothorax. Sometimes, a patient's underyling lung is injured so that he has a pneumothorax, perhaps under tension. c. The best way of treating the paradoxical movement caused a flail chest is to use internal pneumatic fixation with IPPR, tion, and tracheostomy. This has to be continued for several weeks while a patient's ribs unite. IPPR has the added difficulty it should be combined with careful monitoring of his blood

Even if he is skillfully nursed on a respirator, the results of treatment are not good. If IPPR is impractical, you have two alternatives:

(1) You can intubate a patient and control his respiration with a self- inflating bag, while you transfer him to a larger hospital, Which has a ventilator.

(2) You can try to fix the floating segment of his chest wall by applying some form of traction for several weeks. Bilateral flail chest is usually fatal without IPPR. But you may be able to treat a patient with a unilateral flail chest, provided he has no serious injures inside his thorax. Unfortunately, most of these patients die. But, if a patient does survive the immediate injury, his outlook is good. Even a permanent dent in his rib cage is unlikely to be important. A tracheostomy sometimes helvs.

FLAIL CHEST

FIRST AID Make sure the patient has a clear airway.

If he now breathes adequately, no further first aid is necessary.

If he is not breathing adequately, try the following methods of keeping the flail segment still until you find one which works.

(1) Gently press it with your hand.

(2) Turn the patient on to his side. This will: (a) keep the flail segment still, (b) keep his uninjured lung uppermost, and (c) prevent blood from his injured lung draining downwards into it.

(3) Support him with strapping or sandbags.

CAUTION ! Don't apply a pad or bandage, because this will only hide the abnormal movement, without stopping it. If necessary intubate him and inflate him with a self-inflating bag. If possible, refer him.

If you cannot refer him, he will certainly need a chest drain and an underwater seal.

Treat his pain. Intercostal blocks (A 6.7) will help him. A single intravenous morphine injection may make a mildly blue, anoxic, sweating patient quiet and pink. Give it cautiously and don't give more than is necessary.

PREVENTING PARADOXICAL MOVEMENT IN A FLAIL CHEST

Fig. 65-10 TRACTION FOR A FLAIL CHEST. Towel clips (A) are usually the most convenient way to apply traction. Or, you can apply it with a Steinmann pin and a stirrup (B and C). If the patient has a severe open injury and is still alive, you can drill his ribs and pass a Kirschner wire through them (D and E). After de Palma and Peter Bewes.

Under local anaesthesia, use any of the following methods to apply traction to one, two, or more points on the floating part of the patient's rib cage.

(1) Grip his flail ribs or sternum with several towel clips, or suitable forceps, and then tie these together with string. The clips or forceps must have a ratchet so that they remain closed.

(2) Pass wire or strong sutures under his ribs or sternum.

(3) Screw some sterile cup hooks into his ribs or sternum

(4) Pass a Steinmann pin under his pectoral muscles close to his ribs, as in B, and C, Fig. 65-10.

Attach cords to any of these traction points, pass them over pulleys, and then tie weights to the cords. Usually, about 500 g per traction point is enough. You may need up to about 5 kg on either side. Fix the pulleys to a frame (70.9), as for fractures.

MANAGEMENT Pay great attention to the patient's breathing. Encourage him to cough and clear his respiratory tract. If loud rhonchi show that fluid is accumulating, consider doing a tracheostomy (52.2).

If the patient's breathing is 'rattly' and he cannot cough, suck out his pharynx. If this fails to clear his airway ade. quately, try bronchoscopic suction.

If his breathing becomes very weak and shallow, resuscitate him with a self-inflating bag (A 13.1), especially during the first 24 hours.

If he is still bleeding after 24 hours, he needs a thoracotomy to find the bleeding point. Continue traction until his chest moves as one piece when the weights are temporarily lifted.

DIFFICULTIES WITH A FLAIL CHEST

If a patient has a FLAIL STERNUM, this is particularly serious. He is in great pain and cannot cough, so he retains his bronchial secretions, and his lungs become oedematous. If you don't have an Abrams pin, use any of the above methods to exert traction on his sternum. Cup hooks are useful.

If he is VERY FAT or muscular, traction will be difficult. You may need to expose his ribs and apply it to them directly.

65.7 Open chest wounds

If a patient has an open chest wound, his injured pleural cavity fills with air (sometimes under tension), his lung collapses, he is in great respiratory distress, and he may die. There may be a sucking noise each time he breathes, or froth from his injured lung may come out of the hole in his chest-a sucking chest wound is an extreme emergency.

Teach your ambulance driver to put an occlusive dressing on open chest wounds. These need a surgical toilet, just like any other wound, but the patient's pleural cavity must be closed. Sucking wounds of the chest, including most gunshot wounds, need a thoracotomy. If you cannot refer a patient, you may be able to treat him, as described below.

OPEN CHEST WOUNDS

Can you hear air being sucked into the patient's pleural cavity each time he breathes? Is his trachea or apex beat displaced? I f so he has a sucking chest wound. He may also have a tension pneumothorax.

EMERGENCY TREATMENT Block the hole with a pad made of several thicknesses of vaseline gauze and dry gauze. Keep it in place with adhesive strapping. if this is not available, use anything convenient.

ANAESTHESIA For large injuries intubate the patient and give him trichlorethylene or a ketamine drip with relaxants (A 8.4). For small injuries use intercostal blocks.

OPERATION Clean the patient's wound, and tie off any bleeding vessels. if you decide to probe, do so cautiously. Do a careful wound toilet. You will be wise to leave most foreign bodies where they are. Remove broken fragments of rib and muscle.

Close the patient's pleura. If possible, try to close his wound by suture. If this is not possible, close it with flaps of near by skin and muscle. If necessary, use Kirschner wire to thread together the ends of any fractured ribs.

If the patient's wound is heavily contaminated, close his pleura, but leave his skin wound open for delayed primary closure.

Insert two intercostal drains, one just below his clavicle to remove air, on one just above his diaphragm posteriorly to remove fluid (65.2). if you suture his skin without inserting a drain he may get massive surgical emphysema.

65.8 Stab wounds of the chest

You may have great difficulty deciding how deep a stab wound is, or which organs in a patient's chest or abdomen have been pierced or are bleeding. If there is air or blood in his pleural cavity, drain them. He will need a thoracotomy: (1) If blood continues to drain from his chest, because it may be coming from his lung, or some other organ inside his thorax. (2) If the stab wound is over his heart or the great vessels at the root of his neck. (3) When an underwater seal drain has failed to slow the loss of blood.

If there is the slightest possibility that the stab wound might have gone through a patient's diaphragm, explore his abdomen, and repair any injured abdominal organs. You do not want to find faeces coming out of a chest tube!

MANY ABDOMINAL ORGANS LIE UNDER THE RIBS!

65.9 Cardiac tamponade

Fig. 65-11 ASPIRATING A PATIENT'S PERICARDIUM from under his xiphoid process. After Naderio, with kind permission

This rare, treatable emergency usually follows a penetrating chest injury, or occasionally a blunt one, which causes bleeding into the patient's pericardial cavity. This prevents his heart filling normally, which: (1) raises his jugular venous pressure, (2) makes his heart sounds faint, (3) causes pulsus paradoxus. Normally, the peripheral pulse becomes stronger on inspiration, because the lower intrathoracic pressure increases the venous return. In pulsus paradoxus the peripheral pulse is stronger on expiration. (4) When there is blood in the pericardial cavity, X-rays show a widening of the heart shadow, especially in the cardiophrenic angle. Screening shows diminished excursion of the borders of the heart. If you can aspirate blood from a patient's pericardial cavity, you may save his life.

CARDIAC TAMPONADE Insert a needle into the patient's pericardial cavity from just under his xiphoid. Alternatively, and less satisfactorily, approach it through his fourth left inter costal space 5 cm from the midline, so as to avoid his internal mammary vessels. Refer him for thoracotomy urgently.

65.10 Other difficulties with a chest injury

There are three important difficulties, the collapse of a lung, traumatic asphyxia, and surgical oedema. Collapse is much the most common; traumatic asphyxia and surgical emphysema are alarming rather than serious.

OTHER DIFFICULTIES WITH A CHEST INJURY

If a whole lobe of a patient's LUNG FAILS TO EXPAND when you insert an underwater seal drain, he is suffering from

PULMONARY COLLAPSE. This is partly due to retained secretions, which is why trying to get a patient with a chest injury to cough is so important, painful although this may be. If he will not cough out retained secretions, aspirate them.

If you have failed to prevent collapse, first try physiotherapy bronchoscope him within an hour. If you cannot do this, pass &sterile rubber catheter or bougie into his unanaesthetized l arynx to start him coughing. if he has to be bronchoscoped more than twice, do a tracheostomy, so that you can aspirate secretions regularly with a fine catheter. Oxygen and antibiotics are only of minor value. Collapse of a lung is common and can complicate any severe chest injury.

If a patient's whole head and arms are COVERED WITH PETECHIAE, he is suffering from TRAUMATIC ASPHYXA. In this rare syndrome violent compression of his chest forces blood into the veins of his head, neck, and arms. Small blood vessels burst and cover his skin with petechiae. He may also have retinal and conjunctival haemorrhages, and become unconscious. Provided he recovers from any other injuries he may have, traumatic asphyxia is not in itself serious. Sit him up in bed and give him oxygen.

If his FACE SWELLS ALARMINGLY, as in Fig. 65-1, and there is a crepitant swelling under the skin and muscles of his neck, he is suffering from SURGICAL EMPHYSEMA. This is common, but it is seldom serious in itself, and soon disappears. He may swell from his pelvis to his forehead. If his eyelids are swollen and he has difficulty seeing, show him how he can milk the air out of them. Where necessary, treat the underlying cause. This may be a leak from a lung that requires an underwater seal. You can remove small quantities of air by massaging it into a few pockets, and then aspirating i t with a syringe and needle. If surgical emphysema spreads or threatens his life, do a tracheostomy. This abolishes coughing and the large rises in intrathoracic pressure it causes.

If air escapes into his mediastinium and pleura from tears in his trachea, oesophagus, or bronchi, it may press on the veins at the base of his neck and congest the veins of his head. Insert an underwater drain and seal and remove the air trapped in his pleura. This may cure him.