Flail Chest. Paradoxical chest wall motion secondary to multiple fractured ribs.

Treatment by intubation and chest tube on affected side. Positive-pressure ventilation may lead to a tension pneumothorax.

Tension pneumothorax. Air under pressure in the pleural space.

Decreased breath sounds, shifted heart sounds, dyspnea, trachea shift from midline, hyperresonance on percussion, distended neck veins, chest pain, hypotension.

Treatment. Needle thoracostomy followed by a chest tube.

Simple pneumothorax-hemothorax from deceleration or penetrating trauma (pneumothorax may also occur spontaneously).

Symptoms as above but without midline shift, may have hypotension from blood loss in hemothorax.

Best to do expiratory chest radiograph. CT scanning is more sensitive, but the clinical significance of pneumothorax-hemothorax found only on CT scan is unknown. Some suggest the placing of a chest tube if the patient has rib fractures and is going to have positive-pressure ventilation.

Treatment. Tube thoracostomy (chest tube)  

If small pneumothorax (<15%), can observe.

Cardiac tamponade

Clinically. Note hypotension, juglar venous distension, muffled heart sounds, pulsus paradoxus.

Pulsus paradoxus. Normally, systolic pressure drops less than 10 mm Hg on inspiration. Decide on systolic pressure when patient has exhaled. Next have the patient inhale and determine the difference between the two systolic pressures. If this number is >10, "pulsus paradoxus" is present.

Treatment is rapid fluid infusion, pericardiocentesis.

Myocardial contusion defined as blunt trauma to the heart.

33% to 88% will have abnormal ECG.

Many have normal CPK-MB, and there is no correlation between the CPK-MB and the degree of injury.

Best diagnostic tests are echocardiography, first-pass biventricular angiography.

Best approach is to simply monitor the hemodynamically stable patient. Specific intervention is seldom needed, and the stable patient does not require diagnostic imaging studies to "prove" the presence of cardiac contusion. Usually the only clinical problem is episodes of PSVT or self-limited ventricular tachycardia.

Aortic disruption.

From deceleration injury.

Look for widened mediastinum on chest radiograph, blurred and enlarged aortic knob, esophageal deviation to right (look at NG tube), apical cap (blood collected at the upper apex of the lungs), chest pain, hypotension. Definitive diagnosis by CT or angiogram. More recently transesophageal echocardiogram has been used with success. Accuracy depends on experience in a particular institution.

Open emergency thoracotomy is not indicated for blunt chest trauma. It is almost never successful. A stab wound to the heart or aorta may be amendable to emergency department intervention. Do this only if trained in the technique and with the blessing of the surgeon who will manage the case in the OR unless patient is obviously terminal if not treated immediately.