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Introduction to Chest Injuries

By Thomas G. Weiser, MD, MPH, Department of Surgery, Section of Trauma & Critical Care, Stanford University School of Medicine

Chest injuries most often affect the ribs, upper part of the abdomen, lungs, blood vessels, heart, muscles, soft tissues, and breastbone. Sometimes the esophagus, collarbone, or shoulder blade is also injured.

In the United States, chest injuries cause about 25% of deaths due to severe injury. Many of the injuries that can cause death during the first minutes or hours after injury can be treated or stabilized in the emergency department without the need for major surgery.

Causes

The chest can be injured by blunt force (such as in motor vehicle crashes, falls, or sports injuries) or by an object that penetrates it (such as a bullet or knife).

Chest injuries are often serious or immediately life threatening because they interfere with breathing or circulation. Some injuries damage the ribs and chest muscles (called the chest wall) severely enough to make it difficult for the lungs to inflate normally. Damage to the lungs themselves interferes with gas exchange, the main function of the lungs in which oxygen is acquired and carbon dioxide is expelled (see Exchanging Oxygen and Carbon Dioxide). Chest injuries can cause circulatory problems if they result in a lot of bleeding. Bleeding is often inside the chest wall, which also interferes with breathing. Also, injury to the heart can affect circulation by interfering with the heart's ability to pump blood to the body.

Chest injuries that are common or can be severe include the following:

Did You Know...

  • Simple treatments such as insertion of needles or tubes to treat certain chest injuries can be lifesaving.

Symptoms

The injured area is usually tender or painful. Pain is worse when people inhale. The chest may be bruised. Sometimes people are short of breath. If the injury is severe, they may feel very short of breath, drowsy, or confused, and the skin may be cold, sweaty, or blue. Such symptoms may develop when the lungs malfunction severely (respiratory failure—see Respiratory Failure) or people are in shock (see Shock). People in shock typically have dangerously low blood pressure and feel as if their heart is racing.

Other symptoms depend on the specific chest injury. For example, sometimes air accumulates under the skin in people with pneumothorax. Affected skin feels crackly and makes a crackling sound when touched. The veins in the neck are sometimes enlarged if blood or fluid accumulates in the sac around the heart and interferes with the heart's ability to pump blood (called cardiac tamponade—see Cardiac Tamponade) or if tension pneumothorax develops (see Tension Pneumothorax).

Diagnosis

  • A doctor's evaluation

  • Imaging

Usually, a chest injury is obvious. However, the severity of chest injuries cannot be determined without a doctor's evaluation.

First, doctors use a stethoscope to determine whether all parts of the lungs are receiving air, and they carefully examine the neck and chest for injuries. When people are having difficulty breathing, doctors place a sensor on the person's finger (pulse oximeter) to measure the amount of oxygen in the blood. Sometimes doctors measure the amount of oxygen and carbon dioxide in the blood with a blood test (arterial blood gas measurement).

A chest x-ray is almost always taken. Chest x-ray shows most cases of pneumothorax, hemothorax, and collarbone fractures, as well as some rib fractures. However, ultrasonography is usually needed to show heart injuries. Computed tomography (CT), ultrasonography, and/or aortography (angiography of the aorta) may be done if doctors suspect injury to the aorta (see Overview of Imaging Tests).

Sometimes blood tests and electrocardiography (ECG) are also done.

Treatment

  • Support of breathing and circulation

  • Treatment of the specific injury

Injuries that are immediately life threatening are treated as quickly as possible. The specific treatment depends on the injury.

For all injuries, doctors take measures to support breathing and circulation if necessary. People may be given oxygen (for example, by nasal prongs, by face mask, or through a breathing tube) and intravenous fluids or sometimes blood transfusions. People with severe chest injuries are admitted to the hospital.

People may be given pain relievers (analgesics) to lessen pain.

For some injuries, a tube must be inserted into the chest (thoracostomy or chest tube—see Chest Tube Insertion) to drain blood (in hemothorax) or air (in pneumothorax) from the chest. This procedure helps collapsed lungs reinflate. Insertion can usually be done using only local anesthesia.

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