Why breathlessness after chest trauma matters
Chest injuries kill through a few problems that can be found by examining the patient and fixed at the bedside, often before any scan. The skill is a primary survey done in order, treating each problem as you find it and then looking again.
What to ask in the history
- How the accident happened: speed, what hit him, whether he wore a helmet, how he landed
- Time since the injury, and whether the breathlessness is getting worse
- Chest pain: where it is, and whether it is worse on breathing in
- Other injuries: head (did he black out), neck, abdomen, pelvis, limbs
- Coughing up blood
- Past illness, regular medicines (especially blood thinners), allergies, when he last ate
Red flags
- Breathlessness or breathing rate getting worse
- Falling oxygen saturation
- Fast pulse, low blood pressure, cold clammy skin
- Breath sounds absent or reduced on one side
- The windpipe pushed to one side, or distended neck veins
- Part of the chest wall moving the wrong way with breathing
- Agitation, confusion or drowsiness
What to examine
- Primary survey in order: airway with the neck protected, breathing, circulation, disability, exposure
- Chest: look for bruising, wounds and uneven movement; feel for tenderness, crackling under the skin and rib movement
- Percussion and breath sounds on each side; position of the trachea; neck veins
- Circulation: pulse, blood pressure, capillary refill, and every place he could be bleeding (chest, abdomen, pelvis, long bones, outside)
- Conscious level and pupils
- Full exposure, keeping him warm, and a log roll to see his back
First investigations
- Continuous monitoring of oxygen saturation, pulse and blood pressure
- Blood gas
- Chest X-ray in the resuscitation room, without delaying treatment the examination already calls for
- Bedside ultrasound of the chest and abdomen (eFAST)
- Full blood count, blood group and crossmatch, clotting, kidney function
- CT once he is stable enough to travel
Differential diagnosis of breathlessness after chest trauma
Grouped, not ranked. Which one fits this patient is for you to work out in the case.
Air in the chest
- Tension pneumothorax
- Simple pneumothorax
- Open (sucking) chest wound
Blood in the chest
- Haemothorax
- Massive haemothorax
- Cardiac tamponade
Chest wall and lung
- Rib fractures
- Flail chest
- Pulmonary contusion
Elsewhere
- Bleeding into the abdomen or pelvis causing shock
- Diaphragm injury
- Airway injury
Common mistakes
- Sending for an X-ray before treating a problem the examination has already found.
- Looking only at the chest and missing bleeding in the abdomen, pelvis or limbs.
- Under-treating rib pain, so he cannot breathe deeply or cough.
- Not repeating the primary survey after each intervention.