Treatment of the most frequent lesions

They are the most common lesion associated to chest trauma. If they are multiple or bilateral and pain is poorly controlled they may require admission, including ICU (Intensive Care Unit) admission for initial monitoriztion and pain management.

• Pain management: It is a fundamental pillar of the treatment of chest wall trauma. Pain control improves ventilation, cough and decreases the risk of respiratory complications

  • Epidural catheter: It may be recommended in cases of flail chest, multiple and bilateral rib fractures

  • Intercostal nerve block

  • NSAIDs: Intravenously or orally

  • Acetaminophen: Intravenously or orally

  • Other analgesic medications as: Morphine derivates, tramadol, etc.

• Complications’ prevention: Most of the complications after chest trauma are related with the impaired ventilatory mechanisms related to the trauma itself and with poor pain management. The most common complications are pneumonia, atelectasis and pleural effusion. To prevent them, chest physiotherapy is strongly recommended.

They are related to increased intensity traumas, for this reason it is important to rule-out other associated lesions. Unless they imply a great deformity or displacement the treatment is based in pain control and complication´s prevention.

Respiratoy mechanischs are significantly impaired in these lesions and in more than 50% of the cases it ends up with respiratory insufficiency requiring mechanical ventilation. The treatment should be directed to assure adequate oxygenation, pain management and complication’s prevention. Compression devices or external rib fixation advantages remain controversial and they should be individually indicated.

It is the most frequent lesion associated with chest trauma. If there are multiple areas of the lung affected or other associated lesions it may require admission for adequate management, specially in those cases associated with respiratory insufficiency. Apart from pain control and respiratory physiotherapy, it may require oxygen supplementation, fluid administration and mechanical ventilation. The administration of prophylactic antibiotics and corticoids have not shown any advantages.

It is defined as a lung parenchyma disrupture. It is associated with air in the pleura (pneumothorax) or with penetrating chest injuries and with different grades of bleeding. Most of them are located in the lung surface, and are resolved with lung reexpansion, normally achieved with chest tube placement. However, other lesions with uncontrolled bleeding and more centrally located may need surgery to repair them.

It is defined as air located in the pleura after chest trauma. It can appear in up to 20% of the patients, alone or with blood, causing a traumatic hemo-pneumothorax. Depending on the amount of air in the pleura, it can be treated with observation (small amount of air), with chest tube placement (in large amounts of air or if the air is displacing intrathoracic structures) or minimally invasive surgery (in the cases of prolonged air leak or inadequate lung re-expansion)

These injuries are normally related with acceleration mechanisms. The main associated sign is the presence of subcutaneous emphysema (air located under the skin, producing swelling). If the lesion measures less than 3 cm, affects the posterior membranous wall of the trachea and there is no respiratory insufficiency associated, it can be treated with conservative treatment, including always antibiotics. In other cases, surgery is needed for repair. The best approach (through the neck or the chest) will be used based on the lesion location.

It can be closed or penetrating. The most common closed heart trauma is the cardiac contusion.  It can be associated with arrhythmias, valvular or interventricular septum lesions and in worst cases with cardiac rupture. Based on the findings the treatment of these lesions ranges from clinical observation to emergent heart surgery with extracorporeal circulation.

The most common penetrating traumas are gunshot and stab injuries. Most of the patients with these injuries die prior to their arrival to the hospital. In these cases surgery is needed to stop the bleeding and repair the lesions.

They are caused by motor vehicle accidents with great acceleration and high height falls. If the rupture of the vessels is not contained, the bleeding is massive, causing death most of the times. If the rupture is contained, surgery is needed to repair the vessel.

They are rare and normally occur in the neck after penetrating injuries. Surgical repair in the first 24 hours is the treatment of choice.

Their presentation differs greatly, making them difficult to diagnose and sometimes delaying their repair. They must be surgically repaired, although the best approach (VATS, laparoscopy) will be chosen by your doctor based in other associated lesions and the time after the injury.