Surgery - Breathing

Timing of Breathing Assessment

Breathing should be assessed only after the airway has been cleared and secured.

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Mechanisms of Injury Affecting Breathing

Blunt trauma may compromise breathing through direct impact to the chest.

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Shear forces may also cause thoracic injury, such as when a patient is run over by a motor vehicle.

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Deceleration injuries may occur following high-speed road traffic collisions or falls from height.

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Penetrating trauma may result from stab wounds.

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Gunshot wounds can also cause severe penetrating thoracic injury.

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Blast injuries may follow a nearby explosion and can cause pulmonary damage secondary to capillary haemorrhage and alveolar rupture.

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Assessment of Breathing

Breathing should be assessed systematically using inspection, auscultation, palpation, and percussion.

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Inspection

Cyanosis may indicate significant hypoxia.

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An increased respiratory rate may be an early sign of respiratory compromise.

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Asymmetrical chest expansion may indicate unilateral thoracic injury.

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Use of accessory muscles, tracheal tug, or visibly increased work of breathing suggests respiratory distress.

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Paradoxical chest wall movement occurs when a segment of the chest moves inward during inspiration and outward during expiration, usually because of multiple rib fractures.

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The chest should be inspected for superficial signs of trauma such as bruising, gunshot wounds, stab wounds, and seatbelt marks.

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Auscultation

All lung zones should be auscultated for areas of reduced or absent air entry.

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Bronchial breathing may indicate underlying pulmonary pathology.

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Wheeze may occur because of bronchospasm associated with intrathoracic injury.

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Palpation and Percussion

Air movement should be assessed to confirm that the patient is breathing spontaneously.

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The trachea should be palpated for deviation.

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The chest should be percussed for areas of dullness or hyperresonance.

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Subcutaneous emphysema may indicate an underlying pneumothorax or other air leak associated with thoracic injury.

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Immediately Life-Threatening Thoracic Injuries

Four important life-threatening thoracic injuries must be identified during the primary survey.

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These are tension pneumothorax, open pneumothorax, massive haemothorax, and flail chest.

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Tension Pneumothorax

A tension pneumothorax occurs when air accumulates under pressure within the pleural cavity.

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The rising intrathoracic pressure compresses the ipsilateral lung and may displace the mediastinum and compromise the contralateral lung and venous return.

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It usually develops through a one-way valve mechanism in which air enters the pleural cavity but cannot escape effectively.

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Clinical Features of Tension Pneumothorax

Ipsilateral chest expansion may be reduced.

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The trachea may deviate away from the affected side, although this is usually a late sign.

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Percussion over the affected side may be hyperresonant.

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Air entry may be markedly reduced or absent on the affected side.

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The patient may develop tachycardia, tachypnoea, severe respiratory distress, and hypoxia.

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Distended neck veins may occur because of impaired venous return, although they may be absent if the patient is also hypovolaemic.

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Open Pneumothorax

An open pneumothorax occurs when there is a chest wall defect that communicates directly with the pleural cavity.

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If the defect is sufficiently large, air preferentially enters through the chest wall wound rather than through the trachea.

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It is traditionally called a sucking chest wound because air may be heard moving through the wound during respiration.

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Clinical Features of Open Pneumothorax

There may be an obvious chest wall defect with a sucking sound during inspiration.

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Air entry is reduced on the affected side.

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Chest expansion is reduced on the affected side.

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Tachycardia and tachypnoea are common.

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Massive Haemothorax

A massive haemothorax is traditionally defined as accumulation of more than 1500 mL of blood within the pleural cavity.

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It may result from injury to intercostal vessels, pulmonary vessels, or major intrathoracic vessels.

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Clinical Features of Massive Haemothorax

Ipsilateral chest expansion is reduced.

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Percussion over the affected side is dull.

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Air entry is reduced on the affected side.

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The patient may develop tachypnoea, tachycardia, and signs of hypovolaemic shock.

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Flail Chest

Flail chest occurs when multiple adjacent ribs are fractured in multiple places, creating a free-floating segment of chest wall.

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The unstable segment may move paradoxically inwards during inspiration and outwards during expiration.

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Clinical Features of Flail Chest

Paradoxical chest wall movement may be visible.

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Crepitus may be felt on palpation of the injured area.

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Air entry may be reduced on the affected side.

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Tachypnoea and tachycardia are common.

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Associated pulmonary contusion is often an important contributor to respiratory compromise.

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Immediate Management of Tension Pneumothorax

Tension pneumothorax is a clinical diagnosis and should be treated immediately without waiting for imaging.

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Emergency decompression should be performed promptly, followed by definitive chest drain insertion.

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Needle decompression has traditionally been used, although finger thoracostomy may be preferred in some trauma systems where expertise is available.

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Landmarks for Emergency Thoracic Decompression

A traditional site for needle decompression is the second intercostal space in the mid-clavicular line.

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Many current trauma protocols also accept or prefer the fourth or fifth intercostal space in the anterior to mid-axillary line, particularly because chest wall thickness may make the anterior approach less reliable.

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Landmarks for Chest Drain Insertion

A chest drain is usually inserted within the safe triangle, commonly around the fourth or fifth intercostal space between the anterior and mid-axillary lines.

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The tube should be inserted just above the upper border of the rib to reduce the risk of injury to the intercostal neurovascular bundle.

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Management of Open Pneumothorax

The open chest wound should be covered promptly with an appropriate occlusive or vented dressing.

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A traditional temporary technique is to secure an occlusive dressing on three sides, creating a flutter-valve effect that limits air entry while allowing air to escape.

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A chest drain should then be inserted on the affected side at a separate clean site away from the wound.

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Definitive surgical closure of the chest wall defect may subsequently be required.

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Blood Investigations

A group and cross-match should be performed if significant bleeding or transfusion is anticipated.

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An arterial blood gas may provide information about oxygenation, ventilation, acid-base status, lactate, and haemoglobin concentration.

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Co-oximetry can be used to measure carboxyhaemoglobin when smoke inhalation or carbon monoxide exposure is suspected.

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Chest X-Ray

A chest X-ray remains an important investigation in thoracic trauma, although treatment of immediately life-threatening conditions should not be delayed for imaging.

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A pneumothorax may appear as a visible pleural line with loss of peripheral lung markings beyond it.

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The size of a pneumothorax should not be estimated using the old assumption that a 1 cm rim equals 10% lung-volume loss, as this is unreliable.

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A haemothorax may produce blunting of the costophrenic angle on an erect chest X-ray.

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Several hundred millilitres of pleural blood may be required before costophrenic angle blunting becomes visible on an erect film.

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Chest X-ray may also assist in identifying pulmonary contusion, parenchymal injury, rib fractures, mediastinal abnormalities, and other thoracic pathology.

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CT Imaging

CT scanning can provide more detailed information about thoracic injuries.

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It should generally be reserved for patients who are sufficiently stable for transfer to the scanner.

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CT is usually performed after immediate life-threatening problems have been addressed and often as part of the secondary survey or definitive trauma imaging pathway.