Symposium on trauma. 2. Chest trauma: current concepts

Blunt chest trauma continues to be an important cause of death following motor vehicle accidents in Canada. Current methods of diagnosis are presented emphasizing a physiologic approach. The most important physiologic consequence of trauma associated with chest wall instability or ruptured diaphragm is pulmonary contusion. Current therapy therefore stresses the treatment of pulmonary contusion (Trinkle's regimen) rather than the associated chest wall instability. A widened mediastinum or a fractured first rib on the chest film, or upper limb hypertension should suggest possible rupture of the aorta, which can be confirmed by aortography. Early surgical repair is recommended. Current techniques for repair are detalied. Cardiac tamponade and exsanguinating hemorrhage are the common causes of death following cardiac trauma. Methods for recognizing and treating cardiac tamponade are outlined. The indications for early thoracotomy following cardiac trauma are listed; thoracotomy should be done in a fully equipped operating room rather than the emergency room. Successful management of major chest injuries requires an aggressive physiologic approach to diagnosis and emphasis on maintaining effective ventilation and adequate cardiac output.