A chest injury, also known as chest trauma, encompasses any form of physical damage to the chest area, including the ribs, heart, and lungs.

Chest injuries most frequently impact the ribs, upper abdomen, lungs, blood vessels, heart, muscles, soft tissues, and breastbone. Occasionally, the esophagus, collarbone, or shoulder blade may also be affected.

The chest can sustain injury from blunt force (such as in motor vehicle collisions, falls, or sports accidents) or from a penetrating object (like a bullet or knife).

Chest injuries are often severe or immediately life-threatening because they disrupt breathing or circulation. Some injuries inflict enough damage on the ribs and chest muscles (collectively known as the chest wall) to impede the normal inflation of the lungs. Damage to the lungs themselves interferes with gas exchange, which is the primary function of the lungs involving oxygen intake and carbon dioxide expulsion. Chest injuries can also lead to circulatory problems if they cause significant bleeding. Bleeding often occurs within the chest cavity, further hindering respiration. Additionally, injury to the heart can compromise circulation by impairing its ability to pump blood effectively throughout the body.

Classification/Types

Chest injuries are categorized as either blunt or penetrating. Blunt and penetrating injuries exhibit distinct pathophysiologies and clinical progression.

Specific types of injuries include:

• Injuries to the chest wall

  • Chest wall contusions or hematomas: A contusion is a bruise to the skin, muscle, or ribs, which may cause pain, tenderness, and swelling. Contusions typically heal within a few days to several weeks.

  • Rib fractures

  • Flail chest: This condition involves broken ribs where a segment of the rib cage detaches due to severe impact, remaining connected only by surrounding soft tissue. This detached section moves paradoxically to the rest of the ribcage during breathing, causing intense pain and potentially life-threatening complications.

  • Sternal fractures

  • Fractures of the shoulder girdle

• Pulmonary injury (injury to the lung) and injuries involving the pleural space

  • Pulmonary contusion: This is essentially a bruise of the lung tissue, resulting from chest trauma.

  • Pulmonary laceration: A chest injury where lung tissue is torn or cut. This is potentially more serious than a pulmonary contusion.

  • Pneumothorax: Often referred to as a “collapsed lung,” this occurs when air becomes trapped in the pleural cavity (the space between the lung and chest wall), compressing the lung. Sufficient air accumulation can not only collapse the lung but also push it against the heart and the other lung.

  • Hemothorax: A type of pleural effusion characterized by the accumulation of blood in the pleural cavity. This excess fluid can impede normal breathing by restricting lung expansion. Treatment often involves inserting a chest tube through the chest wall to drain blood and air, which is left in place for several days to re-expand the lung.

  • Hemopneumothorax: This condition involves the presence of both blood and air in the pleural cavity. The primary cause is typically a penetrating chest wound, such as from a gunshot or stabbing.

• Injury to the airways

  • Tracheobronchial tear: Usually associated with blunt trauma, involving a partial or complete laceration or puncture of the tracheal or bronchial wall.

• Cardiac injury

  • Pericardial tamponade: A clinical syndrome caused by fluid accumulation in the pericardial space (around the heart), leading to reduced ventricular filling and subsequent compromise of blood circulation. This is a medical emergency with potential complications including pulmonary edema, shock, and death.

  • Myocardial contusion: A bruise of the heart muscle that can result from serious bodily injury. Common causes include car accidents, falls from significant heights, or chest compressions during cardiopulmonary resuscitation.

  • Traumatic arrest: A state where the heart ceases to beat due to blunt or penetrating trauma, such as a stab wound to the chest. This is a critical medical emergency that, without prompt advanced medical care, will invariably result in death.

  • Hemopericardium: Refers to the presence of blood within the pericardial sac of the heart. Clinically similar to a pericardial effusion, its volume and rapid development can lead to cardiac tamponade.

• Blood vessel injuries

  • Traumatic aortic rupture

  • Thoracic aorta injury: A tear in the large artery that transports blood from the heart to the rest of the body.

  • Aortic dissection

• And injuries to other structures within the torso

  • Esophageal injury (Boerhaave syndrome)

  • Diaphragm injury

CAUSES OF CHEST TRAUMA

Chest trauma typically results from high-force incidents. Examples include:

• Motor vehicle accidents, which account for up to 70 percent of blunt force chest trauma

• Motorcycle accidents

• ATV (All-Terrain Vehicle) accidents

• Falls from significant heights

• Sports-related injuries

• Gunshot wounds

• Knife injuries

• Combat blast injuries

SYMPTOMS.

• The injured area is usually tender or painful.

• Pain worsens upon inhalation.

• The chest may exhibit bruising.

• Individuals sometimes experience shortness of breath.

• Drowsiness

• Confusion

• The skin may appear cold, sweaty, or blue (indicating respiratory failure).

• Shock

• A rapid heart rate.

• Air in the pleural cavity (pneumothorax) can cause the affected skin to feel crackly and produce a crackling sound when touched.

• Enlarged neck veins are sometimes observed if blood or fluid accumulates in the sac around the heart, interfering with its pumping ability (known as cardiac tamponade), or if tension pneumothorax develops.

• Difficulty breathing

• Hypotension due to blood loss

• Failure of the lungs to expand properly

• Crunching sounds upon palpation of the rib cage

• Bruising of the chest wall

• Coughing up blood

• Flail chest, where a section of the chest wall moves inward during inhalation.

• Puncture wound to the chest that allows air to be sucked in.

DIAGNOSIS

• Physical examination: A doctor uses a stethoscope to determine if all parts of the lungs are receiving air and examines the neck and chest for injuries.

• Imaging: Such as CT scans, MRI scans, and chest X-rays (CTX). These show most cases of pneumothorax, hemothorax, collarbone fractures, and rib fractures.

• The doctor may order the administration of IV contrast dye to visualize the contours of arteries and veins. Then, an X-ray machine connected to a computer generates cross-sectional images of the chest cavity, including the lungs, bones, and heart. This is an effective test for identifying areas of bleeding or damage to the heart and major blood vessels.

• In some cases, an MRI examination is performed. MRI machines are particularly adept at detecting soft tissue injuries, even without contrast. They provide cross-sectional images similar to CT scanners but acquire images using a strong magnet and radio waves.

• Ultrasonography is conducted to detect heart injuries.

• Angiography (which visualizes veins and arteries) may be performed if an injury to the aorta is suspected.

• Blood tests are done to measure the amount of oxygen and carbon dioxide in the blood (arterial blood gas measurement).

• Sometimes, an electrocardiography (ECG) is also performed.

TREATMENT

• This is a medical emergency.

• If blood bubbles from the wound or air is heard passing through the chest cavity, tape a cover down on three sides to prevent air from building up in the chest.

• Do not remove any objects that have penetrated the chest.

• The management of chest injuries begins in the field, as rapid treatment at the scene of the accident can be life-saving.

• Admit the patient to the ward.

• Immediately life-threatening injuries are treated as quickly as possible, with specific treatment depending on the injury.

• Place an airtight plastic or metallic dressing over any opening that extends into the chest cavity.

• Apply pressure over the dressing to control bleeding.

• If blood saturates the dressing, apply additional dressings on top of the existing one.

• Position the injured person with the injured side facing down. This helps to pool blood in the already injured area.

• If breathing becomes weak, administer CPR as instructed.

• For a flail chest, where nearby ribs are fractured in two or more places, specific stabilization may be required.

• Provide the injured person with pure oxygen to breathe. This is beneficial in cases of blood loss or impaired ventilator function.

• Immobilize the patient’s neck and back as soon as possible to prevent dislocating any potential fractures of the cervical, thoracic, or lumbar spine.

• For all injuries, measures to support breathing and circulation are essential. Patients may receive oxygen (e.g., via nasal prongs, face mask, or breathing tube).

• Intravenous fluids or, at times, blood transfusions.

• Pain relievers, such as diclofenac, are administered.

• For some injuries, a tube must be inserted into the chest (thoracostomy, or 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 performed using only local anesthesia.

• If there is a sudden force on the chest, as seen in high-speed collisions, falls from great heights, or being pinned under an object, there is a sudden increase in chest pressure. Blood may not circulate properly through the heart, and the patient may appear cyanotic. In such a case, elevate the head of the bed to 30 degrees to reduce excess chest pressure.

• Supplemental oxygen is necessary until surgery corrects any damaged heart structures.

• In pericardial tamponade, blood fills the pericardial space, preventing the heart from fully expanding as it pumps. Pulses become diminished, and pulse pressure decreases. The treatment involves inserting a needle into the pericardial space to withdraw the excess blood.

• Commotio cordis: A condition where a healthy person experiences sudden cardiac arrest due to ventricular fibrillation, caused by a sudden impact to the middle of the chest. This must occur at a specific moment during the heartbeat to trigger the event. CPR and defibrillation are the most effective treatment options.

• Surgery is often required for serious chest injuries.

COMPLICATIONS

• Respiratory failure

• Pneumonia

• Pleural sepsis

• Hemothorax

• Pneumothorax

• Acute renal failure