Recognising and treating the immediately life-threatening chest injuries, and decision-making for blunt and penetrating abdominal trauma.
At the bedside
Timed steps- 1
Tension pneumothorax: treat clinically
ImmediateRespiratory distress, hypotension, absent breath sounds, distended neck veins (may be absent in hypovolaemia), tracheal deviation late. Decompress immediately: needle at 4th/5th intercostal space anterior to mid-axillary line (adults), or 2nd ICS mid-clavicular; then finger thoracostomy and chest drain.
- 2
Open pneumothorax
Three-sided occlusive dressing, then chest drain away from the wound.
- 3
Massive haemothorax
> 1500 mL immediately on drain insertion, or > 200 mL/h for 2-4 h, or ongoing transfusion need: blood products and urgent thoracotomy. Use 28-32 Fr drain in trauma (or smaller per local practice).
- 4
Flail chest and rib fractures
Analgesia is the treatment: paracetamol, opioids, regional blocks (serratus anterior, erector spinae, epidural). Oxygen, incentive spirometry, early NIV/HFNC; intubate if failing. Consider surgical rib fixation for flail.
- 5
Cardiac tamponade
Beck triad (hypotension, raised JVP, muffled heart sounds), eFAST pericardial fluid. Penetrating: thoracotomy/sternotomy by surgeon; pericardiocentesis only as a bridge if no surgeon.
- 6
Abdominal trauma: unstable
Haemodynamically unstable + positive FAST (blunt) or penetrating with peritonitis/evisceration: straight to laparotomy (damage control).
- 7
Abdominal trauma: stable
Contrast CT abdomen/pelvis. Solid organ injury (liver, spleen) in stable patients: non-operative management with ICU/HDU monitoring, serial Hb and examination, angioembolisation for blush.
- 8
Watch for missed injuries
Hollow viscus and pancreatic injuries can be missed on early CT; tertiary survey at 24 h. Monitor intra-abdominal pressure after massive transfusion.
Thoracic killers: signs and action
| Injury | Key signs | Action |
|---|---|---|
| Tension pneumothorax | Hypotension, absent breath sounds, hyperresonance | Needle/finger decompression, drain |
| Open pneumothorax | Sucking wound | 3-sided dressing, drain |
| Massive haemothorax | Dull percussion, shock, > 1500 mL drained | Blood, drain, thoracotomy |
| Flail chest | Paradoxical segment, hypoxia | Analgesia, O2, NIV, ventilation |
| Tamponade | Beck triad, eFAST effusion | Surgery; pericardiocentesis as bridge |
Calculators for this topic
References
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Blunt abdominal trauma
Step 1 of ~4
Decision: Haemodynamically stable (or responds to resuscitation)?
Based on American College of Surgeons Committee on Trauma; Rossaint R, Afshari A, Bouillon B, et al. Educational use; follow local protocol.
Pathophysiology
Positive-pressure ventilation converts a simple pneumothorax into tension by forcing air into the pleural space, compressing venous return. Pulmonary contusion evolves over 24-72 h, so oxygenation often worsens after admission.
Evidence
- ATLS 10th edition moved the adult needle decompression site to the 4th/5th ICS anterior to the mid-axillary line because chest wall thickness at the 2nd ICS often exceeds standard needle length [ATLS 2018].
- Non-operative management of solid organ injury succeeds in most haemodynamically stable patients when CT, angioembolisation and ICU monitoring are available [EU trauma 2023].
Controversies
- Small-bore (14 Fr) versus large-bore drains for traumatic haemothorax: emerging evidence supports smaller drains in stable patients.
- Prophylactic antibiotics for chest drains in trauma.
🇮🇳 India notes
- Most Indian chest trauma is blunt from road traffic accidents; delayed presentation is common. Re-examine after transfer: contusion and haemothorax progress.
- Where CT is not available, serial eFAST and clinical examination guide decisions; transfer stable solid-organ injuries to centres with surgery and interventional radiology.
References
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