This section will review the skeletal, pulmonary, vascular, and cardiac systems and their function/dysfunction during chest trauma. This assessment builds upon the ABCs learned in earlier levels.

Chest Trauma Assessment of the Skeletal System

The skeletal system has the most externally obvious signs of injury but also has the greatest number of areas to inspect. As such, it is beneficial to use a standardized approach that you can apply to every patient. These vital steps are to question, inspect, palpate, and re-assess. 

• QUESTION: Ask about any areas of impact or pain to target your detailed assessment. 

• INSPECT: Inspect the entire neck, ribcage, spine, and clavicles, looking for signs of injury such as abnormal movement, guarding, bruising, bleeding, and asymmetry. It is important to inspect all skin surfaces to look for hidden injuries, then focus on the abnormal areas brought up in the question step.

• PALPATE: Gentle pressure should be applied to all areas identified as abnormal in the previous two steps to assess the severity of underlying fractures. This takes on special importance in the rib cage. Areas of suspected trauma in the ribcage that give way to gentle pressure may indicate a "compound fracture," which predisposes patients to flail chest. Always palpate the sternum, as sternal fracture implies a high-energy mechanism of injury.

• RE-ASSESS: The status of a patient with injuries to any vital organs, blood vessels, or airway structures can change from minute to minute. Since all of these vital structures are contained within the chest, chest trauma patients have a significant risk of sudden decompensation. Regularly repeat questioning, inspection, and palpation at regular intervals or if patient status suddenly changes.

Chest Trauma Assessment of the Pulmonary, Cardiac, and Vascular Systems

Due to the close association between the pulmonary, cardiac, and vascular systems, they are assessed together, using many of the same techniques to elicit signs and symptoms. Each system ensures that the body obtains oxygen from the environment and delivers oxygen to the cells.

Because the symptoms of injury can overlap across these systems, an injury suspected in one should prompt an investigation of all. Common symptoms of damage to these systems include altered mental status, shortness of breath, pain, and changes in vital signs. The following section describes vital sign changes and physical exam findings that should raise concern for these systems.

VITAL SIGNS

• HEART RATE: Initially elevated due to psychological effects of trauma, sudden changes in heart rate more than a short time following trauma should prompt alarm. Increased heart rate is often seen in hypovolemia or hypoxia, while abnormal rhythms are often due to arrhythmia. Both of these findings are signs of damage to the heart muscle, lungs, or the great vessels that enter/leave the heart. 

• BLOOD PRESSURE: The body has many mechanisms to maintain healthy blood pressure. The body can increase the cardiac output or the constriction of the blood vessels extremely rapidly, which is why hypotension is a very late sign of severe hemorrhage. Sudden hypotension very shortly after trauma points to damage to a large blood vessel and probably high-volume internal/external bleeding. Instant hypotension combined with neurological dysfunction points to nerve damage, preventing blood vessel constriction.

• RESPIRATORY RATE: The respiratory rate is one of the first signs that something is wrong with any of the above-listed systems. As with heart rate, the fight-or-flight reflex can increase the respiratory rate, but sudden changes outside the trauma window should prompt an alarm. A decrease in breathing rate can be associated with nerve damage or brain damage, while rapid breaths are often due to fractures of the rib cage preventing deep breaths or hypoxia due to low levels of oxygen reaching the cells. Deep and rapid breaths may indicate large volumes of fluid filling the lungs.

PHYSICAL EXAM FINDINGS

• PULMONARY:

  • Breath sounds may be decreased in hemothorax or pneumothorax.
  • Abnormal movement of a segment of the chest wall may indicate multiple rib or sternal fractures.
  • Stridor or severe wheezing may indicate accompanied tracheal/bronchial collapse/rupture.
  • Pulmonary contusion and Acute respiratory distress syndrome (ARDS) are notable for minimal findings on physical exam despite low O2 saturation and dyspnea.
  • Hemoptysis (coughing up blood) may indicate damage to the lung tissue, bronchi, or trachea itself has occurred. 

• VASCULAR:

  • Changes in or absence of pulses in the extremities are a sign of possible vascular damage upstream of the limb or severe blood loss anywhere in the body.
  • Distention of the veins in the neck indicates a problem getting blood through the heart, which can be due to damage of the great vessels (The vena cava, pulmonary arteries/veins, and aorta).
  • A decrease in the level of consciousness may point to severe blood loss.
  • Finally, the presence of a pulsatile mass is concerning for an aneurysm, which can uncommonly result from acute trauma.

• CARDIAC: Distended neck veins may also signify direct cardiac damage. The other findings of cardiac damage are nonspecific.

  • ECG and lab tests are required to rule out if cardiac trauma is suspected.
  • Hypotension, tachycardia, bradycardia, cyanosis, and low SPO2% are all possible findings, which are unfortunately shared with many other complications of trauma.
  • Arrhythmia or abnormal rhythms that are NEW to the patient are common in survivable cardiac trauma.
  • By far, the most common sign is sudden death due to cardiac arrest or induction of an unsurvivable rhythm.
     
• SKIN and EXTREMITIES: The skin and extremities cannot be ignored. While a full assessment of the extremities is often delayed until the initial workup of the chest is complete, the state of the extremities can provide several clues about a patient's chest injuries.
   
  • Hypoperfusion is the most common condition that presents initially in the extremities--cyanosis, hypothermia, increased turgor, and diaphoresis are signs of hypoperfusion that are seen in the extremities. This could point to a major chest injury that is leading to severe blood loss.

In Summary,

     Symptoms relating to the pulmonary, vascular, and cardiac systems are all intertwined. Any suspected dysfunction in the patient's oxygenation ability should prompt an investigation of all these systems. By far, a change in the level of consciousness and changes in vital signs shortly following trauma are the earliest indicators of an underlying issue.