Basildon EM Handbook 2018

Regional: chest

March 2018 | by EMauthor

Sternal fractures  

Usually the result of direct force to the sternum.  Can happen as part of major trauma or as an isolated injury in RTA from seat belts. Always x-ray sternum if patient complains of sternal pain and or tenderness· Check for associated rib fractures or associated thoracic visceral injuries (haemothorax, Pneumothorax or mediastinal injuries).  Always do an ECG in patients with chest pain following trauma.  If there is fractured sternum, send for cardiac enzymes

Management

•Undisplaced fractures, can be discharged with analgesia if the ECG and cardiac enzymes are normal and no evidence of thoracic visceral injuries on CXR.

•Displaced fractures should be referred to general surgical team.

Rib fractures  

Can result from major trauma or can be an isolated injury following a fall

Up to 50% may not show on an initial chest x-ray

The principal management aim is to assess for associated pulmonary injury, i.e. Pneumothorax, haemothorax or pulmonary contusion for ribs as they will not alter the management of the patient

Management

•Simple rib fractures: without lung injury can be discharged with proper analgesia and advice on breathing exercise. The best analgesics is paracetamol/codeine combinations or ibuprofen or both, GP follow up if needed.  Consider admission in the elderly patient with poor chest expansion and or underlying cardiac or pulmonary disease, refer then to physician/COTE.

•First and second rib fractures: can be associated with significant injuries to chest and thoracic inlet viscera

•Multiple rib fractures can be associated with severe pain and poor chest expansion, consider admission for pain relief and observation if you fail to control the pain.  If there is evidence of circulatory compromise, especially with lower rib fractures that is not accounted for by Pneumothorax or haemothorax, consider the possibility of intra-abdominal injury

Traumatic pneumothorax or haemothorax

•As a part of major trauma is dealt with in the major trauma section

•It can happen as an isolated condition with less severe injury

•Although in many cases it is treated with chest drainage, this is not always the case

•Assess the patient carefully, discuss these cases with senior EM doctor or surgical team

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