Chest Trauma

In major trauma – call the Resus team Severe chest trauma e.g. multiple rib fractures, flail chest, haemothorax  
- Resus team will be called and will deal with these
- Manage along ATLS principles 
Fractured rib      
- Isolated rib fracture is not an indication for CXR
- Appropriate analgesia
- Advise breathing exercises and smoking cessation
- Refer to own GP
- Patients with pre-existing lung disease may need admission if they are short of  breath. 
Fractured sternum    
Consider possibility of underlying mediastinal injuries.
Perform 12 lead ECG
- If undisplaced and 12 lead ECG is NAD treat as for fractured rib
- If displaced refer to Cardiothoracic surgeons.          

Subcutaneous Emphysema chest wall  
Note that marked subcutaneous emphysema will obscure lung markings.  Assume a pneumothorax until proved otherwise.  
- Seek senior ED doctor advice  
- No specific treatment
- Treat underlying lung injuries. 
Isolated traumatic pneumothorax
- Small (< 2cm rim on CXR) isolated pneumothoraces in stable patients who are not dyspnoeic may be treated by observation without a chest drain.* Seek senior ED advice.
All require admission.
- All other pneumothoraces should be treated with a (preferably small bore) chest drain 
- Pneumothorax/ Haemothorax may not be obvious on a supine chest x-ray. Try to get an erect chest x-ray.  If the patient cannot be sat up decubitus films or CT are useful.
- Consider admission for patients with any of the following:
               - inadequate pain control
               - underlying lung disease
               - multiple rib fractures
               - hypoxia
               - poor social circumstances
- Patients with chest drains should receive prophylactic antibiotics
- Cefotaxime IV or Cephradine orally for 24 hours.
- Small (occult) pneumothoraces seen only on CT do not need a drain if going to theatre (OPTIC trial). 
* Knottenbelt JD, van der Spuy JW. Traumatic Pneumothorax: a scheme for rapid patient turnover. Injury 1990;21:77-80.