Immediate life-saving attention is required for a trauma victim who suffers any of the following conditions EXCEPT
|C||Massive flail chest|
a. Open pneumothorax, also known as a sucking chest wound, occurs when a significant defect in the chest wall (e.g., from a large-caliber gunshot wound or traumatic thoracotomy) large enough to exceed the laryngeal cross-sectional area allows air to enter from the exterior into the pleural cavity and results in lung collapse because of rapid equilibration between intrathoracic (pleural) and atmospheric pressure.
b. The increased intrathoracic pressure also causes mediastinal shift and decreased venous return. Signs and symptoms include hypoxia, hypercapnia, hypotension, and respiratory and circulatory failure.
c. Management includes application of an occlusive dressing and insertion of a chest tube before closure of the chest wall defect to avoid the development of tension pneumothorax.
d. Flail chest occurs in the presence of two or more fractures in three or more consecutive ribs and causes instability of the chest wall; however, it can also occur after costochondral separation .
e. Flail chest is characterized by paradoxical motion of the chest wall (inward with inspiration and outward with expiration).
f. If respiratory distress develops, endotracheal intubation and mechanical ventilation with peak end-expiratory pressure are usually indicated, provided that pain control is adequate. Open reduction plus internal fixation of sternal or rib fractures is rarely needed.
g. Diaphragmatic injuries are often caused by penetrating injuries. Patients sustaining penetrating injuries below the nipples and above the costal margins should be investigated to rule out diaphragmatic injury.
h. After blunt trauma, injury to the diaphragm involves both sides equally, as reported in autopsy and CT scan studies, although in clinical practice, left-sided injuries are more frequent.