Chest Injury (Thoracic Trauma): Examination

A comprehensive clinical examination is the basis for selecting further diagnostic steps. Treatment of thoracic trauma (chest injury) must be rapid (immediate diagnosis). The entire body must always be searched to rule out concomitant injuries! In principle, an emergency examination according to the Glasgow Coma Scale (GCS) must first be performed on persons who are unconscious:

Assessment

• Points are awarded for each category separately and then added together. The maximum score is 15, the minimum 3 points.
• If the score is 8 or less, a very severe brain dysfunction is assumed and the there is a risk of life-threatening respiratory disorders.
• With a GCS ≤ 8, airway protection must be considered.

This is followed by a comprehensive physical examination:

• ABCDE scheme*
• Vital signs: Monitor blood pressure, pulse, respiration, oxygen saturation (SpO2) closely to detect hypoxia (hypoxia of the organism), hypotension (low blood pressure), cardiac arrhythmias (cardiac arrhythmia) and tension pneumothorax in time.
• Inspection (viewing) of the skin
  • Bounce marks – by belt marks, steering wheel, airbag, etc.
  • Congested neck veins [tension pneumothorax?]
  • Cyanosis (bluish discoloration of the skin/mucous membrane due to lack of oxygen).
  • Skin emphysema (air/gas accumulation in the skin) [rib series fracture? Pneumothorax?]
  • Pallor – symptoms of shock
• Inspection or examination of the thorax
  • Protrusions on the thorax?
  • Breath-dependent pain?
  • Examination of respiratory movements
    • Observation of respiratory excursions – to assess thoracic distensibility (should be done in side-to-side comparison) [unilateral respiratory motion delay: pneumothorax?].
    • Unstable thorax – larger portions detach from rib union [rib series fracture?] → paradoxical breathing: unstable portion moves thorax outward on exhalation and thorax inward on inhalation
    • Slurping sound [tension pneumothorax?]
  • Palpation (palpation) of the thorax.
    • Pressure or compression pain?
  • Percussion (tapping sound) of the thorax.
    • Attenuation or hypersonoric knocking sound.
  • Auscultation (listening) of the thorax
    • Attenuated breath sound
    • Crepitation (sounds like “rattling”, “crunching”)?
    • Side-differentiated breath sounds
  • Hemoptysis (coughing up blood)
• Examination of the lungs (due topossible secondary diseases):
  • Bronchophony (checking the transmission of high-frequency sounds; the patient is asked to pronounce the word “66” several times in a pointed voice while the physician listens to the lungs) [increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e. e.g. in pneumonia) the consequence is, the number “66” is better understood on the diseased side than on the healthy side; in case of decreased sound conduction (attenuated or absent: e.g. in pleural effusion, pneumothorax, emphysema). The result is, the number “66” is barely audible to absent over the diseased part of the lung, because the high-frequency sounds are strongly attenuated]
  • Percussion (knocking sound) of the lungs [z.B. in emphysema; box tone in pneumothorax]
  • Vocal fremitus (checking the transmission of low frequencies; the patient is asked to pronounce the word “99” several times in a low voice while the physician places his hands on the patient’s chest or back) [increased sound conduction due to pulmonary infiltration/compaction of lung tissue (e.g. e.g., pneumonia) the consequence is, the number “99” is better understood on the diseased side than on the healthy side; with decreased sound conduction (attenuated: e.g., atelectasis, pleural rind; severely attenuated or absent: with pleural effusion, pneumothorax, emphysema). As a result, the number “99” is barely audible to absent over the diseased part of the lung, because the low-frequency sounds are strongly attenuated]
• Auscultation (listening) of the heart.
• Palpation (palpation) of the abdomen (abdomen) (pressure pain?, knocking pain?, coughing pain?, defensive tension?, bowel sounds (in rupture (tear) of the diaphragm)?, hernial orifices?, surgical scars?)
• Digital rectal examination (DRU): examination of the rectum (rectum) and adjacent organs with the finger by palpation: assessment of the prostate in size, shape and consistency.

Square brackets [ ] indicate possible pathological (pathological) physical findings.

* ABCDE scheme