Emergency War Surgery NATO Handbook: Part IV: Regional Wounds and Injuries: Chapter XXVIII: Wounds and Injuries of the Chest
United States Department of Defense
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Establishing a diagnosis of a thoracic injury in a combat casualty is exceedingly simple: there is a hole (or holes) in the chest, and the casualty usually complains of pain when be breathes. Often the casualty will be obviously dyspneic or be in frank respiratory distress, fighting for every breath. Those less severely injured will cough up bloody sputum, while gurgling breath sounds will be all too obvious in the dying. The casualty may have some of the more obvious clinical signs of shock: rapid and weak peripheral pulse, cold clammy skin, depressed sensorium, etc. Inspection may reveal a large hole in the chest wall from which frothy fluid is expelled with each exhalation. Certain clinical syndromes have stigmata which are so obvious that they may even be useful in spite of the chaotic conditions of the battlefield. With a tension pneumothorax, the trachea as felt in the neck is displaced to the side opposite to the injury, and the affected hemithorax may sound like a drum when it is percussed. When blunt injury has occurred, the medical officer will find tenderness to palpation and possibly bony crepitus in the traumatized area. He may notice that a portion of the chest wall, in size usually exceeding the area of the palm, appears to be moving out of sequence with the rest of the chest and abdomen.
Given the paucity of diagnostic imaging capabilities in the lower echelons providing combat casualty care, it is indeed fortunate that so much can be done with inspection and palpation. However, chest X-ray is useful if for no other reason than it allows the surgeon to determine that a chest tube has been placed where it should be placed. Furthermore, chest X-ray is helpful in establishing whether a small pneumothorax is present or whether a hemothorax has been adequately evacuated. A chest X-ray may also give some idea as to the likelihood of a cardiac injury, since the localization of a missile within the cardiac silhouette, especially when combined with shock, is suggestive of tamponade. Combat experience has shown that the classic physical findings of tamponade (muffled heart sounds, dilated neck veins, narrowed pulse pressure. a "paradoxical" decrease in systolic pressure of more than 10 mm Hg during inspiration, and enlarged heart to percussion), cannot be depended upon to establish this diagnosis.
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