action of acetic and 4 attempt should be made to localize the gang te for. the purpose of treatment; and if an area of rl, n ness, with moist rales and hollow vLtZvv mur, IS detected, that may be regarS L^'Je^^at 148 I SURGICAL DIAGNOSIS [chap. of the disease. Gangrene is a rare sequel to chest injuries, but is met with occasionally after contu- sions and wounds, particularly if the lung is much lacerated or a foreign body is retained. <Callout type="warning" title="Warning">If gangrene is suspected, immediate surgical intervention is necessary.</Callout> 8. If in a case of pneumo- or hcemomediastinum, or of severe blow upon or wound of the sternum, the distress of the patient becomes considerably in- creased, and there are palpitation of the heart and dyspnoea, or oedema and signs of ve;ious obstruction in the head, neck, and upper limbs, and on percus- sion a dull area is found over the sternum and extending laterally over the costal cartilages, or behind on either side of the vertebral column, and if there is pyrexia, with perhaps rigors, the surgeon must suspect mediastinal abscess, and at once explore the part by trephining the sternum. The abscess may "point" at the suprasternal notch or intercostal spaces close to the sternum or at the epigastrium, as a soft, fluctuating swelling which may have a pulsa- tion transmitted from the heart, or become fuller and tenser during expiration. Or the abscess may suddenly burst into either the pleura or the peri- cardium, setting up acute inflammation. Death often takes place before pointing has occurred. 9. Even within a few hours after a wound of the pericardium, friction may be heard over the cardiac area, showing the development of pericarditis. Pericardial friction is to be distinguished from pleuritic friction by the place where it is heard, by its being unmodified by respiration, and by its accompanying both sounds of the heart. It is distinguished from endocardial murmurs by its creaking or rubbing character, its uniformity with both sounds of the heart, its strict limitation, its want of conduction along the vessels or nit o the axilla, and in some cases by its modification XII] CHEST WOUNDS: COMPLICATIONS 149 on firm pressure with the .stethoscope. If this is followed by an increase in the area of cardiac dullness which takes the shajje of the pericardium, with displacement of the heart's impulse upwards and to the left (the impulse may be quite lost) increased frequency of the heart's action, and loss of the heart-sounds over much of the dull area, while the pulse is small and weak, and dyspnasa very marked, the patient sitting up in bed and leaning- forwards, and having a frequent, dry, short cough pericardial effusion has occurred. Should rigors occur' and there be a tendency to "point" in any part of the dull area, pyoperieardium may be diagnosed • an exploring syringe will determine the nature of' the niud in the sac. 10. When, in connexion with pericarditis, the heart s action becomes extremely weak and irregular leading to syncope on movement or on sitting upright the existence of myocarditis is to be inferred. 11. If the surgeon is able to recognize the develop- ment of an endocardial murmur after a contusion strain, or other injury of the chest, i.e. if he at hi.s early examination finds the heart-sounds clear, and subsequently notes a murmur, it is evidence of the occurrence of endocarditis. 12. If, after a wound in the chest has healed or after a severe contusion, a tumour slowly and gradually appears, which is circumscribed smooth soft roimded, crepitant under pressure, resonant on light percussion, with an impulse on coughing ex- panding with each expiration and contracting dm-inc. inspiration, it is a consecutive prolapse of the hmp or a pneumatocele. These tumours may appear rapidly and attam a arge size ; they may be iore or less reducible, and allow the outline of the aperture through which the lung escapes to be felt
Key Takeaways
- Gangrene is a rare but serious complication of chest injuries, requiring immediate surgical intervention.
- Mediastinal abscesses can develop after severe chest trauma and may require trephining the sternum for exploration.
- Pericardial effusion can lead to myocarditis if not diagnosed and treated promptly.
Practical Tips
- Always perform a thorough examination of any chest injury, as complications like mediastinal abscesses or pericardial effusion may develop rapidly.
- Use percussion and auscultation to detect areas of dullness that could indicate internal injuries or complications.
- Be vigilant for signs of respiratory distress, which can be an early indicator of serious conditions such as pneumatoceles.
Warnings & Risks
- Failure to recognize and treat mediastinal abscesses promptly can lead to severe complications or death.
- Ignoring the development of pericardial friction can result in undiagnosed pericarditis, potentially leading to myocarditis.
- Rapidly expanding tumors after chest injuries may indicate a pneumatocele, which requires immediate attention.
Modern Application
While many of the techniques described here are outdated, the principles of thorough examination and prompt intervention remain crucial in modern survival medicine. Understanding these complications can help in recognizing signs early and seeking appropriate medical care.
Frequently Asked Questions
Q: What is pericardial friction, and how does it differ from pleuritic friction?
Pericardial friction is a creaking or rubbing sound heard over the cardiac area, which can be distinguished from pleuritic friction by its location, lack of modification by respiration, and accompaniment with both heart sounds. It indicates pericarditis.
Q: How can one differentiate between endocardial murmurs and pericardial friction?
Endocardial murmurs are characterized by a creaking or rubbing character, uniformity with both heart sounds, strict limitation, lack of conduction along the vessels, and sometimes modification on firm pressure. Pericardial friction is unmodified by respiration.
Q: What should be done if a patient develops a dull area over the sternum after chest trauma?
If a dull area over the sternum is detected along with signs of respiratory distress, the surgeon must suspect mediastinal abscess and explore the part by trephining the sternum to confirm or rule out this serious complication.