Thoracic trauma

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Background

  • Must determine if injury also traverses the diaphragm (intra-abdominal injury)
    • Most deaths in thoracic trauma patients are due to noncardiothoracic injuries
  • Excessive PPV can lead to reduced venous return, tension pneumothorax (avoid excess bagging)
  • Place central lines on the SAME side as existing injury or pneumothorax (prevent bilateral pneumothorax)
  • Hypotensive resuscitation in chest trauma may be beneficial

Clinical Features

Inspection

  • Seat-belt sign indicates possible deceleration or vascular injury
  • Paradoxical wall movemement indicates flail chest
  • Distended neck veins
    • Tamponade, tension pneumothorax, heart failure
  • Swollen face
    • SVC compression vs subcutaneous emphysema

Palpation

  • Neck
    • Trachea midline or displaced
  • Chest wall
    • Localized tenderness or crepitus due to rib fracture or subcutaneous emphysema
  • Sternum
    • Localized tenderness, crepitus, or mobile segment suggests fracture

Differential Diagnosis

Thoracic Trauma

Evaluation

Imaging

  • Ultrasound
    • Can diagnosis hemothorax, pneumothorax, tamponade, rib fracture, sternum fracture
  • CXR
    • Can diagnosis hemothorax, pneumothorax, rib fracture, pulmonary contusion, diaphragmatic rupture
    • Frequently underestimates the severity/extent of chest trauma
  • CT
    • Gold-standard

Nexus chest CT in trauma rule (major injury)

CT if any one of the following:

  • Abnormal CXR
  • Distracting injury
  • Tenderness of:
    • Chest wall
    • Sternum
    • Thoracic spine
    • Scapula

Sensitivity

  • 99% for major injuries
  • 90% for minor injuries

Management

  • Treat underlying condition

Disposition

  • Asymptomatic thoracic stab wound
    • Repeat CXR in 4-6hr; if not delayed pneumothorax seen patient can be discharged

Complications

Aspiration

  • Common after severe trauma, especially of patient was unconscious at any time
  • Radiologic changes may be delayed up to 24hr (consolidation)
    • Due to chemical pneumonitis from gastric contents
  • No evidence to support prophylactic antibiotics to prevent pulmonary infection

Systemic air embolism

  • Patients with penetrating chest wounds who require PPV are at risk
  • May lead to dysrhythmias or CVA
  • Treatment
    • 100% NRB

See Also

References