Thoracic trauma

Background

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

Differential Diagnosis

Thoracic Trauma

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

Diagnosis

Inspection

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

Palpation

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

Imaging

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

Complications

Aspiration

• Common after severe trauma, esp of pt 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

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

Disposition

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