Thoracic trauma: Difference between revisions

Latest revision as of 22:05, 20 April 2022

Background

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.

Must determine if injury also traverses the diaphragm (intra-abdominal injury)
- Most deaths in thoracic trauma patients are due to non-cardiothoracic injuries
Excessive positive pressure ventilation 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
- determine seatbelt placement (if worn improperly or abnormal body habitus)
Paradoxical wall movement indicates flail chest
Neck veins
- Distended
- Flat
Circulatory shock
Hemothorax
Swollen face
- Conjunctival injection + facial edema + mechanism conducive to traumatic asphyxia may indicate SVC compression
  - also consider judicial/non-judicial hanging and strangulation
Subcutaneous emphysema
- Anterior neck/supraclavicular
  - Tracheobronchial tree
  - Esophagus (Boerhaave's syndrome)
- Chest wall
  - Visceral/parietal pleura

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

Airway/Pulmonary
Cardiac/Vascular
- Cardiac injury
- Traumatic aortic transection
Musculoskeletal
Other

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 no delayed pneumothorax seen, patient can be discharged
Disposition otherwise home, to OR, to ward, or to ICU depending on injuries

Complications

Aspiration

Common after severe trauma, especially if 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

References

Authors:

@@ Line 1: / Line 1: @@
 ==Background==
+[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.]]
 *Must determine if injury also traverses the diaphragm (intra-abdominal injury)
-**Most deaths in thoracic trauma pts are due to noncardiothoracic injuries
+**Most deaths in thoracic trauma patients are due to non-cardiothoracic injuries
-*Excessive PPV can lead to reduced venous return, tension ptx (avoid excess bagging)
+*Excessive positive pressure ventilation can lead to reduced venous return, [[tension pneumothorax]] (avoid excess bagging)
-*Place central lines on the SAME side as existing injury or PTX (prevent b/l ptx)
+*Place central lines on the SAME side as existing injury or [[pneumothorax]] (prevent bilateral [[pneumothorax]])
 *Hypotensive resuscitation in chest trauma may be beneficial
-==DDx==
+==Clinical Features==
-#[[Traumatic Pneumothorax]]
+===Inspection===
-#[[Tension Pneumothorax]]
+*Seat-belt sign indicates possible deceleration or vascular injury
-#[[Hemothorax]]
+**determine seatbelt placement (if worn improperly or abnormal body habitus)
-#[[Flail Chest]]
+*Paradoxical wall movement indicates [[flail chest]]
-#[[Sternal Fracture]]
+*Neck veins
+** Distended
+***[[Pericardial effusion and tamponade|Tamponade]]
+***[[Tension pneumothorax]]
+***[[Congestive heart failure]]
+**Flat
+*Circulatory shock
+*Hemothorax
+*Swollen face
+**Conjunctival injection + facial edema + mechanism conducive to traumatic asphyxia may indicate SVC compression
+***also consider judicial/non-judicial hanging and strangulation
+*Subcutaneous emphysema
+**Anterior neck/supraclavicular
+***Tracheobronchial tree
+***Esophagus (Boerhaave's syndrome)
+**Chest wall
+***Visceral/parietal pleura
-*sternal fx in 8% of thoracic injuries, seen on pa/lat cxr, many recent studies prove most, if no comorbidities, can be d/c home safely (mort= .8%), chk ekg
+===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 [[Sternal Fracture|fracture]]
-*traumatic asphyxia in kids= benign, have discolored upper torso from compression & incr pressure tmitted to valveless veins
+==Differential Diagnosis==
+{{Thoracic trauma DDX}}
-*most tracheobronchial inj are within 2cm of carina, although rare, suspect if constant air leak in c-tube, 90% have sx but hard dx, needs or
+==Evaluation==
+===Imaging===
+*[[Ultrasound: lungs|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
-*card tamponade usu from penetrating, do not rely on becks triad, echo is study of choice but 5% false - rate, usu b/c pericardium decompressing into L chest, so be suspicious if L pulm effussion! nd OR, buy time w/ IVF & needle!
+{{Nexus chest CT in trauma major rule}}
-*Blunt cardiac inj is dx soley w/ ekg & pe, do NOT need enzymes. most common abnl ekg in order= st, pvc, af. dx valve prob w/ pe. rx arrythmia prn but NOT prophylacticly (incr mort!), no tnk for mi here (incr mort), nd angio! severity depends on underlying cad b/c inflamm chngs= redistribute coronary flow that may= ischemic cp. any abnl pe or ekg admit to tele. pts w/ no arrythmia & no hypotension after 6 hr of obs have NO sig blunt cardiac injury!!
+==Management==
+*Treat underlying condition
-*w/ pnetrating chest inj neuro defecit should incr suspicion of vasc inj b/c nv bundle run together
+==Disposition==
+*Asymptomatic thoracic stab wound
+**Repeat CXR in 4-6hr; if no delayed pneumothorax seen, patient can be discharged
+*Disposition otherwise home, to OR, to ward, or to ICU depending on injuries
-*Aortic transection: pt often asx, but die w/o warning, 80% die at scene, hypotension NOT from ruptured aorta (just die). see wide sup mediastinum on cxr (>8cm on supine film), nd high suspicion to dx! ct gd for aorta not branch vessels, if high suspicion nd aortography, the gold stndrd, but 1/4 hve complications ie inf & hematoma. Rx= keep sbp <120 w/ a & b blockers.
+==Complications==
+===Aspiration===
+*Common after severe trauma, especially if 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
-*commotio cordis is most common cause of cardiac death in athlete. sudden death w/o abnl heart from trauma to cw at vent depolarization= vf & death.
+===Systemic [[air embolism]]===
+*Patients with penetrating chest wounds who require PPV are at risk
-*esophageal inj is rare but bad & hard dx to make. rx=controversial if no sx. suspect if L htx or ptx w/o rib fx, or pneumomediastinum, d/t incr pressure of low chest/abd= tear in esoph!
+*May lead to dysrhythmias or CVA
+*Treatment
+**100% NRB
 ==See Also==
-*[[Pulmonary Contusion]]
+*[[Thoracotomy]]
-*[[Traumatic Pneumothorax]]
+*[[Chest tube]]
-*[[Sternum Fracture]]
+*[[NEXUS Chest CT Rule]]
-*[[Rib Fracture]]
+*[[Trauma (main)]]
-==Source==
-Tintinalli's
+==References==
+<references/>
+[[Category:Cardiology]]
+[[Category:Pulmonary]]
 [[Category:Trauma]]