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

DDx

1. Traumatic Pneumothorax
2. Tension Pneumothorax
3. Hemothorax
4. Flail Chest

Tension Pneumothorax

• Diminished or absent breath sounds
• Hypotension or e/o hypoperfusion
• Distended neck veins
  • May not occur if pt is hypovolemic
• Tracheal deviation
  • Late sign
• Tx
  • Immediate needle decompression (temporary) followed by chest tube (definitive)
    • 14ga IV in midclavicular line just above the rib at the second intercostal space

Hemothorax

• Each hemithorax and hold 40% of circulating blood volume
• CXR
  • Hemithorax is completely opacified
    • Mainstem bronchus intubation can appear like a hemorthorax on CXR
• Tx
  • Tube thoracostomy
    • Evacuation of >1500mL of blood immediately or 200mL/hr x 4hr = operative management
  • Autotransfuse lost blood if possible

Pneumothorax

• CXR
  • Thin white line (pleura) between 2 areas of lucency (lung parenchyma and air)
  • No lung markings distal to white line
• US
  • Absence of lung sliding; absence of seashore (M-mode)
• Simple
• Open
  • Communication between pleural space and atmospheric pressure (sucking chest wound)
    • Cover the wound with a three-sided dressing
      • Make sure to avoid complete occlusion (may convert injury to a tension ptx)

Flail Chest

• Free-floating segment of ribs that is no longer attached to rest of thorax
• Commonly associated w/ respiratory failure
  • Consider intubation even if pt's breathing initially seems adequate

• 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

• traumatic asphyxia in kids= benign, have discolored upper torso from compression & incr pressure tmitted to valveless veins

• 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

• 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!

• 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!!

• w/ pnetrating chest inj neuro defecit should incr suspicion of vasc inj b/c nv bundle run together

• 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.

• 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.

• 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!

See Also

• Pulmonary Contusion
• Traumatic Pneumothorax
• Sternum Fracture
• Rib Fracture

Source

Tintinalli's