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
5. Sternum Fracture
6. Traumatic Asphyxia
7. Trachobronchial Injury
8. Cardiac Tamponade
9. Myocardial Contusion
10. Aortic Transection
11. Boerhaave's
12. Pulmonary Contusion
13. Rib Fracture

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

• US
  • 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

Specific Conditions

Pneumomediastinum

• May be asymptomatic or cause mild-moderate chest pain, voice change, cough, stridor
• A search for other more serious injuries (larynx, bronchus, esophagus) is essential

Bronchial Injury

• Primarily due to rapid deceleration
• Most occur w/in 2cm of carina
• S/S
  • Dyspnea, hemoptysis, subcutaneous emphysema, sternal tenderness
  • Ptx, pneumomediastinum
• All lacerations of the bronchi involving more than 1/3 of the circumference need sx

Tracheal Injury

• Usually occurs at junction of trachea and cricoid cartilage
• S/S
  • Subcutaneous emphysema, stridor

Diaphragm Injury

• Associated w/ GSW to lower chest/upper abdomen
  • Rarely a/w blunt trauma
• If missed can lead to herniation of abd viscera and to a tension enterothorax
• Diagnosis Techniques
  • 1. CT C/A/P w/ contrast
  • 2. Pass OG tube and check if tube curves up from abdomen into the chest
  • 3. Upper GI series (looking for viscera in the chest)

Esophageal Injury

• Initial study should be esophagogram w/ water-soluble contrast
  • If negative or ambiguous follow w/ barium contrast or flexible esophagoscopy

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

• 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!

Disposition

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

Source

Tintinalli's