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
- Traumatic Pneumothorax
- Tension Pneumothorax
- Hemothorax
- Flail Chest
- Sternum Fracture
- Traumatic Asphyxia
- Trachobronchial Injury
- Cardiac Tamponade
- Myocardial Contusion
- Aortic Transection
- Boerhaave's
- Pulmonary Contusion
- 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
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
- 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