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
• 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

Disposition

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

Source

Tintinalli's