Thoracic trauma: Difference between revisions
(Text replacement - " dx" to " diagnosis") |
|||
| (6 intermediate revisions by 4 users not shown) | |||
| Line 11: | Line 11: | ||
*Paradoxical wall movemement indicates flail chest | *Paradoxical wall movemement indicates flail chest | ||
*Distended neck veins | *Distended neck veins | ||
**Tamponade, tension pneumothorax, heart failure | **[[Pericardial effusion and tamponade|Tamponade]], [[tension pneumothorax]], [[congestive heart failure]] | ||
*Swollen face | *Swollen face | ||
**SVC compression vs subcutaneous emphysema | **SVC compression vs subcutaneous emphysema | ||
===Palpation=== | ===Palpation=== | ||
*Neck | *Neck | ||
| Line 42: | Line 43: | ||
==Disposition== | ==Disposition== | ||
*Asymptomatic thoracic stab wound | *Asymptomatic thoracic stab wound | ||
**Repeat CXR in 4-6hr; if | **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== | ==Complications== | ||
===Aspiration=== | ===Aspiration=== | ||
*Common after severe trauma, | *Common after severe trauma, especially if patient was unconscious at any time | ||
*Radiologic changes may be delayed up to 24hr (consolidation) | *Radiologic changes may be delayed up to 24hr (consolidation) | ||
**Due to chemical pneumonitis from gastric contents | **Due to chemical pneumonitis from gastric contents | ||
*No evidence to support prophylactic antibiotics to prevent pulmonary infection | *No evidence to support prophylactic antibiotics to prevent pulmonary infection | ||
===Systemic [[air embolism]]=== | ===Systemic [[air embolism]]=== | ||
*Patients with penetrating chest wounds who require PPV are at risk | *Patients with penetrating chest wounds who require PPV are at risk | ||
| Line 57: | Line 60: | ||
==See Also== | ==See Also== | ||
*[NEXUS Chest CT Rule]] | *[[NEXUS Chest CT Rule]] | ||
==References== | ==References== | ||
<references/> | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Pulmonary]] | [[Category:Pulmonary]] | ||
[[Category:Trauma]] | [[Category:Trauma]] | ||
Revision as of 23:54, 27 February 2019
Background
- Must determine if injury also traverses the diaphragm (intra-abdominal injury)
- Most deaths in thoracic trauma patients are due to noncardiothoracic injuries
- Excessive PPV 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
- Paradoxical wall movemement indicates flail chest
- Distended neck veins
- Swollen face
- SVC compression vs subcutaneous emphysema
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
- 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