Thoracic trauma: Difference between revisions

 
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==Background==
==Background==
[[File:Gray530.png|thumb|Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.]]
*Must determine if injury also traverses the diaphragm (intra-abdominal injury)
*Must determine if injury also traverses the diaphragm (intra-abdominal injury)
**Most deaths in thoracic trauma pts are due to noncardiothoracic injuries
**Most deaths in thoracic trauma patients are due to non-cardiothoracic injuries
*Excessive PPV can lead to reduced venous return, tension ptx (avoid excess bagging)  
*Excessive positive pressure ventilation can lead to reduced venous return, [[tension pneumothorax]] (avoid excess bagging)  
*Place central lines on the SAME side as existing injury or PTX (prevent b/l ptx)
*Place central lines on the SAME side as existing injury or [[pneumothorax]] (prevent bilateral [[pneumothorax]])
*Hypotensive resuscitation in chest trauma may be beneficial
*Hypotensive resuscitation in chest trauma may be beneficial


==DDx==
==Clinical Features==
#[[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===
===Inspection===
*Seat-belt sign indicates possible deceleration or vascular injury
*Seat-belt sign indicates possible deceleration or vascular injury
*Paradoxical wall movemement indicates flail chest
**determine seatbelt placement (if worn improperly or abnormal body habitus)
*Distended neck veins
*Paradoxical wall movement indicates [[flail chest]]
**Tamponade, tension ptx, heart failure
*Neck veins
** Distended
***[[Pericardial effusion and tamponade|Tamponade]]
***[[Tension pneumothorax]]
***[[Congestive heart failure]]
**Flat
*Circulatory shock
*Hemothorax
*Swollen face
*Swollen face
**SVC compression vs subcutaneous emphysema
**Conjunctival injection + facial edema + mechanism conducive to traumatic asphyxia may indicate SVC compression
***also consider judicial/non-judicial hanging and strangulation
*Subcutaneous emphysema
**Anterior neck/supraclavicular
***Tracheobronchial tree
***Esophagus (Boerhaave's syndrome)
**Chest wall
***Visceral/parietal pleura
 
===Palpation===
===Palpation===
*Neck
*Neck
**Trachea midline or displaced
**Trachea midline or displaced
*Chest wall
*Chest wall
**Localized tenderness or crepitus due to rib fx or subcutaneous emphysema
**Localized tenderness or crepitus due to [[rib fracture]] or subcutaneous emphysema
*Sternum
*Sternum
**Localized tenderness, crepitus, or mobile segment suggests fx
**Localized tenderness, crepitus, or mobile segment suggests [[Sternal Fracture|fracture]]
==Imaging==
 
*US
==Differential Diagnosis==
**Can dx hemothorax, pneumothorax, tamponade, rib fx, sternum fx
{{Thoracic trauma DDX}}
*CXR
 
**Can dx hemothorax, pneumothorax, rib fx, pulmonary contusion, diaphragmatic rupture
==Evaluation==
===Imaging===
*[[Ultrasound: lungs|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
**Frequently underestimates the severity/extent of chest trauma
*CT
*CT
**Gold-standard
**Gold-standard


==Specific Conditions==
{{Nexus chest CT in trauma major rule}}
===[[Pneumomediastinum]]===


===[[Bronchial Injury]]===
==Management==
*Treat underlying condition


===[[Tracheal Injury]]===
==Disposition==
 
*Asymptomatic thoracic stab wound
===[[Diaphragm Injury]]===
**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
===[[Esophageal Injury]]===
*Initial study should be esophagogram w/ water-soluble contrast
**If negative or ambiguous follow w/ barium contrast or flexible esophagoscopy


==Complications==
==Complications==
===Aspiration===
===Aspiration===
*Common after severe trauma, esp of pt was unconscious at any time
*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===
 
*Pts w/ penetrating chest wounds who require PPV are at risk
===Systemic [[air embolism]]===
*Patients with penetrating chest wounds who require PPV are at risk
*May lead to dysrhythmias or CVA
*May lead to dysrhythmias or CVA
*Treatment
*Treatment
**100% NRB
**100% NRB


==Disposition==
==See Also==
*Asymptomatic thoracic stab wound
*[[Thoracotomy]]
**Repeat CXR in 4-6hr; if not delayed ptx seen pt can be discharged
*[[Chest tube]]
 
*[[NEXUS Chest CT Rule]]
==Source==
*[[Trauma (main)]]
Tintinalli's


[[Category:Cards]]
==References==
[[Category:Pulm]]
<references/>
[[Category:Cardiology]]
[[Category:Pulmonary]]
[[Category:Trauma]]
[[Category:Trauma]]

Latest revision as of 22:05, 20 April 2022

Background

Left pleura cavity (viewed from left) showing intercostal bundles (vein, artery, and nerve) under ribs.
  • Must determine if injury also traverses the diaphragm (intra-abdominal injury)
    • Most deaths in thoracic trauma patients are due to non-cardiothoracic injuries
  • Excessive positive pressure ventilation 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
    • determine seatbelt placement (if worn improperly or abnormal body habitus)
  • Paradoxical wall movement indicates flail chest
  • Neck veins
  • Circulatory shock
  • Hemothorax
  • Swollen face
    • Conjunctival injection + facial edema + mechanism conducive to traumatic asphyxia may indicate SVC compression
      • also consider judicial/non-judicial hanging and strangulation
  • Subcutaneous emphysema
    • Anterior neck/supraclavicular
      • Tracheobronchial tree
      • Esophagus (Boerhaave's syndrome)
    • Chest wall
      • Visceral/parietal pleura

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

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

See Also

References