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 patients are due to | **Most deaths in thoracic trauma patients are due to non-cardiothoracic injuries | ||
*Excessive | *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]]) | *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 | ||
| Line 75: | Line 76: | ||
==See Also== | ==See Also== | ||
*[[Thoracotomy]] | *[[Thoracotomy]] | ||
*[[Chest tube]] | |||
*[[NEXUS Chest CT Rule]] | *[[NEXUS Chest CT Rule]] | ||
*[[Trauma (main)]] | *[[Trauma (main)]] | ||
Latest revision as of 22:05, 20 April 2022
Background
- 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
- Distended
- Flat
- 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
- Conjunctival injection + facial edema + mechanism conducive to traumatic asphyxia may indicate SVC compression
- Subcutaneous emphysema
- Anterior neck/supraclavicular
- Tracheobronchial tree
- Esophagus (Boerhaave's syndrome)
- Chest wall
- Visceral/parietal pleura
- Anterior neck/supraclavicular
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