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
• w/ pnetrating chest inj neuro defecit should incr suspicion of vasc inj b/c nv bundle run together

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

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

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

DDx

1. Traumatic Pneumothorax
2. Tension Pneumothorax
3. Hemothorax
4. Flail Chest
5. Pulmonary Contusion

• 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!

See Also

• Pulmonary Contusion
• Traumatic Pneumothorax
• Sternum Fracture
• Rib Fracture

Source

Tintinalli's

Source

Tintinalli's