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 noncardiothoracic injuries | **Most deaths in thoracic trauma patients are due to noncardiothoracic injuries | ||
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===Inspection=== | ===Inspection=== | ||
*Seat-belt sign indicates possible deceleration or vascular injury | *Seat-belt sign indicates possible deceleration or vascular injury | ||
*Paradoxical wall | **determine seatbelt placement (if worn improperly or abnormal body habitus) | ||
*Distended | *Paradoxical wall movement indicates [[flail chest]] | ||
**Tamponade | *Neck veins | ||
** Distended | |||
***[[Pericardial effusion and tamponade|Tamponade]] | |||
***[[Tension pneumothorax]] | |||
***[[Congestive heart failure]] | |||
**Flat | |||
*Circulatory shock | |||
*Hemothorax | |||
*Swollen face | *Swollen face | ||
**SVC compression | **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 fracture or subcutaneous emphysema | **Localized tenderness or crepitus due to [[rib fracture]] or subcutaneous emphysema | ||
*Sternum | *Sternum | ||
**Localized tenderness, crepitus, or mobile segment suggests | **Localized tenderness, crepitus, or mobile segment suggests [[Sternal Fracture|fracture]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Thoracic trauma DDX}} | {{Thoracic trauma DDX}} | ||
== | ==Evaluation== | ||
===Imaging=== | ===Imaging=== | ||
*[[Ultrasound: lungs|Ultrasound]] | *[[Ultrasound: lungs|Ultrasound]] | ||
**Can | **Can diagnosis hemothorax, pneumothorax, tamponade, rib fracture, sternum fracture | ||
*[[CXR]] | *[[CXR]] | ||
**Can | **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 | ||
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==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 | ||
*May lead to dysrhythmias or CVA | *May lead to dysrhythmias or CVA | ||
*Treatment | *Treatment | ||
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==See Also== | ==See Also== | ||
*[NEXUS Chest CT Rule]] | *[[Thoracotomy]] | ||
*[[Chest tube]] | |||
*[[NEXUS Chest CT Rule]] | |||
*[[Trauma (main)]] | |||
==References== | ==References== | ||
<references/> | |||
[[Category:Cardiology]] | [[Category:Cardiology]] | ||
[[Category:Pulmonary]] | [[Category:Pulmonary]] | ||
[[Category:Trauma]] | [[Category:Trauma]] |
Revision as of 19:57, 8 April 2021
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
- 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