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 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 fracture 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]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Thoracic trauma DDX}}
{{Thoracic trauma DDX}}


==Diagnosis==
==Evaluation==
===Imaging===
===Imaging===
*[[Ultrasound: lungs|Ultrasound]]
*[[Ultrasound: lungs|Ultrasound]]
**Can dx hemothorax, pneumothorax, tamponade, rib fx, sternum fx
**Can diagnosis hemothorax, pneumothorax, tamponade, rib fracture, sternum fracture
*[[CXR]]
*[[CXR]]
**Can dx hemothorax, pneumothorax, rib fx, pulmonary contusion, diaphragmatic rupture
**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 not delayed ptx seen patient can be discharged
**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, esp of patient 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]]===
===Systemic [[air embolism]]===
*Pts w/ penetrating chest wounds who require PPV are at risk
*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

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 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
  • 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