Thoracic trauma: Difference between revisions
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===Pneumomediastinum=== | ===Pneumomediastinum=== | ||
*May be asymptomatic or cause mild-moderate chest pain, voice change, cough, stridor | *May be asymptomatic or cause mild-moderate chest pain, voice change, cough, stridor | ||
* | *Search for other more serious injuries (larynx, bronchus, esophagus) is essential | ||
===Bronchial Injury=== | ===Bronchial Injury=== | ||
*Primarily due to rapid deceleration | *Primarily due to rapid deceleration | ||
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*Initial study should be esophagogram w/ water-soluble contrast | *Initial study should be esophagogram w/ water-soluble contrast | ||
**If negative or ambiguous follow w/ barium contrast or flexible esophagoscopy | **If negative or ambiguous follow w/ barium contrast or flexible esophagoscopy | ||
==Complications== | ==Complications== | ||
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*Treatment | *Treatment | ||
**100% NRB | **100% NRB | ||
==Disposition== | ==Disposition== | ||
*Asymptomatic thoracic stab wound | *Asymptomatic thoracic stab wound | ||
**Repeat CXR in 4-6hr; if not delayed ptx seen pt can be discharged | **Repeat CXR in 4-6hr; if not delayed ptx seen pt can be discharged | ||
==Source== | ==Source== |
Revision as of 23:54, 2 August 2011
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
DDx
- 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
- 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
Specific Conditions
Pneumomediastinum
- May be asymptomatic or cause mild-moderate chest pain, voice change, cough, stridor
- Search for other more serious injuries (larynx, bronchus, esophagus) is essential
Bronchial Injury
- Primarily due to rapid deceleration
- Most occur w/in 2cm of carina
- S/S
- Dyspnea, hemoptysis, subcutaneous emphysema, sternal tenderness
- Ptx, pneumomediastinum
- All lacerations of the bronchi involving more than 1/3 of the circumference need sx
Tracheal Injury
- Usually occurs at junction of trachea and cricoid cartilage
- S/S
- Subcutaneous emphysema, stridor
Diaphragm Injury
- Associated w/ GSW to lower chest/upper abdomen
- Rarely a/w blunt trauma
- If missed can lead to herniation of abd viscera and to a tension enterothorax
- Diagnosis Techniques
- 1. CT C/A/P w/ contrast
- 2. Pass OG tube and check if tube curves up from abdomen into the chest
- 3. Upper GI series (looking for viscera in the chest)
Esophageal Injury
- Initial study should be esophagogram w/ water-soluble contrast
- If negative or ambiguous follow w/ barium contrast or flexible esophagoscopy
Complications
Aspiration
- Common after severe trauma, esp of pt 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
- Pts w/ penetrating chest wounds who require PPV are at risk
- May lead to dysrhythmias or CVA
- Treatment
- 100% NRB
Disposition
- Asymptomatic thoracic stab wound
- Repeat CXR in 4-6hr; if not delayed ptx seen pt can be discharged
Source
Tintinalli's