Thoracic trauma
Revision as of 04:38, 2 July 2016 by Neil.m.young (talk | contribs) (Text replacement - " pt " to " patient ")
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
- 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
Differential Diagnosis
Thoracic Trauma
- Airway/Pulmonary
- Cardiac/Vascular
- Musculoskeletal
- Other
Diagnosis
Imaging
- Ultrasound
- 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
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
Treatment
- Treat underlying condition
Disposition
- Asymptomatic thoracic stab wound
- Repeat CXR in 4-6hr; if not delayed ptx seen patient can be discharged
Complications
Aspiration
- Common after severe trauma, esp of 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
- Pts w/ penetrating chest wounds who require PPV are at risk
- May lead to dysrhythmias or CVA
- Treatment
- 100% NRB
See Also
- [NEXUS Chest CT Rule]]