Thoracic trauma

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 non-cardiothoracic injuries
• Excessive positive pressure ventilation 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
    • Tamponade
    • Tension pneumothorax
    • Congestive heart failure
  • 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
• 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

• Airway/Pulmonary
  • Bronchial injury
  • Diaphragmatic trauma
  • Hemothorax
  • Pneumomediastinum
  • Pulmonary contusion
  • Tracheal injury
  • Trachobronchial injury
  • Traumatic pneumothorax
    • Tension pneumothorax
• Cardiac/Vascular
  • Cardiac injury
    • Blunt cardiac injury
      • Cardiac contusion
      • Commotio cordis
    • Penetrating cardiac injury
    • Cardiac tamponade
  • Traumatic aortic transection
• Musculoskeletal
  • Clavicle fracture
    • Clavicle fracture (peds)
  • Rib fracture
    • Flail chest
  • Scapular fracture
  • Scapulothoracic dissociation
  • Sternoclavicular dislocation
  • Sternum fracture
  • Thoracic and lumbar fractures and dislocations
• Other
  • Esophageal injury or Perforation
  • Pneumomediastinum
  • Pneumopericardium
  • Traumatic asphyxia

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

• Thoracotomy
• Chest tube
• NEXUS Chest CT Rule
• Trauma (main)