• A 35-year-old man presents to the ED with a stab wound to the left chest lateral and above the nipple. The paramedics report that he had been writhing in pain in the ambulance. His blood pressure is 80/50 mmHg, pulse is 120/min, and respirations are 22/min. Tube thoracostomy is performed in the left chest at the fifth intercostal space. About 1500 ml of blood is evacuated immediately, but the patient continues to lose blood.
  • Trauma to chest accounts for ~50% trauma mortality
  • 80% of all chest injuries can be managed non-surgically with simple measures including intubation, chest tubes, and pain control
  • Location and mechanism of injury determines acuity and management strategy
  • Different chest trauma diagnoses can be identified and managed during primary and secondary survey
  • Primary survey
    • airway obstruction
      • acute anxiety, stridor, hoarseness, altered mental status, apnea, cyanosis
    • tension pneumothorax
    • open pneumothorax
    • massive hemothorax
    • flail chest
    • cardiac tamponade
  • Secondary survey
    • pulmonary contusion
      • blunt trauma to chest causing interstitial edema that impairs compliance and gas exchange
    • ruptured diaphragm
      • blunt trauma to chest or abdomen
    • esophageal injury
      • usually due to penetrating trauma
      • pain out of proportion to degree of injury
      • do NOT use barium as it is caustic - gastrograffin is preferred
    • aortic tear
      • 90% of cases tear at subclavian artery near ligamentum arteriosum
        • most die at scene
    • blunt myocardial injury
  • Diseases suspected in primary survey
    • diagnoses are primarily clinically based on history and exam
    • rapid workup can include arterial blood gas, CXR, bedside ultrasound (FAST)
  • Diseases suspected in secondary survey
    • pulmonary contusion
      • CXR: opacification of lung within 6 hours
    • ruptured diaphragm
      • CXR: abnormal peridiaphragmatic anatomy
      • CT scan and endoscopy if further workup needed
    • esophageal injury
      • CXR: potential pneumomediastinum
      • esophagram/esophagoscopy
    • aortic tear
      • CXR, CT scan, TEE
      • CT aortography (gold standard)
    • blunt myocardial injury
      • dysrhythmias, ST changes
  • Airway management: intubate early if airway compromise suspected
  • Needle thoracostomy
    • use large bore needle at 2nd intercostal space in midclavicular line
    • best initial step in management of tension pneumothorax
  • Tube thoracostomy
    • chest tube at 5th intercostal space in anterior axillary line 
    • next step in management after needle placement in tension pneumothorax
  • Oxygenation
    • positive pressure ventilation for flail chest
  • Circulation
    • IV crystalloids early for management of hemodynamic instability
    • transfusion for significant blood loss
  • Thoracotomy
    • indications
      • > 1500 ml total blood loss
      • > 200 ml/h continued drainage of blood for > 3 hours
  • Surgical repair as needed



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