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Updated: Dec 8 2021

Chest Trauma

  • Snapshot
    • 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.
  • Introduction
    • 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
  • Presentation
    • 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
        • respiratory decompensation
      • 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
  • Management
    • 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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