Basics
Etiology
- Gunshot wounds or stab wounds most common
- Impalement on a sharp object from a fall can occur.
Diagnosis
Signs and Symptoms
- Object impaled in the chest wall
- Obvious wound in the chest wall with or without bleeding
- Chest pain
- Dyspnea
- Respiratory distress
- Altered mental status from hypoxemia
- Absent or altered breath sounds on 1 or both sides
- Hypotension
- Jugular venous distention
Essential Workup
- Perform routine assessment of airway, breathing, and circulation.
- Rapid exam:
- Respiratory effort and rate
- Chest excursion
- Crepitus
- Subcutaneous air
- Breath sounds and heart sounds
- Upright CXR is preferred for identifying a pneumothorax:
- Supine CXR should be taken 1st if spinal precautions must be maintained.
- Baseline hemoglobin
- Pulse oximetry
- ABG
- Serum lactate
- Type and screen
Diagnosis Tests & Interpretation
Lab
- Perform echocardiogram if signs of tamponade present or if wound is close to the heart:
- In stab wound to precordium and pericardial sac, hemopericardium may decompress into hemothorax, thus not apparent on initial echo:
- Repeat pericardial US is recommended after tube thoracostomy decompression of the hemothorax.
- Residual hemothorax represents pericardial injury or cardiac laceration.
- ECG
Imaging
- With gunshot wounds, other areas (abdomen, pelvis) should be imaged:
- Total number of wounds and bullets must be the same.
- Arteriogram of aortic arch, carotid arteries, or subclavian artery if great vessel injury is suspected
- Esophageal Gastrografin swallow or endoscopy to identify esophageal perforation
- Bronchoscopy to identify tracheobronchial injuries
Differential Diagnosis
- Simple pneumothorax
- Tension pneumothorax
- Open pneumothorax
- Hemothorax
- Rib fractures
- Flail chest
- Pulmonary contusion
- Myocardial contusion
- Myocardial rupture
- Pericardial tamponade
- Traumatic aortic disruption
- Esophageal injury
- Large vessel injury
- Tracheobronchial injury
- Diaphragmatic injury
- Intra-abdominal injury
- Spinal cord injury
Treatment
Pre-Hospital
- Cautions:
- All patients with signs of life in the field according to reports from EMS personnel should be transported to a trauma center.
- Full spinal immobilization if spinal injury suspected
- Never remove objects impaled in the chest because exsanguination may follow.
- Needle decompression may be necessary if tension pneumothorax suspected:
- Unilaterally absent breath sounds, hypotension, jugular venous distention
- If large open pneumothorax exists, occlusive dressing taped on 3 sides:
- A totally occlusive dressing may produce a tension pneumothorax.
- Controversies:
- Do not delay transport to hospital to obtain IV access:
- IV access may be established en route.
- Do not delay transport to hospital by applying full spinal immobilization to patients who do not have clear clinical signs of spinal injury.
Initial Stabilization/Therapy
- Airway, breathing, and circulation management:
- Intubate for signs of serious chest injury, obvious respiratory distress, or hypotension.
- Oxygen by nonrebreather face mask for patients in stable condition
- Obtain vascular access, 2 peripheral large-bore IV lines (>18G), and fluid resuscitation as needed:
- Restrictive fluid resuscitation is associated with shorter hospital length of stay and lower overall mortality.
- In penetrating aortic trauma, permissive hypotension at systolic BP 90 mm Hg until definitive surgical control prevents further hemorrhage.
- For tension pneumothorax, perform a needle thoracostomy and place a chest tube immediately.
- Do not wait to get a CXR.
- Sonogram has demonstrated higher sensitivity than CXR in diagnosing pneumothorax.
- For pericardial tamponade, perform an emergency pericardiocentesis:
- Follow by rapid transport to the operating room for a pericardial window
- Maintain spinal immobilization if indicated.
Ed Treatment/Procedures
- Notify trauma surgeon about patients arrival.
- Tube thoracostomy if a pneumothorax or hemothorax is identified:
- 36G chest tube in an adult
- In children, use largest tube the intercostal space will accommodate.
- Fluid resuscitation as necessary:
- Contused lung parenchyma will have leaky capillary beds, and aggressive crystalloid resuscitation may aggravate pulmonary dysfunction.
- Any wound with an entry or exit site below the nipple or the posterior tip of the scapula is concerning for an intra-abdominal injury:
- Workup with a diagnostic peritoneal lavage (DPL), US, CT scan, exploratory laparotomy, or laparoscopy
- DPL positive with 5,000 RBC
- Describe the nature of wounds accurately:
- Retain any bullet fragments, clothes, or tissue removed from the wound.
- Probing a chest wound is contraindicated because it can create a pneumothorax or worsen hemorrhage.
- Impaled objects should be removed only in the operating room.
- Tetanus booster if indicated
Medication
- Methylprednisolone (for spinal cord injury): 30 mg/kg IV over 1 hr, followed by a continuous drip of 5.4 mg/kg/h for 23 hr
- Small doses of short-acting analgesics (fentanyl, 1-2 μg/kg IV, morphine 0.1 mg/kg IV) or sedatives (midazolam, 0.05 mg/kg IV) as needed for pain control and sedation
- Treat with IV antibiotics if wound grossly contaminated (e.g., cephalexin 1 g IV).
Follow-Up
Disposition
Admission Criteria
- All patients with penetrating chest trauma should be admitted.
- In penetrating torso trauma, resuscitative thoracotomy in the ED demonstrates survival when pre-hospital CPR does not exceed 15 min.
- A patient who has signs of life in the field but no BP on arrival in the ED should have an emergency thoracotomy performed by the most experienced person present:
- If the source of bleeding is controlled and there are signs of cardiac activity, the patient should go to the operating room for formal operative repair.
- Hemodynamically unstable patients should go immediately to the operating room.
- Any patient with intrathoracic penetration should have a chest tube placed and should be admitted to a monitored setting.
- >1,000-1,500 mL of blood drawn out of the chest tube on initial insertion indicates the need for thoracotomy.
- >200 mL/hr of blood from a chest tube for several hours suggests the need for surgical intervention.
- Patients with large, persistent air leaks usually require surgery.
- Patients with significant rib fractures should be admitted and have an epidural catheter placed for pain control and pulmonary toilet.
Discharge Criteria
Patients with isolated minor chest wounds and a normal CXR can be observed for 3 hr in the ED and have a repeat radiographic study; if no intrathoracic penetration is suspected, the patient can be discharged: �
- CT chest may be an alternative to CXR, if no intrathoracic penetration is suspected; patient can be discharged without repeat radiograph.
Additional Reading
- Ball �CG, Williams �BH, Wyrzykowski �AD, et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma. 2009;67:1123-1124.
- Duke �MD, Guidry �C, Guice �J, et al. Restrictive fluid resuscitation in combination with damage control resuscitation: Time for adaptation. J Trauma Acute care Surg. 2012;73:674-678.
- Haut �ER, Kalish �BT, Efron �DT, et al. Spinal immobilization in penetrating trauma: More harm than good. J Trauma. 2010;68:115-121.
- Ivatury �RR, Cayten �CG, eds. The Textbook of Penetrating Trauma. Baltimore, MD: Williams & Wilkins; 1996.
- Moore �EE, Knudson �MM, Burlew �CC, et al. Defining the limits of resuscitative emergency department thoracotomy: A contemporary Western Trauma Association perspective. J Trauma. 2011;70:334-339.
- Nandipati �KC, Allamaneni �S, Kakarla �R, et al. Extended focused assessment with sonography for trauma (EFAST) in the diagnosis of pneumothorax: Experience at a community based level I trauma center. Injury. 2011;42:511-514.
Codes
ICD9
- 862.9 Injury to multiple and unspecified intrathoracic organs, with open wound into cavity
- 875.0 Open wound of chest (wall), without mention of complication
- 875.1 Open wound of chest (wall), complicated
ICD10
- S21.90XA Unsp open wound of unspecified part of thorax, init encntr
- S21.93XA Puncture wound w/o foreign body of unsp part of thorax, init
- S21.94XA Puncture wound w foreign body of unsp part of thorax, init
- S27.9XXA Injury of unspecified intrathoracic organ, initial encounter
SNOMED
- 283524003 Puncture wound of chest (disorder)
- 283545005 gunshot wound (disorder)
- 283473009 Stab wound of chest (disorder)
- 262560006 penetrating wound (disorder)
- 127314000 Open wound of chest wall (disorder)