Doctor123.org

Chest Trauma, Penetrating, Emergency Medicine

Doctor123.org

Chest Trauma, Penetrating, Emergency Medicine

Basics

Etiology

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: пїЅ

  • 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 rateChest excursionCrepitusSubcutaneous airBreath 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
  • Respiratory effort and rate
  • Chest excursion
  • Crepitus
  • Subcutaneous air
  • Breath sounds and heart sounds
  • Supine CXR should be taken 1st if spinal precautions must be maintained.

Diagnosis Tests & Interpretation

  • 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
  • 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.
  • Repeat pericardial US is recommended after tube thoracostomy decompression of the hemothorax.
  • Residual hemothorax represents pericardial injury or cardiac laceration.
  • 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
  • Total number of wounds and bullets must be the same.

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 suspectedNever 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 distentionIf 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.
  • 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.
  • Unilaterally absent breath sounds, hypotension, jugular venous distention
  • A totally occlusive dressing may produce a tension pneumothorax.
  • 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.
  • Intubate for signs of serious chest injury, obvious respiratory distress, or hypotension.
  • 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.
  • Follow by rapid transport to the operating room for a pericardial window

Ed Treatment/Procedures

  • Notify trauma surgeon about patients arrival.
  • Tube thoracostomy if a pneumothorax or hemothorax is identified:36G chest tube in an adultIn 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 laparoscopyDPL 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
  • 36G chest tube in an adult
  • In children, use largest tube the intercostal space will accommodate.
  • Contused lung parenchyma will have leaky capillary beds, and aggressive crystalloid resuscitation may aggravate pulmonary dysfunction.
  • Workup with a diagnostic peritoneal lavage (DPL), US, CT scan, exploratory laparotomy, or laparoscopy
  • DPL positive with 5,000 RBC
  • Retain any bullet fragments, clothes, or tissue removed from the wound.

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 Ојg/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

  • 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.
  • 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.
  • CT chest may be an alternative to CXR, if no intrathoracic penetration is suspected; patient can be discharged without repeat radiograph.

Additional Reading

  • Ball пїЅCG, Williams пїЅBH, Wyrzykowski пїЅAD, et al. A caveat to the performance of pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma. 2009;67:1123-1124.
  • Duke пїЅMD, Guidry пїЅC, Guice пїЅJ, et al. Restrictive fluid resuscitation in combination with damage control resuscitation: Time for adaptation. J Trauma Acute care Surg. 2012;73:674-678.
  • Haut пїЅER, Kalish пїЅBT, Efron пїЅDT, et al. Spinal immobilization in penetrating trauma: More harm than good. J Trauma. 2010;68:115-121.
  • Ivatury пїЅRR, Cayten пїЅCG, eds. The Textbook of Penetrating Trauma. Baltimore, MD: Williams & Wilkins; 1996.
  • Moore пїЅEE, Knudson пїЅMM, Burlew пїЅCC, et al. Defining the limits of resuscitative emergency department thoracotomy: A contemporary Western Trauma Association perspective. J Trauma. 2011;70:334-339.
  • Nandipati пїЅKC, Allamaneni пїЅS, Kakarla пїЅR, 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)