Thoracic Trauma

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Thoracic Trauma
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Epidemiology

• Significant cause of mortality representing
  20-25 of all deaths from trauma
• Early deaths (30 min to 3 hrs) from thoracic
  trauma are often preventable due to reversible
  causes
• Most of these causes can be managed by ED
  physicians, with less than 10 of blunt 15-30
  of penetrating requiring thoracotomy

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Pathophysiology

• Hypoxia, hypercarbia, and acidosis often result
  from chest trauma
• Hypoxia blood loss, pulmonary ventilation/perfusi
  on mismatch (contusion, hematoma, alveolar
  collapse), intrathoracic pressure relationships
  (tension pneumo, open pneumo)
• Hypercarbia inadequate ventilation depressed
  level of consciousness
• Metabolic acidosis hypoperfusion of tissues

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Initial Assessment Management

• Hypoxia is the most serious feature of chest
  injury early interventions need to correct it
• Most life threatening injuries treated by airway
  control or chest tube/needle decompression
• Secondary survey should be driven by the injury
  pattern high index of suspicion

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Primary Survey Airway

• ABCs MAJOR PROBLEMS SHOULD BE CORRECTED AS THEY
  ARE IDENTIFIED
• Listen to air movement nose, mouth, lung
  fields, inspect the oropharynx
• Skeletal trauma, such as a posterior dislocation
  or fracture/dislocation of the SC joint closed
  reduction may be achieved with extending the
  shoulders, grasping the clavicle with a towel clip

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Normal AP of a patient with a posterior
dislocation of the clavicle.
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Scan reveals the separation of both clavicles
from their sternal attachments with posterior
displacement
                                                                                                   
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Primary Survey Breathing

• Chest Neck completely exposed!
• Assess respiratory movement quality of
  respirations
• Cyanosis is a late sign of hypoxia
• Shallow respirations respiratory rate may be
  the only signs of impending respiratory distress

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Primary Survey Breathing

• These major thoracic injuries should be
  recognized and addressed during the primary
  survey
• Tension pneumo
• Open pneumo
• Flail chest
• Massive hemothorax

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Tension Pneumothorax

• One-way-valve/air leak occurs from the lung or
  chest wall without any escape causing collapse of
  the lung, mediastinum displacement, decreasing
  venous return, compressing the opposite lung
• THIS IS A CLINICAL DIAGNOSIS
• Chest pain, air hunger, respiratory distress,
  tachycardia, hypotension, tracheal deviation,
  unilateral absence breath sounds, distended neck
  veins, cyanosis
• Difficult to differentiate from cardiac
  tamponade, but hyperresonant percussion absent
  breath sounds are more likely with a pneumo

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Tension Pneumothorax

• Immediate decompression by inserting a 16-18
  gauge needle through the 2nd or 3rd interspace
  anteriorly (mid clavicular line) or laterally
  4th-5th intercostal space

               
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Open Pneumothorax

• Open chest wall equilibrates intrathoracic and
  atmospheric pressure if the opening is
  approximately two-thirds the diameter of the
  trachea
• Management closing the defect with a sterile
  occlusive dressing taped on 3 sides chest tube
  inserted placed on the same side at a remote
  location to the wound

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Primary Survey Breathing

• Flail Chest segment of chest wall does not have
  a boney continuity with the rest of the thoracic
  cage results from 2 or more ribs fractured in 2
  or more places
• Severe disruption of normal chest wall motion
  usually underlying pulmonary contusion
• Paradoxical motion of the chest wall is hallmark,
  but may not be dramatic due to muscle splinting
• 30 of cases are not diagnosed until 6 hours
  after admission
• CT much better at diagnosing addressing the
  extent of pulmonary contusion

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Flail Chest Management

• Oxygen, aggressive pulmonary physiotherapy,
  effective analgesia, selective use of intubation,
  close observation in the ICU or step down unit
• Indications for Intubation clinical signs of
  respiratory fatigue, RR gt35 or lt8, PaO2 lt 60 _at_
  FiO2 gt.5, PaCO2 gt55 _at_ FiO2 gt.5, AA gradient gt450,
  sever shock, associated severe head injuries, age
  gt65 or previous pulmonary disease

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Primary Survey Circulation

• Physical Exam
• Pulse quality, rate, regularity, peripheral
  pulses
• Blood pressure pulse pressures
• Skin color temperature
• Neck veins may not be distended in hypotensive
  patients with tamponade, tension pneumo,
  diaphragmatic injury
• Major injuries that should be diagnosed in the
  Primary Survey
• Massive hemothorax Cardiac Tamponade

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Massive Hemothorax

• Rapid accumulation of more than 1500mL of blood
  or 1/3 the patients blood volume or gt200 mL/hour
  for 3 hours
• Associated with pneumo 25
• Usually from penetrating chest trauma injuring
  lung parenchymal vessels most common source (self
  limiting) intercostal internal mammary 2nd
  most common, and rarely hilar vessels
• Shock, absent breath sounds, dullness to
  percussion are signs

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Massive Hemothorax

• 200-300 mL required to blunt costophrenic angles
  on upright chest X-ray
• Supine views can miss large collections of blood

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Hemothorax Management

• Blood should be removed as completely rapidly
  as possible
• 32-40 fr Chest tube inserted anterior axillary
  line directed posteriorly and laterally
• Antibiotics are controversial, however empyema
  rate decrease 9.4 to 0.8 in one study
  intrathoracic infections decreased 17.5 to 2.9
  in another

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Hemothorax Management

• Indications for Thoracotomy
• Initial drainage gt20mL/kg
• Persistent bleeding gt7mL/kg/hr
• Increasing hemothorax via x-rays
• Vital signs remain unstable without any other
  source of bleeding and adequate resuscitation
• Indications for ED Thoracotomy
• Penetrating Traumatic Cardiac arrest with signs
  of life in the field BP lt50 after resuscitation
  shock signs of tamponade
• Blunt Trauma Cardiac arrest in the ED
• Suspected air embolus
• ATLS Manual 7th Ed. Thoracotomy is not
  indicated unless a surgeon, qualified by training
  and experience, is present.
• Consider auto transfusion

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Cardiac Tamponade

• 2 incidence after penetrating trauma, rare with
  blunt trauma
• PE hypotension, distended neck veins, muffled
  heart sounds (BECKs)
• Most reliable sign is CVP gt15 with associated
  hypotension tachycardia
• Pulsus paradoxus decline in systolic BP gt10 mmHg
  on inspiration
• Ultrasound sensitivity 98 Specificity 99.9
• ECG Electrical alternans is highly specific
  marker, but rare in acute tamponade
• Chest x-ray rarely helpful in acute tamponade,
  classic water-bottle seen in chronic
  pericardial effusions

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Cardiac Tamponade
                
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Cardiac Tamponade

• Management
• Volume expansion with crystalloid
• Pericardiocentesis if clinical deterioration
  aspiration of 5-10 mL may cause improvement
• Pericardiocentesis should be done under
  ultrasound if available and with ECG monitoring
• Toracotomy indications as described earlier

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Secondary Survey

• Requires further in-depth physical examination,
  with some studies already discussed in
  conjunction with the previous comorbidities
• HEAD to Toe examination with adjuncts upright
  chest, CTs, ABGs, ECGs
• Eight Lethal injuries that need to be discussed
  that are not always obvious on PE

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Eight Lethal Injuries with the Secondary Survey

• Simple Pneumothorax
• Hemothorax
• Pulmonary contusion
• Tracheobronchial Tree Injury
• Blunt Cardiac Injury
• Traumatic Aortic Disruption
• Traumatic Diaphragmatic injury
• Mediastinal Traversing Wounds

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Simple Pneumothorax

• 1st in the setting of a minor penetrating
  trauma and initial negative exam chest x-rays,
  the patient can be observed for 3-6 hours, have
  x-rays repeated DC
• Isolated simple pneumothoraces lt25, in an
  asymptomatic patient can be observed
• However, general anesthesia or pos pressure
  ventilation should never be done in these
  patients without a chest tube (1/3 will progress)

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Simple Pneumothorax

• Indications for tube thoracotomy
• Traumatic pneumo
• Mod-large pneumo
• Respiratory symptoms regardless of size
• Increasing size with conservative tx
• Recurrence of pneumo after removal of a chest
  tube
• Patient requires ventilator support
• Patient requires general anesthesia
• Associated hemothorax
• Bilateral pneumo regardless of size
• Tension pneumo

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Simple Pneumothorax

• Catheter aspiration can be attempted
• Simple pneumo 24-28 Fr tube thoracotomy, if
  significant air leak under water-seal then
  constant vacuum _at_20-30 ccH2O

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Tracheobronchial Tree Injury

• Can occur in penetrating or blunt trauma, but
  rare (lt3 of all trauma)
• Mortality rate 10 if missed
• If blunt trauma, usually occurs 2 cm from the
  carina
• Massive air leak, hemoptysis, subcutaneous
  emphysema
• Hamman crunch may be audible

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Tracheobronchial Tree Injury

• 2 Clinical Pictures
• Injury opens up into pleural space causes
  continuous air leak, not allowing tube
  thoracotomy to expand the lung constant
  bubbling on water seal
• Complete transaction of tracheobronchial tree
  without a pneumo and patient is relatively
  symptoms free for 1-3 weeks, but presents later
  with atelectasis and pneumonia

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Tracheobronchial Tree Injury

• Pneumomediastinum, subcutaneous emphysema,
  fracture of the upper ribs, air surrounding the
  bronchus all suggest the diagnosis
• gt1 chest tube may be needed to overcome air leak
• Bronchoscopy should be performed
• Intubation over a bronchoscope can aid in
  opposite main step intubation or intubation
  distal to the injury
• Surgery is needed to repair the wound

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Traumatic rupture, tracheobronchial tree
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Pulmonary Contusion

• Most common potentially lethal chest injury
• Occurs in 30-75 of significant blunt chest
  trauma
• Bruise of the lung parenchyma with alveolar edema
  and hemorrhage
• Dyspnea, tachypnea, cyanosis, tachycardia,
  hypotension are all common, with hemoptysis
  present in 50
• Common in children, without associated Fx
• Can be overlooked due to other dramatic findings
  on x-ray
• CT very sensitive findings usually present in
  initial 6 hours and lasts 48-72 hours

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Pulmonary Contusion

• Patients with persistent hypoxia (PaO2 lt65, SaO2
  lt90 RA) should be considered for early
  intubation.
• Restriction of intravenous fluids, aggressive
  pulmonary toilet, suctioning, and pain control
  improve outcomes
• Pneumonia is the most common complication, but
  prophylactic antibiotics is not recommended

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Pulmonary Contusion
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Traumatic Diaphragmatic Injury

• More common on the left side
• Blunt trauma can produce tears allowing acute
  herniation, while penetrating trauma produces
  small perforations and may take years for
  herniation to occur
• If suspected, place an NG this will appear in
  the thorax
• Upper gastrointestinal contrast studies can be
  performed in unclear cases
• Treatment is direct repair

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Diaphragmatic Rupture with Tension Gastrothorax
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Blunt Cardiac Injury

• No gold standard for diagnosing blunt injures
• Accounts for 25 of all deaths at the scene in
  blunt trauma
• 15-25 incidence in blunt chest trauma
• Wide spectrum of injuries pericardial tears,
  rupture of a chamber causing tamponade, valvular
  injuries, contusion, laceration of cardiac
  arteries

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Blunt Cardiac Injury

• Contusion
• Look for external signs of trauma
• Important sequelae are hypotension, conduction
  abnormalities, wall motion abnormality on 2-d
  echo
• MI is very rare
• Common conduction abnormalities PVCs, sinus
  tach, afib, bbb, nonspecific ST changes
• Diagnosis made by appropriate clinic setting with
  new ECG findings, arrhythmia, HF, decreased EF,
  or increased CPK-MB troponins, but new anterior
  wall motion abnormality is most definitive
  finding
• If initial ECG is normal and repeat in 24 hours
  normal, highly unlikely any complications will
  occur

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Traumatic Aortic Disruption

• Common cause of sudden death
• Salvage may be possible if recognized early
• 80-90 of tears in the descending aorta
• Severe deceleration injury causes injury
• 1/3-1/2 of these patients have no external signs
  of injury!
• Most common symptoms are interscapular or
  retrosternal pain, but clinical signs are
  uncommon nonspecific
• Reflex HTN is common as well as HTN in the upper
  extremities and diminished femoral pulses

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Traumatic Aortic Disruption

• Widen mediastinum is the most sensitive sign and
  is 50-92 (specificity 10)
• Other causes of widen mediastinum spinal fx,
  sternum fx, bleeding clavicular fx, previous
  mediastinal mass
• Mediastinal width gt 6 cm in the erect PA film or
  gt 8 cm in the supine AP film or gt 7.5 cm at the
  aortic knob
• Obscured aortic knob, no AP window, displaced NG
  tube, widened rt. Paratracheal stripe may be the
  most specific signs
• False negative rate 7-10
• Helical CT almost 100 sensitivity specificity
• Diagnose and then get them out of your ER

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Widened Mediastinum
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Mediastinal Traversing Wounds

• Diagnosis is made when careful examination of the
  chest x-ray reveals entrance wound in one
  hemithorax an exit or missile in the other
• Surgical consultations is mandatory
• Bilateral tube throacostomy should be performed
  if hemodynamically abnormal patients
• Thoracostomy indications as described earlier

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Mediastinal Traversing Wounds

• Hemodynamically normal patients, with normal
  chest x-rays need intensive evaluation
• Helical CT water contrast esophagography should
  be performed
• If unstable at any time restart ABCDEs
• Overall mortality rate for mediastinal
  penetrating wounds is 20 this doubles if they
  present hemodynamically abnormal

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Mediastinal Traversing Wounds

• Special Note Esophageal Perforations
• Mortality almost 100 if not DX in 24 hours, if
  before 30
• Most Common Causes (in order)
• Iatrogenic
• Foreign bodies
• Caustic burns
• Blunt or penetrating trauma
• Spontaneous rupture (Boerhaaves Syn)
• Postoperative breakdown of anastomosis

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Esophageal Perforations

• Most reliable symptom is pleuritic pain localized
  along the esophagus
• Mediastinal air may surround the heart to produce
  Hammans crunch
• Subcutaneous emphysema may be present
• Cardiopulmonary collapse and sepsis may be the
  initial presentation
• Dx X-ray, and gastrografin study, or urgent
  endoscopy
• TX broad-spectrum antibiotics, volume
  replacement, airway maintenance

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Subcutaneous Emphysema
                
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Fractured Bones

• Ribs
• 1-3 associated with significant force
• 4-8 associated with underlying pulmonary
  contusion
• 9-12 associated with intra-abdominal pathology
• Diagnosis can be made clinically with tenderness,
  bony creptitus, ecchymosis, and muscle spasm over
  the ribs

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Fractured Ribs

• Indications for Rib X-ray studies
• Suspected rib 1-2 Fx or 9-12
• Multiple rib fx
• Elderly patient
• Preexisting pulmonary disease
• Suspected pathologic fracture
• Individuals with suspicion of underlying
  pathology 1st/2nd rib fx should have a helical
  chest CT

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Rib Fractures

• Heal in 3-6 weeks
• Analgesia usually necessary for 1-2 weeks
• Binders, belts, and restrictive devices should
  not be used
• Patients with displaced fractures or multiple
  fractures should be observed

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Sternal Fractures

• Due to anterior blunt chest trauma
• Isolated fractures are benign
• Cardiac contusion in 1.5-6
• Spinal fractures in lt10
• Rib fractures in 20
• Difficult to diagnose on X-ray, unless displaced
  fx
• Associated injuries may be assessed with CT of
  the Chest, ECG, and enzymes
• Management Adequate analgesia

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Key Concepts

• Even minor chest wall injuries, such as rib fx,
  may result in serious complication sin elderly
  patients and patients with pulmonary
  comorbidities
• Children more susceptible to pulmonary contusion
• If initial ECG normal, cardiac contusion is
  usually benign
• Many patients with cardiac rupture or traumatic
  aortic rupture survive to reach the hospital and
  can be salvaged
• Pericardial tamponade can be diagnosed before
  homodynamic decomposition with standard ECHO by
  ED physicians
• Injury to the Esophagus is relatively common with
  penetrating trauma. Presentation is initially
  subtle and potential complications severe, so the
  diagnosis must be pursued in cases in which the
  trajectory of the penetrating wound potentially
  involves the esophagus

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RESOURCES

• ATLS Student Course Manual 7th ED.
• Rosens Emergency Medicine CH 42
• Wilson, Robert. Handbook of Trauma, Pitfalls and
  Pearls