33. Trauma-associated thoracic injuries

Question 1

33. Trauma-associated thoracic injuries

Answer 1

Trauma-associated thoracic injury
-blunt thoracic trauma
>vehicular trauma(most common)
>animal-animal and human-animal interactions
>falls from a height
-most managed conservatively(blunt)
-penetrating thoracic trauma(less common)
>animal-animal interactions
>projectile injuries,impalements
-surgical emergencies after medical
stabilization(penetrating)

Assessment
-most serious thoracic injuries suspected or identified during primary survey
-thorough observation of RR and character
-auscultation
-trauma-associated thoracic injuries(often
several at a time):
>pulmonary injuries
>thoracic wall injuries
>cardiac injuries
>mediastinal injuries
>pleural space injuries

Trauma-associated pulmonary injuries
-pulmonary contusion–lesion of the lung after compression-
decompression injury leading to alveolar collapse and lung consolidation due to hemorrhage and edema
>diagnosis:physical examination+confirmed by radiography
>treatment:oxygen!(signs may worsen over the initial 24h)
-blebs–small pockets of air within the visceral pleura(damage of
alveoli and leakage of air)and bullae–similar to a bleb,but
associated with the pulmonary parenchyma
>diagnosis:radiography, CT
>treatment: indicated if pneumothorax occurs(by rupture of bullae or blebs)

Trauma-associated thoracic wall injuries
-rib fractures
>risk of pneumo-or hemothorax
>diagnosis:physical examination,radiographs
>treatment:pain control,surgery at times
-flail chest–‘’paradoxical“ movement of a floating thoracic segment
>diagnosis:physical examination
>treatment:mostly conservative,surgery sometimes indicated
-penetrating thoracic injury
>diagnosis:physical examination,imaging,surgical wound exploration
>treatment:stabilization,AB,surgical closure,drainage

Trauma-associated cardiac injuries
-cardiac arrhythmias
>diagnostics:auscultation,ECG
>treatment:dependant on the case;ventricular arrhythmias:lidocaine,procainamide
-pericardial effusion(rarely traumatic)–accumulation of fluid in the pericardial space
>diagnostics:auscultation,echocardiography,ECG
>treatment: pericardiocentesis

Trauma-associated mediastinal injuries
-tracheal avulsion–traumatic disruption of the trachea between the tracheal rings
>diagnosis:radiography,tracheoscopy
>treatment:surgical(tracheal resection and anastomosis)
-mainstem broncial rupture
>diagnosis and treatment similar to tracheal avulsion
-pneumomediastinum–accumulation of air in the mediastinal place(may occur secondary to a variety of injuries)
>diagnosis:radiography+search for an underlying cause
>treatment:does not require specific treatment(treat underlying disease!),but can progress to pneumothorax

Trauma-associated pleural space injuries
-pneumothorax
-hemothorax
-chylothorax
-diaphragmatic hernia
-pleural effusion–a buildup of fluid in the pleural
space(many causes; in case of blood or chyle–
possibly caused by trauma)

Pneumothorax
-accumulation of air in the pleural space
-one of the most common trauma-associated thoracic injuries
-open/closed(closed more common)
-diagnosis:clinical examination/auscultation→thoracocentesis(U/S?)
-radiography contraindicated in clinically significant cases!
-treatment: thoracocentesis, oxygen!,AB(open),thoracostomy tube
placement if necessary,surgery (open/recurrent pneumothorax 3-4
days or suspected tracheal avulsion/rupture)

Hemothorax
-the accumulation of blood within the pleural space,results from
disruption of vasculature of the chest wall,lungs,or mediastinal
structures including the great vessels
-uncommonly clinically significant
-diagnosis:clinical examination/auscultation→thoracocentesis only if
necessary(guided by U/S if possible)
-radiography contraindicated in clinically significant cases!
-treatment:thoracocentesis,oxygen!,analgesia,thoracostomy tube
placement if necessary,possible blood transfusion,surgery
(persistent ongoing hemorrhage or penetrating injury)

Chylothorax
-chyle is composed of lymph and chylomicrons(triglycerids)
-traumatic(rare)chylothorax may occur secondary to rupture of the thoracic duct(uncommon)
-not a peracute manifestation of thoracic trauma but is usually noted
within days of the traumatic event
-diagnosis: examination/auscultation→thoracocentesis
-radiography contraindicated in clinically significant cases!
-treatment:thoracocentesis,oxygen!,thoracostomy tube placement if necessary, surgery usually not necessary(performed if
fails to resolve over 2 weeks)

Diaphragmatic hernia
-movement of abdominal viscera through the diaphragm into the pleural space(not always traumatic–can be congenital)
-most common organs herniated into the thorax:liver,small bowel,stomach,spleen,omentum,large bowel,gall bladder,pancreas
-diagnosis:anamnesis, physical examination,diagnostic imaging
-treatment(acute cases):oxygen!, thoracocentesis(in case of concurrent fluid or air in the thoracic cavity),surgical intervention after initial stabilization!