7. Chest injuries

Question 1

Name causal conditions: Chest injuries (4)

Answer 1

• Blunt chest trauma
  
  • Blast injuries
  • Deceleration injury (e.g., motor vehicle accidents and falls)
• Penetrating chest trauma •
  
  • Gunshot wound
  • Stab wound

Question 2

Describe approach: Chest injuries (2)

Answer 2

• It is important to establish the mechanism of injury and the prehospital treatment received (e.g., amount of fluids received, intravenous lines established) as well as the patient’s medical Hx.
• Obtain a Hx of pain associated with thoracic trauma. Delayed onset of pain suggests a flail chest.

Question 3

Name Common injuries associated with thoracic trauma (11)

Answer 3

• Lungs
  
  • Tracheobronchial tree injury Pulmonary contusion
  • Hemothorax
  • Pneumothorax (open, closed, tension)
• MSK
  
  • Clavicle; sternum; rib fracture
  • Flail chest
• Esophagus: Esophageal rupture
• Great vessel: Aortic rupture, Aortic dissection
• Heart:
  
  • Pericardial trauma (pericarditis, acute/delayed tamponade)
  • Myocardial trauma (contusion, coronary vessel injury)
• Diaphragm: Diaphragmatic injury

Question 4

Describe physical exam: chest injuries (5)

Answer 4

Every trauma patient should undergo a primary survey using the ABCDE algorithm followed by a secondary survey:

• Airway:
  
  • if the patient is alert and conversant, then the airway is likely secured.
  • Patients with significant facial bone trauma, upper airway burns, or deteriorating mental status (Glasgow Coma Scale ≤8) require intubation.
  • Current trauma algorithms also include C-spine management along with airway.
  • C-spine protection should be in place with a collar or immobilizing device present.
• Breathing: inspect the patient’s trachea and chest for signs of tension pneumothorax, flail chest, or open pneumothorax and manage immediately.
• Circulation:
  
  • assess for signs of hemorrhagic or cardiogenic shock.
  • Assess vitals in a monitored setting.
• Disability:
  
  • perform a neurologic exam and assess the patient’s level of consciousness and any focal neurologic signs. It is important to document and follow serial GCS assessments.
• Exposure:
  
  • remove patient’s clothing and carefully inspect for missed injuries.
  • Patient is typically logrolled in appropriate spinal precautions and assessed for spinal tenderness/asymmetry/malalignment in addition to a DRE exam.
  • Prevent rapid heat loss with warming blankets and warmed intravenous resuscitation flu id s.

Question 5

Describe: Classification of hemorrhage and associated physiologic Ds

Answer 5

Question 6

Compare: Clinical presentation of obstructive versus hypovolemic shock

Answer 6

Question 7

Describe investigations: Chest injuries (5)

Answer 7

• Vital signs monitored continuously.
• Routine blood work: CBC, electrolytes, and coagulation profile, cross-matched for several units of packed red blood cells. An arterial blood gas panel should also be obtained to assess for adequacy of the patient’s respiratory function.
• Every female patient within childbearing age should have a b-hCG test to exclude pregnancy.
• A portable chest x-ray should be promptly arranged to assess for pneumothorax, hemothorax, or mediastinal widening.
• Depending on the mechanism of injury and pretest index of suspicion, the hemodynamically stable patient should undergo a CT scan of the head, neck, spine, chest, abdomen, pelvis, or extremities to exclude occult injury and prioritize the management approach.

Question 8

Describe: Initial Tx of the thoracic trauma patient.

Answer 8

Question 9

Name indications for immediate ED thoracotomy (7)

Answer 9

• Acute hemodynamic instability or cardiac arrest in the ED
• Penetrating thoracic injury ± signs of electrical cardiac activity
• Blunt thoracic injury + electrical cardiac activity
• Great vessel injury
• Cardiac tamponade
• Suspected air embolus
• Known esophageal, tracheal, or bronchial injury

Question 10

Immediate ED thoracotomy not indicated if what? (2)

Answer 10

• Patient with blunt trauma and no sign of electrical cardiac activity
• No qualified surgeon present