Chest Trauma

Question 1

What should be identified during the primary survey?

Answer 1

Airway obstruction
Tension pneumothorax
Open pneumothorax
Flail chest and pulmonary contusion
Massive hemothorax
Cardiac tamponade

Question 2

ATLS algorithm for monitoring trauma patients

Answer 2

A (Airway with c-spine protection): Is the patient speaking in full sentences?
B (Breathing and Ventilation): Is the breathing labored? Bilateral symmetric breath sounds?
C (Circulation with hemorrhage control): Pulses present and symmetric? Skin appearance (cold clammy, warm well perfused)
D (Disability): GCS scale? Moving all extremities?
E (Exposure/Environmental Control): Completely expose the patient. Rectal tone? Gross blood per rectum?
IV – 2 large bore (minimum 18 Gauge) Antecubital IV
O2 – Nasal cannula, Face Mask
Monitor: Place patient on monitor.

Question 3

Tension Pneumothorax findings

Answer 3

• Shortness of breath chest pain in the setting of trauma and in certain cases traumatic arrest.
• Absent breath sounds ipsilateral to the PTX, tracheal deviation opposite to the PTX, crepitus and jugular venous distension

Question 4

Tension Pneumothorax treatment

Answer 4

needle decompression followed by tube thoracostomy

Question 5

Pneumothorax findings

Answer 5

chest pain and shortness of breath, tachycardia, tachypnea, hypoxia. On physical exam they often have bilateral breath sounds, although typically asymmetric with decreased noted on the site of the PTX

Question 6

What is an open pneumothorax?

Answer 6

Open pneumothorax is a sucking chest wall wound from penetrating injury, usually with a big defect in the chest wall.

Question 7

How does an open pneumothorax present?

Answer 7

chest pain shortness of breath with sonorous breath sounds on physical exam, sucking air from wound and shallow respirations.

Question 8

How do you treat an open pneumothorax?

Answer 8

• square dressing tape on three sides to create an escape valve
• Ultimately a chest tube is placed ipsilateral to the side of the wound but at a different anatomic location than the wound.

Question 9

Hemothorax presentation

Answer 9

Patients present with shortness of breath, chest pain or occasionally asymptomatic. Typically presents with decreased breath sounds, dullness to percussion on exam. Although vital signs typically indicate tachycardia, tachypnea or hypoxia, occasionally they can present as completely normal.

Question 10

Hemothorax treatment

Answer 10

treatment is placement of a chest tube. If the hemothorax is retained despite the chest tube then a video assisted thorascopic surgery is recommended.

Question 11

What are indications for emergent treatment of a hemothorax?

Answer 11

Indications for emergent surgery are greater than 1500 ml of blood on initial chest tube placement and if there is greater than 200 ml/hour of blood for 2-4 hours.

Question 12

What is a flail chest?

Answer 12

multiple rib fractures (3 or more ribs in 2 places)

Question 13

Flail chest findings

Answer 13

chest pain, dyspnea, painful respirations and are tachycardic, tachypneic and hypoxic. Clinical findings are pertinent for a visible or palpable deformity, bruising or crepitus, paradoxical movement and splinting with secondary hypoventilation.

Question 14

Treatment of a flail chest

Answer 14

re-expand the lung with CPAP (positive pressure) or physiotherapy, and to avoid atelectasis. For patients with less severe injuries pain control and incentive spirometry can be attempted. All patients need admission for observation.

Question 15

What is a pulmonary contusion?

Answer 15

Severe blunt chest trauma causes leakage of blood and proteins into alveoli causing atelectasis and that can lead to ARDS

Question 16

Pulmonary contusion findings

Answer 16

shortness of breath, chest pain, hemoptysis and cough. On exam tachypnea, tachycardia, hypoxia is common. In severe cases ecchymosis can be evident over chest wall and decreased breath sounds on auscultation.

Question 17

What is the best imaging for a pulmonary contusion?

Answer 17

CT

Question 18

Treatment of pulmonary contusion

Answer 18

For large pulmonary contusions patients need to be intubated. Smaller contusions can be managed with conservative management that includes incentive spirometry, pulmonary toilet, pain control and careful fluid administration.

Question 19

What are cardiac contusions associated with?

Answer 19

associated with sternal fractures.

Question 20

Cardiac contusion findings

Answer 20

chest pain. Physical exam may be completely normal. Some patients can have chest wall contusions. Those with sternal fractures will have obvious sternal pain. 40% of patients with cardiac contusions can develop signs of decreased cardiac output.

Question 21

Diagnosis of cardiac contusion

Answer 21

requires high clinical suspicion. echocardiograms (2D-ECHOs) for evaluation of EF. If the 2D-ECHO shows a reduced EF (new from prior) patients should undergo a dobutamine stress test.

Question 22

What is Becks triad?

Answer 22

On exam Beck’s triad (hypotension JVD and distant heart sounds) is sometimes present. Cardiac tamponade.

Question 23

Cardiac tamponade findings

Answer 23

• Chest pain, shortness of breath, with air hunger, frequently altered mental status.
• hypotensive in shock, with pulsus parodoxus and narrowing of pulse pressure.

Question 24

Imaging in cardiac tamponade

Answer 24

Diagnosis is clinical however can be made with bedside sonogram while performing the eFAST exam (figure 4). Although EKG can show electrical alternans, it is not frequently seen in traumatic tamponade. CXR can show an enlarged cardiac silhouette.

Question 25

Cardiac tamponade treatment

Answer 25

In hemodynamically stable patients pericardiocentesis is indicated. Unstable patients need emergency surgical intervention in the OR. If patients lose their vitals while in the ED, ED thoracotomy is indicated.

Question 26

When is blunt aortic injury seen?

Answer 26

Usually seen in sudden deceleration type injuries secondary to abrupt deceleration from > 30 mph or > 40 ft fall.

Question 27

Aortic injury diagnosis

Answer 27

Diagnosis is suggested is the mediastinum is widened on a CXR (figure 5). A CTA (spiral CT) is diagnostic. Angiography is considered the gold standard and only performed if the spiral CT is unequivocal.

Question 28

Aortic rupture treatment

Answer 28

The treatment for hemodynamically unstable patients is emergent surgery to cross clamp the aorta. For stable patients aggressive BP control to a SBP< 120 mmHg followed by eventual surgical correction is advocated.

Question 29

Treatment of all chest trauma

Answer 29

Hemodynamically unstable patients: Packed RBC (O-Neg) transfusion), consideration of STAT OR for surgical intervention.
Pneumothorax: Tube thoracostomy. Please see video: http://www.nejm.org/doi/full/10.1056/NEJMvcm071974.9
Open Pneumothorax: Tape wound and tube placement at site separate from injury
Hemothorax: As above, except if greater than 1500 cc of blood obtained on initial chest tube placement or more than 150-200cc/hr x 4 hours, patient needs to go to the OR under Cardiothoracic surgery.
Flail Chest: Symptomatic Support, intubate and ventilate as needed. Incentive spirometry. In extreme cases patient may need cardiothoracic surgical intervention.
Pulmonary Contusion: Symptomatic support, high flow oxygen, early intubation if needed, incentive spirometry.
Cardiac Contusion: Monitoring if any significant changes in ejection fraction
Cardiac Tamponade: Pericardiocentesis followed by OR thoracotomy. Please see video: http://www.nejm.org/doi/full/10.1056/NEJMvcm0907841.10
Blunt Aortic Injury: If stable blood pressure control followed by close observation and delayed aortic repair. If unstable, massive transfusion protocol, transfuse pRBC and stat emergency aortic repair by Cardiothoracic and Vascular surgery.
Great Vessel Injury: Typically unstable shock like presentation: Massive transfusion with concurrent OR thoracotomy.

Question 30

Indications for a resuscitative thoracotomy

Answer 30

Patients with a penetrating injury and PEA, especially if the loss of signs of life is recent, are appropriate candidates for resuscitative thoracotomy.
A qualified surgeon must be present at the time of the patient’s arrival to determine the need and potential for success of an emergency department resuscitative thoracotomy.
Once the chest is opened, bleeding must be controlled.

Question 31

Pearls and Pitfalls of chest trauma patients

Answer 31

Chest trauma patients can present with several conditions each of which can be acutely life threatening; Majority of these conditions can be clinically diagnosed and treated during the primary survey.
Tension pneumothorax is a clinical diagnosis, chest x rays are not indicated for making this diagnosis.
Bedside sonography can be extremely useful for diagnosing acute traumatic chest conditions.
Only hemodynamically stable patients should be sent for advanced imaging such as CT scan
ED Thoracotomies are reserved for Traumatic arrest secondary to penetrating chest trauma only