General Principles of Penetrating Chest Trauma


Background
  1. Definition
  2. Etiology
  3. Victims who survive to reach hospital fare better than blunt trauma victims

Pathophysiology

  1. Multiple potential injuries
  2. Penetrating injuries that violate the pleura typically result in a pneumothorax
  3. Mechanism of injury

Potential Injuries

  1. Hemothorax
  2. Pneumothorax
  3. Tension pneumothorax
  4. Open pneumothorax
  5. Massive hemothorax
  6. Pericardial tamponade
  7. Pulmonary laceration
  8. Penetrating cardiac injuries
  9. Vascular injuries
  10. Transmediastinal injuries
  11. Esophageal injuries
  12. Diaphragmatic injury
  13. Intra-abdominal injuries

Diagnostics

  1. History
  2. Physical exam
  3. Clinical findings
  4. Diagnostic testing

General Treatment

  1. ATLS
  2. Thoracotomies
  3. Other actions
  4. Antibiotics
  5. Tetanus prophylaxis

Disposition

  1. Admit virtually all patients
  2. Trauma / surgery consults
  Physical Exam Investigations Management
Pulmonary Contusion - Blunt trauma to chest
- Interstitial edema impairs compliance and gas exchange
- CXR: areas of opacification of lung within 6 hours of trauma - maintain adequate ventilation
- monitor with ABG, pulse oximeter and ECG
- chest physiotherapy
- positive pressure ventilation if severe
 
Ruptured Diaphragm - Blunt trauma to chest or abdomen (e.g. high lap belt in MVC) - CXR:  abnormality of diaphragm/lower lung fields/NG tube placement   
- CT scan and endoscopy - sometimes helpful for diagnosis
- laparotomy for diaphragm repair and because of associated intra-abdominal injuries
Esophageal Injury - Usually penetrating trauma (pain out of proportion to degree of injury) - CXR: mediastinal air (not always)
- Esophagram (Gastrograffin)      
- Flexible esophagoscopy
- Early repair (within 24 hrs.) improves outcome but all require repair
Aortic Tear    
 
- 90% tear at subclavian (near ligamentum arteriosum), most die at scene
- salvageable if diagnosis made rapidly
- Sudden high speed deceleration (e.g. MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent)

- Decreased femoral pulses, differential arm BP (arch tear)
- CXR, CT scan, transesophageal echo (TEE), aortography (gold standard)
- see below for CXR features
- Thoracotomy (may treat other severe injuries first)
Blunt Myocardial Injury (Rare) - Blunt trauma to chest (usually in setting of multi-system trauma and therefore difficult to diagnose)      
- Physical examination: overlying injury, i.e. fractures, chest wall contusion
- ECG: arrhythmias, ST changes
- Patients with a normal ECG and normal hemodynamics never get dysrhythmias
- O2
- Antiarrhythmic agents
- Analgesia