Authors: Erika McMahon M.D., Elle Walter M.D., Stephanie Polites M.D.
- Thoracic injuries account for 20-25% of deaths from trauma and contribute to 25-50% of the remaining deaths
- 16,000 deaths per year in the U.S. are due to chest trauma
- Gunshots = 10% of all major trauma in the U.S.
- Stabbings = 9.5% of all major trauma in the U.S.
- Deaths within the first 30 minutes to 3 hours are often preventable
- Tension pneumothorax, cardiac tamponade, airway obstruction, uncontrolled hemorrhage
Common penetrating trauma injuries by location
|Chest wall||Intercostal artery lacerations, rib fractures, soft tissue damage|
|Lungs||Pneumothorax, pulmonary contusion, hemothorax, pulmonary laceration|
|Heart||Penetrating wounds often cause tamponade or hemorrhagic shockRight ventricle is most commonly injured chamber|
|Great vessels||Most patients with these wounds expire in the field|
|Diaphragm||Rises up to level of the 4th ICS during expiration so penetrating wounds of the thorax can involve intrabdominal organs|
- Minimize scene time before transport
- Only delay for emergent interventions ie: intubation or needle decompression
- Sucking chest wound: place an occlusive dressing taped on 3 sides over the site to try to seal off air entry into the pleural cavity and prevent a pneumothorax from expanding
- Needle decompression: insert a 14-16G needle/catheter into the 2nd rib space in the mid-clavicular line
- C spine precautions depending on mechanism and/or if patient has an altered mental status or neuro deficits
Primary Survey Specifics
- Immediate intubation with pericardial tamponade or a tension pneumo can worsen hypotension and potentially cause cardiovascular collapse (try to evacuate pericardial effusion or decompress pneumothorax first)
- Inspect chest wall for asymmetry, palpate chest wall for flail segments/step-offs/crepitus, check for tracheal deviation
- If breath sounds are asymmetric and pt is hemodynamically unstable/in respiratory distress: needle decompression followed by chest tube
- Check for diminished pulses and hypotension
- Look for tension pneumo & cardiac tamponade if hypotension
- “Strip and flip”: Look for any other penetrating injuries during the primary survey (including the back)
- Complete inspection including the axilla and gluteal folds
- Check for diminished pulses and hypotension
- Pericardial ultrasound to look for hemopericardium (100% sensitivity/97% specificity)
- Repeat after chest tube is placed
- Look for intraperitoneal free fluid
- In penetrating trauma a negative FAST does NOT exclude intra-abdominal wounds
- Expanded FAST can detect pneumothorax, hemothorax if physical exam is unclear
- More sensitive than a supine X ray
Indications for chest tube thoracostomy
- Tension pneumothorax
- Presentation: hypotension, diminished or absent breath sounds, tracheal deviation to the contralateral side, tracheal deviation and neck vein distention (late signs)
- Immediate needle decompression
- Follow with a large bore chest tube
- Hemothorax or hemopneumothorax
- Suspect in any pt with penetrating trauma
- Presentation: Unilateral diminished breath sounds or SQ air anywhere in the chest wall
Chest tube placement
- Anterior axillary line/5th ICS (nipple level in men/inframammary crease in women)
- Make an oblique skin incision 1-2 cm below the interspace through which the tube will be placed
- Insert a large clamp through the incision and into the intercostal muscles in the intercostal space just above the rib
- Push the clamp through the internal intercostal fascia and then open it to enlarge the hole to 1-2 c.m.
- Insert a finger along the top of the clamp through the hole to verify the position within the thorax
- direct tube towards the apex, high and anteriorly
- 24F or 28F tube
- direct tube posterior and laterally
- 32F to 40F tube
- Patients with penetrating chest wall injury who are intubated or about to be intubated
- Considered for those about to undergo air transport who are at risk for pneumothorax
- Indications for operative management
- Hemodynamically unstable
- Cardiac tamponade, significant hemorrhage, persistent air leak from chest tube
- Drainage of massive amounts of blood after chest tube placement (>1000 mL) or ongoing bleeding (150-200 mL/h for 2-4 hours)
- Massive air leak preventing full lung expansion or impairing ventilation (indicates tracheobronchial tree injury)
- Up to 75% of patients with thoracic trauma can be managed non-operatively with simple tube thoracostomy and volume resuscitation and serial evaluation
- Advanced Trauma Life Support. Ninth ed 2012, Chicago.
- Kuhajda I et. al. Penetrating trauma. Journal of Thoracic Disease 2014 Oct; 6(Suppl 4): S461-S465.
- Mayglothling, J and Legom, E. Initial evaluation and management of penetrating trauma in adults. UpToDate. Retrieved from http://www.uptodate.com/contents/initial-evaluation-and-management-of-penetrating-trauma-in-adults
- Tintinalli, Judith E. et. al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. New York: McGraw-Hill, 2011.
Image from Guarracino et. al.