Primer on Penetrating Thoracic Trauma

Authors: Erika McMahon M.D., Elle Walter M.D., Stephanie Polites M.D.

Epidemiology

• 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

Prehospital Care

• 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 2^nd 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

• Airway
  • 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)
• Breathing
  • 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
• Circulation
  • Check for diminished pulses and hypotension
    • Look for tension pneumo & cardiac tamponade if hypotension
  • Exposure
    • “Strip and flip”: Look for any other penetrating injuries during the primary survey (including the back)
    • Complete inspection including the axilla and gluteal folds

FAST exam

• 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
• Pneumothorax
  • 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/5^th 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
• Pneumothorax
  • direct tube towards the apex, high and anteriorly
  • 24F or 28F tube
• Hemothorax
  • 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

Disposition

• 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

References

• 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.