February 22nd, 2015

Primer on Penetrating Thoracic Trauma

By Daniel Cabrera, M.D.

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

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

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 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

  • 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/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
  • 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.

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 Image from Guarracino et. al.

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