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.