Rosen & Barkin's 5-Minute Emergency Medicine Consult (153 page)

• Check airway, breathing, and circulation (ABCs) to determine the patient’s stability
  
• Focused exam of the chest:
  
  • Respiratory effort and rate
    
  • Chest wall excursion
    
  • Crepitus
    
  • Subcutaneous air
    
  • Breath sounds and heart sounds
    
  • Presence of jugular venous distention
    
• Obtain a supine CXR immediately:
  
  • Avoid an upright CXR because of potential for other injuries (especially spinal injuries)
    
• ECG and monitor to detect myocardial ischemia or dysrhythmias
  
• Consider use of US for detecting small pneumothoraces, especially given the poor sensitivity of supine CXR in detecting such injuries.
  

• Baseline hemoglobin
  
• Pulse oximetry
  
• ABG
  
• Serum lactate
  
• Type and cross-match
  
• Coagulation profile
  
• Cardiac enzymes when indicated
  
• Periodic chemistry panel for patients receiving significant fluid resuscitation
  

• CXR is the initial radiologic study of choice:
  
  • If CXR reveals widened mediastinum and patient hemodynamically stable, repeat film in upright position.
    
• Chest CT is more specific for pneumothoraces and pulmonary contusions/occult injuries.
  
• Thoracic US can be efficiently used for detecting pneumothoraces and pericardial injuries. The sensitivity, specificity, and overall accuracy in the ED setting for such injuries is >90%.
  
• Chest CT with contrast, or aortic angiogram, is useful in identifying aortic and large-vessel injuries.
  
• Esophagoscopy for direct endoscopic visualization if esophageal injury suspected
  
• Contrast esophagogram (with water and then barium) for possible esophageal injuries if esophagoscopy negative, but patient at risk for esophageal injury (e.g., pneumomediastinum)
  
  • Combination of these 2 tests in sequence (each 80–90% sensitive individually) reaches close to 100% sensitivity
    
• ECG if sternal tenderness is present or abnormalities on cardiac monitor
  

• If patient’s condition is unstable, emergency thoracotomy may be necessary to repair a traumatic aortic disruption.
  
• If there are signs of cardiac tamponade, and patient is stable, perform an echocardiogram urgently:
  
  • Pericardial effusions, wall motion defects, aortic injuries, valvular or other intracardiac pathology may also be identified.
    
• If there are signs of cardiac tamponade and the patient is unstable, consider emergent pericardiocentesis, followed by immediate transport to the OR for a pericardial window.
  
• Bronchoscopy often indicated for possible upper airway injuries (e.g., a large persistent air leak after chest tube)
  

• In pregnant patients, remember to use the least amount of radiation available and to shield the uterus during imaging when possible.
  
• Take note of the differences in anatomy of the thoracic cavity in pregnant patients, as well as differences in lab values, intravascular volume, and cardiovascular physiology.
  
• See “Pregnancy,” “Trauma in,” for details.
  

• Simple pneumothorax
  
• Tension pneumothorax
  
• Open pneumothorax
  
• Hemothorax
  
• Rib fractures
  
• Flail chest
  
• Sternoclavicular fractures/dislocations
  
• Pulmonary contusion
  
• Myocardial contusion
  
• Myocardial rupture
  
• Cardiac (pericardial) tamponade
  
• Traumatic aortic disruption
  
• Esophageal injury
  
• Large vascular injury (subclavian artery, pulmonary artery)
  
• Tracheobronchial injury
  
• Diaphragmatic injury
  

The rib cage is highly elastic in children and can withstand significant forces without overt signs of external trauma and can underestimate even major intrathoracic injuries.

Elderly patients have been shown to have greater respiratory complications, including ARDS and pneumonia, than younger patients in the setting of blunt chest trauma. This is especially true in those >85 yr of age.

TREATMENT

• All patients with any signs of life in the field should be transported to a trauma center.
  
• Full spinal precautions should be employed.
  
• Needle decompression is indicated for tension pneumothorax:
  
  • Unilaterally absent breath sounds
    
  • Hypotension
    
  • Jugular venous distention
    
  • Hyper-resonance to percussion
    
• If large, open pneumothorax exists, tape an occlusive dressing on 3 sides only to prevent causing a tension pneumothorax.
  
• Do not delay transport to hospital for IV access.
  

• ABCs management; intubate patient early if signs of respiratory insufficiency, shock, or altered mental status exist.
  
• Resuscitation attempts should be initiated only in patients who arrive in the ED with vital signs.
  
• Any patient who presents in blunt traumatic arrest is not likely to survive a thoracotomy in the ED, and it is therefore generally not indicated in this group.
  
• If the patient’s condition is unstable and clinically shows signs of a tension pneumothorax, perform needle thoracostomy and place a chest tube immediately afterward.
  
• Do not wait to obtain a CXR.
  
• Place chest tube on the affected side or bilaterally if injury site is unclear.
  
• Deliver oxygen by nonrebreather face mask for stable patients.
  
• Obtain vascular access, preferably 2 large-bore IV lines (>18G).
  
• Maintain spinal immobilization.
  

• Tube thoracostomy if pneumothorax or hemothorax is identified:
  
  • 36F chest tube in an adult
    
  • In children, use the largest tube that the intercostal space will accommodate.
    
• Provide resuscitation with isotonic fluids and blood products as necessary:
  
  • Aggressive fluid resuscitation may be harmful if severe pulmonary contusions exist (consider permissive hypotension).
    
• Workup for associated intra-abdominal injuries (e.g., with abdominal US, abdominal CT scan, less commonly diagnostic peritoneal lavage):
  
  • Patients with chest trauma frequently have concomitant intra-abdominal injuries.
    

• Tetanus booster if indicated
  
• Consider methylprednisolone (for signs of spinal cord injury): 30 mg/kg IVI over 1 hr, followed by a continuous drip of 5.4 mg/kg/h for next 23 hr
  

FOLLOW-UP

• Patients with conduction blocks, frequent ectopy, or ischemic changes visible on EKG should be admitted to a monitored setting for possible myocardial contusion.
  
• Hemodynamically unstable patients should go to the OR on an emergency basis for thoracotomy or laparotomy.
  
• >1,000–1,500 mL of blood drawn out of the chest tube on initial insertion indicates need for thoracotomy/operative management.
  
• >200 mL of blood per hour from chest tube for several hours suggests the need for operative intervention.
  
• Patients with significant rib fractures should be admitted for pain control:
  
  • Consider epidural catheter for analgesia.
    
• Patients who lose vital signs in the ED should undergo rapid open thoracotomy.
  

Patients with clinically insignificant chest wall contusions and an initial negative upright CXR may be observed for 6 hr in the ED and often be discharged if a repeat radiograph at that time reveals no pneumothorax, hemothorax, or pulmonary contusion, the patient is able to breathe deeply and to cough, remains clinically stable, and has no other significant injuries.

• Notify trauma surgeon promptly about patients with significant injuries requiring surgical intervention or admission.
  
• Indications for emergent surgical referral:
  
  • Traumatic thoracotomy with loss of chest wall integrity
    
  • Blunt diaphragmatic injuries
    
  • Massive air leak following chest tube insertion
    
  • Massive hemothorax or continued high rate of blood loss via the chest tube (i.e., 1,500 mL on insertion of tube or continued loss of 200–300 mL/hr)
    
  • Radiographically or endoscopically confirmed tracheal, major bronchial, or esophageal injury
    
  • GI tract contents recovered on chest tube placement
    
  • Cardiac tamponade
    
  • Radiographic confirmation of a great-vessel injury
    
  • Embolism or missile into pulmonary artery, great vessel, or heart
    

• Patients should be closely followed by trauma or cardiothoracic surgeons after hospital discharge, as indicated, depending upon the injuries discovered and treatment rendered.
  
• Patients with thoracostomy tubes should have a CXR and routine wound care follow-up within 48 hr to remove the dressing and reassess clinical status.
  

• Blunt chest trauma is responsible for up to 1/4 of all trauma-related deaths.
  
• Trauma patients arriving at a nontrauma center should be stabilized and transferred to facilities that can provide definitive care as soon as possible.
  
• Open thoracotomy in the ED has not been shown to improve survival in patients found to be in cardiopulmonary arrest after blunt trauma and is generally only indicated if the patient arrives in the ED with vital signs present.
  
• The extent of injury is not always clinically obvious upon initial presentation. This is particularly true in pediatric patients.
  

• American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular.
  Circulation
  . 2010;122(18 suppl 3)
  
• Centers for Disease Control and Prevention. Accidents/unintentional injuries. Retrieved October 2008 from
  http://www.cdc.gov/nchs/FASTATS/acc-inj.htm
  
• Karmy-Jones R, Jurkovich GJ. Blunt chest trauma.
  Curr Probl Surg
  . 2004;41(3):211–380.
  
• Lotfipour S, Kaku SK, Vaca FE, et al. Factors associated with complications in older adults with isolated blunt chest trauma.
  West J Emerg Med
  . 2009;10(2). Retrieved from
  http://escholarship.org/uc/item/9922n5
  
• Resnick DK. Updated guidelines for the management of acute cervical spine and spinal cord injuries.
  Neurosurgery.
  2013;72:1. (
  http://dx.doi.org/10.1227/NEU.0b013e318276ee7e
  )
  
• Sartorelli KH, Vane DW. The diagnosis and management of children with blunt injury of the chest.
  Semin Pediatr Surg
  . 2004;13(2):98–105.