Rosen & Barkin's 5-Minute Emergency Medicine Consult (154 page)

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Authors: Jeffrey J. Schaider,Adam Z. Barkin,Roger M. Barkin,Philip Shayne,Richard E. Wolfe,Stephen R. Hayden,Peter Rosen

Tags: #Medical, #Emergency Medicine

BOOK: Rosen & Barkin's 5-Minute Emergency Medicine Consult
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CODES
ICD9
  • 807.4 Flail chest
  • 922.1 Contusion of chest wall
  • 959.11 Other injury of chest wall
ICD10
  • S20.20XA Contusion of thorax, unspecified, initial encounter
  • S22.5XXA Flail chest, initial encounter for closed fracture
  • S29.9XXA Unspecified injury of thorax, initial encounter
CHEST TRAUMA, PENETRATING
Jean C.Y. Lo
BASICS
ETIOLOGY
  • Gunshot wounds or stab wounds most common
  • Impalement on a sharp object from a fall can occur.
DIAGNOSIS
SIGNS AND SYMPTOMS
  • Object impaled in the chest wall
  • Obvious wound in the chest wall with or without bleeding
  • Chest pain
  • Dyspnea
  • Respiratory distress
  • Altered mental status from hypoxemia
  • Absent or altered breath sounds on 1 or both sides
  • Hypotension
  • Jugular venous distention
ESSENTIAL WORKUP
  • Perform routine assessment of airway, breathing, and circulation.
  • Rapid exam:
    • Respiratory effort and rate
    • Chest excursion
    • Crepitus
    • Subcutaneous air
    • Breath sounds and heart sounds
  • Upright CXR is preferred for identifying a pneumothorax:
    • Supine CXR should be taken 1st if spinal precautions must be maintained.
  • Baseline hemoglobin
  • Pulse oximetry
  • ABG
  • Serum lactate
  • Type and screen
DIAGNOSIS TESTS & NTERPRETATION
Lab
  • Perform echocardiogram if signs of tamponade present or if wound is close to the heart:
    • In stab wound to precordium and pericardial sac, hemopericardium may decompress into hemothorax, thus not apparent on initial echo:
      • Repeat pericardial US is recommended after tube thoracostomy decompression of the hemothorax.
      • Residual hemothorax represents pericardial injury or cardiac laceration.
  • ECG
Imaging
  • With gunshot wounds, other areas (abdomen, pelvis) should be imaged:
    • Total number of wounds and bullets must be the same.
  • Arteriogram of aortic arch, carotid arteries, or subclavian artery if great vessel injury is suspected
  • Esophageal Gastrografin swallow or endoscopy to identify esophageal perforation
  • Bronchoscopy to identify tracheobronchial injuries
DIFFERENTIAL DIAGNOSIS
  • Simple pneumothorax
  • Tension pneumothorax
  • Open pneumothorax
  • Hemothorax
  • Rib fractures
  • Flail chest
  • Pulmonary contusion
  • Myocardial contusion
  • Myocardial rupture
  • Pericardial tamponade
  • Traumatic aortic disruption
  • Esophageal injury
  • Large vessel injury
  • Tracheobronchial injury
  • Diaphragmatic injury
  • Intra-abdominal injury
  • Spinal cord injury
TREATMENT
PRE HOSPITAL
  • Cautions:
    • All patients with signs of life in the field according to reports from EMS personnel should be transported to a trauma center.
    • Full spinal immobilization if spinal injury suspected
    • Never remove objects impaled in the chest because exsanguination may follow.
    • Needle decompression may be necessary if tension pneumothorax suspected:
      • Unilaterally absent breath sounds, hypotension, jugular venous distention
    • If large open pneumothorax exists, occlusive dressing taped on 3 sides:
      • A totally occlusive dressing may produce a tension pneumothorax.
  • Controversies:
    • Do not delay transport to hospital to obtain IV access:
    • IV access may be established en route.
    • Do not delay transport to hospital by applying full spinal immobilization to patients who do not have clear clinical signs of spinal injury.
INITIAL STABILIZATION/THERAPY
  • Airway, breathing, and circulation management:
    • Intubate for signs of serious chest injury, obvious respiratory distress, or hypotension.
  • Oxygen by nonrebreather face mask for patients in stable condition
  • Obtain vascular access, 2 peripheral large-bore IV lines (>18G), and fluid resuscitation as needed:
    • Restrictive fluid resuscitation is associated with shorter hospital length of stay and lower overall mortality.
    • In penetrating aortic trauma, permissive hypotension at systolic BP 90 mm Hg until definitive surgical control prevents further hemorrhage.
  • For tension pneumothorax, perform a needle thoracostomy and place a chest tube immediately.
  • Do not wait to get a CXR.
  • Sonogram has demonstrated higher sensitivity than CXR in diagnosing pneumothorax.
  • For pericardial tamponade, perform an emergency pericardiocentesis:
    • Follow by rapid transport to the operating room for a pericardial window
  • Maintain spinal immobilization if indicated.
ED TREATMENT/PROCEDURES
  • Notify trauma surgeon about patient’s arrival.
  • Tube thoracostomy if a pneumothorax or hemothorax is identified:
    • 36G chest tube in an adult
    • In children, use largest tube the intercostal space will accommodate.
  • Fluid resuscitation as necessary:
    • Contused lung parenchyma will have leaky capillary beds, and aggressive crystalloid resuscitation may aggravate pulmonary dysfunction.
  • Any wound with an entry or exit site below the nipple or the posterior tip of the scapula is concerning for an intra-abdominal injury:
    • Workup with a diagnostic peritoneal lavage (DPL), US, CT scan, exploratory laparotomy, or laparoscopy
    • DPL positive with 5,000 RBC
  • Describe the nature of wounds accurately:
    • Retain any bullet fragments, clothes, or tissue removed from the wound.
  • Probing a chest wound is contraindicated because it can create a pneumothorax or worsen hemorrhage.
  • Impaled objects should be removed only in the operating room.
  • Tetanus booster if indicated
MEDICATION
  • Methylprednisolone (for spinal cord injury): 30 mg/kg IV over 1 hr, followed by a continuous drip of 5.4 mg/kg/h for 23 hr
  • Small doses of short-acting analgesics (fentanyl, 1–2 μg/kg IV, morphine 0.1 mg/kg IV) or sedatives (midazolam, 0.05 mg/kg IV) as needed for pain control and sedation
  • Treat with IV antibiotics if wound grossly contaminated (e.g., cephalexin 1 g IV).
FOLLOW-UP
DISPOSITION
Admission Criteria
  • All patients with penetrating chest trauma should be admitted.
  • In penetrating torso trauma, resuscitative thoracotomy in the ED demonstrates survival when pre-hospital CPR does not exceed 15 min.
  • A patient who has signs of life in the field but no BP on arrival in the ED should have an emergency thoracotomy performed by the most experienced person present:
    • If the source of bleeding is controlled and there are signs of cardiac activity, the patient should go to the operating room for formal operative repair.
  • Hemodynamically unstable patients should go immediately to the operating room.
  • Any patient with intrathoracic penetration should have a chest tube placed and should be admitted to a monitored setting.
  • >1,000–1,500 mL of blood drawn out of the chest tube on initial insertion indicates the need for thoracotomy.
  • >200 mL/hr of blood from a chest tube for several hours suggests the need for surgical intervention.
  • Patients with large, persistent air leaks usually require surgery.
  • Patients with significant rib fractures should be admitted and have an epidural catheter placed for pain control and pulmonary toilet.

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