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Trauma

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Emergency Medicine Manual, 6th Edition > Section 19. Trauma >

INTRODUCTION
Thoracic trauma accounts for 25% of civilian trauma deaths. Penetrating injuries frequently
result in pneumothorax or hemothorax. Hemothorax accompanies pneumothorax in 75% of
cases. Blunt trauma causes injury by several mechanisms: compression (organ rupture), direct
trauma (fractures and soft tissue injuries), and acceleration and deceleration forces (vessel
shear and tear).

GENERAL PRINCIPLES AND CONDITIONS

All patients should be assessed with initial consideration for airway, breathing, and circulation.
Cervical spine immobilization should be maintained via inline stabilization until a spinal injury
can be safely and completely excluded. In all cases of significant respiratory distress, the
airway should be secured, and adequate oxygenation and ventilation should be provided.
Indications for endotracheal intubation include the need to protect airway patency, failure of
oxygenation or ventilation, and planned procedures necessitating intubation (general
anesthesia or bronchoscopy).
The patient's breathing and oxygenation should be rapidly assessed. High-flow oxygen may
help prevent secondary injury from hypoxia. Tracheal position and breath sounds should be
examined. The presence of bowel sounds in the chest should suggest the possibility of a
diaphragmatic injury. Inequality of breath sounds may suggest a pneumothorax, hemothorax,
or an improperly placed endotracheal tube. It is essential to recognize tension pneumothorax,
cardiac tamponade, flail chest, open pneumothorax, and massive hemothorax. The patient
should be completely exposed. Any associated hemorrhage must be controlled and any
associated injuries must be stabilized. Strong consideration must be given to associated
abdominal and pelvic injuries. Life-threatening injuries must be rapidly recognized and
stabilized.
If subclavian venous cannulation is required, it should be placed on the side of the injury. In
patients with cardiac arrest due to chest trauma, external cardiac compression is of no value
and may be harmful secondary to additional trauma to thoracic and abdominal organs or
vessels. If cardiac compression is deemed potentially beneficial, emergency department (ED)
thoracotomy and internal cardiac compression are warranted.

CHEST WALL INJURIES

Clinical Features and Diagnosis and Differential
Small open chest wounds (sucking chest wounds) can act as one-way valves by allowing air to
enter during inspiration but none to exit during expiration. This will result in an expanding
pneumothorax. These injuries should be covered immediately by a sterile petroleum gauze
dressing, and a chest tube should be placed at a separate site to relieve the pneumothorax.
Injuries with large amounts of chest wall tissue loss will require mechanical ventilation and
surgical repair.
Patients with subcutaneous emphysema should be presumed to have a pneumothorax, even if

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the initial chest radiograph does not show a pneumothorax. If severe subcutaneous
emphysema is palpated, then a major bronchial injury should be suspected. Clavicular fractures
occasionally may injure the subclavian vein, producing a large hematoma or venous
thrombosis.
Rib fractures should be assumed to be present in any patient with localized tenderness over 1
or more ribs after chest trauma. Up to 50% of rib fractures may not be apparent on initial
radiographs. Fractures of the first or second ribs suggest high-force injuries and frequently are
associated with other significant injuries.
Flail chest refers to segmental fractures (ie, fractures in 2 or more locations on the same rib) in
3 or more adjacent ribs. This injury is characterized by paradoxical inward movement of the
involved portion of the chest wall during spontaneous inspiration and outward movement
during expiration. Sternal fractures should alert the physician of possible underlying soft tissue
injuries, especially to the heart or great vessels.

Emergency Department Care and Disposition

Bleeding from chest wall injuries is best controlled by direct pressure.
Probing of these wounds is not recommended in the ED.
If significant subcutaneous emphysema is present, a pneumothorax should be presumed to be
present, and a chest tube should be inserted, especially if endotracheal intubation is imminent.
Rib fractures:
Adequate analgesia (with NSAIDs and opioid analgesics) and pulmonary toilet are the
mainstays of treatment.
Patients with multiple rib fractures should be admitted for 2448 hrs if they:
cannot cough and clear secretions,
are elderly,
or have preexisting pulmonary disease.
In patients with intractable pain: consider
intercostal nerve blocks
intrapleural administration of anesthetics
epidural analgesia.
Flail chest injuries:
The preferred treatment is analgesia to allow the patient to fully expand the underlying lung,
with a goal of improving ventilation and pulmonary toilet.
Indications for ventilatory support include:
3 or more associated injuries
severe head trauma
comorbid pulmonary disease
fracture of 8 or more ribs
age > 65 yrs.
Surgical repair of flail chest is controversial.
Sternal fractures: Patients should have a screening ECG for blunt myocardial injury.

LUNG INJURIES
Clinical Features and Diagnosis and Differential
The diagnosis of a tension pneumothorax should be made on physical examination and not by
radiograph. Signs and symptoms include dyspnea, hypoperfusion, distended neck veins,

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decreased or absent breath sounds on the affected side, hyperresonant percussion on the
affected side, and deviation of the trachea away from the affected side. Tension pneumothorax
needs to be recognized and treated immediately.
Pulmonary contusions are defined as direct damage to the lung resulting in hemorrhage and
edema in the absence of a pulmonary laceration. These injuries are a significant source of
morbidity and mortality. Two sources of injury occur in pulmonary contusion. The first is the
direct tissue injury, and the second results from fluid administration during resuscitation. The
radiographic diagnosis of pulmonary contusion may be delayed for up to 6 hours.
Hemothorax should be considered in the severely traumatized patient with unilateral decreased
breath sounds. Volumes of blood as low as 200 to 300 mL are usually visualized on an upright
chest radiograph. However, volumes in excess of 1 L may be missed on a supine chest
radiograph. If a pneumothorax is suspected but not seen on the initial chest radiograph, an
expiratory chest film may facilitate diagnosis. Subcutaneous emphysema in the neck or the
presence of a crunching sound (Hamman sign) over the heart during systole suggests the
presence of pneumomediastinum. Although readily seen on computed tomography (CT), this
diagnosis may be missed on chest radiograph. It is essential to look for injury to the larynx,
trachea, major bronchi, pharynx, or esophagus.

Emergency Department Care and Disposition

Tension pneumothorax:
When suspected, immediate needle thoracostomy with a 14-gauge IV catheter in the second
intercostal space, midclavicular line is mandatory.
This procedure converts a tension pneumothorax into an open pneumothorax and often
significantly improves that patient's clinical condition.
Lack of improvement should signal another cause of hypoperfusion.
Subsequent placement of a chest tube is required.
Pulmonary contusions:
Treatment includes:
maintenance of adequate ventilation
pain control
adequate pulmonary toilet.
Patients with > 25% of total lung involvement frequently require mechanical ventilation.
However, mechanical ventilation, with the use of positive end-expiratory pressure may be
required, even if < 25% of the lung volume is involved.
If a hemothorax or nontension pneumothorax is suspected in a patient with severe respiratory
distress, a chest tube should be inserted before obtaining a chest radiograph.
Hemothorax:
Tube thoracostomy, with a 36- or 40-French chest tube, is the mainstay of treatment.
Ongoing assessment of blood loss from chest tubes is essential.
Indications for thoracotomy include:
initial drainage of 1,500 mL of blood
continued drainage of 100 mL of blood per hour for 6 or more hours
persistent air leakage or failure of the lung to completely reexpand after tube thoracostomy
clinical judgment of the thoracic surgeon in the face of a hemodynamically unstable patient.
Occult pneumothorax (one seen on CT scan but not on plain film):
Chest tube drainage of is not required, unless the patient requires mechanical ventilation.
A chest radiograph should be obtained in all patients after insertion of a chest tube.
Persistent air leakage and failure of the lung to completely expand may indicate the need for

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thoracotomy.
Small pneumothoraces that have not expanded on serial chest radiographs taken 612 hrs
apart usually do not require chest tube insertion; however, admission for serial examination is
recommended.

TRACHEOBRONCHIAL INJURIES
Most injuries to major bronchi are due to deceleration shearing forces on mobile bronchi from
the more fixed proximal structures, although compression against vertebral bodies or forced
expiration against a closed glottis also may damage bronchi. Dyspnea, hemoptysis,
subcutaneous emphysema, Hamman sign, and sternal tenderness are the most common
presenting signs and symptoms, although approximately 10% are asymptomatic. On chest
radiograph, a large pneumothorax, pneumomediastinum, deep cervical emphysema, or
endotracheal tube balloon that appears round suggest tracheobronchial injury. Most
tracheobronchial injuries occur within 2 cm of the carina or at the origin of lobar bronchi.
Management includes assuring adequate ventilation and referral for immediate
bronchoscopy to evaluate and treat the injury. Injuries of the cervical trachea usually occur
at the junction of the trachea and cricoid cartilage and are caused by direct trauma. Inspiratory
stridor is common and indicates 70% to 80% obstruction. Orotracheal intubation, preferably
over a bronchoscope, should be attempted. If gentle intubation is not possible, a formal
tracheostomy should be performed.

DIAPHRAGMATIC INJURIES
Most diaphragmatic injuries are caused by penetrating trauma. The incidence of left-versus
right-side diaphragmatic injuries may be equal, although left-side injuries are more commonly
diagnosed, because right-side lesions may be masked due to the liver blocking herniation of
abdominal contents. Evidence of intrathoracic injury from a penetrating abdominal wound
should alert the physician to the likely possibility of diaphragmatic disruption. With blunt
trauma, any abnormality of the diaphragm or lower lung fields on chest radiograph should
arouse suspicion for diaphragmatic tear. CT and upper gastrointestinal series may diagnose
less obvious diaphragmatic injuries. However, many of these injuries are diagnosed only on
laparotomy or thoracotomy. The treatment of these injuries is surgical repair of the diaphragm.

PENETRATING INJURIES TO THE HEART

Clinical Features and Diagnosis and Differential
Blunt and penetrating cardiac injuries have the potential to cause cardiac tamponade. The
presentation is similar to tension pneumothorax and includes the Beck triad of hypotension,
distended neck veins, and muffled heart tones. Bedside ultrasonography can quickly and
accurately facilitate the diagnosis of cardiac tamponade. Other causes of Beck triad include
tension pneumothorax, myocardial dysfunction, and systemic air embolism.
A hypotensive patient with penetrating chest injury anywhere near the heart should be
considered to have sustained a cardiac injury until proven otherwise. Penetrating wounds to
the heart are usually rapidly fatal, with fewer than 25% of patients reaching the hospital alive.
Factors affecting survival include the weapon used, the size of myocardial injury, the chamber
injured, coronary artery damage, the presence of tamponade, associated injuries, and the time
taken to reach the hospital.
Chest radiographs are rarely helpful in diagnosing acute cardiac injury, and changes in ECG are
usually nonspecific. Bedside ultrasonography and transesophageal echocardiography are rapid
and sensitive modalities for diagnosing pericardial effusion. Pericardiocentesis has limited value
in the evaluation of patients with possible cardiac injury due to a high incidence of false

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positive and false negative aspirates. Pericardiocentesis should be reserved for patients in
extremis, when the possibility of tamponade must be excluded in a matter of seconds. In the
hemodynamically stable patient, when echocardiography is not available, a subxiphoid
pericardial window can be performed in the operating room under general anesthesia.

Emergency Department Care and Disposition

Initial management:
Includes airway, breathing, and circulation.
Two large-bore IV catheters should be placed, with one catheter in a leg vein in the event that
the superior vena cava or one of its major branches is injured.
Patients in shock who do not respond to adequate fluid resuscitation and who are suspected of
having a cardiac injury should undergo emergent thoracotomy.
Cardiac tamponade:
Immediate treatment is pericardiocentesis, with subsequent surgical repair.
An initial fluid bolus should be given to increase filling pressure in the right atrium; however, this
effect is transitory, and decompression of the tamponade by pericardiocentesis or surgery will be
needed.
A patient with penetrating thoracic trauma who loses vital signs just before arriving (<
510 mins) at the ED may require emergent thoracotomy to assess for and treat pericardial or
cardiac wall injury.

BLUNT INJURIES TO THE HEART

Clinical Features and Diagnosis and Differential
The most common mechanism of injury causing blunt cardiac trauma is a deceleration injury,
such as motor vehicle crashes (even at speeds slower than 20 mph), falls, direct blows to the
chest, crush injuries, blast injuries, and athletic trauma. Blunt cardiac trauma may result in
rupture of an outer chamber wall, septal rupture, valvular injuries (with the aortic valve being
the most common), direct myocardial injury (contusion), laceration or thrombosis of coronary
arteries, and pericardial injury. Blunt cardiac injury can be difficult to detect. A history of
moderate to severe chest or upper abdominal injury, even without abnormalities on physical
examination, should raise the suspicion of cardiac injury.
Blunt myocardial injury (BMI) is a term used to include myocardial contusion and myocardial
concussion. The areas most commonly affected include the anterior right ventricular wall, the
anterior interventricular septum, and the anterior-apical left ventricle. The most common
clinical features of BMI include tachycardia out of proportion to blood loss, arrhythmias
(especially premature ventricular contractions and atrial fibrillation), and conduction defects.
Screening tests, such as ECG and cardiac isoenzymes, usually do not accurately indicate the
severity of injury, nor are they predictive of major morbidity or mortality. Chest radiography
has its greatest value in the recognition of associated injuries. A normal initial ECG and cardiac
troponin I in a patient without other clinical findings is reasonably predictive of absence of
serious BMI. Echocardiography is best reserved for patients who demonstrate cardiac
dysrhythmias or dysfunction.

Emergency Department Care and Disposition

Although occasional patients with BMI will require treatment for heart failure or rhythm and
conduction disturbances, specific treatment or intervention is rarely required.
Patients should be treated with supplemental oxygen and given analgesics PRN.
Nitrates should be avoided unless the patient has preexisting coronary artery disease.
IV fluids and inotropic agents (dopamine or dobutamine) may be used for hypotension once
cardiac tamponade has been excluded.

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For patients with BMI, an initial ECG may identify dysrhythmias or injury patterns.
If the initial ECG is normal, continuous cardiac monitoring should be performed for 46 hrs. If
there are no identified dysrhythmias and the patient is otherwise uninjured, then the patient may
be discharged home.
If the ECG is abnormal, but there is no hemodynamic instability, the patient should be admitted
to a monitored setting, with repeat ECG in 1224 hrs.
Upon discharge from the hospital, patients with cardiac injury should have close follow-up to
evaluate for:
posttraumatic pericarditis
ventricular septal defect
valvular defects
ventricular aneurysms.

PERICARDIAL INFLAMMATION SYNDROME

Although the cause of this syndrome is unclear, pericardial inflammation syndrome should be
suspected in patients who develop chest pain, fever, and pleural or pericardial effusions 2 to 4
weeks after cardiac trauma or surgery. A friction rub may be present, and ECG may show STsegment changes consistent with pericarditis. Treatment is primarily symptomatic. with
nonsteroidal anti-inflammatory agents as a first line therapy. Occasionally, corticosteroids may
be required.

PENETRATING TRAUMA TO THE GREAT VESSELS

Clinical Features and Diagnosis and Differential
Simple lacerations of the great vessels may cause exsanguination, tamponade, hemothorax, air
embolism, and development of an arteriovenous fistula or false aneurysm. The size of the
knife, its length, and the angle of penetration may suggest the vessels or organs most likely to
be injured. Projectile missile wounds may enter a major vessel and embolize to distant
locations. Assessment of bilateral upper extremity pulses should be noted, and the entire chest
should be auscultated for bruits, which may represent a false aneurysm or arteriovenous
fistula.
On chest radiograph, widening of the upper mediastinum may indicate injury to the
brachiocephalic vessels. A "fuzzy" foreign body may indicate motion artifact caused by a
foreign body within or adjacent to pulsatile vascular structures. In stable patients, CT can
localize hematomas adjacent to major vascular structures. The use of contrast helps further
evaluate these structures and may demonstrate a vascular defect or false aneurysm. A
preoperative arteriogram will help visualize the arch of the aorta and its major branches.
Water-soluble contrast swallows or endoscopy may help diagnose esophageal injuries, but
these studies require a hemodynamically stable patient.

Emergency Department Care and Disposition

If the patient did not have "signs of life" in the field, then no resuscitative efforts are warranted.
However, if the patient "lost vital signs" immediately before (510 mins) arriving in the ED, then
ED thoracotomy is indicated.
Early endotracheal intubation should be performed in patients with penetrating injuries to the
thoracic inlet. This approach avoids problems with expanding hematomas that may occlude the
airway.
In patients with severe shock (systolic BP <60 mm Hg), immediate surgery is indicated.
With mild to moderate shock (systolic BP 6090 mm Hg), infusion of 23 L crystalloid should
be rapidly administered while the need for emergent surgery is evaluated.

BLUNT TRAUMA TO THE GREAT VESSELS

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Clinical Features and Diagnosis and Differential

About 80% to 90% of patients with blunt trauma to the thoracic great vessels (especially the
aorta) die at the scene; 50% of the remaining patients die within 24 hours if not treated
promptly.
Preexisting vascular disease (atherosclerosis or medial necrosis) does not appear to predispose
patients to traumatic aortic rupture. Approximately 90% of patients with blunt aortic injuries
who reach the hospital alive have their aortic injury in the isthmus, between the left subclavian
artery and the ligamentum arteriosum. Other common sites of injury are the innominate or left
subclavian artery at their origins or a subclavian artery over the first rib.
Most patients initially will be asymptomatic after an aortic injury. Therefore, this injury should
be suspected in anyone with a sudden, severe deceleration or a high-speed impact from the
side. About 33% of patients with blunt trauma to the aorta have no external evidence of
thoracic injury. Physical examination findings that suggest aortic injury include an acute onset
of upper extremity hypertension, difference in pulse amplitude in the upper and lower
extremities, and the presence of a harsh systolic murmur over the precordium or interscapular
area.
Up to 33% of patients with traumatic rupture of the aorta initially will present with a normal
chest radiograph. Radiographic abnormalities associated with traumatic aortic rupture include
superior mediastinal widening, deviation of the esophagus and/or trachea at T-4, obscuration
of the aortic knob and/or descending aorta, displacement of the left mainstem bronchus more
than 40 below horizontal, widening of the paratracheal stripe, displacement of the paraspinal
lines, obscuration of the medial aspects of the left upper lobe, apical cap, and fracture of the
first or second rib.
Transesophageal echocardiography is a highly sensitive diagnostic modality for evaluating
traumatic aortic rupture. It also can be performed on hemodynamically unstable patients in the
ED. However, due to variability of findings and operator availability, its role in the acute
evaluation of aortic injury has not been defined. Newer-generation helical CT scans may offer a
rapid and available diagnostic modality for traumatic aortic injury; however, angiography
remains the gold standard.
Very few patients with injury to the ascending aorta survive long enough for the diagnosis to
be established and the repair to be completed. If there is an associated valvular injury, a
murmur of aortic insufficiency may be heard. Injuries to the descending aorta are uncommon.
Descending aortic injuries present with paraplegia, mesenteric ischemia, anuria, or lower
extremity ischemia.
Blunt injuries to the innominate artery are second in frequency only to rupture of the aorta at
the isthmus in patients reaching the hospital alive. These injuries are associated with rib
fractures, flail chest, hemopneumothorax, fractured extremities, head injuries, facial fractures,
and abdominal injuries. Diminished right radial or brachial pulse is found in 50% of patients.
Chest radiographic findings are similar to those for traumatic aortic disruption. CT angiography
is widely used as an initial screening tool, but aortography is generally required to make the
diagnosis.
Subclavian artery injuries are caused most often by fractures to the first rib or clavicle.
Absence of a radial pulse on the affected side is the most important sign. A pulsatile mass or
bruit at the base of the neck is suggestive of injury to the subclavian artery. Associated injury
to the brachial plexus occurs in 60% of patients. Horner syndrome often indicates avulsion of

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nerve roots from the spinal cord. Chest radiograph may show a widened superior mediastinum
without obscuration of the aortic knob.

Emergency Department Care and Disposition

Patients with traumatic aortic injury should not be allowed to develop a systolic BP > 120 mm Hg
or to perform a Valsalva maneuver.
Fluid administration should be monitored carefully, and administration of sedatives, vasodilators,
analgesics, and -blockers may be required to reduce the systolic BP.
A nasogastric tube should be inserted cautiously to avoid gagging or coughing in the patient.
Although surgical repair is the accepted standard of care, aggressive medical control of BP with
delayed repair and prolonged observation may be alternatives to patients at high risk for surgery.
Endovascular stenting may provide a less invasive approach to surgical repair.

ESOPHAGEAL AND THORACIC DUCT INJURIES

Injury to the thoracic esophagus is rare. If suspected, a swallow study with water-soluble
contrast should be obtained. If this study is negative, then a follow-up barium swallow is
recommended. Flexible esophagoscopy is another diagnostic study that may be considered.
Immediate esophageal repair is the treatment of choice. If repair is delayed beyond 24 hours,
local edema and tissue necrosis make repair unlikely. Mortalities for esophageal injury are 5%
to 25% if repaired within 12 hours and 25% to 66% if treated after 24 hours. Most injuries to
the thoracic duct result in chylothorax on the right side. Drainage, usually with a chest tube, is
the treatment of choice. Patients also should be kept NPO (nothing by mouth).
For further reading in Emergency Medicine: A Comprehensive Study Guide, 6th ed., see
Chapter 259, "Thoracic Trauma," by Timothy G. Buchman, Bruce L. Hall, William M. Bowling,
and Gabor D. Kelen.
Copyright 2007 The McGraw-Hill Companies. All rights reserved.
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