Trauma! Chest Injuries II

aka Trauma Tribulation 018

Your patient from Trauma Tribulation 017 managed to survive the primary survey. He’s not out of the woods yet though, as there are other potentially life-threatening chest injuries to consider. Can you diagnose and manage them in the emergency department?


Questions

Q1. What potentially life-threatening chest injuries should be considered in the secondary survey of major trauma patients?

Answer and interpretation

With a little bit of contortionism, potentially life-threatening chest injuries can also be remembered using ATOM-FC (I hate learning two mnemonics when one will do!):

  • Aortic dissection
  • Thorax injuries (non-massive hemothorax, simple pneumothorax)
  • Oesphageal perforation
  • Muscular diaphragmatic injury (a stretch this one, I know)
  • Fistula (bronchopleural) and other tracheobronchial injury
  • Contusion to the heart or lungs

Q2. How you would recognize and manage aortic disruption?

Answer and interpretation

Aortic disruption in trauma typically involves a tear on the aortic wall due to acceleration-deceleration forces. Those that make it to hospital may only have the outer aortic wall layer, the adventitia, intact containing a hematoma.

Recognition

  • Conscious patients may experience tearing chest and back pain. Neurological deficits may also be present (e.g. dissection involvement origins of carotid arteries, spinal arteries, etc)
  • Clinical signs (such as differences in blood pressure and pulses between the upper limbs) are unreliable.
  • Suspect based on mechanism and the presence of other injuries (e.g. fractures of the sternum, upper ribs and scapula)
  • Look for features of aortic dissection on CXR (especially widened mediastinum) — though these are often absent
  • Essential to have a low threshold for definitive test: CT angiogram of the aorta

Management

  • High flow oxygen 15L/min via non-rebreather mask
  • Avoid excessive fluid resuscitation
  • Lower the pulse rate to decrease aortic shear forces by commencing beta blockade (e.g. titrated esmolol infusion) then commence GTN infusion to aiming for systolic blood pressure of 90-100 mmHg and adequate tissue perfusion.
  • Definitive treatment is surgery, stenting or both

Q3. How would you recognize and manage a simple pneumothorax?

Answer and interpretation

Recognition

Management

  • High flow oxygen 15L/min via non-rebreather mask
  • Small traumatic pneumothoraces may only require observation
  • Significant simple pneumothoraces require intercostal catheter insertion, especially if the patient require intubation due to the risk of conversion to tension pneumothorax.

Q4. How would you recognize and manage a (non-massive) haemothorax?

Answer and interpretation

Recognition

Management

  • High flow oxygen 15L/min via non-rebreather mask
  • Intercostal catheter insertion (re-expansion of the ipsilateral lung may help tamponade bleeding vessels and ongoing blood loss can be monitored)

Q5. How would you recognize and manage an oesophageal perforation?

Answer and interpretation

Traumatic esophageal perforation is usually caused by penetrating trauma.

Recognition

  • Chest or epigastric pain, dysphagia, hematemesis
  • Neck and/or chest wound
  • Surgical emphysema
  • Pleural effusion, especially on left side (CXR or bedside ultrasound)
  • Drainage of gastrointestinal contents from an intercostal catheter
  • Shock (sepsis ensues if delayed presentation due to GI contents in the thoracic cavity)

Management

  • High flow oxygen 15L/min via non-rebreather mask
  • Fluid resuscitation
  • Nasogastric tube on free drainage
  • Broad spectrum antibiotics
  • Formal surgical repair

Q6. How would you recognize and manage a diaphragmatic injury?

Answer and interpretation

Diaphragmatic injuries may occur from either blunt or penetrating trauma (especially on the left side) and are easily missed. Blunt injury causes radial tears that tend to allow herniation of abdominal structures into the thoracic cavity early. Penetrating injuries can cause small defects that don’t present with herniation until years later.

Recognition

  • Suspect with any penetrating injury that could extend to between the T4 and T12 levels
  • Suspect with severe blunt trauma to the torso, especially if there were compressive or rapid deceleration forces
  • May be asymptomatic initially
  • Abdominal pain, guarding and/or rigidity
  • Cardiovascular and/or respiratory compromise may occur if abdominal contents herniate into the thoracic cavity
  • Herniation may be detected by hearing bowel sounds on chest auscultation, or by CXR (NG tube tip may extend into the thoracic cavity) or bedside ultrasound
  • Diagnosis of diaphragmatic rupture is usually on multidetector CT, though even a normal CT does not rule out the diagnosis
  • Laparoscopy or open exploration are the gold standard for diagnosis

Management

  • Laparoscopy or thoracoscopy if suspected
  • Most require formal surgical repair

This is what can happen years down the track when a diaphragmatic rupture is missed: Trauma Tribulation 004 — A Fiendish Finding


Q7. How would you recognize and manage a bronchopleural fistula?

Answer and interpretation

Tracheobronchial injury usually occurs close to the carina, and is associated with severe blunt trauma.

Recognition

  • Haemoptysis, cough and respiratory distress
  • Subcutaneous emphysema
  • Pneumothorax with persistent air leak after correct placement of an intercostal catheter (continues to bubble vigorously with little resolution of pneumothorax)

Management

  • High flow oxygen 15 L/min via non-rebreather mask
  • Multiple intercostal catheters may be required
  • Urgent bronchoscopy and operative intervention

Q8. How would you recognize and manage a pulmonary contusion?

Answer and interpretation

Pulmonary contusion can occur with any significant thoracic injury. Lung hemorrhage and pulmonary edema leads to impaired gas exchange and respiratory insufficiency. Lesions may progress over hours to days then gradually improve.

Recognition

  • Suspect in any significant thoracic trauma.
  • May occur in small children in the absence of fractures due to the high compliance of the chest wall.
  • Respiratory distress, hemoptysis, cyanosis
  • Decreased breath sounds and crackles in the affected lung area
  • Hypoxia and/ or hypercapnia on ABG
  • Pulmonary contusions are detectable on bedside ultrasound
  • Alveolar opacities on CXR

Management

  • High flow oxygen 15 L/min via non-rebreather mask
  • ‘Fluid restriction’ may reduce size of contusion but may not affect outcomes
  • Analgesia for pain from associated thoracic injuries, which may impair respiratory function
  • Respiratory support — severe cases require intubation and mechanical ventilation

Q9. How would you recognize and manage a cardiac contusion?

Answer and interpretation

Recognition

  • Suspect if severe blunt trauma with fractures of the sternum, ribs and/ or thoracic vertebrae
  • Chest pain
  • Persistent unexplained tachycardia
  • Suspect if any underlying ECG abnormality, including any arrhythmia, conduction defect or ischaemic changes such as ST segment deflections and T wave changes.
  • Troponin doesn’t alter management

Management

  • Cardiology consult and admission for cardiac monitoring and echocardiogram
Further Reading

Trauma Tribulation back

CLINICAL CASES

Trauma Tribulation

Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also the Innovation Lead for the Australian Centre for Health Innovation at Alfred Health and Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.

After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.

He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE.  He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.

His one great achievement is being the father of two amazing children.

On Twitter, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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