Chest Trauma: The List of Deadlies

Trauma to the chest accounts for 50% of trauma deaths. Ironically 80% of all chest injuries can be managed non-surgically with simple measures such as intubation, chest tubes, and pain control. Chest trauma can be divided into two categories—those found in the primary survey and those found during secondary survey.

*3-way seal for open pneumothorax (i.e. sucking chest wound)—allows air to escape during the expiratory phase (so that patient does not get a tension pneumothorax) but seals itself to allow adequate breaths during the inspiratory phase.

**Pulsus paradoxus—a drop in blood pressure of > 10mmHg with inspiration. Recall that blood pressure normally drops with inspiration, but what’s “paradoxical” about this is that it drops more than it should.

***Kussmaul sign is a paradoxical rise in jugular venous pressure (JVP) on inspiration, or a failure in the appropriate fall of the JVP with inspiration. It can be seen in some forms of heart disease and is usually indicative of limited right ventricular filling due to right heart dysfunction. Kussmaul sign is not to be confused with Kussmaul breathing is a deep and labored breathing pattern often associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA) but also kidney failure.

Mnemonic to remember signs that indicate aortic tear: ABC WHITE. These are present in 85% of cases but absence cannot rule out diagnosis.

Aortic tear on x-ray

Bronchus pleural Cap

Wide mediastinum (most consistent)

Haemothorax

Indistinct aortic knuckle

Tracheal deviation to right side

Esophagus (NG tube) deviated to right

Other potentially life-threatening injuries related to the chest include penetrating neck trauma:

·      Includes all penetrating trauma to the three zones of the neck

·      Management: injuries deep to the platysma require further evaluation by angiography, contrast CT, or surgery.

·      DO NOT insert NG tube

·      DO NOT remove weaponry/impaled object

·      DO NOT clamp or explore open neck wounds except in surgery

Anatomy reminder: 3 zones of the neck I~III

Zone I: sternal notchà cricothyroid membrane

Zone II: cricothyroid membraneà angle of mandible

Zone III: angle of mandibleà skull base

Always have a high suspicion of airway injury. Two major organs involved are the larynx and trachea/bronchus.

Trachea

·      History: strangulation, direct blow, blunt trauma, any penetrating injury involving platysma

·      Triad: hoarseness, subcutaneous emphysema, palpable fracture

·      Other symptoms: hemoptysis, dyspnea, dysphonia

·      Investigations: CXR, CT scan, arteriography (if penetrating injury)

·      Management

o   Airway—manage early because of edema

o   C-spine may also be injured, consider mechanism of injury

o   Surgical—tracheotomy vs. repair

Larynx/bronchus

·      Frequently missed

·      History: deceleration, penetration, increased intra-thoracic pressure, complaints of dyspnea, hemoptysis

·      Examination: subcutaneous air, Hamman’s sign (crunching sound synchronous with heart beat)

·      CXR: mediastinal air, persistent pneumothorax or persistent air leak after chest tube insertion for pneumothorax

·      Management: surgical repair if > 1/3 circumference

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