RT Book, Section
A1 Koenig, George J.
A1 Efron, David T.
A2 Yuh, David D.
A2 Vricella, Luca A.
A2 Yang, Stephen C.
A2 Doty, John R.
SR Print(0)
ID 1104583883
T1 Thoracic Trauma
T2 Johns Hopkins Textbook of Cardiothoracic Surgery
YR 2014
FD 2014
PB McGraw-Hill Education
PP New York, NY
SN 978-0-07-166350-2
LK accesssurgery.mhmedical.com/content.aspx?aid=1104583883
RD 2024/04/20
AB EpidemiologyTwenty  percent  of  all  trauma  patients  sustain  chest  injuries.PathophysiologyThoracic  injuries,  like  with  all  traumas,  can  result  from  blunt  or  penetrating  mechanism.  Fractures  and  soft  tissue  injuries  are  common.  Compromised  breathing  remains  a  particularly  urgent  concern  in  these  patients,  which  is  unique  to  thoracic  injuries  and  demonstrates  common  physiologic  signs  regardless  of  cause.  Structures  that  can  be  injured  include  the  protective  bony  thorax  (ribs,  sternum,  scapula,  and  spinal  column).  The  diaphragm  inferiorly,  and  the  soft  tissue  content  of  the  thorax  (heart,  lungs,  esophagus,  and  great  vessels).  Severe  cardiovascular  compromise  can  also  result  from  injury  to  the  chest.Clinical  featuresOutside  of  the  pain  of  injury,  obvious  clinical  compromise  that  results  from  thoracic  injury  includes  primarily  signs  of  respiratory  embarrassment  and  hemodynamic  instability.  Presenting  symptoms  vary  according  to  the  injured  structure.  Potential  symptoms  include  dyspnea,  tachypnea,  and  pain  on  palpation.  Signs  include  contusions,  penetrating  wounds,  subcutaneous  emphysema,  crepitance,  distant  or  unequal  breath  sounds  on  auscultation,  muffled  heart  sounds,  tracheal  deviation,  jugular  venous  distension,  absent  upper  extremity  pulses,  shock,  and  distal  neurologic  deficit.DiagnosticsPhysical  examination  including  vital  signs  as  part  of  the  primary  survey  remains  the  initial  most  important  diagnostic  evaluation.  Chest  x-ray,  upright  where  possible,  is  desirable.  This  will  delineate  injury  to  most  bony  structures,  identify  hemopneumothoraces,  raise  suspicion  about  mediastinal  injury,  and  potentially  aid  in  determination  of  trajectory  of  penetrating  injuries.  The  patient’s  hemodynamic  status  and  mechanism  of  injury  guide  further  diagnostic  workup.  Focused  assessment  with  sonography  for  trauma  (FAST)  ultrasound  can  identify  presence  of  fluid  or  the  absence  thereof  in  the  pericardial  sac.  Thoracic  computed  tomography  (CT)  scan  and  CT  angiography  are  valuable  and  reliable  in  assessing  injuries  to  the  great  vessels  in  stable  patients  at  risk  and  helpful  in  determining  at-risk  structures  given  the  trajectory  of  the  penetrating  injury.  Esophagoscopy,  bronchoscopy,  and  esophagography  all  play  a  role  in  assessing  the  integrity  of  these  structures  and  identifying  the  need  for  operative  repair.  In  some  situations,  diagnosis  is  made  necessarily  at  the  time  of  therapeutic  intervention  as  in  the  placement  of  a  chest  tube  for  signs  of  a  tension  pneumothorax,  relief  of  pericardial  tamponade  via  an  emergency  department  (ED)  thoracotomy  in  an  arrested  patient,  or  pericardial  window  at  laparotomy.TreatmentAs  with  all  trauma  patients,  the  best  approach  in  management  is  delineated  by  ATLS  guidelines.  Addressing  the  need  for  a  secure  airway  and  ensuring  adequate  breathing  and  circulation  necessitates  rapid  assessment  of  the  thorax,  diagnosis,  and  intervention  for  life-threatening  abnormalities.  Further  management  depends  on  structure-specific  injuries.OutcomesOutcomes  for  thoracic  trauma  are  widely  varied,  are  injury  and  mechanism  dependent,  and  vary  tremendously  according  to  patient  presentation  and  the  specific  structures  that  are  injured.