whiteguardian
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04.29.06 (2 years ago)
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BLUNT THORACIC TRAUMA
1. Chest Wall Injuries
· Rib fracture is the most common thoracic injury
· Significant intrathoracic injury may be present without rib fracture in children due to rib cage elasticity
· Narcotics and intercostal nerve blocks are sufficient for simple rib fractures
· Patients with flail chest should be supported with mechanical ventilation for several days to regain chest wall stability
· Consider tracheostomy for prolonged intubation to minimize laryngeal injury and facilitate pulmonary care
· First rib fracture indicates significant force, and aortography is indicated if the patient also has brachial plexus deficit, absent radial pulse, pulsating supraclavicular mass, or widened mediastinum
2. Pulmonary Injuries· Pulmonary contusion probably occurs to a varying degree in all thoracic injuries and is a major component of flail chest
· Significant hypoventilation and shunting from contusion requires judicious fluid management and ventilatory support, if indicated
· Partial, complete, and tension pneumothorax should all be managed promptly with chest tube insertion
· Subcutaneous emphysema should prompt investigation for pneumothorax but is not in itself an indication for chest tube placement
· Hemothorax should be managed with early chest tube drainage to prevent clot formation and incomplete evacuation
· Surgical exploration is recommended if initial output is more than 1000 ml or chest tube drainage is more than 100 ml/hr for 4 hours
· A clotted hemothorax should be evacuated early by thoracotomy to improve pulmonary function and prevent late fibrothorax
3. Tracheal/Bronchial Injuries· Most tracheal injuries are cervical and range from crush injuries to compete tracheal separation
· If endotracheal intubation is not possible, a surgical airway should be obtained
· Primary repair of tracheal lacerations or separation should be performed, if possible
· Blunt trauma typically causes a circumferential laceration of either main bronchus with complete separation
· Only 50% of patients will have a pneumothorax with this injury, and hemothorax is uncommon
· Only 1/3 of patients are diagnosed in the first 24 hours, and only 1/2 within the first month
· Early repair is the preferred treatment if the diagnosis is made, and requires thoracotomy with intubation of the uninjured bronchus
· Late strictures from incomplete tears or parenchymal isolation from complete tears can be repaired with bronchoplastic procedures, but may require pulmonary resection
4. Cardiac/Great Vessel Injuries
· Myocardial contusion is the most common injury and is suspected with EKG changes and serial enzyme elevations
· Coronary artery injury can result in thrombosis and myocardial infarction
· Atrial or ventricular rupture is usually fatal, although the pericardium may restrict bleeding enough to allow survival to the ER
· The patient should be monitored in the ICU and may require heparinization for coronary thrombosis and anti-arrhythmic therapy
· Echocardiography and angiography are indicated for tamponade and post-injury murmurs, which suggest valvular insufficiency or septal defect
· Aortic rupture is also usually fatal, but can result in formation of a false aneurysm, typically at the aortic isthmus
· Patients with a widened mediastinum on CXR should have prompt aortography, which will demonstrate an intimal tear
· Surgical repair should be done promptly, as fatal hemorrhage can occur at any time
· Techniques include LA-FA bypass, proximal aorta-distal aorta shunting, and cross-clamping without cardiopulmonary bypass
5. Diaphragm Rupture· Most lacerations occur on the left hemidiaphragm and result from automobile accidents
· Usually, the stomach herniates and undergoes volvulus, massively dilates, and causes left lung collapse and mediastinal shift to the right
· Gastric distension can also result in perforation and should be prevented by NG tube placement
· Splenic and liver injury is also common in this setting
· The diaphragm can be repaired either through the chest or abdomen, and all tears should be closed in double-layer fashion
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