Thoracic Trauma

Published on 24/03/2015 by admin

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Last modified 24/03/2015

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Chapter 62 Thoracic Trauma

Howard Kadish, MD

1 What are the most common injuries in blunt and penetrating thoracic trauma?

Blunt thoracic trauma: Lung contusions (58%), pneumothorax or hemothorax (38%), and rib fractures (38%)

Penetrating thoracic trauma: Pneumothorax or hemothorax (64%), diaphragmatic lacerations (15%), cardiac injuries (13%), and vascular injuries (10%)

2 How does thoracic trauma differ in children and adults?

Pediatric thoracic trauma differs from adult thoracic trauma in mechanism of injury, type of injury, and other organ systems involved. Falls are the most common mechanism of injury in infants and children. Older children are often injured as pedestrians or unrestrained passengers in motor vehicle accidents. Adolescents are more likely to be occupants in motor vehicle–related accidents and to experience penetrating injuries secondary to violence.

Lung contusion is the most common pediatric thoracic injury, with intrapleural injury second. Only 30% of children, compared with 50–75% of adults, sustain rib fractures because of increased compliance in the pediatric thoracic cage secondary to increased cartilage content and greater elasticity of the bones. Thus, a child may have an internal injury (lung contusion) without external evidence of trauma (rib fracture, laceration, bruising). The pediatric trachea has a smaller internal diameter than the adult trachea; therefore, a small amount of obstruction secondary to blood, secretions, or edema can cause significant respiratory distress and hypoxia. The younger pediatric patient is also more sensitive to hypoxia and may develop reflex bradycardia or asystole. In evaluating pediatric patients with thoracic trauma, the health care provider must consider head, neck, and intra-abdominal injuries because approximately 80% of cases of thoracic trauma in children are part of multisystem injury. Thoracic trauma is routinely associated with abdominal trauma in children because the chest and abdominal cavities lie in close proximity.

3 How do I evaluate a patient with thoracic trauma?

The ABCs (airway, breathing, circulation) of trauma management apply regardless of the organ system injured. The injured child should be evaluated according to the primary survey of trauma management. Indications for endotracheal intubation in thoracic trauma patients include depressed neurologic status, inadequate oxygenation or ventilation, compromised circulatory status, or unstable airway (including burns). If a patient has an abnormal examination but appears to be oxygenating and ventilating well and is not in shock, chest radiography is indicated. If breathing is inadequate after endotracheal intubation, with asymmetry of breath sounds, intervention is required prior to chest radiography. Pericardial tamponade, tension pneumothorax, or hemothorax should be considered in poorly perfused patients with signs of shock in whom other sources of blood loss have been excluded and volume resuscitation has not improved clinical status. Once the patient is stabilized and immediate life-threatening injuries, such as airway obstruction, tension pneumothorax, hemothorax, and pericardial tamponade, are treated, chest radiography and thoracic computed tomography provide valuable information about other potentially life-threatening and operative injuries.

4 What are the predictors of thoracic injury in children sustaining blunt trauma?

Low systolic blood pressure

Elevated respiratory rate

Abnormal results of thoracic examination

Abnormal chest auscultation findings

Glasgow Coma Scale score < 15

5 Which thoracic injuries require operative intervention?

Tracheal/bronchial rupture

Laceration of lung parenchyma, internal mammary artery, or intercostal artery

Esophageal disruption

Diaphragmatic hernia

Pericardial tamponade

Great vessel laceration

6 Describe signs and symptoms related to each operative thoracic injury

See Table 62-1.

Table 62-1 Signs and Symptoms of Thoracic Injuries

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Injury	Signs and Symptoms
Tracheal/bronchial rupture	Active chest tube air leak
Lung parenchyma	Chest tube bleeding > 2–3 mL/kg/hr
Internal mammary or intercostal artery laceration	Hypotension unresponsive to transfusions
Esophageal disruption	Abnormal esophagogram (leak) or esophagoscopic result Gastric contents in the chest tube
Diaphragmatic hernia

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