MEDICAL DECISION MAKING

Immediately immobilize all patients at risk for cervical

spine injury, perform a primary and secondary s urvey, and

address any emergent life threats. All patients with potential

cervical spine injury require some form of C-spine clearance. The NEXUS criteria and Canadian C-spine rules can

be used to identify patients at a low risk of significant injury

who can be clinically cleared without the need for radiographic studies (Tables 86-4 and 86-5). Patients who do not

meet either criterion require radiographic clearance.

Posterior

laminal ----.. \

line

Predental space:

< 3 mm in adult

< 5 mm in child

Figure 86-4. The predental space demonstrated on a

lateral C-spine radiograph. The posterior laminar line

should be drawn from the base of the spinous processes

of C1 to C3. The base of the spinous process of C2

should be within 2 mm of this line. This can help rule

out pseudosubl uxation of C2 on C3, which is commonly

seen in pediatric patients. Repri nted with permission

from Bai l itz J, Bokhari F, Scaletta TA, et al. Emergent

Management of Trauma. 3rd ed. New York: McGrawHill Education, 201 1.

A. Figure 86-5. Normal prevertebral soft tissue distance

on the lateral C-spine. Increased distance indicates soft

tissue swelling and possible associated fracture or liga ­

mentous injury. Repri nted with permission from Bail itz J,

Bokhari F, Sca letta TA, et al. Emergent Management of

Trauma. 3rd ed. New York: McGraw-Hill Education,

201 1.

Low-risk patients with unremarkable plain films can be

treated symptomatically. Pursue CT imaging in patients at

a moderate to high risk for injury and those with inade ­

quate or abnormal plain films. Proceed with MRI for any

CHAPTER 86

.&. Figure 86-6. AP view of the C-spine. Note the

unequal distance between the spinous processes,

indicating a C-spine fracture. Reprinted with permission

from Bail itz J, Bokhari F, Scaletta TA, et al. Emergent

Management of Trauma. 3rd ed. New York: McGrawHill Education, 201 1.

Alignment

of lateral

margins

Equal spaces Odontoid process

Figure 86-7. Odontoid view. Note symmetric alignment

of the lateral masses of C1 and C2. Reprinted with

permission from Bail itz J, Bokhari F, Sca letta TA, et al.

Emergent Management of Trauma. 3rd ed. New York:

McGraw-Hill Education, 201 1.

Table 86-4. National Emergency X-Radiography

Uti lization Study criteria: Cervical spine imaging

unnecessary in patient meeting these 5 criteria.

Absence of midline cervical tenderness

Normal level of alertness and consciousness

No evidence of intoxication

Absence of focal neurologic deficit

Absence of painful distracting injury

Reprinted with permission from Baron BJ, McSherry KJ, Larson, J r.

J L, Scalea TM. Chapter 255. Spine and Spinal Cord Trauma. In:

Tintinalli JE, Stapczynski JS, C l i n e D M , Ma OJ, Cydulka RK, Meckler

G D, eds. Tintinolli's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York: McGraw-Hill, 201 1.

Table 86-5. Canadian C-Spine Rule for radiography:

Cervical spine imaging unnecessary in patients meeting these 3 criteria.

Question or Assessment

There are no high-risk

factors that mandate

radiography.

Definitions

High-risk factors include:

Age �65 years

A dangerous mechanism of injury (fall

from a height of >3 ft; an axial loading injury; high-speed motor vehicle

crash, rollover, or ejection; motorized

recreational vehicle or bicycle collision)

The presence of paresthesias in the

extremities

There are low-risk factors Low-risk factors include:

that allow a safe Simple rear-end motor vehicle crashes

assessment of range of

motion. Patient able to sit up in the ED

The patient is able to

actively rotate his/her

neck.

Patient ambulatory at any time

Delayed onset of neck pain

Absence of midline cervical tenderness

Can rotate 45 degrees to the left and

to the right

Reprinted with permission from Baron BJ, McSherry KJ, Larson, J r.

J L, Scalea TM. Chapter 255. Spine and Spinal Cord Trauma. In:

Tintina lli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler

G D, eds. Tintinol!i's Emergency Medicine: A Comprehensive Study

Guide. 7th ed. New York: McGraw-Hill, 201 1.

patients with findings concerning for spinal cord injury or

ligamentous instability. All patients with abnormal imaging and/or neurological deficits require neurosurgical

consultation. Transfer such patients to a higher level of

care if necessary (Figure 86-8).

TREATMENT

All patients with suspected cervical spine injury require

immediate immobilization on presentation. The collar can be

temporarily removed to facilitate endotracheal intubation as

necessary provided an additional health care provider can

maintain appropriate in-line stabilization. If available, some

of the newer fiber-optic devices permit endotracheal intubation with little to no movement of the cervical spine.

Patients who are either clinically or radiographically cleared

can be managed with oral analgesics. Those who require parenteral pain control should have their diagnosis reconsidered.

The use of steroids in SCI remains highly controversial.

The recent Consortium for Spinal Cord Medicine (2008)

concluded that there is no current evidence to definitely

recommend the use of steroids in the standard management of patients with blunt spinal cord injury. Furthermore,

the most current American Association of Neurological

Surgeons guidelines (2013) state that the use of steroids for

acute spinal cord injury is not recommended and there is

CERVICAL SPINE I NJURI ES

Potential cervical spine injury

Immobil ize patient, primary

and secondary survey

NEXUS/Canadian C-spine

criteria met

NEXUS/Canadian c -spine

criteria not met

Radiographs C-spine

Normal radiographs with

adequate visual ization, no

persistent pain

Abnormal or inadequate

radiographs, new neuro

deficit, persistent pain

Figure 86-8. Cervical spine injuries diag nostic algorithm. CT, computed tomography; MRI, magnetic resonance

imaging; SCIWORA, spinal cord injury without radiologic abnormal ity.

no Class I or Class II evidence to suggest clinical benefit,

while there is evidence to suggest harmful side-effects.

DISPOSITION

..... Admission

Admit all patients with documented SCI to an intensive

care unit (ICU) setting with neurosurgical consultation for

frequent neurologic evaluations. In addition, all patients

with unstable injuries regardless of the presence or absence

of associated cord injury require ICU admission pending

operative management. If the appropriate subspecialty

services are unavailable, transfer to an institution that specializes in SCI. Patients with significant persistent pain

despite negative imaging, the elderly, and those with poor

social s upport may require admission for pain management

and/or placement for rehabilitation.

..... Discharge

Low-risk patients who have either been clinically cleared or

complain only of minimal persistent pain with negative

imaging studies can be safely discharged. In addition, it

is safe to discharge patients with stable fractures ( eg, anterior wedge, spinous process) after neurosurgical consultation, provided they are given clear plans for outpatient

follow-up .

SUGGESTED READING

Baron BJ, McSherry KJ, Larson JL, TM Scalea. Spine and spinal

cord trauma. In: Tintinalli JE, Stapczynski JS, Ma OJ, Cline

DM, Cydulka RK, Meckler GD. Tintinalli's Emergency

Medicine: A Comprehensive Study Guide. 7th ed. New York,

NY: McGraw-Hill, 20 1 1, pp. 1 709-1 730.

Hoffman JR, Mower WR, Wolfson AB, et al. Validity of a set of

clinical criteria to rule out injury to the cervical spine in

patients with blunt trauma. N Engl J Med. 2000;343:94.

Hurlbert RJ et al. Pharmacological therapy for acute spinal cord

injury. Neurosurgery 201 3;72(3):supplement 93-105 .

Stiell IG, Wells GA, Vandemheen KL, et al. The Canadian C-spine

rule for radiography in alert and stable patients. ]AMA.

2001;286:1841.

Thoracic Trauma

Michael A. Schindl beck, MD

Key Points

• Thoracic trauma is the second leading cause of

traumatic death in the Un ited States.

• All patients require a rapid primary survey focused on

patient airway, breathing, and circulation and stabilization of any emergent life-threatening conditions.

INTRODUCTION

Thoracic trauma accounts for more than 16,000 deaths in

the United States annually and constitutes approximately

25% of all trauma related mortality. For clinical purposes,

patients can be divided into blunt and penetrating categories based on the mechanism of injury. Approximately 80%

of cases of significant blunt thoracic trauma are secondary

to motor vehicle collisions (MVC), whereas most cases of

penetrating trauma in the United States are due to stab

wounds and low-velocity handgun injuries.

� Blunt Thoracic Injuries

Injuries that occur after blunt thoracic trauma include fractures (sternum/ribs), flail chest, pulmonary contusion, myocardial injury, and aortic injury. Although fractures to the

sternum and ribs are usually not life-threatening, displaced

and/or multiple rib fractures are an exception. Evaluate for

injury to underlying structures-the mediastinum and great

vessels with ribs 1-3, the lungs with ribs 4-8, and the liver or

spleen with ribs 9-12. Flail chest occurs when �3 contiguous

ribs are fractured in � places, thereby creating a "free floating" segment of the chest wall.

Pulmonary contusions are focal regions of bruised lung

parenchyma resulting in alveolar hemorrhage and edema,

which can significantly impair normal respiratory function.

• Emergent life th reats in thoracic trauma include airway

obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, and pericardia! tamponade.

• In sel ect penetrating trauma victims who suffer wit ­

nessed loss of vital signs, emergent thoracotomy can

be a lifesaving proced u re.

They typically develop over several hours post injury and

are often missed on the initial patient assessment.

Blunt myocardial injury (BMI) should be considered in

any patient with significant direct trauma to the anterior chest

wall. Myocardial contusions present as regions of "stunned"

tissue that clinically behave analogous to myocardial infarctions. Rarely, patients with significant BMI may progress to

outright cardiogenic shock due to impaired pump function

or dysrhythmia.

Blunt aortic injury (BAI) is seen in patients when a

rapid decelerating force causes significant sheer strain and

secondary rupture of the aorta. More than 80% of cases

occur at the site of the ligamentum arteriosum just distal

to the takeoff of the left subclavian artery. Roughly 20% of

patients with BAI will survive to emergency department (ED)

presentation because of the tamponading effects of an

intact adventitia. As the presenting symptoms and clinical

picture are highly variable, a high index of suspicion for

BAI should be maintained for any patient with the

appropriate mechanism of injury.

� Penetrating Thoracic Injuries

Injuries common after penetrating thoracic trauma include

pneumothorax, hemothorax, cardiac injury, pericardia!

tamponade, great vessel injury, and tracheobronchial injury.

Pneumothoraces (PTX) are rather common after penetrating

374

THORACIC TRAUMA

thoracic trauma, but can also be seen in blunt injuries when

a fractured rib lacerates the underlying pleura. A simple

pneumothorax occurs when injured 1 ung tissue creates an air

leak in the potential space between the visceral and parietal

pleura. An open or communicating PT X occurs when a large

open defect in the thoracic wall allows communication

between the intrapleural space and the environment. Defects

greater than two thirds of the diameter of the trachea

will lead to severe respiratory impairment. A tension

pneumothorax arises when an injury to the thoracic wall

and/or underlying bronchopulmonary structures allows the

progressive accumulation of air into the intrapleural space.

Rising intrathoracic pressure will eventually inhibit the

venous return of circulating blood to the right atrium,

resulting in cardiovascular collapse and ensuing pulseless

electrical activity (PEA) arrest. Tension PTX is a clinical

diagnosis that requires immediate intervention.

Hemothoraces (HT X) develop secondary to the

accumulation of blood into the intrapleural space after

injury to the lungs, heart, or thoracic vasculature. Each

hemithorax can accommodate up to 40% of a patient's

circulating blood volume. Massive HTX (accumulation

> 1 ,500 mL) is an emergent life-threatening condition that

can induce severe hypoxia and systemic hypotension.

Penetrating cardiac injury (PCI) can be rapidly fatal.

Occasionally patients, especially those with stab wounds to

the anterior heart, will survive to ED presentation because

of the tamponading effects of an intact pericardium.

Accumulating fluid in the pericardia! space will e ventually

collapse the right side of the heart, resulting in cardiac

arrest. Pericardia! tamponade is an emergent life threat

requiring immediate intervention.

Penetrating great vessel injury (PGVI) presents with

massive HTXs with persistent high-volume bloody chest

tube effluent. Suspect venous air embolism (VAE) in patients

with penetrating vascular trauma, especially involving the

subclavian vein, who suddenly decompensate into PEA

arrest without alternative explanation.

Tracheobronchial injury can be seen in both blunt and

penetrating trauma and should be suspected in patients

with an appropriate mechanism and either extensive

subcutaneous emphysema or a persistent high-volume air

leak after chest tube placement.

CLINICAL PRESENTATION

� History

A detailed history is usually deferred until the completion of

the primary survey and stabilization of any evolving emergent

life threats (Table 87-1). T he severity of the mechanism

should be estimated to determine the potential for underlying injury. Emergency medical service (EMS) personnel are

an invaluable asset. Clues to significant injuries after an MVC

include lack of seat-belt restraint, dashboard deformity, significant intrusion into the passenger compartment, pro ­

longed extraction, ejection from the vehicle, and on-the-scene

Table 87-1. Emergent life threats in thoracic trauma.

Airway obstruction

Tension pneumothorax

Pericardia! tamponade

Open pneumothorax

Massive hemothorax

death of other occupants. Sudden deceleration mechanisms,