MEDICAL DECISION MAKING

The management of the thoracic trauma patient should

be algorithmic based on the mechanism and location of

injury. Initial efforts should focus on a rapid primary

survey and immediate aggressive intervention for any

emergent life threats encountered. A more comprehensive

secondary survey is then performed, aided by laboratory

and imaging studies as outlined previously (Figure 87-6).

TREATMENT

...... Blunt Thoracic Injuries

Sternal and Rib Fractures

Provided there are no corresponding injuries to underlying

viscera, care of these injuries should focus on adequate analgesia. Suboptimal pain control can result in impaired l ung

ventilation and the potential for secondary pneumonia.

Intercostal nerve block can be an invaluable for pain control.

Pulmonary Contusions

These injuries are treated supportively with supplemental

oxygen via a nonrebreather mask to maintain adequate

systemic oxygenation. Patients with extensive contusions

or those unresponsive to supplemental oxygen will require

endotracheal intubation and positive pressure ventilation.

Care must be taken to avoid overaggressively hydrating

these patients to limit progressive alveolar edema and

extension of the underlying contusion.

Blunt Myocardial Injury

Clinically significant injuries requmng aggressive

intervention are very rare. Stable patients with normal

initial ECGs can be discharged home without further

evaluation. Patients with ECG anomalies should be

observed for 12-24 hours on continuous telemetry to

assess for the development of progressive dysrhythmias or

cardiogenic shock. Patients who decompensate into cardiogenic shock should be managed via the appropriate

Advanced Cardiac Life Support algorithms with the caveat

that, for the most part, antiplatelet and anticoagulant

medications should be avoided.

Blunt Aortic Injury

If possible, the systolic blood pressure (BP) should be

aggressively lowered to -ll0-120 mm Hg to reduce the

shearing forces on the vessel wall and limit the potential for

aortic rupture. Ideal agents include a combination of intravenous (IV) esmolol and either nitroprusside or nicardip ­

ine drips. Copious analgesia may be necessary to facilitate

adequate BP control. Definitive treatment involves surgical

repair or endovascular stenting.

...... Penetrating Thoracic Injuries

Pneumothorax

Almost all traumatic PTXs require tube thoracostomy

within the ED. This is especially true of patients with

bilateral PTXs or those undergoing positive pressure ventilation. Patients with an asymptomatic simple PTX

smaller than 1 em on CXR and no visible HTX or those

with PTX visible only on CT imaging (occult PTX) can be

observed on 1 00% supplemental oxygen, with tube thoracostomy reserved for those with evidence of increasing

volume on serial imaging or the development of associated symptoms. Tension PTXs require immediate needle

thoracostomy followed by chest tube placement. Open

PTXs require placement of a 3-sided occlusive dressing

over the wound to create a flutter valve and restore the

integrity of the chest wall followed by subsequent tube

thoracostomy.

Hemothorax

Almost all HTXs large enough to be detected on CXR

should be drained with tube thoracostomy. Operative

intervention is required in <5% of cases of HTX and

should be reserved for cases of massive HTX with either

initial volumes of evacuated blood > 1,500 mL, persistent

chest tube output of >200 mL/hr over the first 2-4 hours,

or hemodynamic instability despite aggressive volume

THORACIC TRAUMA

Operative vs.

endovascu lar

repair

I ntervene, stabilize,

fr reassess

Cardiac box

.A. Figure 87-6. Thoracic trauma diag nostic algorithm. ABCs, airway, breathing, and circulation; CT, computed

tomography; CXR, chest x-ray; ECG, electrocard iogram; OR, operating room.

resuscitation. Autotransfusion should be considered in the

majority of these patients.

Penetrating Cardiac Injury

Patients with loss of vital signs either in the field or ED

should undergo emergent thoracotomy. Those with

pericardia! tamponade from an anterior cardiac stab

wound have the highest likelihood of survival. Unstable

patients with signs of pericardia! tamponade either on

physical exam or US should undergo emergent

pericardiocentesis. Stable patients with evidence of bleeding in the pericardia! sac on bedside ECHO should be

taken to the operating room for either a pericardia! window or an operative thoracotomy.

Penetrating Great Vessel Injury

The majority of these patients who survive to ED

presentation will require emergent operative intervention.

Early endotracheal intubation should be considered given

the potential for significant mediastinal hematoma

CHAPTER 87

formation and secondary tracheal compromise. Any

retained implements should be stabilized in place, and

their removal should be performed only within the

operating room.

Tracheobronchial Injury

All patients with presumed tracheobronchial trauma

should undergo emergent bronchoscopy to determine the

location and severity of injury. The majority of these

patients will require operative repair. If necessary,

endotracheal intubation should be performed under

bronchoscopic guidance to limit any further trauma to the

tracheobronchial tree and prevent the aberrant placement

of the endotracheal tube into a false soft-tissue lumen.

DISPOSITION

� Admission

The majority of thoracic trauma patients will require hospital admission. Hemodynamically stable patients with an

isolated PTX or small HTX can be admitted to a standard

hospital bed after chest tube placement. Patients with BMI

or pulmonary contusions should be admitted to either a

telemetry unit or intensive care unit (I CU) setting depend ­

ing on the severity of symptoms. Patients with BAI, PCI,

PGVI, or tracheobronchial injury will require operative

intervention followed by an ICU admission.

� Discharge

Patients with uncomplicated rib or sternal fractures can

be safely discharged home provided that their pain can

be adequately managed. Stable penetrating thoracic

trauma patients with a normal initial CXR and otherwise negative work-up should have repeat imaging performed within 3-6 hours to check for the development

of a delayed PTX. If negative, these patients can be safely

discharged home.

SUGGESTED READING

Bastos R et al. Penetrating thoracic trauma. Semin Thorac

Cardiovasc Surg. 2008;20:1 9-25.

Brunett PH, Yarris LM, Cevik AA. Pulmonary 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, 2011.

Keel M, Meier C. Chest injuries: What is new? Curr Opin Grit

Care. 2007;13:674-679.

McGillicuddy D, Rosen P. Diagnostic dilemmas and current

controversies in blunt trauma. Emerg Med Clin North Am.

2007;25:695-7 11.

Ross C, Schwab TM. Cardiac t rauma. ln: 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, 201 1.

Abdominal Trauma

Matthew T. Emery, MD

Key Points

• A normal physical examination cannot be used as the

sole means to exclude significant injury in patients with

abdominal trauma.

• Hemodynamically unstable patients with penetrating

injuries into the peritoneal cavity or blunt abdominal

trauma and evidence of intraperitoneal hemorrhage

require emergent lapa rotomy.

INTRODUCTION

Victims of abdominal trawna can present with intraperitoneal,

retroperitoneal, and intrathoracic injuries. Intraperitoneal

structures at a high risk of injury include the solid organs

(liver and spleen), hollow viscera (small and large intes ­

tines), and diaphragm, whereas commonly involved retroperitoneal structures include the kidneys and genitourinary

( GU) tract, duodenum, pancreas, and portions of the large

intestine. The initial evaluation and management of

patients with abdominal trawna can be divided by the

mechanism of injury into blunt and penetrating pathways.

Motor vehicle collisions (MVC) and significant falls account

for the majority of cases of blunt abdominal trauma,

whereas stab wounds (SW) and gunshot wounds (GSW)

account for most cases of penetrating trauma. Keep in

mind that the location of an entrance wound can frequently be misleading. Although a wound located on the

anterior abdomen is obviously a high-risk injury, alterna ­

tive sites (lower chest, pelvis, back, or flank) can also result

in significant intraperitoneal (or retroperitoneal) injury

depending on the trajectory of the bullet, knife, or other

wounding implement.

When evaluating patients with penetrating trawna, the

abdomen can be divided up into 4 distinct zones to help

381

• Gunshot wounds that violate the peritoneum require

operative exploration because of the high likeli hood of

inju ry.

• In patients with blunt abdominal trauma, negative

computed tomograhy imaging has an excellent

negative predictive value for excluding significant injury.

predict which anatomic structures are at risk of injury. The

anterior abdomen extends between the anterior axillary

lines from the costal margins down to the inguinal ligaments (Figure 88-1). The thoracoabdominal region

extends circurnferentially around the entire trunk between

the costal margins inferiorly and the nipple line or inferior

scapular borders superiorly (Figure 88-2). Trauma to this

region can injure intrathoracic and intraperitoneal struc ­

tures as well as the diaphragm. The flanks compose the

third anatomical zone and extend between the anterior

and posterior axillary lines from the costal margins to the

iliac crests. Consider injuries to both intraperitoneal and

retroperitoneal structures in this region. The final anatomical

zone is the back, which extends between the posterior axil ­

lary lines from the inferior scapular borders to the iliac

crests. Trauma to this region is most likely to result in

retroperitoneal injury.