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Penetrating Chest Trauma Algorithm

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Arresting Patient

ED Thoracotomy indications:

  • Trauma patient, CPR, no signs of life (SOL) +:
    • Blunt trauma with CPR <10min
    • Penetrating trauma with CPR <15min
    • Penetrating trauma to neck/extremity < 5 min

No Signs of Life (SOL):

□ No pulse
□ No pupils
□ No movement
□ No breaths
□ No PEA
□ No cardiac motion (US)

Procedure:

  • Resuscitative Thoracotomy (Open the left chest)
    • Release tamponade and open resuscitation of heart
    • Control bleeding
    • Cross-clamp aorta → Shunt blood up
  • Right Chest Tube
    • Blood? → Clamshell thoracotomy to control bleeding

Survival rates:

  • Overall survival rate 7.4%, dictated by location & mechanism of injury (J Am Coll Surg 2000;190:288- 98)
  • Thoracic injury 10.7% (Cardiac-19.4%), abdominal injury 4.5%
  • Penetrating injury 8.8% (stab wounds 17%, GSW 4.3%) blunt trauma 1.4%
Penetrating Chest Trauma Algorithm
Penetrating Chest Trauma Algorithm

Unstable Patient

Resuscitation

  • Critical Actions
    • Crystalloid resuscitation
    • Initiate cross-matching
  • Remains Unstable?
    • Continue resuscitation
      • Blood transfusion → uncross-matched or type specific
      • Thaw FFP
      • Target endpoint → SBP 90, talking

Localize bleeding (See Blunt Chest Trauma Algorithm)

  • Cardiac Ultrasound
    • Pericardial effusion
    • Tamponade phenomenon, collapse of RV
  • Lung Ultrasound
    • Pneumothorax: Anterior air-no sliding lung
    • Hemothorax: Blood in pleural cavity
  • CXR (Chest X-Ray)
    • Pneumothorax: deep sulcus sign, Subcutaneous air
    • Hemothorax: haziness in lung fields
  • Chest tube, Clinically directed
    • Indications
      • Hemothorax/Pneumothorax
      • Clinical exam/diagnostic
    • OR
      • Output>1-1.5L
      • Continuous output > 200-250ml/h X 2-4h
      • Clinical judgment
  • Rule out other areas of blood loss (Pelvis, extremities, externally)
    • Stop bleeding

Stable Patient

General

  • ABCs
  • IV, O2, Monitor …

Discharge Home Checklist:

□ Examinable
□ Isolated thoracic Injury
□ Negative U/S + radiographs
□ Serial clinical exams
□ Initial and repeat CXR at 3 hours

What is at risk of injury?

  • External wounds → roll early
  • Plain X-rays → missile localization and trajectory mapping

Check for specific areas of injury

Pneumothorax

Diagnosis

  • Lung Ultrasound as part of FAST
  • Rule Out Pneumothorax:
    • Initial CXR
    • If CXR negative → Repeat CXR at 3 hours (J Trauma 2008;65:549-53)
    • Previously would repeat CXR at 6 hours → No additional benefit gained from CXR at 6 vs 3 hours

Penetrating Cardiac Injury

Diagnosis

  • Clinical exam, CXR, ECG, Pericardiocentesis → poor sensitivity and specificity
  • Cardiac Ultrasound
    • Annals of Surgery 1996;223(6):737-746 → Sens 100%, Spec 100%
    • Annals of Surgery 1998;228(4):557-567 → Sens 100%, Spec 99.3%
    • J Trauma. 2000 Dec;49(6):1159 → Sens 100%, Spec 97%
  • Conclusion
    • Ultrasound should be the initial diagnostic adjunct for precordial wounds
    • Ultrasound is highly sensitive for cardiac injury, and immediate surgical intervention when positive
  • ECHO: If US equivocal, may need formal Cardiac ECHO

Treatment

  • OR immediately for sternotomy
  • ER thoracotomy if too unstable for OR
  • Pericardiocentesis if unable to perform thoracotomy

Transmediastinal Injury

Traditional approach

  • Unstable → OR
  • Stable → pan-endoscopy, contrast swallow, angiography, echo

CT as screening approach (J Trauma 2002;53:635–638) (Ann Thorac Surg. 2007;83:377-82):

  • CT Negative → 100% Negative predictive value, no need for further testing
  • CT positive

Left Thoracoabdominal Region Injury

Rule Out Diaphragm Injury

  • Location:
    • Superior: Nipple → scapula tip
    • Inferior: Costal margin
  • Delayed diagnosis
    • If not diagnosed at time of trauma, diagnosis may be delayed many years
    • Occult diaphragmatic injury in 26% of Stab Wound and 13% of Gunshot Wound at laparoscopy
  • CXR
    • May show pneumothorax, hemothorax, herniation of abdominal contents into chest or completely normal
    • Usually non-diagnostic
  • CT
    • Accuracy 96% for diaphragm injury in one study (J Trauma 2007;63:538-43)
    • Laparoscopy gold standard to exclude diaphragm injury
    • LAC + USC Protocol:
      • 6-12 hour observation to rule out GI tract injury
      • Then laparoscopic eval +/- repair
      • Rule out Pneumothorax as above

References

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