Penetrating Chest Injury

Penetrating chest injuries (PCIs) are caused by an object puncturing the chest wall. Penetrating chest injuries can be high velocity, such as with gunshot wounds (GSWs); medium velocity, such as with pellet gunshots; or low velocity, such as with stab wounds. Penetrating chest injuries have a higher mortality rate than blunt chest injuries but are less common. Performing the standardized trauma evaluation (primary and secondary surveys), as well as ordering proper imaging, is critical to determining the diagnosis and aiding in management decisions. The majority of PCIs do not require major surgery and can be managed by observation or tube thoracostomy, although surgical repair of injuries may be needed.

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Overview

Definition

A penetrating chest injury (PCI) can be defined as any trauma that violates the chest wall in an area bordered superiorly by the lower neck and inferiorly by the lower costal margin.

Epidemiology

  • Less common than blunt chest trauma but with ↑ mortality rates
  • 20% of all major trauma in the United States is from gunshot wounds (GSWs) and stabbings.
  • GSWs are the 2nd-leading cause of death for youth in the United States.
  • 9% of all trauma-related deaths are from injuries to the chest → 33% are penetrating trauma
  • 15%–30% of PCIs require surgery, as opposed to < 10% from blunt chest trauma.
  • Penetrating trauma causes > 90% of thoracic great-vessel injuries.
  • Traumatic cardiac penetration has a fatality rate of 70%–80%.

Etiology

Mechanism of injury categorized by object’s velocity:

  • Low velocity: < 350 m/sec
    • Characterized by localized tissue damage along the object’s trajectory
    • Includes stab wounds, glass from windshield, falls with impaling 
  • Medium: approximately 350–650 m/sec 
    • Creates more damage than low-velocity wounds
    • Includes most handguns, shotguns, and pellet guns
  • High velocity: > 650 m/sec
    • Generates both permanent and temporary cavities → results in damage beyond direct contact of projectile and tissue
    • Includes GSWs from rifles, military weapons, and improvised explosive devices (IEDs)

Pathophysiology

Penetrating object’s ability to produce tissue damage is dependent on the following:

  • Velocity and mass (energy)
  • Shape and diameter (impact surface area)
  • High-velocity penetration has ↑ kinetic energy → shock waves → 3 areas of tissue damage:
    • Permanent cavity: wound tract of object where tissue has been lacerated and crushed
    • Area adjacent to permanent cavity that has tissue damage from stretching and shearing of object’s energy shock wave
    • Temporary cavity: surrounding tissue that has ↓ filling of small blood vessels and extravasation of blood leading to edema

Initial Approach to Trauma Patient

Trauma evaluation

All trauma patients should be checked for penetrating chest trauma. Treatment algorithms and guidelines (primary and secondary survey) direct the evaluation.

  • Primary survey (ABC (airway, breathing, circulation)):
    • Airway:
      • Look for intraoral airway trauma (oral GSWs may appear benign on exterior).
      • Assess for injury to trachea (tracheal injury means intubation will be complex).
      • Listen for unusual breathing sounds (stridor suggests narrowing by foreign body or edema).
    • Breathing:
      • Look at chest wall movement for even and spontaneous breathing (uneven chest movement suggests “flail chest”).
      • Listen to breath sounds (↓ or absent may suggest pneumothorax or hemothorax).
      • Observe for open pneumothorax → involving unsealed opening in chest wall, often making “sucking” sound
    • Circulation:
      • Palpate pulses on all 4 extremities (tachycardia suggests hemodynamic instability).
      • Assess capillary refill on extremities.
      • Entrance wound without exit wound → possible retained foreign body with potential to embolize
      • Emergency thoracotomy should be considered in all penetrating chest wounds leading to cardiac arrest.
  • Secondary survey:
    • Mechanism of injury:
      • Helps determine severity of injury
      • GSWs → caliber and type of bullets can aid in injury assessment
      • Determination of entrance and exit wounds of GSWs
      • Bombs or IEDs create penetrating and blast injury.
    • Close inspection of chest wall:
      • All clothes must be removed
      • GSWs:
        • Bullet may not travel along a straight pathway.
        • All potential injuries should be considered despite the point of entry (e.g., GSW to arm travels into chest).

Imaging

While the initial approach to stabilizing a patient with chest trauma is standardized by performing the primary and secondary surveys, further imaging and testing are dependent on the injury discovered during the initial assessment.

  • e-FAST (emergency focused assessment with sonography for trauma): 
    • Detect life-threatening conditions to determine management priorities
    • Should be performed on all patients 
    • May be part of primary survey
  • Chest X-ray: indicated in all hemodynamically stable patients
  • Chest computed tomography (CT) scan if: 
    • Patient is hemodynamically stable
    • Mechanism is consistent with or there are symptoms or signs of esophageal, tracheobronchial, or vascular injury
    • Plain chest radiograph does not explain symptoms

Injury to Chest Wall

Intercostal artery lacerations

  • Clinical features:
    • Bleeding
    • Hemodynamic instability
  • Imaging: hemothorax
  • Management:
    • Chest tube placement in hemothorax
    • Massive bleeding → arterial embolization may be helpful

Rib fracture

  • Clinical features:
    • Pain localized and reproducible by taking deep breaths
    • Location of pain points to possible further underlying injury:
      • 1st rib: possible trauma of lung apices, subclavian vessels
      • 2nd rib: possible ascending aorta, superior vena cava trauma
      • 10th rib: possible diaphragmatic, liver, splenic injury
      • 11th rib: possible diaphragmatic, liver, splenic injury
      • 12th rib: possible renal injury
  • Physical exam findings:
    • Point tenderness to palpation
    • Possible visible bruising or deformity
    • Crepitus may be audible.
  • Imaging:
    • X-ray (stable patients):
      • Posterior-anterior (PA) chest X-ray 
      • Poor sensitivity, but useful to identify associated pneumothorax, hemothorax, and pulmonary contusion
    • CT scan (suggested for more severe injury):
      • Usually not performed if only rib fracture is suspected
      • Higher sensitivity
      • Useful for better-detailed anatomy
    • Ultrasound:
      • Less commonly used
      • Useful in detailing extent of associated pneumothorax, hemothorax, and pulmonary contusion

Injury to Lungs

Tension pneumothorax

  • Clinical features:
    • Acute dyspnea
    • Sudden-onset unilateral (usually) chest pain corresponding to side of collapsed lung
  • Physical exam findings:
    • ↓ breath sounds
    • Hyperresonance on percussion
    • Mediastinal shift away from tension pneumothorax
    • ↓ tactile vocal fremitus
    • Jugular venous distention
  • Imaging: chest X-ray: 
    • Modality of choice
    • Hyperlucency 
    • Tracheal deviation or mediastinal shift away from collapsed lung
  • Management:
    • Emergent needle decompression
    • Thoracostomy tube placement to prevent re-accumulation of air

Tension pneumothorax:
Spontaneous and traumatic pneumothoraces can develop into a tension pneumothorax if the defect which allows air into the pleural space becomes a 1-way valve (air enters during inspiration, but cannot escape during expiration). This process causes rising pressure in the pleural cavity, shifting the mediastinum to the contralateral side.

Image by Lecturio.

Open pneumothorax

  • Clinical features:
    • Hypoxia
    • Respiratory distress
  • Physical exam findings:
    • Unsealed opening in the chest wall (“sucking” chest wound)
    • ↓ breath sounds
    • Hyperresonance on percussion
    • ↓ tactile vocal fremitus
  • Imaging: Radiologic confirmation is not necessary.
  • Management:
    • Supplemental (100%) oxygen
    • Flap-valve dressing (applying of occlusive dressing to wound on 3 sides only)
    • Insertion of chest drain

Hemothorax

  • Clinical features:
    • Chest pain
    • Acute-onset dyspnea
  • Physical exam findings:
    • ↓ breath sounds
    • Dullness on percussion
    • Tracheal deviation, mediastinal shift
    • ↓ tactile vocal fremitus
    • Signs of hemorrhagic shock in large hemothoraces:
      • Hypotension
      • Tachycardia
      • Tachypnea
      • ↓ jugular venous pressure
  • Imaging: 
    • Chest X-ray: 
      • Best initial diagnostic study
      • Upright imaging shows layering of blood.
      • Supine imaging shows haziness or opacity (whiteout).
      • May also show free air if pneumothorax is present
    • Ultrasound of lungs:
      • Part of e-FAST exam
      • Able to be obtained quickly
      • Can show complex fluid in pleural cavity
      • More sensitive than chest X-ray in detecting hemothorax, but is technician dependent
    • Chest CT definitive imaging choice:
      • Should only be obtained if patient is stable 
      • CT can show other associated pathology.
      • CT angiogram can show source of bleeding.
  • Management:
    • Chest tube
    • Thoracotomy (if > 1.5 L blood drained directly or continuous high output) 

Stepwise illustration of how to insert a chest tube to drain a fluid accumulation from the pleural space

Image by Lecturio.

Injury to Heart

Pericardial tamponade

  • Clinical features:
    • Blood in pericardial space
    • Results in ↓ ventricular filling and subsequent hemodynamic compromise
    • Dyspnea and tachypnea
    • Chest discomfort or pressure
  • Physical exam findings:
    • Beck’s triad: 
      • Hypotension
      • Jugular venous distension 
      • Muffled heart sounds
    • Pulsus paradoxus: disproportionately large drop in systolic blood pressure on inspiration
    • Pericardial rub: audible crescendo-decrescendo extra heart sound (grating noise) 
  • Imaging: 
    • Chest X-ray: 
      • Enlarged and globular cardiac silhouette (“water bottle” heart shape)
      • Clear lung fields
    • Echocardiogram: fluid around heart
  • Management: Echocardiography-guided pericardiocentesis is both diagnostic and therapeutic.

Hemopericardium:
Collection of fluid in the pericardial sac (in this case, blood) can restrict the heart muscle, leading to impaired cardiac contractility, also known as pericardial tamponade.

Image: “Hemopericardium” by BruceBlaus. License: CC BY 3.0

Cardiac laceration

  • Clinical features:
    • Elevated prehospital mortality
    • Chest pain
    • Syncope
  • Physical exam findings:
    • Evident chest wound
    • Jugular venous distension 
  • Imaging:
    • Chest X-ray may show hemothorax.
    • Echo may show pericardial effusion.
    • CT angiogram is gold standard if patient is stable.
  • Management: emergency thoracotomy

Chest X-ray image showing bullet in right side of heart:
The bullet has penetrated the right atrium. Laceration of the cardiac muscle is highly fatal.

Image: “Bullet in heart” by Lyman A. Brewer III, M.D., and Thomas H. Burford, M.D. License: Public Domain

Injury to Blood Vessel

Laceration of the great vessels

  • Great vessels: 
    • Ascending aorta
    • Pulmonary trunk and pulmonary veins
    • Superior and inferior vena cava
  • Clinical features:
    • Chest pain
    • Shortness of breath
    • Altered mental status
  • Physical exam findings:
    • Evident chest wound
    • Hypotension
    • Muffled heart sounds
  • Imaging:
    • Chest X-ray often obtained per trauma protocol can show the following:
      • Mediastinal widening and deviation
      • Distorted aortic arch outline
      • Hemothorax, especially above left lung apex 
    • Chest CT angiogram and transesophageal echocardiogram (TEE) are definitive diagnostic modalities but used only in stable patients.
  • Management:
    • Antihypertensive therapy
    • Emergent surgical repair

Injury to Esophagus or Diaphragm

Diaphragmatic laceration

  • Clinical features:
    • Respiratory distress 
    • Nausea/vomiting
  • Physical exam findings:
    • Bowel sounds in chest due to bowel herniation through diaphragm
    • Decreased lung sounds
    • Dullness on percussion
    • Findings more common on left side (right side protected by liver)
  • Imaging: Findings may be identified by CT or chest X-ray.
    • Elevation of hemidiaphragm
    • Small bowel in thoracic cavity
  • Management: surgical closure

Axial CT scan of the chest:
Gas-filled large bowel loops are visible behind the heart, lying anteriorly to the spine and the aorta.

Image: “Axial CT” by Department of Anatomical, Histological, Forensic and Locomotor System Sciences, V, A, Borelli 50, Rome, 00161, Italy. License: CC BY 2.0

Esophageal lacerations

  • Clinical features: difficult to detect, non-specific findings
    • Chest pain
    • Difficulty swallowing
  • Physical exam findings:
    • Subcutaneous crepitus
    • Neck hematoma
  • Imaging: 
    • Chest X-ray or CT:
      • Pneumomediastinum
      • Pleural effusion
    • Water-soluble contrast esophagography is diagnostic.
  • Management:
    • Antibiotics and supportive care
    • Surgical repair for significant leakage with systemic inflammatory response

Differential Diagnosis

  • Hemothorax: collection of blood in the pleural cavity. Usually occurs following chest trauma, which leads to lung laceration or damage to intercostal arteries. Symptoms include shortness of breath and chest pain. Signs include hypotension, tachycardia, decreased air entry, tracheal deviation, and dullness on percussion. Management is chest tube insertion. Thoracotomy may be indicated.
  • Pulmonary contusion: traumatic parenchymal lung injury. Patients present with tachypnea, tachycardia, and hypoxemia. Imaging studies show patchy alveolar infiltrates not restricted by anatomical borders (non-lobar opacification). Management involves oxygen administration, pain control, chest physiotherapy, and mechanical ventilation in severe cases.
  • Pneumothorax: abnormal collection of air in pleural space. Types include simple and tension pneumothorax. Pneumothoraces can be spontaneous, iatrogenic, or traumatic. Exam shows decreased breath sounds, tracheal deviation, mediastinal shift, decreased tactile vocal fremitus, and distended jugular veins. Management includes needle decompression and thoracostomy. 
  • Cardiac tamponade: accumulation of fluid in the pericardial space, resulting in reduced ventricular filling and subsequent hemodynamic compromise. Severe form of a pericardial effusion. In trauma setting, the fluid is blood. Physical examination findings include Beck’s triad (hypotension, jugular venous distention, and muffled heart sounds). Treatment is pericardiocentesis.
  • Aortic dissection: occurs when fissure develops in inner coat (tunica intima) of aortic wall, which causes blood to enter the media layer. Marked by severe pain, characteristically known as a “tearing pain.” Risk factors include hypertension, genetic diseases, and trauma. Treatment starts with blood pressure control and often requires cardiovascular surgery for stenting of aorta.

References

  1. Winkle, J. (2020). Initial evaluation and management of penetrating thoracic trauma in adults. Retrieved December 10, 2020, from: https://www.uptodate.com/contents/initial-evaluation-and-management-of-penetrating-thoracic-trauma-in-adults
  2. Legome, E. and Hammel, J. (2020). Initial evaluation and management of chest wall trauma in adults. Retrieved December 10, 2020, from: https://www.uptodate.com/contents/initial-evaluation-and-management-of-chest-wall-trauma-in-adults
  3. LoCicero J 3rd, Mattox KL. Epidemiology of chest trauma. Surg Clin North Am. 1989 Feb. 69 (1):15-9.
  4. Seamon MJ, Haut ER, Van Arendonk K, Barbosa RR, Chiu WC, Dente CJ, et al. An evidence-based approach to patient selection for emergency department thoracotomy: A practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg. 2015 Jul. 79 (1):159-73.
  5. Onat S, Ulku R, Avci A, Ates G, Ozcelik C. Urgent thoracotomy for penetrating chest trauma: analysis of 158 patients of a single center. Injury. 2011 Sep. 42 (9):900-4. 
  6. Magnotti LJ, Weinberg JA, Schroeppel TJ, Savage SA, Fischer PE, Bee TK, et al. Initial chest CT obviates the need for repeat chest radiograph after penetrating thoracic trauma. Am Surg. 2007 Jun. 73 (6):569-72; discussion 572-3.

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