Penetrating Chest Injury

Penetrating chest injuries (PCIs) are caused by an object puncturing the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. 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 Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. 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 Blunt chest trauma Blunt chest trauma is a non-penetrating traumatic injury to the thoracic cavity. Thoracic traumatic injuries are classified according to the mechanism of injury as blunt or penetrating injuries. Different structures can be injured including the chest wall (ribs, sternum), lungs, heart, major blood vessels, and the esophagus. 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 Blunt chest trauma Blunt chest trauma is a non-penetrating traumatic injury to the thoracic cavity. Thoracic traumatic injuries are classified according to the mechanism of injury as blunt or penetrating injuries. Different structures can be injured including the chest wall (ribs, sternum), lungs, heart, major blood vessels, and the esophagus. 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 Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of 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 Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock wave
    • Temporary cavity: surrounding tissue that has ↓ filling of small blood vessels and extravasation of blood leading to edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema

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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 Trachea The trachea is a tubular structure that forms part of the lower respiratory tract. The trachea is continuous superiorly with the larynx and inferiorly becomes the bronchial tree within the lungs. The trachea consists of a support frame of semicircular, or C-shaped, rings made out of hyaline cartilage and reinforced by collagenous connective tissue. Trachea (tracheal injury means intubation will be complex).
      • Listen for unusual breathing sounds (stridor suggests narrowing by foreign body or edema Edema Edema is a condition in which excess serous fluid accumulates in the body cavity or interstitial space of connective tissues. Edema is a symptom observed in several medical conditions. It can be categorized into 2 types, namely, peripheral (in the extremities) and internal (in an organ or body cavity). Edema).
    • Breathing:
      • Look at chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. Chest Wall movement for even and spontaneous breathing (uneven chest movement suggests “ flail chest Flail chest Flail chest is a life-threatening traumatic injury that occurs when 3 or more contiguous ribs are fractured in 2 or more different locations. Patients present with chest pain, tachypnea, hypoxia, and paradoxical chest wall movement. Flail Chest”).
      • Listen to breath sounds (↓ or absent may suggest pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax or hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax).
      • Observe for open pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax → involving unsealed opening in chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. 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 Cardiac arrest Cardiac arrest is the sudden, complete cessation of cardiac output with hemodynamic collapse. Patients present as pulseless, unresponsive, and apneic. Rhythms associated with cardiac arrest are ventricular fibrillation/tachycardia, asystole, or pulseless electrical activity. 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 Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. 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 Arm The arm, or "upper arm" in common usage, is the region of the upper limb that extends from the shoulder to the elbow joint and connects inferiorly to the forearm through the cubital fossa. It is divided into 2 fascial compartments (anterior and posterior). 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 Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
  • Management:
    • Chest tube placement in hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax
    • Massive bleeding → arterial embolization may be helpful

Rib fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures

  • Clinical features:
    • Pain localized and reproducible by taking deep breaths
    • Location of pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology 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 Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver, splenic injury
      • 11th rib: possible diaphragmatic, liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. 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 Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax, hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax, and pulmonary contusion
    • CT scan (suggested for more severe injury):
      • Usually not performed if only rib fracture Fracture A fracture is a disruption of the cortex of any bone and periosteum and is commonly due to mechanical stress after an injury or accident. Open fractures due to trauma can be a medical emergency. Fractures are frequently associated with automobile accidents, workplace injuries, and trauma. Overview of Bone Fractures is suspected
      • Higher sensitivity
      • Useful for better-detailed anatomy
    • Ultrasound:
      • Less commonly used
      • Useful in detailing extent of associated pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax, hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax, and pulmonary contusion

Injury to Lungs

Tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax

  • Clinical features:
    • Acute dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
    • Sudden-onset unilateral (usually) chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. Chest Pain corresponding to side of collapsed lung
  • Physical exam findings:
    • ↓ breath sounds
    • Hyperresonance on percussion
    • Mediastinal shift away from tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. 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

Tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax:
Spontaneous and traumatic pneumothoraces can develop into a tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. 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 Mediastinum The mediastinum is the thoracic area between the 2 pleural cavities. The mediastinum contains vital structures of the circulatory, respiratory, digestive, and nervous systems including the heart and esophagus, and major thoracic vessels. Mediastinum and Great Vessels to the contralateral side.

Image by Lecturio.

Open pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax

  • Clinical features:
    • Hypoxia
    • Respiratory distress
  • Physical exam findings:
    • Unsealed opening in the chest wall Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Acute-onset dyspnea Dyspnea Dyspnea is the subjective sensation of breathing discomfort. Dyspnea is a normal manifestation of heavy physical or psychological exertion, but also may be caused by underlying conditions (both pulmonary and extrapulmonary). Dyspnea
  • Physical exam findings:
    • ↓ breath sounds
    • Dullness on percussion
    • Tracheal deviation, mediastinal shift
    • ↓ tactile vocal fremitus
    • Signs of hemorrhagic shock Shock Shock is a life-threatening condition associated with impaired circulation that results in tissue hypoxia. The different types of shock are based on the underlying cause: distributive (↑ cardiac output (CO), ↓ systemic vascular resistance (SVR)), cardiogenic (↓ CO, ↑ SVR), hypovolemic (↓ CO, ↑ SVR), obstructive (↓ CO), and mixed. Types of Shock in large hemothoraces:
      • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. 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 Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. Pneumothorax is present
    • Ultrasound of lungs Lungs Lungs are the main organs of the respiratory system. Lungs are paired viscera located in the thoracic cavity and are composed of spongy tissue. The primary function of the lungs is to oxygenate blood and eliminate CO2. 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 Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. 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) 
Insertion of a chest tube - thoracostomy

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 Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
      • Jugular venous distension 
      • Muffled heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). 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

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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Syncope Syncope Syncope is a short-term loss of consciousness and loss of postural stability followed by spontaneous return of consciousness to the previous neurologic baseline without the need for resuscitation. The condition is caused by transient interruption of cerebral blood flow that may be benign or related to a underlying life-threatening condition. Syncope
  • Physical exam findings:
    • Evident chest wound
    • Jugular venous distension 
  • Imaging:
    • Chest X-ray may show hemothorax Hemothorax A hemothorax is a collection of blood in the pleural cavity. Hemothorax most commonly occurs due to damage to the intercostal arteries or from a lung laceration following chest trauma. Hemothorax can also occur as a complication of disease, or hemothorax may be spontaneous or iatrogenic. Hemothorax.
    • Echo may show pericardial effusion Pericardial effusion Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade.
    • CT angiogram is gold standard if patient is stable.
  • Management: emergency thoracotomy
Bullet in heart

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 Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. Veins
    • Superior and inferior vena cava
  • Clinical features:
    • Chest pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Shortness of breath
    • Altered mental status
  • Physical exam findings:
    • Evident chest wound
    • Hypotension Hypotension Hypotension is defined as low blood pressure, specifically < 90/60 mm Hg, and is most commonly a physiologic response. Hypotension may be mild, serious, or life threatening, depending on the cause. Hypotension
    • Muffled heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). Heart Sounds
  • Imaging:
    • Chest X-ray often obtained per trauma protocol can show the following:
      • Mediastinal widening and deviation
      • Distorted aortic arch Aortic arch The branchial arches, also known as pharyngeal or visceral arches, are embryonic structures seen in the development of vertebrates that serve as precursors for many structures of the face, neck, and head. These arches are composed of a central core of mesoderm, which is covered externally by ectoderm and internally by endoderm. Branchial Apparatus and Aortic Arches 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 Diaphragm The diaphragm is a large, dome-shaped muscle that separates the thoracic cavity from the abdominal cavity. The diaphragm consists of muscle fibers and a large central tendon, which is divided into right and left parts. As the primary muscle of inspiration, the diaphragm contributes 75% of the total inspiratory muscle force. Diaphragm
    • Decreased lung sounds
    • Dullness on percussion
    • Findings more common on left side (right side protected by liver Liver The liver is the largest gland in the human body. The liver is found in the superior right quadrant of the abdomen and weighs approximately 1.5 kilograms. Its main functions are detoxification, metabolism, nutrient storage (e.g., iron and vitamins), synthesis of coagulation factors, formation of bile, filtration, and storage of blood. Liver)
  • Imaging: Findings may be identified by CT or chest X-ray.
    • Elevation of hemidiaphragm
    • Small bowel in thoracic cavity
  • Management: surgical closure
Congenital asymptomatic diaphragmatic hernias

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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain
    • Difficulty swallowing
  • Physical exam findings:
    • Subcutaneous crepitus
    • Neck hematoma
  • Imaging: 
    • Chest X-ray or CT:
      • Pneumomediastinum
      • Pleural effusion Pleural Effusion Pleural effusion refers to the accumulation of fluid between the layers of the parietal and visceral pleura. Common causes of this condition include infection, malignancy, autoimmune disorders, or volume overload. Clinical manifestations include chest pain, cough, and dyspnea. 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 Arteries Arteries are tubular collections of cells that transport oxygenated blood and nutrients from the heart to the tissues of the body. The blood passes through the arteries in order of decreasing luminal diameter, starting in the largest artery (the aorta) and ending in the small arterioles. Arteries are classified into 3 types: large elastic arteries, medium muscular arteries, and small arteries and arterioles. Arteries. Symptoms include shortness of breath and chest pain Chest Pain Chest pain is one of the most common and challenging complaints that may present in an inpatient and outpatient setting. The differential diagnosis of chest pain is large and includes cardiac, gastrointestinal, pulmonary, musculoskeletal, and psychiatric etiologies. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain control, chest physiotherapy, and mechanical ventilation in severe cases.
  • Pneumothorax: abnormal collection of air in pleural space. Types include simple and tension pneumothorax Pneumothorax A pneumothorax is a life-threatening condition in which air collects in the pleural space, causing partial or full collapse of the lung. A pneumothorax can be traumatic or spontaneous. Patients present with a sudden onset of sharp chest pain, dyspnea, and diminished breath sounds on exam. 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 Veins Veins are tubular collections of cells, which transport deoxygenated blood and waste from the capillary beds back to the heart. Veins are classified into 3 types: small veins/venules, medium veins, and large veins. Each type contains 3 primary layers: tunica intima, tunica media, and tunica adventitia. 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 Pericardial effusion Pericardial effusion is the accumulation of excess fluid in the pericardial space around the heart. The pericardium does not easily expand; thus, rapid fluid accumulation leads to increased pressure around the heart. The increase in pressure restricts cardiac filling, resulting in decreased cardiac output and cardiac tamponade. Pericardial Effusion and Cardiac Tamponade. In trauma setting, the fluid is blood. Physical examination findings include Beck’s triad (hypotension, jugular venous distention, and muffled heart sounds Heart sounds Heart sounds are brief, transient sounds produced by valve opening and closure and by movement of blood in the heart. They are divided into systolic and diastolic sounds. In most cases, only the first (S1) and second (S2) heart sounds are heard. These are high-frequency sounds and arise from aortic and pulmonary valve closure (S1), as well as mitral and tricuspid valve closure (S2). Heart Sounds). Treatment is pericardiocentesis.
  • Aortic dissection Aortic dissection Aortic dissection occurs due to shearing stress from pulsatile pressure causing a tear in the tunica intima of the aortic wall. This tear allows blood to flow into the media, creating a "false lumen." Aortic dissection is most commonly caused by uncontrolled hypertension. 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 Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain, characteristically known as a “tearing pain Pain Pain has accompanied humans since they first existed, first lamented as the curse of existence and later understood as an adaptive mechanism that ensures survival. Pain is the most common symptomatic complaint and the main reason why people seek medical care. Physiology of Pain.” Risk factors include hypertension Hypertension Hypertension, or high blood pressure, is a common disease that manifests as elevated systemic arterial pressures. Hypertension is most often asymptomatic and is found incidentally as part of a routine physical examination or during triage for an unrelated medical encounter. 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 Chest wall The chest wall consists of skin, fat, muscles, bones, and cartilage. The bony structure of the chest wall is composed of the ribs, sternum, and thoracic vertebrae. The chest wall serves as armor for the vital intrathoracic organs and provides the stability necessary for the movement of the shoulders and arms. 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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