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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: Anatomy. 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 Stab wounds Penetrating wounds caused by a pointed object. Penetrating Abdominal Injury. Penetrating chest injuries have a higher mortality rate Mortality rate Calculated as the ratio of the total number of people who die due to all causes over a specific time period to the total number of people in the selected population. Measures of Health Status 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 Tube Thoracostomy Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Thoracic Surgery, although surgical repair of injuries may be needed.

Last updated: 29 Mar, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

A penetrating chest injury Chest Injury Pediatric Chest Abnormalities (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: Anatomy in an area bordered superiorly by the lower neck Neck The part of a human or animal body connecting the head to the rest of the body. Peritonsillar Abscess 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 Mortality All deaths reported in a given population. Measures of Health Status 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 Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) penetration Penetration X-rays 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 Stab wounds Penetrating wounds caused by a pointed object. Penetrating Abdominal Injury, 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 Mass Three-dimensional lesion that occupies a space within the breast Imaging of the Breast (energy)
  • Shape and diameter (impact surface area)
  • High-velocity penetration Penetration X-rays 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

Related videos

Initial Approach to Trauma Patient

Trauma evaluation

All trauma patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship should be checked for penetrating chest trauma. Treatment algorithms and guidelines (primary and secondary survey Secondary Survey ABCDE Assessment) direct the evaluation.

  • Primary survey Primary Survey Thoracic Trauma in Children (ABC ( airway Airway ABCDE Assessment, breathing, circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment)):
    • Airway Airway ABCDE Assessment:
      • Look for intraoral airway Airway ABCDE Assessment trauma (oral GSWs may appear benign Benign Fibroadenoma 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: Anatomy (tracheal injury means intubation Intubation Peritonsillar Abscess will be complex).
      • Listen for unusual breathing sounds ( stridor Stridor Laryngomalacia and Tracheomalacia suggests narrowing by foreign body Foreign Body Foreign Body Aspiration 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: Anatomy 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 Open Pneumothorax 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: Anatomy, often making “sucking” sound
    • Circulation Circulation The movement of the blood as it is pumped through the cardiovascular system. ABCDE Assessment:
  • Secondary survey Secondary Survey ABCDE Assessment:
    • 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 Inspection Dermatologic Examination 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: Anatomy:
      • 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: Anatomy 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 E-FAST Focused Assessment with Sonography for Trauma (FAST) (extended  focused assessment with sonography for trauma Focused Assessment with Sonography for Trauma Focused assessment with sonography for trauma is a point-of-care ultrasound examination protocol for the abdominal and thoracic cavities performed in the emergency room as part of the secondary survey in advanced trauma life support. The main goal of the fast exam is to identify free intraperitoneal fluid (blood) and pericardial effusion from trauma. Focused Assessment with Sonography for Trauma (FAST)): 
  • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests: indicated in all hemodynamically stable patients Hemodynamically Stable Patients Blunt Chest Trauma
  • Chest computed tomography Chest Computed Tomography Hemothorax (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 Tube placement Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Thoracic Surgery 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 Embolization A method of hemostasis utilizing various agents such as gelfoam, silastic, metal, glass, or plastic pellets, autologous clot, fat, and muscle as emboli. It has been used in the treatment of spinal cord and intracranial arteriovenous malformations, renal arteriovenous fistulas, gastrointestinal bleeding, epistaxis, hypersplenism, certain highly vascular tumors, traumatic rupture of blood vessels, and control of operative hemorrhage. Gastrointestinal Bleeding may be helpful

Rib fracture Rib fracture Fractures of any of the ribs. Thoracic Trauma in Children

  • Clinical features:
    • Pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways localized and reproducible by taking deep breaths
    • Location of pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways points to possible further underlying injury:
      • 1st rib: possible trauma of lung apices, subclavian vessels
      • 2nd rib: possible ascending aorta Ascending aorta Mediastinum and Great Vessels: Anatomy, superior vena cava Superior vena cava The venous trunk which returns blood from the head, neck, upper extremities and chest. Mediastinum and Great Vessels: Anatomy 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: Anatomy, 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: Anatomy, splenic injury
      • 12th rib: possible renal injury
  • Physical exam findings:
  • Imaging:
    • X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests ( stable patients Stable Patients Blunt Chest Trauma):
      • Posterior-anterior (PA) chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests 
      • Poor sensitivity Sensitivity Binary classification measures to assess test results. Sensitivity or recall rate is the proportion of true positives. Blotting Techniques, 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 Pulmonary Contusion Flail Chest
    • CT scan (suggested for more severe injury):
    • 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 Pulmonary Contusion Flail Chest

Injury to Lungs

Tension pneumothorax Tension Pneumothorax Pneumothorax

  • Clinical features:
    • Acute dyspnea Acute Dyspnea Dyspnea
    • Sudden-onset unilateral (usually) chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways corresponding to side of collapsed lung
  • Physical exam findings:
    • ↓ breath sounds
    • Hyperresonance on percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination
    • Mediastinal shift away from tension pneumothorax Tension Pneumothorax Pneumothorax
    • ↓ tactile vocal fremitus
    • Jugular venous distention
  • Imaging: chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests
  • Management:
    • Emergent needle decompression Needle Decompression Pneumothorax
    • Thoracostomy Thoracostomy Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Hemothorax tube placement Tube placement Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Thoracic Surgery to prevent re-accumulation of air
Tension pneumothorax

Tension pneumothorax Tension Pneumothorax Pneumothorax:
Spontaneous and traumatic pneumothoraces can develop into a tension pneumothorax Tension Pneumothorax Pneumothorax if the defect which allows air into the pleural space Pleural space The thin serous membrane enveloping the lungs (lung) and lining the thoracic cavity. Pleura consist of two layers, the inner visceral pleura lying next to the pulmonary parenchyma and the outer parietal pleura. Between the two layers is the pleural cavity which contains a thin film of liquid. Pleuritis becomes a 1-way valve (air enters during inspiration Inspiration Ventilation: Mechanics of Breathing, but cannot escape Escape With constant immune mechanisms holding unstable tumor cells in equilibrium, tumor-cell variants may emerge. These cancer cells may express fewer antigens on their surfaces or lose their MHC class I expression.Variants may also protect themselves from T-cell attack via expression of IC molecules on their surfaces, like normal cells.Creation of an immunosuppressive state in the microenvironment is another way to grow without immunologic interference. Cancer Immunotherapy during expiration Expiration Ventilation: Mechanics of Breathing). This process causes rising pressure in the pleural cavity Pleural cavity Paired but separate cavity within the thoracic cavity. It consists of the space between the parietal and visceral pleura and normally contains a capillary layer of serous fluid that lubricates the pleural surfaces. Pleura: Anatomy, 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: Anatomy to the contralateral side.

Image by Lecturio.

Open pneumothorax Open Pneumothorax Pneumothorax

  • Clinical features:
  • 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: Anatomy (“sucking” chest wound)
    • ↓ breath sounds
    • Hyperresonance on percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination
    • ↓ 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 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

  • Clinical features:
    • Chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • 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 Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination
    • Tracheal deviation Tracheal Deviation Pneumothorax, 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 Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children
      • Tachypnea Tachypnea Increased respiratory rate. Pulmonary Examination
      • jugular venous pressure Jugular Venous Pressure Portal Hypertension
  • Imaging: 
    • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests
      • Best initial diagnostic study
      • Upright imaging shows layering of blood.
      • Supine imaging shows haziness or opacity Opacity Imaging of the Lungs and Pleura (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: Anatomy:
      • Part of e-FAST E-FAST Focused Assessment with Sonography for Trauma (FAST) exam
      • Able to be obtained quickly
      • Can show complex fluid in pleural cavity Pleural cavity Paired but separate cavity within the thoracic cavity. It consists of the space between the parietal and visceral pleura and normally contains a capillary layer of serous fluid that lubricates the pleural surfaces. Pleura: Anatomy
      • More sensitive than chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests 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 CT angiogram A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Pulmonary Function Tests can show source of bleeding.
  • Management:
    • Chest tube
    • Thoracotomy Thoracotomy Surgical incision into the chest wall. Thoracic Surgery (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 Pleural space The thin serous membrane enveloping the lungs (lung) and lining the thoracic cavity. Pleura consist of two layers, the inner visceral pleura lying next to the pulmonary parenchyma and the outer parietal pleura. Between the two layers is the pleural cavity which contains a thin film of liquid. Pleuritis

Image by Lecturio.

Injury to Heart

Pericardial tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis

  • 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: 
  • Management: Echocardiography Echocardiography Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues. The standard approach is transthoracic. Tricuspid Valve Atresia (TVA)-guided pericardiocentesis Pericardiocentesis Puncture and aspiration of fluid from the pericardium. Cardiac Surgery 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 Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) contractility, also known as pericardial tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis.

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

Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) laceration Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma

  • Clinical features:
    • Elevated prehospital mortality Mortality All deaths reported in a given population. Measures of Health Status
    • Chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • 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:
  • Imaging:
    • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests 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 Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade.
    • CT angiogram CT angiogram A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Pulmonary Function Tests is gold standard if patient is stable.
  • Management: emergency thoracotomy Thoracotomy Surgical incision into the chest wall. Thoracic Surgery
Bullet in heart

Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests image showing bullet in right side of heart:
The bullet has penetrated the right atrium. Laceration Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma of the cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) 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 Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma of the great vessels

  • Great vessels: 
  • Clinical features:
    • Chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways
    • Shortness of breath Shortness of breath 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
    • Altered mental status Altered Mental Status Sepsis in Children
  • Physical exam findings:
  • Imaging:
    • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests often obtained per trauma protocol can show the following:
      • Mediastinal widening and deviation
      • Distorted aortic arch Aortic arch Mediastinum and Great Vessels: Anatomy outline
      • 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, especially above left lung apex 
    • Chest CT angiogram CT angiogram A non-invasive method that uses a ct scanner for capturing images of blood vessels and tissues. A contrast material is injected, which helps produce detailed images that aid in diagnosing vascular diseases. Pulmonary Function Tests and transesophageal echocardiogram Echocardiogram Transposition of the Great Vessels ( TEE TEE Ultrasonic recording of the size, motion, and composition of the heart and surrounding tissues using a transducer placed in the esophagus. Imaging of the Heart and Great Vessels) are definitive diagnostic modalities but used only in stable patients Stable Patients Blunt Chest Trauma.
  • Management:
    • Antihypertensive therapy
    • Emergent surgical repair

Injury to Esophagus or Diaphragm

Diaphragmatic laceration Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma

  • Clinical features:
    • Respiratory distress 
    • Nausea Nausea An unpleasant sensation in the stomach usually accompanied by the urge to vomit. Common causes are early pregnancy, sea and motion sickness, emotional stress, intense pain, food poisoning, and various enteroviruses. Antiemetics/ vomiting Vomiting The forcible expulsion of the contents of the stomach through the mouth. Hypokalemia
  • Physical exam findings:
    • Bowel sounds in chest due to bowel herniation Herniation Omphalocele 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: Anatomy
    • Decreased lung sounds
    • Dullness on percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination
    • 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: Anatomy)
  • Imaging: Findings may be identified by CT or chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests.
    • Elevation of hemidiaphragm
    • Small bowel Small bowel The small intestine is the longest part of the GI tract, extending from the pyloric orifice of the stomach to the ileocecal junction. The small intestine is the major organ responsible for chemical digestion and absorption of nutrients. It is divided into 3 segments: the duodenum, the jejunum, and the ileum. Small Intestine: Anatomy in thoracic cavity
  • Management: surgical closure
Congenital asymptomatic diaphragmatic hernias

Axial Axial Computed Tomography (CT) CT scan of the chest:
Gas-filled large bowel loops are visible behind the heart, lying anteriorly to the spine Spine The human spine, or vertebral column, is the most important anatomical and functional axis of the human body. It consists of 7 cervical vertebrae, 12 thoracic vertebrae, and 5 lumbar vertebrae and is limited cranially by the skull and caudally by the sacrum. Vertebral Column: Anatomy and the aorta Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy.

Image: “ Axial Axial Computed Tomography (CT) 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
  • Physical exam findings:
  • Imaging: 
    • Chest X-ray X-ray Penetrating electromagnetic radiation emitted when the inner orbital electrons of an atom are excited and release radiant energy. X-ray wavelengths range from 1 pm to 10 nm. Hard x-rays are the higher energy, shorter wavelength x-rays. Soft x-rays or grenz rays are less energetic and longer in wavelength. The short wavelength end of the x-ray spectrum overlaps the gamma rays wavelength range. The distinction between gamma rays and x-rays is based on their radiation source. Pulmonary Function Tests or CT:
      • Pneumomediastinum Pneumomediastinum Mediastinitis
      • 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 Contrast Esophagography Esophageal Perforation is diagnostic.
  • Management:
    • Antibiotics and supportive care
    • Surgical repair for significant leakage with systemic inflammatory response

Differential Diagnosis

  • 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: collection of blood in the pleural cavity Pleural cavity Paired but separate cavity within the thoracic cavity. It consists of the space between the parietal and visceral pleura and normally contains a capillary layer of serous fluid that lubricates the pleural surfaces. Pleura: Anatomy. Usually occurs following chest trauma, which leads to lung laceration Laceration Torn, ragged, mangled wounds. Blunt Chest Trauma 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: Histology. Symptoms include shortness of breath Shortness of breath 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 and chest pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways. Signs include 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 Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, decreased air entry, tracheal deviation Tracheal Deviation Pneumothorax, and dullness on percussion Percussion Act of striking a part with short, sharp blows as an aid in diagnosing the condition beneath the sound obtained. Pulmonary Examination. Management is chest tube insertion. Thoracotomy Thoracotomy Surgical incision into the chest wall. Thoracic Surgery may be indicated.
  • Pulmonary contusion Pulmonary Contusion Flail Chest: traumatic parenchymal lung injury. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship present with tachypnea Tachypnea Increased respiratory rate. Pulmonary Examination, tachycardia Tachycardia Abnormally rapid heartbeat, usually with a heart rate above 100 beats per minute for adults. Tachycardia accompanied by disturbance in the cardiac depolarization (cardiac arrhythmia) is called tachyarrhythmia. Sepsis in Children, and hypoxemia Hypoxemia Neonatal Respiratory Distress Syndrome. Imaging studies show patchy alveolar infiltrates not restricted by anatomical borders (non-lobar opacification). Management involves oxygen administration, pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways control, chest physiotherapy Physiotherapy Spinal Stenosis, and mechanical ventilation Ventilation The total volume of gas inspired or expired per unit of time, usually measured in liters per minute. Ventilation: Mechanics of Breathing in severe cases.
  • 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: abnormal collection of air in pleural space Pleural space The thin serous membrane enveloping the lungs (lung) and lining the thoracic cavity. Pleura consist of two layers, the inner visceral pleura lying next to the pulmonary parenchyma and the outer parietal pleura. Between the two layers is the pleural cavity which contains a thin film of liquid. Pleuritis. Types include simple and tension pneumothorax Tension Pneumothorax Pneumothorax. Pneumothoraces can be spontaneous, iatrogenic Iatrogenic Any adverse condition in a patient occurring as the result of treatment by a physician, surgeon, or other health professional, especially infections acquired by a patient during the course of treatment. Anterior Cord Syndrome, or traumatic. Exam shows decreased breath sounds, tracheal deviation Tracheal Deviation Pneumothorax, 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: Histology. Management includes needle decompression Needle Decompression Pneumothorax and thoracostomy Thoracostomy Surgical procedure involving the creation of an opening (stoma) into the chest cavity for drainage; used in the treatment of pleural effusion; pneumothorax; hemothorax; and empyema. Hemothorax
  • Cardiac Cardiac Total Anomalous Pulmonary Venous Return (TAPVR) tamponade Tamponade Pericardial effusion, usually of rapid onset, exceeding ventricular filling pressures and causing collapse of the heart with a markedly reduced cardiac output. Pericarditis: accumulation of fluid in the pericardial space Pericardial Space Pericardial Effusion and Cardiac Tamponade, resulting in reduced ventricular filling Ventricular filling Cardiac Cycle and subsequent hemodynamic compromise. Severe form of a pericardial effusion Pericardial effusion Fluid accumulation within the pericardium. Serous effusions are associated with pericardial diseases. Hemopericardium is associated with trauma. Lipid-containing effusion (chylopericardium) results from leakage of thoracic duct. Severe cases can lead to cardiac tamponade. Pericardial Effusion and Cardiac Tamponade. In trauma setting, the fluid is blood. Physical examination findings include 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 distention, and muffled heart sounds Muffled Heart Sounds Pericardial Effusion and Cardiac Tamponade). Treatment is pericardiocentesis Pericardiocentesis Puncture and aspiration of fluid from the pericardium. Cardiac Surgery.
  • 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 Fissure A crack or split that extends into the dermis Generalized and Localized Rashes develops in inner coat ( tunica intima Tunica intima The innermost layer of an artery or vein, made up of one layer of endothelial cells and supported by an internal elastic lamina. Arteries: Histology) of aortic wall, which causes blood to enter the media layer. Marked by severe pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways, characteristically known as a “tearing pain Pain An unpleasant sensation induced by noxious stimuli which are detected by nerve endings of nociceptive neurons. Pain: Types and Pathways.” 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 Aorta The main trunk of the systemic arteries. Mediastinum and Great Vessels: Anatomy.

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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