Edit concept Create issue ticket

Penetrating Chest Trauma

Stab Wound of Chest

Penetrating chest trauma predominantly occurs after gunshot or stab wounds and the extent of injury can range from mild and local tissue damage to life-threatening bleeding, hemo/pneumothorax, and respiratory failure. Dyspnea, hemoptysis, and shock are some of the most common symptoms. A properly conducted physical examination is sufficient to make the initial diagnosis that is further supported by imaging studies such as ultrasonography and computed tomography (CT).


Presentation

Chest trauma is more commonly described in clinical practice after blunt force injuries (motor vehicle accidents, falls, sport-related contact, etc.), but in approximately 10% of cases, penetrating chest trauma may be encountered [1]. Gunshot (mainly high-velocity) and stab wounds are the two main causes of such trauma, while impalement and other forms have been observed in some cases [2] [3] [4]. This type of injury is seen across all ages and males seem to be more frequently affected [2] [5]. One of the worrisome aspects of penetrating chest trauma is the potential damage to the vascular structures (major blood vessels and the heart), which is why mortality rates are higher compared to blunt chest trauma [1] [3] [4]. Furthermore, skeletal fractures (of the ribs, and the sternum), direct lung injury (causing pneumothorax, hemothorax, contusion, or damage of the parenchyma), as well as diaphragmatic and esophageal injury can accompany penetrating chest trauma [4] [5] [6]. The clinical presentation may not always reflect the severity of trauma [1], and respiratory-related complaints are reported - dyspnea, hypoxemia, and hemoptysis [4]. As both cardiac output and respiratory function might decline rapidly (particularly if the heart is damaged), hemorrhage and cardiorespiratory insufficiency can cause life-threatening shock [1] [3] [4]. Sepsis is a late, but very important complication [3].

Painful Cough
  • Patient complained of pain, cough, breathlessness and hemoptysis. After admission pulse rate was 126/min, blood pressure 106/62, respiratory rate was 42/min, room air SpO2 was 88%.[jusurgery.com]
  • The clinical picture may include painful swallowing; throat, neck, or chest pain; cough; hematemesis; dyspnea; and/or subcutaneous emphysema.[ahcmedia.com]
Regurgitation
  • Traumatic aorto-right ventricular fistulas and aortic regurgitation are often masked by the primary injury and may take months or years to become clinically evident.[ncbi.nlm.nih.gov]
Hypotension
  • Symptoms and signs include tachypnea, hypotension, hypoxia, cyanosis, and air movement through the wound during respiration.[journals.lww.com]
  • The reduction in venous return will reduce the preload of the left ventricle, leading to a decrease in cardiac output and consequential poor perfusion and hypotension.[emsworld.com]
  • Prehospital hypertonic saline/dextran infusion for post-traumatic hypotension: the U.S.A. Multicenter Trial. Ann Surg. 1991 1991: 213; 482-491. Bickell WH, Wall MJ Jr, Pepe PE et al.[bestbets.org]
  • Tachycardia and hypotension will become profound, followed by decreased level of consciousness.[medictests.com]
  • Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N Engl J Med 1994; 331:1105-1109. 4. Gross D, Landau EH, Assalia A, Krausz MM.[books.google.it]
Chest Pain
  • Two weeks later the patient returned to the hospital with pleuritic chest pain and shortness of breath.[ncbi.nlm.nih.gov]
  • Chest pain and breathlessness were the commonest presenting features. Haemorrhagic shock and haemoptysis were noted in 30% and 20% cases respectively. Fire arms injury was the leading cause of chest trauma, being present in 80 (53.33%) cases.[ncbi.nlm.nih.gov]
  • A 35-yr-old man presented to our emergency department complaining of pleuritic left chest pain, shortness of breath, and fever 19 days after being hospitalized for a stab wound to the left chest.[ncbi.nlm.nih.gov]
  • A young man, after a non penetrating chest trauma, developed recurrent episodes of fever, chest pain, pleural and pericardial effusion, without laboratory evidence of viral infections, or positivity for conventional autoimmunity markers.[ncbi.nlm.nih.gov]
  • MVC, fall, airplane crash), complaints of chest pain, dyspnea, hoarseness (frequently absent) - Decreased femoral pulses, differential arm BP (arch tear) - CXR , CT scan, transesophageal echo (TEE), aortography (gold standard) - see below for CXR features[fprmed.com]
Continuous Murmur
  • He was treated conservatively, and presented six years later with exertional dyspnoea and a continuous murmur. Echocardiography detected an aorta-right ventricular fistula and an important aortic regurgitation.[ncbi.nlm.nih.gov]
Subcutaneous Crepitus
  • He had palpable subcutaneous crepitus over the chest and abdomen with massive scrotal swelling, and his back exam revealed multiple penetrating wounds ( Figure 1 ). Autopsy results found five right-sided posterior thoracic gunshot wounds.[westjem.com]

Workup

As early initiation of proper therapy could be life-saving, the importance of a prompt diagnostic workup is of critical importance. Physicians should be able to make the diagnosis after a detailed inspection of the chest, suggesting the pivotal role of a physical examination. The presence of bowel sounds in the thorax and abnormal breathing sounds are important abnormal findings [4]. A thorough patient history must cover the mode of injury, when it occurred, and assess the course and progression of symptoms. Imaging studies, however, are necessary to determine the extent of injury and the status of the surrounding organs and tissues. Plain radiography is described as a good initial method to start the diagnostic workup [7], but thoracic ultrasonography, because of the ability to use it in the field and more easily in the emergency setting, has emerged as an equally effective, if not superior procedure for the evaluation of penetrating chest trauma [6] [8]. Digital radiography seems to be highly useful for the assessment of skeletal injuries [5], but the introduction of computed tomography (CT) has greatly improved the overall quality of diagnostics [9]. Multidetector CT (MDCT) is the gold-standard for identifying the exact status of the organs situated in the thorax and should be employed whenever possible [1] [7].

Atrioventricular Dissociation
  • We report a case of fatal inferior wall myocardial infarction following traumatic injury to the right coronary artery, complicated by atrioventricular dissociation, in a patient with a combination of hypertrophic cardiomyopathy and non-occlusive coronary[ncbi.nlm.nih.gov]

Treatment

  • Clinical skill and judgment along with plain radiographs provide the basis for treatment in most cases. More sophisticated imaging techniques, with the exception of angiography, are of limited value.[ncbi.nlm.nih.gov]
  • Chest tube insertion alone was the main treatment initiated. This technique was used on 73.8% of the patients.[ncbi.nlm.nih.gov]
  • The aim of this retrospective study was to report the clinical presentations, diagnosis, complications and treatment for a series of TPPs at a hospital in Turkey.[ncbi.nlm.nih.gov]
  • The Society for Vascular Surgery published data regarding the use of endovascular grafts in the treatment of acute aortic transections; 97% were due to a motor vehicle accident.[emedicine.medscape.com]
  • Instead, diagnosis and treatment should focus on identification and resolution of the underlying cause. Antibiotics are recommended when pneumoscrotum arises after intestinal perforation or infection.[westjem.com]

Prognosis

  • Chest trauma can present in many unique and unusual ways, but, if managed in time, patients can have an excellent prognosis. This video shows three cases of chest trauma with different modes of injury and varied presentations.[ctsnet.org]
  • In patients with GSWs from high-caliber missiles, the absence of an organized cardiac rhythm portends a grave prognosis.[emedicine.medscape.com]
  • Prognosis The outcomes of treating patients with PCT are directly related to the extents of patients' injuries and the timeliness of initiation of treatments.[emedicine.medscape.com]
  • Age and gender are the most important determinants of injury mechanism, pattern, and prognosis. Chest trauma in infants and toddlers is most commonly the result of abuse or motor vehicle crashes.[clinicaladvisor.com]
  • Evaluation of MGAP and GAP trauma scores to predict prognosis of multiple-trauma patients. Trauma Mon 2017;22:e33249. Soar J, Perkis GD, Abbas G, et al.[ahcmedia.com]

Etiology

  • An expanding scrotum with crepitus may provide a valuable clue to an underlying serious etiology that is not immediately obvious.[westjem.com]
  • “Prehospital Pathophysiology” provides an opportunity for EMS providers to either refresh their knowledge related to the etiology of a certain disease or expand their knowledge base regarding common and not-so-common disease processes.[emsworld.com]
  • This procedure is reserved for patients with significant hemodynamic compromise without another likely etiology. Echocardiography is a rapid, noninvasive, and accurate test for pericardial fluid.[emedicine.medscape.com]
  • Etiology Mechanism of injury The mechanism of injury may be categorized as low, medium, or high velocity, as follows: Low-velocity injuries include impalement (eg, knife wounds), which disrupts only the structures penetrated Medium-velocity injuries include[emedicine.medscape.com]
  • Ongoing controversies regarding etiology, diagnosis, treatment Trauma protocols, including the ATLS protocols, are constantly under review and are updated regularly.[clinicaladvisor.com]

Epidemiology

  • A prospective, population-based study of the demographics, epidemiology, management, and outcome of out-of-hospital pediatric cardiopulmonary arrest. Ann Emerg Med. ‎[books.google.it]
  • The authors also provide a concise overview of the epidemiology and physiology of pediatric chest trauma. Dowd, MD, Keenan, HT, Bratton, SL. "Epidemiology and prevention of childhood injuries". Crit Care Med. vol. 30. 2002. pp. S385-92.[clinicaladvisor.com]
  • Epidemiology of chest trauma. Surg Clin North Am 1989; 69 (1) 15–9. 2. Thoracic trauma. In: ATLS : Advanced trauma life support. 6th ed. Chicago (IL): American College of Surgeons; 1997. p. 127–41. 3. Martin K.[journals.lww.com]
  • Epidemiology of chest trauma. Surg Clin North Am . 1989 Feb. 69 (1):15-9. [Medline] . Davis JS, Satahoo SS, Butler FK, Dermer H, Naranjo D, Julien K, et al. An analysis of prehospital deaths: Who can we save?.[emedicine.medscape.com]
  • Epidemiology of chest trauma. Surg Clin North Am . 1989 Feb. 69(1):15-9. 3. Mancini MC. Blunt Chest Trauma . Retrieved 15 November 2015. 4. Champion HR et al. The Major Trauma Outcome Study: establishing national norms for trauma care.[ems1.com]
Sex distribution
Age distribution

Pathophysiology

  • The book is not intended to serve as a comprehensive volume of pathophysiology and management in trauma; rather the goal is to provide practical solutions on how to treat injuries surgically.[books.google.com]
  • Also discussed will be assessment and treatment problems relating to the pathophysiology of these injuries.[emsworld.com]
  • Although the pathophysiology of delayed pericardial effusion is unclear, autoimmune postpericardiotomy syndrome has been proposed as the cause of this rare condition.[cambridge.org]
  • CONCLUSION: Anatomical and pathophysiological knowledge and the standardized management of the international guidelines are the key to keep a high level of suspect with a patient with chest penetrating trauma.[ncbi.nlm.nih.gov]
  • Sufficient evidence supports the notion that the pathophysiologic findings associated with severe chest wall trauma are related to the underlying injuries, chiefly pulmonary contusion and parenchymal injuries, and have little to do with the movement of[emedicine.medscape.com]

Prevention

  • Placing chest tubes on continuous low pressure suction after penetrating chest trauma helps evacuation of blood, expansion of lung and prevents the development of clotted Haemothorax.[ncbi.nlm.nih.gov]
  • Certain interventions may be performed in the field or at nontrauma centers to prevent imminent death, but rapid evacuation to a trauma center should not be delayed. A.[link.springer.com]
  • Air flows into the pleural space along a pressure gradient during inspiration and is prevented from leaving because a clot or other tissue creates a one-way valve.[journals.lww.com]
  • […] for Guideline Development Using GRADE GRADE Training Opportunities GRADE Instruction Available at “Teaching Evidence Assimilation for Collaborative Healthcare (TEACH)” Guideline Development Workshop Browse all guidelines All-Terrain Vehicle Injuries, Prevention[east.org]
  • Although blood in this capacity will prevent gas exchange due to alveolar collapse, it also can cause death from blood loss without one drop of blood ever leaving the body.[emsworld.com]

References

Article

  1. Mirka H, Ferda J, Baxa J. Multidetector computed tomography of chest trauma: indications, technique and interpretation. Insights Imaging. 2012;3(5):433-449.
  2. Inci I, Ozçelik C, Taçyildiz I, Nizam O, Eren N, Ozgen G. Penetrating chest injuries: unusually high incidence of high-velocity gunshot wounds in civilian practice. World J Surg. 1998;22(5):438-442.
  3. O'Connor JV, Adamski J. The diagnosis and treatment of non-cardiac thoracic trauma. J R Army Med Corps. 2010;156(1):5-14.
  4. Richter T, Ragaller M. Ventilation in chest trauma. J Emerg Trauma Shock . 2011;4(2):251-259.
  5. Szucs-Farkas Z, Kaelin I, Flach PM, et al. Detection of chest trauma with whole-body low-dose linear slit digital radiography: a multireader study. AJR Am J Roentgenol. 2010;194(5):W388-395.
  6. Brooks A, Davies B, Smethhurst M, Connolly J. Emergency ultrasound in the acute assessment of haemothorax. Emerg Med J. 2004;21(1):44-46.
  7. Mirvis SE. Imaging of acute thoracic injury: the advent of MDCT screening. Semin Ultrasound CT MR. 2005;26(5):305-311.
  8. Demetriades D, Velmahos GC. Penetrating injuries of the chest: indications for operation. Scand J Surg. 2002;91(1):41-45.
  9. Magnotti LJ, Weinberg JA, Schroeppel TJ, et al. Initial chest CT obviates the need for repeat chest radiograph after penetrating thoracic trauma. Am Surg. 2007;73(6):569-572;discussion 572-573.

Ask Question

5000 Characters left Format the text using: # Heading, **bold**, _italic_. HTML code is not allowed.
By publishing this question you agree to the TOS and Privacy policy.
• Use a precise title for your question.
• Ask a specific question and provide age, sex, symptoms, type and duration of treatment.
• Respect your own and other people's privacy, never post full names or contact information.
• Inappropriate questions will be deleted.
• In urgent cases contact a physician, visit a hospital or call an emergency service!
Last updated: 2018-06-21 23:00