Thoracic Injury: Introduction, Thoracic injuries account for approximately 25% of all trauma deaths and contribute to an additional 25% of deaths annually in the United States. Immediate deaths usually involve disruption of the heart or great vessel injury. Deaths within a few hours are frequently caused by airway obstruction, tension pneumotho-rax, hemorrhage, or cardiac tamponade. Pulmonary complications, sepsis, and missed injuries account for the late deaths. Although thoracic injuries are often life threatening, most patients with thoracic injuries are managed nonoperatively. Treatment options include analgesia, pulmonary hygiene, endotracheal intubation, and tube thoracostomy. Only 10% to 15% of patients with chest trauma will require thoracotomy or sternotomy. . Immediate Evaluation A. Physical examination includes: evaluation of upper airway, chest wall symmetry and stability, breath sounds, and heart tones. Findings of decreased breath sounds, subcutaneous emphysema, jugular venous distention (JVD), and tracheal deviation are specifically sought early in the evaluation. B.Begin resuscitation: while performing concurrent diagnostic procedures. Administer oxygen by high-flow nonrebreathing mask. If the patient does not respond adequately to volume resuscitation (persistent hypotension, tachycardia, decreased mental status), consider ongoing blood loss, and reevaluate for cardiac tamponade, tension pneumothorax, and cardiogenic shock from blunt cardiac injury. C.Monitor pulse oxymetry and electrocardiogram (ECG) continuously. D.Obtain a chest x-ray (CXR) early in the evaluation of patients with thoracic injury. Sites of missile entry or penetration should be identified with radiopaque markers (e.g., metallic markers, paper clips). E.In patients with significant injury, an arterial blood gas (ABG) can be used to determine adequacy of ventilation and acid base status. F.Identify indications for immediate operation. Massive hemothorax (> 1,500 mL blood returned on insertion of chest tube) Ongoing bleeding from chest (>200 mL/hour for ≥ 4 hours) Evidence of cardiac tamponade Penetrating transmediastinal chest wounds with unstable hemodynamics Chest wall disruption or impalement wounds to the chest Massive air leak from the chest tube or major tracheobronchial injury seen on bronchoscopy Mediastinal hematoma or radiographic evidence of great vessel injury with unstable hemodynamics Suspected air embolism
Posted on: Tue, 02 Jul 2013 14:24:28 +0000
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