Chest Trauma

Immediate Life-Threats:
● Aortic dissection/disruption
● Pericardial tamponade
● Tension pneumothorax
● Uncontrolled hemorrhage
● Death on scene: myocardial wall or thoracic
aortic ruptures

Aortic dissection
Blunt Cardiac Injury
Pulmonary Contusion
Chest Wall Fractures
Penetrating Trauma
Pneumo/Hemothorax
Aortic Dissection
RED FLAGS Dx:
● high-speed deceleration ● CXR
● retrosternal/interscapular ● CTA
pain Tx:
● pulse deficits ● OR
● dyspnea ● 𝛽-blocker/BP
● harsh systolic murmur
● often unsurvivable
Aortic Dissection
CXR CXR normal ⅓ of
● mediastinal widening the time
● obscured aortic knob
● loss of AP window CT angio = gold
● rightward displacement NGT
standard
● displaced left main bronchus
● wide paratracheal stripe
● wide paraspinous stripe
● left apical cap
Types of Aortic Dissection
Type I = intimal tear Type I →
Type II = intramural hematoma conservative
Type III = pseudoaneurysm
Type IV = rupture Type II-IV → OR

Aortic dissection
Blunt Cardiac Injury
Pulmonary Contusion
Chest Wall Fractures
Penetrating Trauma
Pneumo/Hemothorax

Blunt Cardiac Injury

RED FLAGS Tx:
● rapid deceleration ● supportive
● RV>LV (less EKG Δes) ● no lytics
● Rx
● tachycardia/dysrhythmias
dysrhythmias
● echo → wall motion abnl ● telemetry
● positive troponin admit

EKG = sinus tach or BBB

Remember that other than mild tachycardia if you see
ANYTHING on ECG the right move is to admit the patient for
tele.

Aortic dissection
Blunt Cardiac Injury
Pulmonary Contusion
Chest Wall Fractures
Penetrating Trauma
Pneumo/Hemothorax

Pulmonary Contusion
RED FLAGS Dx:
● direct chest wall trauma ● repeat CXR 6 hr
● interstitial edema Tx:
● ↓ O2 sats (v/q mismatch) ● +/- NiPPV or
● hemoptysis common intubation
● can be delayed ● avoid aggressive
IVF
CXR = patchy infiltrate/consolidation
 Patchy opacities
up to 6 hr delay,
progresses over 48-72 hr

Patchy opacities
up to 6 hr delay,
progresses over 48-72 hr

Rx: oxygenation and

ventilation

Aortic dissection
Blunt Cardiac Injury
Pulmonary Contusion
Chest Wall Fractures
Penetrating Trauma
Pneumo/Hemothorax
Rib Fractures
● >50% not seen on Management
CXR ● ≥2 fx → look for
● 9th-11th rib fx ➔ internal injury
liver/spleen ● Admit: elderly or
● 1st-2nd rib fx ➔ chronic lung disease
myocardial ● Angio if
contusion, bronchial neurovascular
tear, vascular injury compromise

Rib Fractures
FLAIL CHEST Tx:
● segmental rib fx (≥3) ● intubate (if
● paradoxical motion during needed)
breathing ● consider
● pulmonary contusion chest tube
Sternal Fracture
RED FLAGS Management
● high energy ● get ECG
● high mortality ● lateral CXR
● myocardial contusion ● CT for other
injuries
● mediastinal hematoma
● supportive
care

Clavicle Fracture
Middle ⅓ is most common.

Proximal ⅓ ➔ intrathoracic trauma

Ortho consult if:

● tenting, open fx, displacement, > 2 cm
shortening
Scapula Fracture
RED FLAGS Dx:
● high energy ● Xray or CT
mechanism to chest or Tx:
shoulder ● most are
● scapular body/neck non-surgical
most common
● pulm/chest wall injury

If you see what seems like an isolated scapula fracture the key
is to think about other injuries given that really high
mechanism of injury.

Aortic dissection
Blunt Cardiac Injury
Pulmonary Contusion
Chest Wall Fractures
Penetrating Trauma
Pneumo/Hemothorax
Pericardial Tamponade
RED FLAGS Dx:
● US/echo
● penetrating trauma to
Tx:
heart
● pericardiocentesis
● ↓ BP, narrow PP, ↑ HR ● thoracotomy
● pulsus paradoxus ● OR
Beck’s Triad
hypotension
muffled Heart Sounds
JVD

Esophageal Injury
● rare after blunt trauma Tx:
● OR
● chest/neck pain ● antibiotics
● crepitus
● pneumomediastinum

Dx:
● CT Chest
● Esophagography/Esophagoscopy
 CXR findings:
pneumomediastinum,
pleural effusion
mediastinal widening

Aortic dissection
Blunt Cardiac Injury
Pulmonary Contusion
Chest Wall Fractures
Penetrating Trauma
Pneumo/Hemothorax

Hemothorax
RED FLAGS Tx:
● ↓ breath sounds ● chest tube
● associated w/PTX

Dx: CXR
● Supine CXR: Blood Layers
● Blunted CPA = 200-300 cc
● US: 100% sensitive for 100cc
Hemothorax

Massive Hemothorax

OR THORACOTOMY
● Unstable
● Initial > 1500 mL
● >200 mL/hr

Pneumothorax
RED FLAGS Tx:
● blunt trauma or rib fracture ● O2
● dyspnea/chest pain ● Chest tube,
● ↓ breath sounds pigtail, or
● open PTX if penetrating observe
trauma

CT sensitivity > US > CXR!

Simple Pneumothorax
Dx: Tx:
● Small ● O2 if <2 cm from
● Stable pleural line
● No mediastinal shift ● Needle aspiration
or pigtail if >2 cm

Tension Pneumothorax
RED FLAGS Tx:
● severe dyspnea ● FINGER
thoracostomy
● distended neck veins
(4th/5th IC space)
● tracheal deviation ● chest tube
● abnormal vitals

Don’t wait for CXR

Open Pneumothorax
● Communication b/t PTX Tx:
and atmosphere via chest ● Occlusive
dressing on 3
wall defect
sides
● Usually from penetrating ● Chest tube
trauma remote from
● Can → tension PTX if flap wound
lets air out but not in

Image Attribution
Mediastinal structures on chest X-ray by Mikael Häggström, from source images by ZooFari,
Stillwaterising and Gray's Anatomy creators is licensed under CC BY-SA 3.0

Chest Xray PA 3-8-2010 by Stillwaterising is licensed under CC Public Domain Mark 1.0

AoDiss ChestXRay by J. Heuser JHeuser is licensed under CC BY-SA 3.0

Pulmonary contusion by Karim is licensed under CC BY-SA 3.0

Flail chest 1 by Dr AA Cevik is licensed under CC BY 2.0

Sternumfraktur mit Dislokation und Osteosynthese 57M - CT sagittal Planung CR Kontrolle seitlich -
001 by Hellerhoff is licensed under CC BY 4.0

A Case Report of Cardiac Tamponade by Derek JC Hunt, DO, Kevin McLendon, DO and Matthew
Wiggins, MD for JETem 2018 is licensed under CC BY 4.0

Mediastinalemphysem Perforation Oesophaguskarzinom - Annotation by Hellerhoff is licensed under

CC BY 4.0

CRIEM2014-454970.001 by R. Amin and B. H. Waibel is licensed under CC BY 4.0

Pneumothorax CXR photographed by User Clinical Cases 00:42, 7 November 2006 is licensed under CC
BY 2.5