HWN Suggests

Penetrating Chest Trauma

Don’t rush to the airway. In most situations, you have some time so resuscitate before you intubate. Give blood products and get the BP up a bit to give yourself a little better physiologic situation in which to intubate.

Start your massive transfusion immediately if the patient is shocked. There’s always a delay in getting products but the earlier you start, the shorter the delay.

Include US in your primary survey. Your E-FAST should start with the cardiac window, then go to the lungs and then, finally, the abdomen. This order focuses on finding pathology you can fix immediately.

If the patient is shocked and peri-arrest or recently lost vitals, open the chest…

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Articles of Interest

Critical Decisions in Trauma: Penetrating chest trauma

Classically, penetrating injuries between the nipple lines anteriorly or the scapula posteriorly have the potential for cardiac or great vessel injury. The ‘‘danger zone’’ has been described as the region between the epigastrium to the sternal notch and laterally within 3 cm of the sternum.

GSW to the Chest

I agree with inserting a chest tube at the rural ED — should be able to put one in and secure it within 3-5 minutes. If the patient becomes more unstable it is very nice to know how much blood is coming out of the chest tube and how fast. Also, it takes tensison pneumothorax right out of the equation. You can insert a chest tube on the side of the bullet wound even without a CXR — I would definitely do it in the penetrating trauma patient who is unstable on arrival before the CXR.

Little Wound, Long Knife

The management of patients with stab wounds to the chest but otherwise normal vital signs, physical examination and chest x-ray is more controversial. Remember that chest wounds that extend below the nipples (or the scapulae posteriorly) may enter the abdominal cavity. Unless there is an indication for urgent laparotomy, FAST scan and CT abdomen are often needed as well as laparoscopy to identify diaphragmatic injury.

Penetrating Trauma: What We Miss and How We Can Improve

In the acute setting the most important thing we can miss is a tension pneumothorax. Thankfully, ultrasound is accessible and with ultrasound education being integral in most residency training programs, it is only a matter of time until most ED doctors can rule it out nearly 100% of the time.

Primer on Penetrating Thoracic Trauma

Deaths within the first 30 minutes to 3 hours are often preventable.

Treating Sucking Chest Wounds and Other Traumatic Chest Injuries

Another type of injury, sucking chest wounds, are a dramatic wound pattern with a fairly simple out-of-hospital treatment: placing an occlusive dressing on the chest wound. Early treatment of a sucking chest wound included placing an air-occlusive dressing over the site and taping it on three sides. It was thought that this dressing prevented additional air from entering the pleural cavity during inhalation and allowed trapped air to escape from the untaped edge during exhalation. However, the time required to apply this dressing and the limited effectiveness of the adhesive to stick to a diaphoretic bleeding patient often resulted in dressing failure.

Resources

EMS World

Penetrating chest trauma most frequently involves mechanisms such as stabbing and gunshot wounds (GSW), although there are a variety of ways the chest can be penetrated—some of them very dramatic (industrial incidents, fence poles).