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Traumatic Asphyxia

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Clinical Summary

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The clinical findings of traumatic asphyxia are due to a sudden increase in intrathoracic pressure against a closed glottis. The elevated pressure is transmitted to the veins, venules, and capillaries of the head, neck, extremities, and upper torso, resulting in capillary rupture. Strangulation and hanging are common mechanisms. Survivors demonstrate plethora, ecchymoses, petechiae, and subconjunctival hemorrhages. Severe cases may produce CNS injury with seizures, posturing, and paraplegia.

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Emergency Department Treatment and Disposition

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Treatment is supportive, with attention to other concurrent injuries. Long-term morbidity is related to the associated injuries.

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Figure 7.1.
Graphic Jump Location

Traumatic Asphyxia. This 45-year-old male was pinned when the truck he was working under fell on his chest. He was unable to breathe for 3 to 4 minutes until his coworkers rescued him. The violaceous coloration of the shoulders, face, and upper chest is apparent. (Photo contributor: Stephen W. Corbett, MD.)

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Figure 7.2.
Graphic Jump Location

Traumatic Asphyxia. A closer view showing the petechial nature of this rash. The patient was observed in the hospital overnight and recovered completely. (Photo contributor: Stephen W. Corbett, MD.)

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Pearls

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  1. Facial petechiae are known as Tardieu spots.

  2. One should be alert for associated rib and vertebral fractures.

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Flail Chest

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Clinical Summary

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A flail chest occurs when a segment of the thoracic cage is detached from the rest of the chest wall, resulting in suboptimal ventilation and oxygenation. Typically, several ribs are broken in one or more places. This creates a segment of the chest wall (a flail segment) that does not move in unison with the rest of the thorax. When the diaphragm produces negative inspiratory pressure, the flail segment, no longer anchored to the rib cage, tends to move inward, reducing ventilatory capacity. Pulmonary contusion, hemothorax, pneumothorax, and great vessel injuries frequently accompany a flail chest.

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Emergency Department Treatment and Disposition

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Pain control and pulmonary toilet are initial standard therapy. Mechanical ventilation is reserved for those with respiratory insufficiency or failure in spite of standard therapy. Treatment of underlying pulmonary injuries and intensive care unit admission is required for these critically ill patients.

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Figure 7.3.
Graphic Jump Location

Flail Chest. Localized blunt trauma to the left anterior chest 4 cm inferior to the mid-clavicle, with resultant flail segment. Positive intrathoracic pressure (panel A) and negative intrathoracic pressure (panel B) demonstrate the paradoxical movement of the flail segment. (Photo contributor: Lawrence B. Stack, MD.)

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