Chapter 261: Pulmonary Trauma

INTRODUCTION AND EPIDEMIOLOGY

Blunt thoracic injuries account for up to one fourth of all injury-related deaths.¹ The mechanism of injury and severity of tissue damage predict the clinical course and outcome.² Injuries that do not violate the pleura usually can be managed with conservative measures, such as wound management or observation. Penetrating injuries that violate the pleura typically result in pneumothorax, with an accompanying hemothorax in most cases. Treatment is generally supportive care after tube thoracostomy.

Blunt trauma produces damage by direct injury, compression, and forces of acceleration or deceleration. Patients with significant blunt injury may require intubation and mechanical ventilation and invasive procedures such as tube thoracostomy. In general, victims of penetrating injuries who survive to reach the hospital often have better outcomes than those who have sustained blunt injuries. Blunt chest trauma from blast injuries is discussed in chapter 7, "Bomb, Blast, and Crush Injuries." Penetrating chest injuries in the "cardiac box" (see Figure 262-1), an area bounded by the sternal notch, xiphoid process, and nipples, should be presumed cardiac or great vessel injuries until proven otherwise.

CLINICAL FEATURES

HISTORY

The most frequent symptoms of thoracic trauma are chest pain and shortness of breath. The pain is most often localized to the involved area of the chest wall, but sometimes it is referred to the abdomen, neck, shoulder, back, or arms. Dyspnea and tachypnea are nonspecific findings and may also be caused by blood loss or pain from other injuries or by anxiety.

PHYSICAL EXAMINATION

Rapidly perform the physical examination during the primary and secondary surveys to detect life-threatening injuries.

Inspect the chest wall for contusions, abrasions, and other signs of trauma, including a "seat belt sign" that can indicate deceleration or vascular injury. Examine the chest for signs of paradoxical segments or flail chest, intrathoracic bleeding, and open chest wounds. The patient must be making a reasonable ventilatory effort to demonstrate these injuries.

Distended neck veins may indicate the presence of pericardial tamponade, tension pneumothorax, cardiac failure, or air embolism; however, in the setting of hypovolemia, this sign may be absent. If the face and neck are cyanotic and/or swollen, then suspect severe injury to the superior mediastinum with occlusion or compression of the superior vena cava. Subcutaneous emphysema from a torn bronchus or laceration of the lung can also cause severe swelling of the neck and face.

A scaphoid abdomen may indicate a diaphragmatic injury with herniation of abdominal contents into the chest. Excessive abdominal movement during breathing may indicate chest wall damage that might not otherwise be apparent.

Breath sounds are most readily heard in the axillae. Unilaterally decreased breath sounds may indicate the presence of hemothorax or pneumothorax. If the patient has an endotracheal tube in ...