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Blunt thoracic injuries account for up to one fourth of all injury
deaths.1 This chapter focuses on the recognition,
evaluation, and management of pulmonary, esophageal, and chest wall
injuries resulting from thoracic trauma.
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In most cases of thoracic trauma, the mechanism of injury predicts
the clinical course and outcome. Simple lacerations or punctures
that do not violate the pleura can usually be managed with conservative
measures, such as simple wound management or observation. Penetrating
injuries that violate the pleura typically result in pneumothorax,
with accompanying hemothorax in 75% of such cases. A trajectory
of injury that appears to traverse the diaphragm should raise concerns
for an intra-abdominal injury and may indicate need for laparotomy
or laparoscopy.
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Blunt trauma produces damage by direct trauma, compression, and
forces of acceleration or deceleration. The severity of the tissue
damage predicts clinical course and outcome.2 Patients
with significant blunt injury may require intubation and mechanical
ventilation, and procedures such as thoracostomy to drain a hemopneumothorax.
These patients are at risk for secondary sequelae such as pneumonia,
persistent air leak, or iatrogenic complications. In general, victims
of penetrating injuries who survive to reach the hospital often
have better outcomes than those who have sustained blunt injuries.
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Initial resuscitation and airway management should be performed
according to established principles (see Chapter 250, Trauma in Adults). If the patient is making little or
no respiratory efforts, central nervous system dysfunction due to
head trauma, intoxication, or spinal cord injury should be considered.
In patients with respiratory efforts but with little or no air movement,
upper airway obstruction should be suspected.
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Absent or abnormal breath sounds may indicate flail chest, hemopneumothorax,
diaphragmatic injury, or parenchymal lung damage. Although each
of these has specific therapies, respiratory distress that is not immediately
relieved by specific intervention should prompt the provider to
secure the airway by tracheal intubation or surgical airway and
mechanically ventilate the patient with 100% oxygen.
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Although emergent rapid sequence intubation of trauma patients
is safe, cardiac decompensation and arrest may occur after endotracheal
intubation for reasons related to the initial injury or the procedure
(Table 258-1). If the patient has poor venous
return due to hypovolemia, hyperventilation may increase intrathoracic
pressure and further decrease venous return to the heart. In the
hypovolemic patient, the resultant reduction in cardiac output can
lead to cardiac arrest.3 In the presence
of pulmonary injury or preexisting bullous disease, vigorous positive
pressure ventilation can lead to tension pneumothorax, further reducing venous
return.
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