Initial assessment

In general, the diagnostic evaluation of patients with chest injuries is similar to that of other trauma patients. The initial emphasis is on ensuring that there is an adequate airway and ventilation, controlling sites of bleeding, and restoring adequate tissue perfusion ( Ks,h.e.ttry...and B.pl.m.a.n 1994). Patients with significant chest injuries may present with severe respiratory distress or frank respiratory failure and require immediate institution of assisted ventilation.

Tension pneumothorax is a relatively common cause of respiratory distress and shock in the patient with chest trauma. Tracheal deviation and decreased breath sounds contralateral to the side of the deviation strongly suggest this diagnosis and call for immediate needle decompression and/or tube thoracostomy. Early tube thoracostomy, without waiting for a chest radiograph, is warranted in patients with penetrating chest wounds who present with significant respiratory distress or hypotension.

Patients with significant hemorrhage due to chest injuries require fluid resuscitation to restore adequate circulation and prevent ongoing deficits in tissue perfusion. This is usually accomplished with crystalloid infusions initially, followed by packed red blood cells if the patient remains refractory to the administration of 2 liters of isotonic fluid. The use of delayed resuscitation for patients with penetrating truncal trauma remains controversial, and there is no information about its applicability to patients with blunt chest trauma.

Although the usual cause of hypotension in trauma patients is hemorrhagic shock, patients with chest trauma may also have cardiogenic shock. Blunt injuries to the chest may produce significant myocardial contusion with resultant myocardial dysfunction. Acute cardiac tamponade due to bleeding within the pericardial sac may be produced by both penetrating and blunt mechanisms. This should be suspected in patients who have refractory shock and evidence of elevated central venous pressures. Decompression of the pericardium may be life saving in this latter group of patients.

A chest radiograph should be obtained during the initial resuscitative efforts. If this study shows a significant pneumothorax or hemothorax, closed-tube thoracostomy should be performed. The chest radiograph should also be evaluated for bony and soft tissue injuries, pulmonary parenchymal infiltrates, deviation of the tracheobronchial tree, lesions of the mediastinum, particularly widening of the mediastinal silhouette, and abnormal diaphragmatic shadows. These findings will help decide what additional diagnostic or therapeutic interventions need to be undertaken.

Emergency room thoracotomy is primarily used in patients with penetrating chest trauma who sustain a cardiac arrest in the emergency department or shortly prior to arrival. A small but significant number of these patients, particularly those who have suffered stab injuries to the heart, may be salvaged. In general, emergency room thoracotomy is not warranted for patients with blunt chest trauma, since their survival with this procedure is negligible. The procedure should only be performed by those who can repair the injuries.

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