Chapter 51 Penetrating Chest Injury (Case 34)
Case: A 23-year-old male sustained a single stab wound to the left chest.
PATIENT CARE
Clinical Thinking
• Consider review of the primary and secondary surveys in Chapter 47, Introduction to the Trauma Patient and Using the Primary and Secondary Surveys.
• Breathing: Assess for breath sounds over each lung field and the presence of jugular venous distention (JVD) and/or tracheal deviation.
• Circulation: Place two large-bore IV lines in the antecubital fossa and begin fluid resuscitation with lactated Ringer’s or normal saline. Place direct pressure over any active bleeding sites.
History
• What was the stabbing implement? What was the handedness of the assailant and the trajectory of the stabbing?
Physical Examination
| CXR (erect if possible): Evaluate pneumothorax, hemothorax, pneumomediastinum. Note: in urgent settings these ideally should be clinical diagnoses rather than radiographic. | $120 |
| Clinical Entities | Medical Knowledge |
|---|---|
| (Simple) Pneumothorax | |
| PΦ | Simple pneumothorax is a collapsed lung secondary to a stab wound through the parietal and visceral pleura with accumulation of air within the pleural space. |
| TP | Clinical findings will include the stab wound and decreased breath sounds on the affected side. |
| Dx | Dx is made by CXR, provided hemodynamics are stable. |
| Tx | Chest tube placement is appropriate tx. See Sabiston 20, 57; Becker 11. |
| Tension Pneumothorax | |
| PΦ | A tension pneumothorax is created when ongoing air leak allows continual ingress of air into the pleural space. This accumulation of air compresses the lung and mediastinal structures. |
| TP | Early findings include anxiety, dyspnea, tachypnea, tachycardia. Diminished breath sounds and hyperresonance of the chest wall on the affected side may be present. The typical patient will have hypoxia related to collapse of the ipsilateral lung and hypotension related to shifting of the mediastinum, which compromises venous return. The trachea may be deviated away from the side of the pneumothorax. JVD may be present. |
| Dx | Dx should be made by physical examination. Chest radiography should not be needed to identify a tension pneumothorax, and therapeutic intervention should not be delayed. |
| Tx | Immediate needle decompression of the chest with a 16-gauge angiocath in the second intercostal space, midclavicular line should be performed when a tension pneumothorax is suspected. Once accomplished, a chest tube is placed in a standard location. See Sabiston 20, 57; Becker 11. |
| Hemothorax | |
| PΦ | Hemothorax following a stab wound to the chest can be caused by bleeding from any structure in the thorax: the intercostal arteries, the lung, the great vessels, or the heart. |
| TP | Initial findings include anxiety, dyspnea, tachypnea, and tachycardia. Diminished breath sounds and dullness to percussion are found over the affected hemithorax. Massive hemothorax can produce significant hemodynamic instability secondary to hemorrhagic shock. |
| Dx/Tx | When confronted with a stab wound and decreased breath sounds, place a chest tube. Findings of 1,500 mL of blood initially, or more than 200 mL/hour for 2 to 4 hours, generally mandate a thoracotomy to control bleeding. Witnessed loss of vital signs in the ED is an indication for ED thoracotomy. When encountering a hemothorax in either penetrating or blunt trauma, the possibility of a subdiaphragmatic injury must also be considered, as bleeding may have its origin from an intra-abdominal source. Focused assessment sonography in trauma (FAST) examination or CT of the abdomen/pelvis may aid in dx. See Sabiston 20, 57; Becker 11. |
| Cardiac Tamponade | |
| PΦ/TP | The pericardium is a two-layered membrane surrounding the heart that normally contains 20 to 50 mL of fluid. Rapid accumulation of as little as 150 mL of fluid after trauma can produce cardiac tamponade and hypotension. Traumatic sources of intrapericardial blood include chamber rupture, usually right-sided, because of the anterior orientation, or coronary artery laceration. The accumulation of fluid in the pericardial space increases the stiffness of the ventricle, and higher filling pressures are required to sustain cardiac output. With further fluid accumulation, increasing pericardial pressures cause reduction in systemic venous return, diastolic filling, and cardiac output. If untreated, cardiac tamponade can produce cardiovascular collapse and death. Beck’s triad (arterial hypotension, venous hypertension, and muffled heart tones) is the classic presentation of tamponade. Narrowing of pulse pressures and pulsus paradoxus, a change of greater than 10 mmHg in the systolic pressure between inspiration and expiration, may also be seen. Patients with acute tamponade may present with dyspnea, tachycardia, and tachypnea. |
| Dx | Dx is made by vital signs and by physical examination. FAST examination may reveal pericardial fluid. Echocardiography may used in stable patients. A surgical pericardial window may be required for diagnosis. |
| Tx | Cardiac tamponade from penetrating injury is treated with immediate operative exploration and repair of the source of bleeding. Fluid resuscitation is needed to maintain preload and sustain cardiac output during transport to the OR. Subxiphoid percutaneous pericardiocentesis may be required as a temporizing measure. See Sabiston 5, Becker 11. |
