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Emergency and acute medicine – penetrating chest trauma
Cause and mechanism
Penetrating chest trauma most commonly results from gunshot wounds or stab wounds. Less frequently, injury occurs from impalement on a sharp object following a fall or high-energy impact. These mechanisms place intrathoracic organs and major vessels at high risk for rapid deterioration.
Clinical features
Patients may present with an object impaled in the chest wall or an obvious penetrating wound with variable external bleeding. Common symptoms include chest pain, dyspnea, and respiratory distress. Altered mental status may occur secondary to hypoxemia or shock. Physical findings can include absent or asymmetric breath sounds, hypotension, and jugular venous distention, suggesting pneumothorax, hemothorax, or cardiac tamponade.
Initial evaluation
A rapid assessment of airway, breathing, and circulation is mandatory. The focused exam should evaluate respiratory effort, chest wall excursion, crepitus, subcutaneous emphysema, breath sounds, and heart sounds. An upright chest radiograph is preferred to identify pneumothorax, although a supine film should be obtained first if spinal precautions are required. Baseline hemoglobin, pulse oximetry, arterial blood gas, serum lactate, and type and screen should be obtained early.
Diagnostic studies
Echocardiography is indicated when tamponade is suspected or when a wound is near the heart. In penetrating precordial injuries, hemopericardium may decompress into the pleural space, so repeat pericardial ultrasound after chest tube placement is recommended. Electrocardiography assists in identifying myocardial injury. With gunshot wounds, imaging must account for all entry and exit sites, and additional studies of the abdomen or pelvis may be required. Arteriography is indicated if great vessel injury is suspected. Esophageal evaluation with contrast swallow or endoscopy and bronchoscopy should be considered when aerodigestive injury is possible.
Differential considerations
Life-threatening diagnoses include pneumothorax, tension or open pneumothorax, hemothorax, pulmonary contusion, myocardial contusion or rupture, pericardial tamponade, traumatic aortic injury, tracheobronchial or esophageal injury, diaphragmatic rupture, intra-abdominal injury, and spinal cord injury.
Prehospital priorities
All patients with signs of life should be transported rapidly to a trauma center. Full spinal immobilization is indicated when spinal injury is suspected. Impaled objects must never be removed in the field because they may be tamponading major bleeding. Suspected tension pneumothorax requires immediate needle decompression. Large open pneumothoraces should be covered with a three-sided occlusive dressing to prevent tension physiology. Transport should not be delayed for intravenous access.
Early resuscitation
Airway, breathing, and circulation management is the priority. Endotracheal intubation is indicated for respiratory distress, hypoxia, or hypotension. Supplemental oxygen should be provided to stable patients. Two large-bore peripheral IV lines should be established, with cautious fluid resuscitation. In penetrating aortic injury, permissive hypotension with a systolic pressure around 90 mm Hg is recommended until surgical control is achieved. Suspected tension pneumothorax requires immediate needle thoracostomy followed by chest tube placement without waiting for imaging. Pericardial tamponade with instability warrants emergency pericardiocentesis followed by rapid operative intervention.
Emergency department management
The trauma surgeon should be notified immediately. Tube thoracostomy is required for pneumothorax or hemothorax, using appropriately sized tubes. Aggressive crystalloid resuscitation should be avoided when pulmonary contusion is present. Wounds below the nipple line or posterior scapular tip raise concern for intra-abdominal injury and require further evaluation with ultrasound, CT, diagnostic peritoneal lavage, or operative exploration. Chest wounds should not be probed, and impaled objects should only be removed in the operating room. All foreign material should be preserved as forensic evidence. Tetanus prophylaxis should be updated as indicated.
Medications and supportive care
Analgesia and sedation should be provided using small, titrated doses of short-acting agents to avoid respiratory compromise. High-dose steroids for spinal cord injury remain controversial and should follow institutional protocols. Broad-spectrum intravenous antibiotics are indicated if wounds are grossly contaminated.
Disposition and outcomes
All patients with penetrating chest trauma require hospital admission. Hemodynamically unstable patients should proceed directly to the operating room. Emergency department thoracotomy may be lifesaving in selected patients with penetrating torso trauma who had signs of life in the field and short prehospital CPR duration. Large initial chest tube output or persistent bleeding mandates surgical intervention. Patients with isolated minor chest wall wounds and normal imaging may be observed briefly and discharged if repeat evaluation excludes intrathoracic injury and the patient remains stable.
Cause and mechanism
Penetrating chest trauma most commonly results from gunshot wounds or stab wounds. Less frequently, injury occurs from impalement on a sharp object following a fall or high-energy impact. These mechanisms place intrathoracic organs and major vessels at high risk for rapid deterioration.
Clinical features
Patients may present with an object impaled in the chest wall or an obvious penetrating wound with variable external bleeding. Common symptoms include chest pain, dyspnea, and respiratory distress. Altered mental status may occur secondary to hypoxemia or shock. Physical findings can include absent or asymmetric breath sounds, hypotension, and jugular venous distention, suggesting pneumothorax, hemothorax, or cardiac tamponade.
Initial evaluation
A rapid assessment of airway, breathing, and circulation is mandatory. The focused exam should evaluate respiratory effort, chest wall excursion, crepitus, subcutaneous emphysema, breath sounds, and heart sounds. An upright chest radiograph is preferred to identify pneumothorax, although a supine film should be obtained first if spinal precautions are required. Baseline hemoglobin, pulse oximetry, arterial blood gas, serum lactate, and type and screen should be obtained early.
Diagnostic studies
Echocardiography is indicated when tamponade is suspected or when a wound is near the heart. In penetrating precordial injuries, hemopericardium may decompress into the pleural space, so repeat pericardial ultrasound after chest tube placement is recommended. Electrocardiography assists in identifying myocardial injury. With gunshot wounds, imaging must account for all entry and exit sites, and additional studies of the abdomen or pelvis may be required. Arteriography is indicated if great vessel injury is suspected. Esophageal evaluation with contrast swallow or endoscopy and bronchoscopy should be considered when aerodigestive injury is possible.
Differential considerations
Life-threatening diagnoses include pneumothorax, tension or open pneumothorax, hemothorax, pulmonary contusion, myocardial contusion or rupture, pericardial tamponade, traumatic aortic injury, tracheobronchial or esophageal injury, diaphragmatic rupture, intra-abdominal injury, and spinal cord injury.
Prehospital priorities
All patients with signs of life should be transported rapidly to a trauma center. Full spinal immobilization is indicated when spinal injury is suspected. Impaled objects must never be removed in the field because they may be tamponading major bleeding. Suspected tension pneumothorax requires immediate needle decompression. Large open pneumothoraces should be covered with a three-sided occlusive dressing to prevent tension physiology. Transport should not be delayed for intravenous access.
Early resuscitation
Airway, breathing, and circulation management is the priority. Endotracheal intubation is indicated for respiratory distress, hypoxia, or hypotension. Supplemental oxygen should be provided to stable patients. Two large-bore peripheral IV lines should be established, with cautious fluid resuscitation. In penetrating aortic injury, permissive hypotension with a systolic pressure around 90 mm Hg is recommended until surgical control is achieved. Suspected tension pneumothorax requires immediate needle thoracostomy followed by chest tube placement without waiting for imaging. Pericardial tamponade with instability warrants emergency pericardiocentesis followed by rapid operative intervention.
Emergency department management
The trauma surgeon should be notified immediately. Tube thoracostomy is required for pneumothorax or hemothorax, using appropriately sized tubes. Aggressive crystalloid resuscitation should be avoided when pulmonary contusion is present. Wounds below the nipple line or posterior scapular tip raise concern for intra-abdominal injury and require further evaluation with ultrasound, CT, diagnostic peritoneal lavage, or operative exploration. Chest wounds should not be probed, and impaled objects should only be removed in the operating room. All foreign material should be preserved as forensic evidence. Tetanus prophylaxis should be updated as indicated.
Medications and supportive care
Analgesia and sedation should be provided using small, titrated doses of short-acting agents to avoid respiratory compromise. High-dose steroids for spinal cord injury remain controversial and should follow institutional protocols. Broad-spectrum intravenous antibiotics are indicated if wounds are grossly contaminated.
Disposition and outcomes
All patients with penetrating chest trauma require hospital admission. Hemodynamically unstable patients should proceed directly to the operating room. Emergency department thoracotomy may be lifesaving in selected patients with penetrating torso trauma who had signs of life in the field and short prehospital CPR duration. Large initial chest tube output or persistent bleeding mandates surgical intervention. Patients with isolated minor chest wall wounds and normal imaging may be observed briefly and discharged if repeat evaluation excludes intrathoracic injury and the patient remains stable.
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