Approach to penetrating chest injury: Clinical sciences

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Introduction0:00–0:43

Penetrating chest injury is a dangerous type of trauma that commonly occurs from gunshot wounds, stabbings, and impalement.
For any patient presenting with penetrating injury to the chest, you must have a high clinical suspicion for life-threatening injuries to heart, lungs, and the great vessels.
Timely diagnosis and immediate intervention is key to reducing morbidity and mortality. In clinical practice, the majority of penetrating chest injuries can be managed nonoperatively, but if left untreated, even a minor wound can become fatal in a short span of time.Alright, your first step in evaluating a patient presenting with a penetrating chest injury is to perform a primary survey by assessing their ABCDE, which will help you determine if the patient is stable or unstable.

Acute Management0:43–2:08

Start by evaluating and securing the airway. Stabilize the C-spine with a C-collar to immobilize the spine, keeping in mind that the spinal cord could be injured from the penetrating trauma.
If needed, intubate or create a surgical airway like a cricothyroidotomy. Then, check for breathing, ensure adequate ventilation, provide supplemental oxygen, and auscultate the lungs for bilateral breath sounds.
Next, obtain two large bore IVs or an intraosseous line and start fluid resuscitation including transfusion of blood products if massive hemorrhage is suspected.
At the same time, continuously monitoring vital signs including heart rate, blood pressure, and oxygen saturation. Then, assess disability, or neurologic status, by calculating the patient’s GCS, and perform a pupillary exam and a neurologic exam.
Lastly, expose the patient by removing all clothing and bandages to ensure no injuries are missed. After examining the patient, place a warm blanket over them to avoid hypothermia.
Okay, let’s first discuss unstable patients. Once you have completed the primary survey and initiated the acute management, your next step is to perform the secondary survey, which is a head to toe physical exam.

Unstable Patient2:08–2:48

The focus of the secondary survey is to look for life-threatening injuries and signs of impending hemodynamic collapse. In clinical practice, adjunctive tests like labs and diagnostic imaging are also done during the secondary survey, but a thorough physical exam is the most important tool to help you identify the life-threatening injury for this type of trauma.Alright, the first condition to look for is tension pneumothorax.

Tension Pneumothorax2:48–4:05

Physical exam will typically reveal hypotension, jugular venous distention, and tracheal deviation, as well as absent lung sounds on auscultation and resonance to percussion of the chest wall.
Depending on the injury, you might even see an open sucking chest wound. These are classic features of a tension pneumothorax, which occurs when the penetrating injury tears the pleural lining of the thoracic cavity creating a “one-way valve” effect.
The air enters through the tear and accumulates within the pleural space with each breath. As the cavity fills with the trapped air, the lung becomes compressed and the mediastinum is pushed towards the opposite side.
If left untreated, mediastinal structures, like the inferior vena cava and the heart, become further compressed, leading to a marked decrease in venous return and cardiac output, resulting in obstructive shock.
Remember, tension pneumothorax is a clinical diagnosis, so you should go directly to treatment such as needle decompression or tube thoracostomy.
Okay, let’s discuss massive hemothorax! This typically occurs when there’s an injury to a major cardiovascular structure like the heart, great vessels, or intercostal arteries, and can quickly lead to at least a third of a patient’s blood volume accumulating within the thoracic cavity!

Massive Hemothorax4:05–5:14

On exam, you can expect to find hypotension, decreased lungs sounds on auscultation, and dullness to percussion over the affected side.
If these are your findings, consider a hemothorax. Your next step is to obtain an extended focused assessment with sonography in trauma, or e-FAST, which will typically show dense fluid within the pleural cavity.
Then, place a tube thoracostomy right away to drain the blood so the lung can inflate. An immediate output of blood greater than 1500 milliliters is diagnostic of a massive hemothorax.
This is a surgical emergency that needs immediate operative intervention!Moving on to cardiac tamponade. This occurs when blood accumulates in the pericardial sac.

Cardiac Tamponade5:14–6:32

As blood fills the pericardial space, it restricts and pushes on the heart, decreasing its ability to fill, and ultimately reducing cardiac output.
And because the pericardial space is relatively small, even a small accumulation of blood can quickly lead to cardiogenic shock.
So, on exam, you will likely find Beck triad, which is hypotension, jugular vein distension, and muffled heart sounds. This should lead you to consider a cardiac tamponade.
Then, obtain an e-FAST to visualize the fluid within the pericardium. Abnormal fluid within the pericardium confirms your diagnosis of cardiac tamponade.
Treatment involves draining the pericardial fluid with pericardiocentesis, which can be done at the bedside, or a pericardial window in the operating room.
Here’s a clinical pearl! Any trauma within the “cardiac box,” which is bordered by clavicles and sternal notch superiorly, costal margin inferiorly and the nipple lines laterally, can indicate a serious cardiac injury.
Now that the life-threatening conditions are taken care of, let’s talk about other urgent injuries you might find in a stable patient.

Stable Patient6:32–7:24

Unlike immediately life-threatening conditions, urgent injuries on a stable patient might not be as obvious on initial physical examination.
Diagnosis requires a high index of suspicion and appropriate use of adjunctive studies. If overlooked, these injuries can lead to increased risk of morbidity and mortality.
Your first step is to perform a detailed secondary survey and obtain adjunctive tests like labs including blood type and cross, CBC, CMP, lactate, urinalysis, and urine toxicology screen.
Additionally, diagnostic tests like a chest X-ray can help you narrow down your differential. To start, let’s explore injuries to the tracheobronchial tree or the thoracic esophagus.

Tracheobronchial and Esophageal Injury7:24–8:34

On exam, you might find crepitus around the face, neck, or chest, and in severe cases hemoptysis or cyanosis. Chest X-ray will likely reveal pneumomediastinum and subcutaneous emphysema, which are concerning for a tracheobronchial tree or an esophageal injury.
To differentiate the two, perform a bronchoscopy and obtain a contrast esophagram. If on bronchoscopy, you have direct visualization of airway injury, you can confirm your diagnosis of tracheobronchial injury.
On the other hand, if the esophagram reveals extravasation of contrast from the esophagus, that’s an esophageal injury. Keep in mind that the trachea and esophagus are in close proximity to each other within the thorax, so if one is injured it's likely the other is injured as well; tracheobronchial injuries can also be associated with pneumothorax and air leak.
Next is pulmonary parenchymal injury. On exam, these patients may have chest wall tenderness to palpation with increasing oxygen requirements.

Parenchymal Lung Injury8:34–9:41

A chest X-ray with bilateral patchy airspace opacities should raise suspicion for pulmonary parenchymal injury, where other clues like associated rib fractures may also be present.
Parenchymal injuries include direct tearing of the lung parenchyma without damage to the large airways or vasculature, as well as pulmonary contusion.
Both injuries can cause pulmonary edema as blood and other fluids accumulate in the lung tissue. This can interfere with proper oxygenation and ventilation of the lung, leading to hypoxia.
Although the patient might seem stable initially, parenchymal injuries can progress into respiratory failure as the edema worsens.
So, if you suspect this type of injury, look out for impending respiratory failure even with proper treatment.Now, let’s discuss hemopneumothorax.
Physical exam will typically reveal decreased breath sounds of the affected area, and sometimes tracheal deviation. On chest X-ray, you can expect to see a thin visceral pleural line without peripheral lung markings due to the pneumothorax, blunting of the costophrenic angle due to blood in the pleural space, and possible contralateral tracheal and/ or mediastinal deviation.

Hemopneumothorax9:41–10:43

These findings are consistent with a hemopneumothorax. Often, penetrating injury to the pleura causes both pneumothorax and a hemothorax as blood from injury accumulates in the pleural space.
Unlike a massive hemothorax, hemopneumothorax does not usually involve injury of the major vessels to cause massive bleeding.
Although a chest tube is necessary to reinflate the lung, operative intervention is not needed for most cases. Our final diagnosis is diaphragmatic injury!

Diaphragmatic Injury10:43–11:27

This occurs when a penetrating trauma traverses the diaphragm. You should have a high suspicion if a patient presents with an injury to the thoracoabdominal region, which is defined as the area between the nipple line and the inferior costal margins.
On further exam, you might hear decreased lung sounds in addition to bowel sounds in the chest, since, depending on the extent of the injury, intra-abdominal organs like the stomach or the bowel can herniate into the chest.
You can expect the chest X-ray to show an elevated hemidiaphragm with a gastric bubble or loops of bowel in the chest, confirming your diagnosis.
Alright, as a quick recap… Penetrating chest injuries are often caused by gunshots, stab wounds, or impalement. As with any trauma patient, your first step is to perform a primary survey and determine if the patient is stable or unstable.

Review11:27–12:06

In an unstable patient, look for life- threatening causes such as tension pneumothorax, massive hemothorax, and cardiac tamponade.
In stable patients A thorough secondary survey with the adjunctive tests like imaging can narrow down the differential injuries in stable patients can include tracheal bronchial injury oesophageal injury
Approach to penetrating chest injury: Video | Osmosis