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Penetrating Chest Trauma Workup

  • Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Jeffrey C Milliken, MD  more...
 
Updated: Nov 06, 2015
 

Laboratory Studies

Laboratory examinations are rarely required in the acute treatment of patients with penetrating chest injuries. Hemoglobin or hematocrit values and arterial blood gas determinations offer the most useful information for treating these patients; however, tests may be temporarily delayed until patients are stabilized. Blood chemistry results, serum electrolyte values, and WBC and platelet counts add little information for initial treatment but can establish a baseline by which to follow the course of the patient through his or her therapy. Underlying medical conditions (eg, diabetes, chronic renal insufficiency), either known or discovered via the laboratory examinations, should be noted and treated when appropriate.

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Imaging Studies

 

With improvements in modern imaging, a number of different diagnostic modalities are available to aid in precisely defining the extent of trauma. Various groups have championed their own protocols as preeminent. In reality, any number of acceptable algorithms can help in the treatment of a patient with PCT.

Admission history and physical examination are usually brief and are oriented to the injury. Evaluations of vital signs, consciousness, airway competency, vascular integrity, and pump (cardiac) function are rapidly performed before devoting attention to the point of injury. If the patient is stable and no significant injury is found that requires immediate surgery, a full diagnostic evaluation can be performed.

Chest radiography remains the basis for initiating other investigations.

CT scanning is rapidly evolving into a primary diagnostic tool because of its ability to image various intrathoracic structures and to differentiate substances of different densities (eg, solid vs air-containing fluid collections). With the advent of multidetector CT in clinical practice, the speed of data acquisition and image reconstruction has improved dramatically, and many reports emphasizing this change in imaging approach have been published.[13] Delayed radiographs have been the standard of care for stable patients with penetrating chest trauma. Initial chest CT scan obviates the need for repeat chest radiograph after penetrating thoracic trauma.[14]

Aortography, once considered the criterion standard for determining vascular injuries, has gradually fallen out of favor for faster, less invasive, and better-tolerated imaging techniques. The revival of aortography with endovascular intervention for trauma to the thoracic aorta or branches of the aortic arch (innominate, carotid, and subclavian arteries) is largely a product of modern technology. Endovascular stent graft arterial repair has altered the approach to vascular trauma.[15]

Penetrating injuries traversing the mediastinum or in proximity to posterior mediastinal structures dictate esophageal and tracheal evaluation, preferably by direct visualization (eg, esophagoscopy, bronchoscopy).

Specialized windows for ultrasonography have been developed to allow imaging of some intrathoracic structures despite the presence of lung air. Using the Focused Assessment with Sonography for Trauma protocols, evaluation of the thorax and the abdomen can be completed within minutes.

Readily available in most centers, echocardiography has been developed to a point at which it is now indispensable in helping evaluate injuries to the heart and the ascending and descending aortas. More recent work has demonstrated that ultrasonography can also be used to detect hemothoraces and pneumothoraces with accuracy.[16]

In appropriate settings, close observation (without thoracotomy) may be considered. However, the limitations of each of the above-noted diagnostic modalities must be remembered, and these modalities must not be extended beyond their functional limits, especially if patient safety is compromised.

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Other Tests

Because most trauma patients are young, extensive cardiac evaluations are often unnecessary. Admission ECGs can be deferred until the patient is stable unless cardiac injury is considered likely. Frequently, however, immediacy of resuscitation and definitive treatment preclude obtaining ECGs. In elderly patients, ECG evidence of prior myocardial infarctions may assist in the management of dysrhythmias or potential cardiac failure.

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Contributor Information and Disclosures
Author

Rohit Shahani, MD, MS, MCh Consulting Staff, Department of Cardiothoracic Surgery, Health Quest Medical Practice and Vassar Brothers Medical Center

Rohit Shahani, MD, MS, MCh is a member of the following medical societies: American College of Cardiology, American College of Surgeons, American Medical Association, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Jan David Galla, MD, PhD Assistant Professor, Department of Cardiothoracic Surgery, Mount Sinai Medical Center

Jan David Galla, MD, PhD is a member of the following medical societies: Aerospace Medical Association, American Association for the Advancement of Science, American College of Cardiology, American College of Surgeons, American Heart Association, American Medical Association, Civil Aviation Medical Association, International Society for Heart and Lung Transplantation, Society of Thoracic Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Daniel S Schwartz, MD, FACS Medical Director of Thoracic Oncology, St Catherine of Siena Medical Center, Catholic Health Services

Daniel S Schwartz, MD, FACS is a member of the following medical societies: Society of Thoracic Surgeons, Western Thoracic Surgical Association, American College of Chest Physicians, American College of Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Jeffrey C Milliken, MD Chief, Division of Cardiothoracic Surgery, University of California at Irvine Medical Center; Clinical Professor, Department of Surgery, University of California, Irvine, School of Medicine

Jeffrey C Milliken, MD is a member of the following medical societies: Alpha Omega Alpha, American Association for Thoracic Surgery, American College of Cardiology, American College of Chest Physicians, American College of Surgeons, American Heart Association, American Society for Artificial Internal Organs, California Medical Association, International Society for Heart and Lung Transplantation, Phi Beta Kappa, Society of Thoracic Surgeons, SWOG, Western Surgical Association

Disclosure: Nothing to disclose.

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Upright posteroanterior chest rediograph of patient with right-sided hemothorax.
 
 
 
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