Penetrating Chest Trauma Workup
- Author: Rohit Shahani, MD, MS, MCh; Chief Editor: Jeffrey C Milliken, MD more...
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.
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. 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.
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.
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.
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.
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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