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Tintinalli's Emergency Medicine Manual, 8e

Chapter 164: Cardiothoracic Injuries

Paul Nystrom

INTRODUCTION
Bedside diagnosis and immediate intervention by the emergency provider may be lifesaving for significant injuries associated with severe chest trauma
such as tension pneumothorax, hemothorax, and cardiac tamponade. Initial resuscitation and airway management should follow established
principles, as discussed in Chapter 156, “Trauma in Adults.” It is important to avoid hypoxia and hypotension to prevent secondary injury in head-
injured patients. In the hemodynamically unstable, polytrauma patient who requires emergency surgery without CT imaging, exclude immediate life
threats rapidly at the bedside using ultrasound, radiographs, and physical examination.

Physical examination should include assessment for visible trauma to the chest wall including any “seat belt sign,” focal areas of tenderness,
subcutaneous emphysema, and open chest wounds. Tracheal deviation, unequal chest rise, abnormal breath sounds, and bowel sounds in the chest
are less frequent but also important to note. Consider endotracheal intubation for patients in respiratory distress (Table 164-1).

Table 164-1

Considerations for Early Ventilatory Assistance after Thoracic Trauma

Altered mental status

Hypovolemic shock
Multiple injuries
Multiple blood transfusions
Elderly patients
Preexisting pulmonary disease
Respiratory distress
Poor oxygen saturation
Severe pulmonary contusions

LUNG INJURIES
Tension pneumothorax occurs when air enters the pleural space, either by escaping from damaged lung, tracheobronchial tissue, or an open chest
wound. The pneumothorax may become pressurized during respiration causing tension with resultant respiratory and circulatory compromise.
Patients may have dyspnea, tachycardia, hypotension, distended neck veins, tracheal deviation, and unequal breath sounds. Recognize and treat
tension pneumothorax immediately with needle decompression without waiting for radiographs. Insert a 14-G, 4.5-cm over-the-needle
catheter in the second intercostal space at the midclavicular line (a standard 14-G IV catheter may not reach the pleural space in many patients). A rush
of air through the catheter is confirmatory. Leave the catheter in until a chest tube can be inserted, as the catheter converts the tension pneumothorax
to an open pneumothorax.

Treat a small pneumothorax with inpatient observation; tube thoracostomy may not be necessary. Treat a large pneumothorax with tube
thoracostomy (24 to 28 F (8.0 to 9.3 mm)). Patients with pneumothoraces of any size and those with subcutaneous emphysema (requiring
presumption of an occult pneumothorax) who will be intubated or who will be transported by air should receive a tube thoracostomy, as positive
pressure ventilation and decreased barometric pressure can cause expansion of trapped air and progression to a tension pneumothorax. Never clamp
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a chest tube, but always place it on water seal when taken off suction. See Table 164-2 for causes of failure of the lung to fully reinflate after tube
Chapter 164: Cardiothoracic Injuries, Paul Nystrom Page 1 / 5
thoracostomy.
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Table 164-2
to an open pneumothorax.
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Treat a small pneumothorax with inpatient observation; tube thoracostomy may not be necessary. Treat a large pneumothorax with tube
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thoracostomy (24 to 28 F (8.0 to 9.3 mm)). Patients with pneumothoraces of any size and those with subcutaneous emphysema (requiring
presumption of an occult pneumothorax) who will be intubated or who will be transported by air should receive a tube thoracostomy, as positive
pressure ventilation and decreased barometric pressure can cause expansion of trapped air and progression to a tension pneumothorax. Never clamp
a chest tube, but always place it on water seal when taken off suction. See Table 164-2 for causes of failure of the lung to fully reinflate after tube
thoracostomy.

Table 164-2

Causes for Failure of Complete Lung Expansion or Evacuation of a Pneumothorax

Improper connections or leaks in the external tubing or water-seal collection apparatus

Improper positioning of the chest tube
Occlusion of bronchi or bronchioles by secretions or foreign body
Tear of one of the large bronchi
Large tear of the lung parenchyma

Treat a hemothorax with tube thoracostomy. A 32- to 40-F (10.7 to 13.4 mm) chest tube has historically been used but the larger size may not be
necessary. Indications for surgery include an immediate return of 1 L of blood or ongoing bleeding of 150 to 200 mL/h for 2 to 4 hours. Consider using
a heparinized autotransfusion device if massive hemothorax is suspected but do not delay tube thoracostomy.

Pulmonary contusions are direct injuries to the lung parenchyma without laceration. Hypoxia develops as bleeding and edema compromise contused
lung tissue. Seventy percent of pulmonary contusions are not immediately visible on initial chest radiograph, but may appear as patchy opacities,
typically within 6 hours. CT scan is much more sensitive. Initial management should include pain control to prevent hypoventilation,
avoidance of unnecessary IV fluids to prevent pulmonary edema, and strict pulmonary toilet. Administer crystalloids judiciously to
maintain perfusion and use blood products early in resuscitation. A trial of positive pressure ventilation by mask is reasonable in a patient with normal
mental status who requires limited respiratory support. Patients with involvement of >25% of lung tissue will likely require intubation, but should not
be intubated preemptively. If intubated, use positive-end expiratory pressure. Use diuretics if the patient is thought to have volume overload.

CHEST WALL INJURIES

A small open chest wound can progress to a tension pneumothorax through a one-way valve effect. Cover the wound with sterile petroleum gauze
taped on three sides to allow air to exit but not enter. Perform tube thoracostomy but not through the wound.

Flail chest occurs when a section of ribs fractures in multiple locations, causing instability of a segment of the chest wall. Intubation and positive
pressure ventilation will stabilize the flail segment. Surgical fixation may be needed, although the greater danger is the underlying lung contusion that
compromises respiration.

Rib fractures may suggest other injuries or cause morbidity independently. Fractures of the first and second ribs require great force and should
therefore cause high suspicion for other major thoracic injuries including myocardial, vascular, and bronchial injuries. Multiple lower rib fractures
should raise suspicion for liver or splenic injuries. The focus of diagnostic imaging is to exclude other injuries such as pneumothorax, pulmonary
contusion, and intraabdominal injury.

Even in the absence of coexisting injury, the pain of rib fractures may eventually lead to splinting, ventilatory compromise, and pneumonia. Consider
intercostal nerve blocks and epidural anesthesia for pain control. Patients being discharged should generally receive nonsteroidal anti-inflammatory
drugs (NSAIDs) and opioid analgesics. Remind them to breathe deeply or perform incentive spirometry exercises. Admit patients with multiple
fractures, medical comorbidities, or older age for a period of observation until they are stabilized on a regimen of pain control and pulmonary toilet.
Do not attempt to stabilize the chest wall with tape or binding. Assess patients with a sternal fracture for cardiac injury by ECG, serial troponin
measurements, and cardiac monitoring.

Assume patients with subcutaneous emphysema have a pneumothorax even if not seen on the initial chest radiograph. Supine chest radiograph is a
relatively insensitive screening tool for pneumothorax and for hemothoraces of <200 mL. Up to 1000 mL may appear as only diffuse haziness. Lung
collapse from intubation of a mainstem bronchus can have a similar appearance. If the patient can safely sit up, upright and expiratory views can
increase sensitivity. Ultrasound has been shown to have good sensitivity for pneumothorax, with loss of the sliding pleura sign while a
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hemothorax will show fluid in the dependent portion of the chest. CT scan is highly sensitive for both of these conditions. If subclavian
Chapter 164: Cardiothoracic Injuries, Paul Nystrom Page 2 / 5
venous cannulation is attempted, it should be done on the side of the suspected injury so that an iatrogenic pneumothorax does not result in bilateral
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pneumothoraces.
measurements, and cardiac monitoring.
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Assume patients with subcutaneous emphysema have a pneumothorax even if not seen on the initial chest radiograph. Supine chest radiograph is a
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relatively insensitive screening tool for pneumothorax and for hemothoraces of <200 mL. Up to 1000 mL may appear as only diffuse haziness. Lung
collapse from intubation of a mainstem bronchus can have a similar appearance. If the patient can safely sit up, upright and expiratory views can
increase sensitivity. Ultrasound has been shown to have good sensitivity for pneumothorax, with loss of the sliding pleura sign while a
hemothorax will show fluid in the dependent portion of the chest. CT scan is highly sensitive for both of these conditions. If subclavian
venous cannulation is attempted, it should be done on the side of the suspected injury so that an iatrogenic pneumothorax does not result in bilateral
pneumothoraces.

Penetrating wounds should never be deeply probed. A small stab wound may develop into a delayed pneumothorax; repeat the ultrasound or chest
radiograph at 4 to 6 hours after the initial presentation.

PNEUMOMEDIASTINUM AND TRACHEOBRONCHIAL INJURIES

Pneumomediastinum is most often caused by ruptured alveoli with dissection of air to the mediastinum and does not require treatment in the
asymptomatic patient. Coughing, heavy breathing (such as seen in drug inhalation), or exertion can rupture alveoli and release air into the
mediastinum. However, pneumomediastinum can also be the result of injuries to the trachea and large airways from high energy or major
deceleration. Dyspnea, hemoptysis, subcutaneous emphysema in the neck, a crunching sound with the cardiac cycle, and a massive continued air leak
through a chest tube suggest tracheobronchial injury.

DIAPHRAGMATIC INJURIES
All penetrating injuries from the level of the nipples to the umbilicus have the potential to injure the diaphragm. Small lacerations can be asymptomatic
and then progress to the rupture of abdominal contents into the chest weeks to months later. The diagnosis is obvious if imaging shows herniation of
abdominal contents into the chest or coiling of a gastric tube within the chest. Subtle abnormalities may also be seen on chest radiograph, CT, or
upper GI series with contrast. Laparotomy and laparoscopy remain the gold standards to exclude diaphragmatic injuries. All diaphragmatic lacerations
require surgical repair.

PENETRATING CARDIAC INJURIES

The right ventricle is the most commonly injured portion of the heart because of its large anterior exposure. Accumulation of blood in the pericardial
space compresses the heart, which prevents diastolic filling. The diagnosis is typically made by bedside ultrasound. Pericardiocentesis should only be
attempted for a patient in shock with confirmed cardiac tamponade since it is technically difficult and may result in laceration of a coronary artery or
injury to the myocardium. Stable patients should have a pericardial window or thoracotomy performed in the operating room.

Patients with penetrating chest injuries with signs of life in the field but who subsequently become pulseless may be candidates for ED thoracotomy.
Relieving cardiac tamponade, controlling hilar bleeding, cross clamping the descending aorta, or repairing a myocardial laceration may be lifesaving.
Stab wounds to the heart are more likely to be amenable to repair than injuries from gunshot wounds. Once the chest is opened, the heart is delivered
from the pericardium so that potential injuries can be visualized. Direct digital pressure, staples, sutures, or a Foley catheter with inflated balloon may
be used to temporize bleeding lacerations on the way to the operating room for definitive repair.

BLUNT INJURIES TO THE HEART

Blunt cardiac injury can lead to death from damage to cardiac structures, coronary artery injury and thrombosis, and contusion of the myocardium
resulting in impaired contractility and arrhythmias. ECG changes consistent with ischemia suggest coronary artery dissection or thrombosis, which are
evaluated and treated by cardiac catheterization and stenting. A direct blow to the chest such as when a young athlete is struck by a hard ball can
induce ventricular fibrillation cardiac arrest even without myocardial injury (commotio cordis). Treat according to advanced cardiac life support
(ACLS) algorithms because there is usually no structural damage to the heart.

A patient with cardiac injury may present with chest pain, tachycardia unexplained by hemorrhage, and arrhythmias. Bedside echocardiography by the
emergency provider should be performed as a first screen for cardiac tamponade and grossly impaired contractility. Treat tamponade the same as
tamponade from penetrating cardiac injury. Patients with hypotension not explained by another cause, arrhythmias, and impaired contractility
should undergo further evaluation by formal echocardiography and cardiac enzymes, with transesophageal echocardiogram being three times more
sensitive than transthoracic echocardiogram for blunt myocardial injury. Give antiarrhythmic and inotropic medications according to ACLS algorithms.
Indications for admission include abnormalities on echocardiogram, ECG, or cardiac enzymes. Discharge patients with normal vital signs, normal initial
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ECG, no underlying cardiac disease, and age <55 years after 4 to 6 hours of normal cardiac monitoring.
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TRAUMA TO THE GREAT VESSELS
A patient with cardiac injury may present with chest pain, tachycardia unexplained by hemorrhage, and arrhythmias. Bedside echocardiography by the
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emergency provider should be performed as a first screen for cardiac tamponade and grossly impaired contractility. Treat tamponade the same as
tamponade from penetrating cardiac injury. Patients with hypotension not explained by another cause, arrhythmias, and impaired contractility
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should undergo further evaluation by formal echocardiography and cardiac enzymes, with transesophageal echocardiogram being three times more
sensitive than transthoracic echocardiogram for blunt myocardial injury. Give antiarrhythmic and inotropic medications according to ACLS algorithms.
Indications for admission include abnormalities on echocardiogram, ECG, or cardiac enzymes. Discharge patients with normal vital signs, normal initial
ECG, no underlying cardiac disease, and age <55 years after 4 to 6 hours of normal cardiac monitoring.

TRAUMA TO THE GREAT VESSELS

Trauma to the major thoracic vessels is often lethal, with 90% of those sustaining blunt aortic injury dying at the scene. The most common site of blunt
aortic injury is at the proximal descending aorta between the left subclavian artery and the ligamentum arteriosum. Injury to the subclavian and
innominate arteries can be related to shoulder belts, fractures of the first and second ribs, and proximal clavicle. Half of patients present without
external physical findings, so suspicion for this injury needs to be high with mechanisms involving high-speed deceleration.

Table 164-3 shows radiographic findings of thoracic aortic injury, although a normal chest radiograph does not exclude major vascular injury. All the
patients with a mechanism highly concerning for great vessel injury should undergo CT angiogram with IV contrast. Conventional aortography is still
used in some cases to assess injuries and guide operative planning. Transesophageal echocardiogram is useful for diagnosing aortic intimal lesions,
but is contraindicated in airway compromise or suspected cervical spinal injury.

Table 164-3

Radiographic Findings Suggestive of a Great Vessel Injury

Fractures
Sternum
Scapula
Multiple ribs
Clavicle in multisystem-injured patients
First and second rib
Mediastinal Clues
Obliteration of the aortic knob contour
Widening of the mediastinum
Depression of the left mainstem bronchus
Loss of paravertebral pleural stripe
Calcium layering at aortic knob
Abnormal general appearance of mediastinum
Deviation of nasogastric tube to the right
Lateral displacement of the trachea
Other Findings
Apical pleural hematoma (cap)
Massive left hemothorax
Obvious diaphragmatic injury

Source: Reproduced with permission from Mattox KL, Moore EE, Feliciano DV: Trauma, 7th ed. New York, NY: McGraw-Hill; 2013.

Indications for immediate operation for vascular injury are hemodynamic instability, radiographic evidence of a rapidly expanding hematoma, or
large-volume chest tube output. Control hypertension in order to decrease shear stress on the vessel wall by titration of narcotic pain medications and
sedatives. A short-acting β-blocker, such as esmolol, may be titrated to a systolic blood pressure of 100 to 120 mm Hg and a heart rate above 60
beats/min. If bradycardia prevents further dosing of a β-blocker, infuse an arterial dilator such as sodium nitroprusside. Do not use sodium
nitroprusside without a β-blocker secondary to the reflex tachycardia that may develop.

ESOPHAGEAL AND THORACIC DUCT INJURIES

Penetrating and occasionally blunt trauma may cause injury to the thoracic esophagus. If suspected, evaluate the patient by esophagram with water-
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soluble contrast, which is less likely to cause mediastinitis. A negative study with water-soluble contrast should be followed by the use of barium
Chapter 164: Cardiothoracic Injuries, Paul Nystrom Page 4 / 5
contrast, which has a higher sensitivity for injury. Flexible esophagoscopy is an alternative modality for assessing injury. Delayed diagnosis of
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esophageal injury has a high mortality if mediastinitis ensues. Injuries to the area of the left proximal subclavian vein may result in chylothorax, causing
delayed pleural effusion with a mortality rate of approximately 50%. Initial treatment is chest tube insertion.
beats/min. If bradycardia prevents further dosing of a β-blocker, infuse an arterial dilator such as sodium nitroprusside. Do not use sodium
nitroprusside without a β-blocker secondary to the reflex tachycardia that may develop. Campbell University
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ESOPHAGEAL AND THORACIC DUCT INJURIES

Penetrating and occasionally blunt trauma may cause injury to the thoracic esophagus. If suspected, evaluate the patient by esophagram with water-
soluble contrast, which is less likely to cause mediastinitis. A negative study with water-soluble contrast should be followed by the use of barium
contrast, which has a higher sensitivity for injury. Flexible esophagoscopy is an alternative modality for assessing injury. Delayed diagnosis of
esophageal injury has a high mortality if mediastinitis ensues. Injuries to the area of the left proximal subclavian vein may result in chylothorax, causing
delayed pleural effusion with a mortality rate of approximately 50%. Initial treatment is chest tube insertion.

PERICARDITIS
Patients may develop chest pain, fever, and a friction rub 2 to 4 weeks after cardiac trauma or surgery which may indicate pericarditis. ECG may show
diffuse ST-segment elevation consistent with pericarditis. Pericardial and pleural effusions may be seen on echocardiography and chest radiograph,
respectively. Treatment is with nonsteroidal anti-inflammatory medications.

FURTHER READING

For further reading in Tintinalli's Emergency Medicine: A Comprehensive Study Guide , 8th ed., see Chapter 254, “Trauma in Adults,” by Cameron
Peter, Knapp Barry J.; Chapter 261, “Pulmonary Trauma,” by Jones David, Nelson Anna, Ma O. John; Chapter 262, “Cardiac Trauma,” by Ross
Christopher, Schwab Theresa.

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