MVCs account for the majority of cases of significant

blunt abdominal trauma across all demographic groups,

with the spleen by far the most commonly involved organ.

With penetrating trauma, abdominal SWs are roughly 3

times more common than GSWs. That said, the latter

accounts for roughly 90% of fatal injuries, as SWs are far

less likely to violate the peritoneal cavity and cause

significant injury. Abdominal GSWs most commonly

CHAPTER 88

I r ..-··-

/

.A. Figure 88-1. Anterior abdominal region.

involve the small bowel, colon, and liver, as these organs

take up the largest volume within the abdominal cavity.

Abdominal SW s most commonly affect the liver, but

laparotomy is required in only one quarter to one third of

patients.

The severity of injury is proportional to the amount of

energy transferred to target tissues. Blunt abdominal trauma

causes injury primarily by the direct transmission of external forces to underlying organs. Solid viscera, namely the

spleen and liver, are the most likely structures to be involved.

Hollow viscera can be injured when sudden crushing forces

induce a rapid spike in intraluminal pressure and secondary

rupture. Blunt trauma can also transmit shearing forces to

underlying structures. Significant injury is most c ommonly

seen in areas of transition from fixed to mobile positions

such as the small bowel at the ligament of Treitz or the

ileocolic junction.

In penetrating trauma, SWs result in low-energy

mechanisms that cause injury only to those tissues directly

impacted by the stabbing implement. As most assailants are

right-hand dominant, the left upper quadrant is the most

likely region to be affected. GSW s, on the other hand, transmit substantial amounts of energy and frequently result in

significant intra-abdominal injury. Missile size, stability, and

velocity all help to determine the amount of energy imparted.

High -velocity projectiles (> 2,000 ftl sec) as seen with combat

wounds and hunting rifles can create waves of energy that

result in temporary cavity formation and the disruption of

tissues remote from the missile tract. In fact, intraperitoneal

injury has been known to occur with high-velocity GSWs in

the absence of peritoneal violation. Shotgun injuries are

unique in that the velocity of the pellets decreases rapidly

with the length of distance traveled. Furthermore, the spread

of the pellets increases proportionally to the distance

between the victim and the shooter. Wounds with a pellet

spread of 1 0-25 em most likely occurred at a distance of 3-7

yards and possess sufficient energy to penetrate into the

peritoneal cavity. Finally, the potential for introducing contamination in the form of clothing or wadding further

complicates GSW injuries.

CLINICAL PRESENTATION

..... History

A rapid primary survey and patient stabilization should

always take precedence over a thorough medical history.

That said, obtain a quick AMPLE (Allergies, Medications,

Past illnesses, Last meal, Events preceding injury) history as

with all trauma patients and ask focused questions to

delineate the potential severity of mechanism. Emergency

medical service personnel can provide invaluable informa ­

tion about the mechanism of injury, initial scene evaluation, and response to interventions provided during

transport. With patients from an MVC, inquire about the

Figure 88-2. Thoracoabdominal reg ion.

ABDOMI NAL TRAUMA

severity of vehicular damage, seatbelt use, airbag deployment, need for patient extrication, and injuries to other

occupants. For GSW victims, ask about the number of

shots fired and the type of weapon involved.

Ask all patients about the presence of abdominal pain,

vomiting, hematemesis, and rectal bleeding. Pain in the

shoulder that is not associated with either tenderness on

exam or discomfort with shoulder movement suggests that

free intraperitoneal blood is irritating the diaphragm

inducing referred pain (Kehr sign).

� Physical Examination

Check a complete set of vital signs and proceed with the

primary survey. Any evidence of hemodynamic instability

suggests hemorrhagic shock and requires aggressive

intervention.

Perform a thorough examination of the chest and abdomen.

Inspect the patient and note any contusions, hematomas, and

abdominal distention. Lap-belt ecchymoses are highly con ­

cerning for underlying hollow viscus injuries or vertebral

body (Chance) fractures. Note all open wounds and identify

the zone of injury. GSWs may not follow a linear trajectory,

and a thorough examination of the entire body is necessary

to document all potential penetrating wounds. Look for

retained implements and eviscerations as each require operative intervention. Carefully palpate all 4 quadrants to detect

any point tenderness or signs of evolving peritonitis. Perform

a rectal exam to assess for the presence of gross blood. Keep

in mind that the abdominal examination in isolation lacks

adequate sensitivity to identify all patients with significant

injuries that require operative intervention.

DIAGNOSTIC STUDIES

� Laboratory

As with all victims of significant trauma, obtain a complete

blood count, metabolic panel, coagulation studies, and type

and screen. Serial hemoglobin measurements, and, if avail ­

able, bedside lactate and base deficit analysis may help to

determine the severity of injury and physiologic response to

resuscitation. Obtain a urine sample for rapid pregnancy

testing, urinalysis, and toxicology screening. Hemodynamically stable adults without evidence of gross blood on

bedside urinary inspection do not require a urinalysis to

search for microscopic hematuria, as significant GU injury

is highly unlikely. Liver function tests and pancreatic

enzymes are nonspecific and poorly predictive of injury

severity. As such, they are of minimal clinical utility in the

routine evaluation of patients with abdominal trauma.

� Imaging

Obtain an upright chest x-ray (CXR) in all patients to

detect subdiaphragmatic free air suggestive of an underlying

hollow viscus injury or the intrathoracic herniation of

abdominal viscera indicative of a diaphragmatic rupture.

In patients with penetrating thoracoabdominal trauma,

Figure 88-3. CT sca n demonstrating a splenic laceration (arrow). Note the free fluid around the liver.

carefully review the CXR to rule out an underlying pneumothorax. Obtain an anteroposterior film of the pelvis in

blunt trauma victims to rule out unstable pelvic fractures

and stabilize any visualized injuries by tightly securing a

bed-sheet around the patient's waist to tamponade off any

active pelvic bleeding. Place r adiopaque markers (eg, electrocardiogram leads) over any open wounds in GSW victims before imaging to help determine the path of the

projectile( s).

Pursue computed tomography (CT) imaging of the

abdomen and pelvis in all stable blunt trauma patients to

detect solid organ injury and hemoperitoneum (Figure 88-3).

This modality is especially useful in patients whose exams are

limited by distracting injuries or altered mental status. With

penetrating trauma to the back and flank, order a "triple

contrast" CT scan (by mouth, intravenous, and per r ectum)

to rule out intraperitoneal and retroperitoneal injury. CT

imaging can also be used to diagnose peritoneal violation in

patients with abdominal SWs. Of note, CT imaging is

inadequately sensitive to exclude small diaphragmatic injuries with penetrating thoracoabdominal trauma and isolated

hollow viscus injuries with significant blunt t rauma.

PROCEDURES

� FAST Scan

Focused assessment with sonography for trauma (FAST)

imaging is a widely available bedside procedure that can

detect volumes of free intraperitoneal blood as low as 100 mL.

It is easy to perform, quick ( <5 minutes), noninvasive, and

readily repeatable. The sensitivity of a FAST exam is directly

proportional to the volume of free intraperitoneal blood,

and this modality is highly sensitive in cases in which intra ­

peritoneal hemorrhage is significant enough to produce

hemodynamic instability. A positive FAST exam in an

unstable patient with blunt abdominal trauma necessitates

emergent laparotomy. See Chapter 8 for further details.

CHAPTER 88

..... Diagnostic Peritoneal Lavage (DPL)

Although largely supplanted by less invasive modalities such

as Cf and FAST, DPL may continue to play a role in the rapid

bedside detection of free intraperitoneal blood in grossly

unstable patients with equivocal FAST exams. This procedure

can be broken down into 2 basic steps. Begin by inserting an

1 8-gauge needle into the peritoneal cavity and attempting to

aspirate free intraperitoneal fluid. An aspirate of � 10 mL of

gross blood or obvious intestinal contents warrants operative

laparotomy. In patients with negative aspirates, insert a guidewire through the needle and place an intraperitoneal catheter

via the Seldinger technique. Infuse 1 L of normal saline into

the peritoneal cavity and then allow it to drain via gravity

back into the empty saline bag. The collected fluid should

then be sent to the lab for cell count analysis. In blunt abdominal trauma, a count > 100,000 red blood cells (RBCs)/JlL is

considered the threshold for detecting significant visceral

injury and the need for laparotomy. For abdominal GSWs, a

count >5,000--10,000 RBCs/JlL is considered positive. For

patients with thoracoabdominal SWs, a similar count of

5,000--10,000 RBCs/JlL is used to exclude diaphragmatic

injuries. For all other abdominal SWs, a cut-off of > 100,000

RBCs/JlL is used.

..... Local Wound Exploration (LWE)

This is a useful modality for excluding peritoneal violation

in patients with anterior abdominal SWs. Carefully extend

the margins of the injury as necessary to facilitate adequate

visualization of the base of the wound. The use of copious

local anesthetics is a must. This technique is far preferable

to blindly probing the wound with blunt instruments.

Assume peritoneal penetration in cases in which the base

of the wound cannot be clearly identified. The deep

exploration of thoracoabdominal wounds is generally

avoided, although LWE may be reasonable to confirm the

depth of very superficial slashing-type injuries.

MEDICAL DECISION MAKING

Begin all evaluations with a rapid primary survey and

complete set of vital signs. Emergent laparotomy is

generally indicated in all unstable patients with either

penetrating abdominal trauma or blunt abdominal trauma

and positive FAST imaging. Regardless of hemodynamic

condition, patients with GSWs that clearly violate the

peritoneal cavity require emergent laparotomy due to the

high rate of significant underlying injury.

Hemodynamically stable patients warrant a work-up

before deciding on the need for surgery. For victims of

penetrating trauma, this might include LWE with anterior

abdominal SWs, plain radiographs to localize radiopaque

foreign bodies, FAST imaging to look for pericardia! and

intraperitoneal free fluid, CT imaging to help determine

the need for and approach to any operative intervention,

 

MEDICAL DECISION MAKING

The management of the thoracic trauma patient should

be algorithmic based on the mechanism and location of

injury. Initial efforts should focus on a rapid primary

survey and immediate aggressive intervention for any

emergent life threats encountered. A more comprehensive

secondary survey is then performed, aided by laboratory

and imaging studies as outlined previously (Figure 87-6).

TREATMENT

...... Blunt Thoracic Injuries

Sternal and Rib Fractures

Provided there are no corresponding injuries to underlying

viscera, care of these injuries should focus on adequate analgesia. Suboptimal pain control can result in impaired l ung

ventilation and the potential for secondary pneumonia.

Intercostal nerve block can be an invaluable for pain control.

Pulmonary Contusions

These injuries are treated supportively with supplemental

oxygen via a nonrebreather mask to maintain adequate

systemic oxygenation. Patients with extensive contusions

or those unresponsive to supplemental oxygen will require

endotracheal intubation and positive pressure ventilation.

Care must be taken to avoid overaggressively hydrating

these patients to limit progressive alveolar edema and

extension of the underlying contusion.

Blunt Myocardial Injury

Clinically significant injuries requmng aggressive

intervention are very rare. Stable patients with normal

initial ECGs can be discharged home without further

evaluation. Patients with ECG anomalies should be

observed for 12-24 hours on continuous telemetry to

assess for the development of progressive dysrhythmias or

cardiogenic shock. Patients who decompensate into cardiogenic shock should be managed via the appropriate

Advanced Cardiac Life Support algorithms with the caveat

that, for the most part, antiplatelet and anticoagulant

medications should be avoided.

Blunt Aortic Injury

If possible, the systolic blood pressure (BP) should be

aggressively lowered to -ll0-120 mm Hg to reduce the

shearing forces on the vessel wall and limit the potential for

aortic rupture. Ideal agents include a combination of intravenous (IV) esmolol and either nitroprusside or nicardip ­

ine drips. Copious analgesia may be necessary to facilitate

adequate BP control. Definitive treatment involves surgical

repair or endovascular stenting.

...... Penetrating Thoracic Injuries

Pneumothorax

Almost all traumatic PTXs require tube thoracostomy

within the ED. This is especially true of patients with

bilateral PTXs or those undergoing positive pressure ventilation. Patients with an asymptomatic simple PTX

smaller than 1 em on CXR and no visible HTX or those

with PTX visible only on CT imaging (occult PTX) can be

observed on 1 00% supplemental oxygen, with tube thoracostomy reserved for those with evidence of increasing

volume on serial imaging or the development of associated symptoms. Tension PTXs require immediate needle

thoracostomy followed by chest tube placement. Open

PTXs require placement of a 3-sided occlusive dressing

over the wound to create a flutter valve and restore the

integrity of the chest wall followed by subsequent tube

thoracostomy.

Hemothorax

Almost all HTXs large enough to be detected on CXR

should be drained with tube thoracostomy. Operative

intervention is required in <5% of cases of HTX and

should be reserved for cases of massive HTX with either

initial volumes of evacuated blood > 1,500 mL, persistent

chest tube output of >200 mL/hr over the first 2-4 hours,

or hemodynamic instability despite aggressive volume

THORACIC TRAUMA

Operative vs.

endovascu lar

repair

I ntervene, stabilize,

fr reassess

Cardiac box

.A. Figure 87-6. Thoracic trauma diag nostic algorithm. ABCs, airway, breathing, and circulation; CT, computed

tomography; CXR, chest x-ray; ECG, electrocard iogram; OR, operating room.

resuscitation. Autotransfusion should be considered in the

majority of these patients.

Penetrating Cardiac Injury

Patients with loss of vital signs either in the field or ED

should undergo emergent thoracotomy. Those with

pericardia! tamponade from an anterior cardiac stab

wound have the highest likelihood of survival. Unstable

patients with signs of pericardia! tamponade either on

physical exam or US should undergo emergent

pericardiocentesis. Stable patients with evidence of bleeding in the pericardia! sac on bedside ECHO should be

taken to the operating room for either a pericardia! window or an operative thoracotomy.

Penetrating Great Vessel Injury

The majority of these patients who survive to ED

presentation will require emergent operative intervention.

Early endotracheal intubation should be considered given

the potential for significant mediastinal hematoma

CHAPTER 87

formation and secondary tracheal compromise. Any

retained implements should be stabilized in place, and

their removal should be performed only within the

operating room.

Tracheobronchial Injury

All patients with presumed tracheobronchial trauma

should undergo emergent bronchoscopy to determine the

location and severity of injury. The majority of these

patients will require operative repair. If necessary,

endotracheal intubation should be performed under

bronchoscopic guidance to limit any further trauma to the

tracheobronchial tree and prevent the aberrant placement

of the endotracheal tube into a false soft-tissue lumen.

DISPOSITION

� Admission

The majority of thoracic trauma patients will require hospital admission. Hemodynamically stable patients with an

isolated PTX or small HTX can be admitted to a standard

hospital bed after chest tube placement. Patients with BMI

or pulmonary contusions should be admitted to either a

telemetry unit or intensive care unit (I CU) setting depend ­

ing on the severity of symptoms. Patients with BAI, PCI,

PGVI, or tracheobronchial injury will require operative

intervention followed by an ICU admission.

� Discharge

Patients with uncomplicated rib or sternal fractures can

be safely discharged home provided that their pain can

be adequately managed. Stable penetrating thoracic

trauma patients with a normal initial CXR and otherwise negative work-up should have repeat imaging performed within 3-6 hours to check for the development

of a delayed PTX. If negative, these patients can be safely

discharged home.

SUGGESTED READING

Bastos R et al. Penetrating thoracic trauma. Semin Thorac

Cardiovasc Surg. 2008;20:1 9-25.

Brunett PH, Yarris LM, Cevik AA. Pulmonary trauma. In: Tintinalli

JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD.

Tintinalli's Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York, NY: McGraw-Hill, 2011.

Keel M, Meier C. Chest injuries: What is new? Curr Opin Grit

Care. 2007;13:674-679.

McGillicuddy D, Rosen P. Diagnostic dilemmas and current

controversies in blunt trauma. Emerg Med Clin North Am.

2007;25:695-7 11.

Ross C, Schwab TM. Cardiac t rauma. ln: Tintinalli JE, Stapczynski

JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide. 7th ed.

New York, NY: McGraw-Hill, 201 1.

Abdominal Trauma

Matthew T. Emery, MD

Key Points

• A normal physical examination cannot be used as the

sole means to exclude significant injury in patients with

abdominal trauma.

• Hemodynamically unstable patients with penetrating

injuries into the peritoneal cavity or blunt abdominal

trauma and evidence of intraperitoneal hemorrhage

require emergent lapa rotomy.

INTRODUCTION

Victims of abdominal trawna can present with intraperitoneal,

retroperitoneal, and intrathoracic injuries. Intraperitoneal

structures at a high risk of injury include the solid organs

(liver and spleen), hollow viscera (small and large intes ­

tines), and diaphragm, whereas commonly involved retroperitoneal structures include the kidneys and genitourinary

( GU) tract, duodenum, pancreas, and portions of the large

intestine. The initial evaluation and management of

patients with abdominal trawna can be divided by the

mechanism of injury into blunt and penetrating pathways.

Motor vehicle collisions (MVC) and significant falls account

for the majority of cases of blunt abdominal trauma,

whereas stab wounds (SW) and gunshot wounds (GSW)

account for most cases of penetrating trauma. Keep in

mind that the location of an entrance wound can frequently be misleading. Although a wound located on the

anterior abdomen is obviously a high-risk injury, alterna ­

tive sites (lower chest, pelvis, back, or flank) can also result

in significant intraperitoneal (or retroperitoneal) injury

depending on the trajectory of the bullet, knife, or other

wounding implement.

When evaluating patients with penetrating trawna, the

abdomen can be divided up into 4 distinct zones to help

381

• Gunshot wounds that violate the peritoneum require

operative exploration because of the high likeli hood of

inju ry.

• In patients with blunt abdominal trauma, negative

computed tomograhy imaging has an excellent

negative predictive value for excluding significant injury.

predict which anatomic structures are at risk of injury. The

anterior abdomen extends between the anterior axillary

lines from the costal margins down to the inguinal ligaments (Figure 88-1). The thoracoabdominal region

extends circurnferentially around the entire trunk between

the costal margins inferiorly and the nipple line or inferior

scapular borders superiorly (Figure 88-2). Trauma to this

region can injure intrathoracic and intraperitoneal struc ­

tures as well as the diaphragm. The flanks compose the

third anatomical zone and extend between the anterior

and posterior axillary lines from the costal margins to the

iliac crests. Consider injuries to both intraperitoneal and

retroperitoneal structures in this region. The final anatomical

zone is the back, which extends between the posterior axil ­

lary lines from the inferior scapular borders to the iliac

crests. Trauma to this region is most likely to result in

retroperitoneal injury.

 

such as falls greater than 30 feet or an MVC greater than

30 mph, should raise concern for potential vascular shearing

injuries. With penetrating trauma, the type of stabbing

implement should be ascertained.

� Physical Examination

An assessment of patient vital signs is the cornerstone of

the primary survey. Progressive sinus tachycardia and sys ­

temic hypotension indicates a serious cardiovascular

derangement that should be addressed immediately.

Significant hypoxia could indicate an underlying pulmonary contusion, HT X, or PT X.

Inspection of the patient's neck might reveal jugular

venous distension indicative of pericardia! tamponade or

tension PT X or tracheal deviation indicative of an evolving

tension PT X. Examination of the thorax should begin with

gross observation. Chest wall asymmetry with regional

paradoxical movement during respiration indicates

underlying flail chest. A large open defect in the chest wall

with audible air movement during respiration indicates a

communicating PT:x. Penetrating wounds either located

within or transecting the "cardiac box" are most likely to

involve the heart and surrounding mediastinal structures

and require a more extensive work-up. T he anterior cardiac

box is defined as the region medial to the nipples extending

between the suprasternal notch and xiphoid process. T he

posterior cardiac box is defined as the region between the

medial borders of the scapulae extending from the superior

border of the scapulae to the costal margin (Figure 87-1).

Palpation of the chest wall can detect point tenderness

indicative of an underlying fracture of the thoracic cage or

soft tissue crepitus suggestive of an underlying PTX or

tracheobronchial injury.

Auscultation of the chest will reveal absent or diminished

breath sounds indicative of an underlying PTX or HT X,

whereas inspiratory crackles suggests an evolving pulmonary

contusion. Diminished heart sounds are heard in patients

with pericardia! bleeding and potential cardiac tamponade.

Patients with significant thoracic trauma often have

concomitant abdominal injuries. A careful examination

of the upper abdomen should be performed in patients

with fractures of the lower ribs due to the potential for

contusion or laceration of the underlying liver or spleen.

Finally, distal pulses should be assessed, as marked

asymmetry could indicate significant vascular injury.

CHAPTER 87

A

B

Figure 87-1. A, B. Anterior and posterior cardiac box.

DIAGNOSTIC STUDIES

..... Laboratory

There are no laboratory studies specific to the work-up of

patients with thoracic trauma. Typical studies obtained

include a complete blood count, electrolyte panel with r enal

function, serum and urine toxicology studies including an

ethanol level, a serum lactate level, and a serum base deficit.

These tests should be used primarily to determine the

severity of the traumatic insult and the adequacy of the

patient's physiologic response.

.... Imaging

All thoracic trauma patients, both blunt and penetrating,

require an initial screening chest x-ray (CJCR) . Sternal

and rib fractures are often difficult to detect, with -50%

missed on the initial CXR. This is especially true for fractures of the anterior and lateral portions of the first 5 r ibs

and sternal fractures when a lateral view is not obtained.

Fortunately, it is the potential injury to any underlying

structures that is of clinical significance. Pulmonary contusions will appear as focal opacifications within the lung

parenchyma and typically manifest within the first

6 hours of presentation. A simple pneumothorax will

appear as free air within the intrapleural space with an

adjacent visible edge of visceral pleura. A good rule of

thumb is that a PTX of 2.5 em in an adult indicates a 40%

loss of lung volume. Penetrating thoracic trauma patients

with a normal initial CXR typically require repeat imaging several hours later to rule out the development of a

delayed PTX. An HTX can be visualized on an upright

CXR once -200 mL of blood has accumulated and will

initially appear as blunting of the ipsilateral costophrenic

angle (Figure 87-2). On a supine CXR, a large HTX will

appear as a diffuse haziness of the entire hemithorax due

to posterior layering of the free-flowing intrapleural

blood. Finally, chest radiography can be used as a screening study for BAl. Concerning findings include a widened

superior mediastinum (>8 em), an indistinct or obscured

aortic knob, rightward displacement of an intraesophageal

nasogastric tube, inferior displacement of the left

mainstem bronchus, or an apical pleural cap (Figure 87-3).

Because of a false-negative rate of -10%, a normal initial

CXR cannot reliably exclude BAl.

.&. Figure 87-2. Right-sided hemopneumothorax. Note

the absence of lung markings in the right hemithorax,

radio-opaque collapsed lung tissue adjacent to the right

hilum, blunting of the costophrenic angle due to blood

in the intrapleural space, and air fluid level pathognomonic for a hemopneumothorax. Reprinted with permission from Young Jr. WF. Chapter 71 . Spontaneous and

Iatrogenic Pneumothorax. In: Tintinalli JE, Stapczynski JS,

Cline OM, Ma OJ, Cydulka RK, Meckler GO, eds. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York: McGraw-Hill, 201 1.

THORACIC TRAUMA

Figure 87-3. Blunt aortic injury on CXR . Note

the widened superior mediastinum (a rrows).

A standard 1 2-lead electrocardiogram (ECG) is the

initial study of choice to work up patients with potential

BMI. Because of its anterior location within the chest, the

right ventricle is the most likely structure affected. Expected

findings include ST-segment changes and/or T-wave

inversions (typically in the inferior and anterior leads),

conduction delays, and dysrhythrnias. A normal initial

ECG in an asymptomatic individual reliably excludes any

future complications of BMI. A bedside echocardiogram

(ECHO) can be a useful adjunct in patients with presumed

symptomatic BMI and may demonstrate focal regions of

myocardial contusion that have the potential to progress to

subsequent cardiogenic shock. Furthermore, ECHO is

indicated in the work-up of any patient with penetrating

trauma to the cardiac box, with aq ualifiedechocardiographer

able to detect accumulations of blood as little as 20 mL

within the pericardia! sac (Figure 87-4). Finally, bedside

ultrasound (US) does have a role in helping to diagnose

PTX and can detect HTX with a volume as low as 50 mL.

Computed tomography angiography ( CTA) has become

the modality of choice in evaluating patients with potential

BAI (Figure 87-5). Because of the high lethality associated

with delayed diagnosis, any patient with a sudden deceleration mechanism (fall >30 ft or MVC >30 mph) and either

an abnormal CXR or evidence of thoracic injury should

undergo CTA. Given improvements in CTA technology, a

normal study is essentially 1 00% sensitive to exclude BAl.

PROCEDURES

...... Needle and Tube Thoracostomy

Needle decompression of a tension PTX is an emergently

life-saving procedure and should be performed during the

primary survey. Chest tube placement should be used for the

management of nearly every traumatic PTX or HTX. See

Chapter 7 for further details.

A Figure 87-4. Traumatic pericardia! effusion on bedside FAST exam. Note the large collection of fluid

with in the pericardia! space (arrow). Reprinted with

permission from Ross C, Schwab TM. Chapter 259.

Cardiac Trauma. In: Tintinalli JE, Stapczynski JS, Cline

DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's

Emergency Medicine: A Comprehensive Study Guide.

7th ed. New York: McGraw-Hill, 201 1.

Figure 87-5. Blunt aortic injury on CTA. Note

the disrupted aortic lumen at the attachment site

of the ligamentum arteriosum (a rrow).

...... Pericardiocentesis

Pericardiocentesis can be an emergently life-saving

procedure for any patient exhibiting peri car dial tamponade.

A long large-gauge needle (eg, a 10-cm 18-gauge spinal

needle) should be inserted at the subxiphoid space and

directed toward the underlying pericardium. US guidance

CHAPTER 87

can facilitate proper placement. Aspiration of volumes as

low as 10 mL of pericardia! blood result in stroke volume

increases between 25% and 50% and can stabilize the

patient pending definitive operative treatment .

...... ED Thoracotomy

A resuscitative thoracotomy can be a life-saving procedure

when performed on patients who lose signs of life either

with EMS in route or in the ED. In the best possible circumstances, survival rates are <10% and usually highest

for victims of penetrating trauma, especially those with

anterior stab wounds. Once the decision is made to per ­

form an ED thoracotomy, the procedure should be done

expediently without delay. An incision should be made in

the fourth or fifth intercostal space extending from the

sternal border to the posterior axillary line. The intercostal

muscles are incised and the ribs are retracted to expose the

underlying thoracic viscera. The pericardium can be visualized by gently retracting the overlying lung, and any

pericardia! blood will be apparent. The pericardium should

be opened with a vertical incision (to avoid trauma to the

nearby phrenic nerves) and the heart lifted forward and

"delivered" from the pericardia! sac. Cardiac wounds are

treated either with suture or staple closure (with care being

made to avoid occluding an underlying coronary artery) or

Foley catheter balloon tamponade. If the patient fails to

respond, the descending aorta should be cross-clamped to

direct any subsequent cardiac output into the cerebral and

cardiopulmonary circulation.