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A 38-year-old woman is brought to the emergency department after exposure to an explosion. The patient is confused but able to answer questions, is short of breath and complaining of pain over her left chest with respiration, and opens her eyes to verbal command. She is tachycardic with a heart rate of 112 bpm; hypotensive with a blood pressure of 92/54 mm Hg; tachypneic, breathing 28 breaths/minute; and has an oxygen saturation of 98% on 2 L of oxygen via nasal cannula. The physical examination is notable for decreased breath sounds over the right lung field and carbonaceous material in her nares.

What thoracic injuries should be considered immediately in this patient?

Patients who experience thoracic trauma may present with life-threatening injuries such as a pneumothorax, hemothorax, traumatic air embolism, cardiac tamponade, major airway injury, aortic rupture, myocardial rupture, and flail chest (Figure 29-1).1-7

Figure 29-1.

Life-threatening complications of thoracic trauma.

A pneumothorax occurs from an injury to the chest wall or lung. As the patient inspires, gas enters the pleural space, where it is trapped. When a one-way valve mechanism occurs at the site of injury, intrapleural pressure increases with each respiratory cycle. Eventually, the ipsilateral lung is compressed and displaced to the opposite side causing a tension pneumothorax. In a tension pneumothorax, kinking of the major vessels entering the heart, decreased venous return, and hypotension occur.8 A hemothorax also occurs after blunt or penetrating thoracic trauma. The diagnosis is confirmed by placement of a chest tube and drainage of blood from the thoracic cavity. A double-lumen tube can be used for lung isolation to prevent further hypoxia (Figure 29-2).

Figure 29-2.

Double-lumen endotracheal tube.

There is paradoxical motion of the chest wall in patients with a flail chest. After rib injury, free-floating segments of a loose chest wall move in response to pleural pressure instead of the mechanical positions of the rest of the chest wall. Compromised lung mechanics make inspiration difficult and lead to a pulmonary contusion as a loose chest wall collides with underlying lung tissue.

In patients who present with stridor or subcutaneous emphysema, major airway injury should be considered.9 There should be a low threshold to intubate patients with suspected injury of the airway. Endotracheal intubation can be difficult when there are changes in the anatomy of the airway. Damage to the bronchial tree can lead to the development of a bronchovenous fistula resulting in a massive air embolus. The presentation of this process may be delayed and unmasked by positive-pressure ventilation.

Almost all patients with an aortic or myocardial rupture die prior to transfer to the intensive care unit (ICU).3,10...

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