Professional Documents
Culture Documents
681
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
Airway obstruction as Deformity over the clavicle and Clinical Dx Immediate reduction if unable to
a result of stridor; depressed medial intubate
retrosternal clavicle on a chest radiograph
clavicular dislocation
Tension pneumothorax JVD, tracheal deviation, and Clinical Dx Needle decompression followed
unilaterally absent breath sounds immediately by tube
thoracostomy
Open pneumothorax Respiratory distress as a result of Clinical Dx Three-sided tape over the wound
a sucking chest wound and tube thoracostomy
Flail chest Respiratory distress, tenderness, Three or more ribs fractured Early CPAP and close attention to
crepitus, and paradoxic in two or more places on a pain control and fluid status
movement chest radiograph
Cardiac tamponade Hypotension and tachycardia, JVD, Ultrasound confirms the Intravenous fluids,
and the Beck triad late diagnosis; chest radiograph; pericardiocentesis, and
ECG insensitive thoracotomy
Massive hemothorax Respiratory distress, chest wall Ultrasound confirms the Initial chest tube output of 1.5-2L
injury, diminished breath sounds, diagnosis; chest radiograph is an indication for surgical
and dullness to percussion with fluid collection intervention
CPAP, Continuous positive airway pressure; Dx, diagnostic testing; ECG, electrocardiogram; JVD, jugular venous distention.
Because children have more elastic chest walls, more energy associated hemothorax or pneumothorax.6,7 The electrocardio-
is transmitted to the underlying lung, and greater force is gram (ECG) should be examined for evidence of cardiac
required for fractures. Excluding other major trauma, 71% of rib injury. Scapula fractures are often missed on the initial chest
fractures in children younger than 2 years result from abuse.5 radiograph unless the scapular outline is specifically inspected.
Shoulder radiographs can confirm suspected fractures
(Fig. 78.1).
PRESENTING SIGNS AND SYMPTOMS Helical computed tomographic (CT) angiography should
be performed on hemodynamically stable patients when clini-
Classically, rib fractures are accompanied by localized tender- cally significant underlying injury is suspected. An abdominal
ness and pleuritic chest pain, as well as splinting, crepitus, CT scan can rule out intraabdominal injury in patients with
and ecchymosis. Patients with a classic sternum fracture have tenderness or fracture of the sixth rib or below, three or more
localized pain and tenderness along with ventral compression, rib fractures, hypotension noted in the field or emergency
ecchymosis, and deformity. Pain at the site of thoracic cage department (ED), abdominal or flank tenderness, pelvic or
injuries increases with cough and deep inspiration. Patients femoral fractures, or gross hematuria.8
with scapular fractures typically have rib and extremity frac-
tures that often mask the diagnosis of scapula fracture.
TREATMENT
DIFFERENTIAL DIAGNOSIS AND MEDICAL Adequate pain control should be provided to prevent atelec-
DECISION MAKING tasis in patients with simple acute rib fractures. Patients
should be instructed to perform incentive spirometry or take
The initial portable anteroposterior (AP) chest radiograph 10 deep breaths every hour. Binders and belts are not recom-
should be inspected to confirm the diagnosis of rib fracture mended because such devices promote hypoventilation, which
and underlying pleura or lung injury. Upright posteroanterior results in atelectasis and pneumonia. Shoulder slings and
(PA) and lateral radiographs should be obtained if a high clini- pendular exercise should be prescribed for most scapular
cal index of suspicion remains for fracture or underlying fractures. Displaced fractures, especially those involving the
injury. The presence of an occult clinical rib fracture with scapular spine and neck, often require consultation with an
tenderness over the rib should be assumed even in the absence orthopedic surgeon for repair.
of radiographic findings. Rib radiographs seldom add to the
clinical evaluation and are not routinely indicated.
Sternum fractures are best detected on the lateral chest FOLLOW-UP, NEXT STEPS IN CARE,
radiograph. Associated rib fractures and mediastinal abnor- AND PATIENT EDUCATION
malities may be evident on the PA view. In experienced hands,
bedside ultrasound may be more sensitive than radiographs Otherwise healthy patients with isolated rib fractures or
for detection of both rib and sternum fractures, as well as sternum or scapula fractures may be discharged home. Elderly
682
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
A
TREATMENT
Immediate chest tube placement is required for assessment
and management of other injuries, including pneumothorax
and hemothorax. Continuous positive airway pressure is
the first-line treatment in awake and cooperative patients
with worsening oxygenation or ventilation.10 Criteria for
intubation include airway obstruction, respiratory distress,
shock, closed head injury, and need for surgery. Endotracheal
intubation should be performed only when necessary to
B
avoid the increased mortality associated with nosocomial
Fig. 78.1 A, Chest radiograph showing fractures of the clavicle pneumonia.
(white arrow)) and scapula (black arrow). B, Lateral scapula Fluid replacement should be managed carefully to avoid
fractures (arrows) visible on a computed tomography scan. (From overhydration and worsening of lung injury. Analgesia is
Westra SJ, Wallace EC. Imaging of pediatric chest trauma. Radiol titrated so that patients are more willing to make sufficient
Clin North Am 2005;43:267-81.) inspiratory effort, but excessive sedation should be avoided.
Intercostal nerve blocks, epidural anesthesia, or even surgical
fixation of the flail segment may be beneficial.11 Stabilization
patients and those with multiple comorbid conditions may of the flail segment in the ED or prehospital setting has not
require admission for pain control and pulmonary therapy. An been shown to be helpful, and aggressive stabilizing efforts
intercostal nerve block can be of marked benefit. Discharged impede overall thoracic mechanics.
patients should be informed that the pain will diminish after
2 weeks but may persist for up to 6 weeks. Follow-up with a
trauma surgeon should be scheduled if pain persists beyond 4 FOLLOW-UP, NEXT STEPS IN CARE,
weeks to detect delayed rib fracture complications. AND PATIENT EDUCATION
Consultation and admission for trauma or cardiothoracic
FLAIL CHEST surgery is advised when flail chest is suspected. Overall mor-
tality from flail chest, though dependent on other injuries,
Flail chest occurs when three or more ribs are fractured in two ranges up to 35%. All patients with flail chest should be
or more places and a discontinuous segment of the thoracic admitted to the intensive care unit, preferably at a level I
wall is produced and moves paradoxically with respiration. trauma center for close observation of respiratory mechanics
Flail chest is diagnosed in approximately 5% of thoracic and worsening of pulmonary contusion.
trauma patients seen in level I trauma centers, typically in the
setting of multisystem trauma. Mechanisms include MVCs,
crush injuries, assault, falls, and even minimal trauma in PNEUMOTHORAX AND
elderly patients. Respiratory insufficiency results primarily HEMOTHORAX
from the underlying pulmonary contusion. Pneumothorax
occurs in 50% of cases and pulmonary contusion in 75%.9 A simple pneumothorax occurs when air accumulates in the
pleural space without shifting the mediastinum or communi-
cating with the atmosphere. Mechanisms include laceration
PRESENTING SIGNS AND SYMPTOMS of the pleura or lung by a fractured rib, alveolar rupture from
compression of the chest against a closed glottis, or a penetrat-
Patients may have the classic signs and symptoms of respira- ing wound in the thorax.
tory distress, tenderness, crepitus, deformity, and paradoxic Tension pneumothorax occurs when injury to the chest wall
motion of the affected thoracic wall. Affected segments will acts as a one-way valve. Outside air enters the pleural space
683
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
PRESENTING SIGNS AND SYMPTOMS Fig. 78.2 Chest radiograph showing obvious left-sided
tension pneumothorax with mediastinal shift. (From Ullman EA,
Patients with a simple pneumothorax classically have chest Donley LP, Brady WJ. Pulmonary trauma emergency department
pain, diminished breath sounds, crepitus, hyperresonance, and evaluation and management. Emerg Med Clin North Am 2003;
21:291-313.)
mild to moderate respiratory distress. Patients with tension
pneumothorax are classically seen in extremis and exhibit
jugular venous distention, tracheal deviation, unilaterally
absent breath sounds, or tachycardia followed by hypotension
immediately before death (or any combination thereof).12 mainstem intubation results in jugular venous distention, tra-
Patients with open pneumothorax have chest wall wounds that cheal deviation to the left, normal resonance, and diminished
produce sonorous sounds and are in severe respiratory dis- breath sounds on the left versus the right. In an intubated
tress. Typical symptoms of hemothorax are respiratory dis- patient, the endotracheal tube should be checked and pulled
tress, chest pain, and diminished breath sounds with dullness back. In the field or resuscitation bay, bilateral needle thora-
to percussion. costomy should be performed when the patient is in distress,
Atypical manifestations are more common than classic even if the diagnosis is uncertain. A rush of air confirms the
ones. Respiratory distress may occur as a result of multiple diagnosis of tension pneumothorax. Chest tubes must be
other causes. Patients can have severe pain from distracting placed after needle decompression.
injuries. Breath sounds may be difficult to hear in a noisy A chest radiograph can confirm the diagnosis of simple
environment. Physical examination in patients with penetrat- pneumothorax and hemothorax. A distance of 1cm or one
ing thoracic trauma is unreliable for the detection of pneumo- fingerbreadth between the chest wall and visceral pleural line
thorax or hemothorax.13 Patients with simple pneumothorax correlates with a small, 10% to 15% pneumothorax. Anything
may be minimally symptomatic or may be cyanotic and in larger requires immediate chest tube insertion. On a supine
severe respiratory distress. Tension pneumothorax most com- portable AP chest radiograph, a deep sulcus sign suggests
monly occurs in intubated patients as a result of positive pneumothorax. The affected costophrenic angle appears
pressure ventilation, sometimes after overzealous bagging. clearer and deep with depression of the hemidiaphragm as a
Clinical reassessment of ventilated patients with decreasing result of localized air collection in a supine patient. In patients
oxygen saturation and hypotension may allow faster detection with a high index of clinical suspicion based on symptoms or
and treatment, even before chest radiographic diagnosis. Open penetrating injuries, some authorities advocate expiratory
pneumothorax may be missed if the patient is not completely upright PA and lateral chest radiographs to make the lung
exposed and rolled during the primary survey. volume smaller and the pneumothorax volume relatively
larger and easier to visualize. Clinically significant pneumo-
thorax should be evident on standard chest radiographs. The
DIFFERENTIAL DIAGNOSIS AND MEDICAL chest CT scan is more sensitive in visualizing pneumothorax;
DECISION MAKING it often detects small occult pneumothoraces, which require
close monitoring.
The differential diagnosis for tension pneumothorax includes In an upright patient, a hemothorax appears as a fluid layer
cardiac tamponade, massive hemothorax, and right mainstem in the affected hemithorax. Early collections are noted to blunt
intubation with left lung collapse. All will produce respiratory the costophrenic angles on the AP and lateral radiographic
distress, hypotension, and tachycardia. Cardiac tamponade views. Hemothorax often appears as only a diffuse hazy infil-
results in diminished heart sounds with normal breath sounds trate in a supine trauma patient. Hemopneumothorax has a
and a midline trachea. Massive hemothorax produces fluid layer with a flat superior border, in contrast to the round
decreased or absent unilateral breath sounds and dullness to meniscus of an isolated hemothorax (Figs. 78.2 and 78.3).
percussion. Chest tube insertion confirms the diagnosis. Right Decubitus views better demonstrate a small hemothorax.
684
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
685
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
TRACHEOBRONCHIAL INJURY
Tracheobronchial injuries are infrequent but present unique
challenges to the emergency physician (EP). Emergency
airway management is often both required and complicated
by these devastating injuries.
Penetrating tracheobronchial injuries are more common
than blunt injuries. Penetrating injuries to the relatively
exposed cervical trachea occur more frequently than injuries
to the protected thoracic trachea. Gunshot wounds involving
the thoracic trachea occur more often than stab wounds. Blunt
injuries to the cervical trachea occur with rapid deceleration
and result in shear stress at the junction of the larynx and
trachea; examples of these types of injury include hyperexten-
sion injury, direct dashboard strikes, and clothesline injuries
in snowmobile and motorcycle accidents.
Blunt injuries to the thoracic trachea are typically caused
Fig. 78.4 Chest radiograph showing right pulmonary by high-energy MVCs, crush injuries, and falls. Rapid decel-
contusion with pneumomediastinum and pneumopericardium. eration produces a shearing force with injury typically within
(From Marx J, Hockberger R, Walls R, editors. Rosens emergency 2cm of the fixed carina. Injuries to the esophagus and spine
medicine: concepts and clinical practice. 6th ed. St. Louis: Mosby; are the most common associated injuries. Head, vascular,
2006.) nerve, and intrathoracic injuries also occur frequently with
both blunt and penetrating tracheobronchial injuries (Box
78.1).
686
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
CT, Computed tomography; CXR, chest radiograph; DPL, diagnostic peri- The pathologic spectrum of blunt cardiac injury begins with
toneal lavage; ECG, electrocardiogram; FAST, focused assessment with cardiac concussion; includes myocardial contusion, coronary
sonography for trauma; PA, posteroanterior. artery injury, and valve and septal injury; and ends with myo-
*Protocols and approach may vary depending on institutional experience cardial rupture. Myocardial contusion remains the most
and availability.
common clinical challenge to the EP. A definitive diagnosis
can be made only at autopsy, and complications are rare but
life-threatening.
Blunt cardiac injury typically results from MVCs but may
occur after falls, crush injuries, blast injuries, direct blows,
tion in the evaluation of penetrating thoracic and tracheobron- and chest compression. Low-speed deceleration injuries occa-
chial injuries. sionally result in significant injury. Proposed mechanisms
include compression of the heart between the sternum and
vertebral bodies and sudden striking of the heart against the
TREATMENT sternum in deceleration injuries.
Cardiac concussion, or commotio cordis, occurs when
Patients with tracheobronchial injuries who are in respiratory a blow to the chest briefly stuns the heart; it results in
distress require immediate intubation and mechanical ventila- dysrhythmia, hypotension, syncope, and often sudden death
tion. Fiberoptic bronchoscopy is the best diagnostic and man- but without permanent cellular damage. Commotio cordis
agement option for patients with cervical and intrathoracic may result from an anterior chest wall impact at a moment
tracheal injuries. When not available and immediate airway when the myocardium is refractory to depolarization and
intervention is required, some authorities recommend orotra- can result in fatal arrhythmia, also known as the R-on-T
cheal intubation without paralysis to prevent loss of paratra- phenomenon.20
cheal muscle support of the injured trachea. The benefits must Myocardial contusion occurs when injury to the anterior
be weighed against the suboptimal intubating conditions in a wall, formed by the right ventricle, results in well-defined
nonparalyzed patient. If paralysis is required, prior prepara- areas of red blood cell extravasation and eventually in
tion for a surgical airway and right-sided thoracotomy is subendocardial and transmural necrosis. Infrequent delayed
necessary. complications include mural thrombus, pericardial effusions,
687
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
constrictive pericarditis, and ventricular aneurysms. Direct of the FAST scan. Formal echocardiography with parasternal
injury to already atherosclerotic coronary arteries or and apical views will better identify small effusions, valve
severely contused myocardium can result in myocardial dysfunction, and wall motion abnormalities. Transesophageal
infarction. The rare blunt cardiac rupture is typically echocardiography is more sensitive than transthoracic echo-
immediately fatal except when limited to the low-pressure cardiography and provides additional imaging of the aorta in
right side of the heart or to small, self-sealing ventricular unstable patients. Routine echocardiography does not predict
injuries. complications in stable patients with suspected blunt cardiac
injury.
688
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
689
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
690
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
A C
691
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
and such mortality is primarily related to the extent of the pleural effusion, pneumothorax, and a widened mediastinum.
injury and condition of the patient. A lateral neck radiograph may reveal prevertebral air displac-
ing the tracheal air column forward. Early in the course of a
perforation, radiographic evidence is often minimal. Later CT
ESOPHAGEAL INJURY scans of the chest may demonstrate collections of air or fluid
as infection develops, but CT scans are not usually performed
Esophageal injuries occur infrequently with both blunt and for esophageal injury.
penetrating trauma. More immediate life-threatening inju- Esophagography and esophagoscopy should be performed
ries often mask the clinical findings, and esophageal leakage in all patients with suspected esophageal injury, although
can progress to fatal mediastinitis. Esophageal evaluation is neither modality alone is sensitive enough to rule out
indicated in patients with a significant penetrating injury esophageal injury. The initial esophagography is done with
to the neck. The majority of esophageal perforations result Gastrografin to avoid mediastinal irritation from leakage
from medical endoscopic procedures, not from traumatic of barium. Incidentally, a CT scan after barium ingestion
injuries. may detect small esophageal perforations and small metallic
Penetrating esophageal injury must be considered in any foreign bodies better than plain radiographs can. Negative
patient with injury near or trajectory through the esophagus. findings on an esophagogram with Gastrografin enhancement
Common mechanisms of penetrating injury include lacera- should be followed by the more sensitive barium-
tion, missile penetration, iatrogenic perforation, and ingested enhanced esophagography. Neither contrast agent prevents
foreign body. Stab wounds to the neck often directly injure the use of endoscopy. If findings on both esophagograms
the esophagus. High-velocity gunshots result in direct esopha- are negative, flexible endoscopy can be used to exclude subtle
geal perforation, as well as delayed necrosis. The majority of injuries.
penetrating injuries occur at the proximal or distal end of the
esophagus during routine endoscopy.
Blunt esophageal injuries are much less common than TREATMENT
penetrating injuries. Common mechanisms include crush
injuries to the cervical esophagus and barotrauma. Blunt Chest tube drainage is often necessary for associated pneu-
laryngotracheal trauma and cervical spine fractures are asso- mothorax. Persistent air leak is suggestive of esophageal
ciated with injuries to the upper part of the esophagus. Blunt injury. Food particles in the chest tube confirm major injury.
injuries to the lower third of the esophagus occur with Patients should be kept on nothing-by-mouth status. Fluid
sudden increases in intraabdominal pressure against a closed resuscitation is mandatory. Broad-spectrum antibiotics that
upper esophageal sphincter, analogous to Boerhaave syn- cover oral anaerobes should be administered. Placement of a
drome. The initial rupture typically originates from an inher- nasogastric tube is controversial because of the risk for medi-
ent weakness in the left posterior aspect of the distal end of astinitis and should be done in consultation with trauma or
the esophagus. general surgery services.
Both cardiopulmonary resuscitation and the Heimlich
maneuver have been associated with perforation of the tho-
racic esophagus. Blast injury can result in primary esophageal FOLLOW-UP, NEXT STEPS IN CARE,
injury as a result of the pressure wave, in secondary injury AND PATIENT EDUCATION
from impact of the patient against fixed structures, and in
tertiary injury from blast projectiles. Management can be operative or nonoperative. Small, mini-
mally symptomatic or chronic perforations, particularly those
involving the cervical esophagus secondary to instrumenta-
PRESENTING SIGNS AND SYMPTOMS tion, are most amenable to a nonsurgical approach.34 Consul-
tation with trauma or general surgery specialists for primary
Typical symptoms of esophageal injury include pleuritic chest surgical repair dramatically improves outcomes.
pain anywhere along the course of the esophagus, dyspnea,
odynophagia, dysphagia, hoarseness, and pain with flexion or
extension of the neck. The physical examination should include
palpation for subcutaneous emphysema and auscultation for a DIAPHRAGMATIC INJURIES
systolic Hamman crunch produced by mediastinal air.
Commonly, patients have emergency life-threatening inju- Diaphragmatic injuries are a diagnostic challenge and are
ries that obscure the clinical findings, which can lead to associated with significant delayed complications. Complica-
delayed recognition and management. Fever, tachycardia, tions often develop weeks to years after the initial trauma
hypotension, and progressive dyspnea are noted as mediasti- and consist of symptoms of visceral herniation. Both blunt
nitis develops. and penetrating trauma can cause diaphragmatic injuries, but
with very different injury patterns. The most common mecha-
nisms for blunt diaphragmatic injuries are MVCs and falls,
DIFFERENTIAL DIAGNOSIS AND MEDICAL followed by pedestrian-versus-vehicle collisions, motorcycle
DECISION MAKING accidents, and crush injuries. Penetrating injuries result
from gunshot or stab wounds. When detected initially, dia-
AP or PA chest radiographs should be examined for evidence phragmatic injury signals that other severe injuries are
of mediastinal air, subcutaneous emphysema, left-sided probably present.
692
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
693
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
SECTION VIII TRAUMATIC DISORDERS
RED FLAGS
Soreide E, Deakin CD. Prehospital fluid therapy in the critically injured patienta
SUGGESTED READINGS clinical update. Injury 2005;36:1001-10.
EAST management of pulmonary contusion and flail chest practice guidelines 2006.
Available at http://www.east.org/.
Eroglu A, Turkyilmaz A, Aydin Y, et al. Current management of esophageal REFERENCES
perforation: 20 years experience. Dis Esophagus 2009;22:374-80.
Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin References can be found on Expert Consult @
injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med www.expertconsult.com.
2005;46:232-6.
Practice management guidelines for emergency department thoracotomy: Working
Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons
Committee on Trauma. J Am Coll Surg 2001;193:303-9.
694
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.
CHAPTER 78 Thoracic Trauma
21. EAST trauma practice guidelines, EAST blunt cardiac injury guidelines. Available
REFERENCES at http://www.east.org/tpg/archive/html/chap2body.html.
22. Ismailov RM, Ness RB, Redmond CK, et al. Trauma associated with cardiac
1. Lee J, Harris Jr JH, Duke Jr JH, et al. Noncorrelation between thoracic skeletal dysrhythmias: results from a large matched casecontrol study. J Trauma 2007;
injuries and acute traumatic aortic tear. J Trauma 1997;43:400-4. 62:1186-91.
2. Gouldman JW, Miller RS. Sternal fracture: a benign entity? Am Surg 1997;63: 23. Jackson L, Stewart A. Best evidence topic report. Use of troponin for the
17-9. diagnosis of myocardial contusion after blunt chest trauma. Emerg Med J 2005;
3. von Garrel T, Ince A, Junge A, et al. The sternal fracture: radiographic analysis of 22:193-5.
200 fractures with special reference to concomitant injuries. J Trauma 2004;57: 24. Ball CG, Williams BH, Wyrzykowski AD, et al. A caveat to the performance of
837-44. pericardial ultrasound in patients with penetrating cardiac wounds. J Trauma
4. Shweiki E, Klena J, Wood GC, et al. Assessing the true risk of abdominal solid 2009;67:1123-4.
organ injury in hospitalized rib fracture patients. J Trauma 2001;50:684-8. 25. Rhee PM, Acosta J, Bridgeman A, et al. Survival after emergency department
5. Kemp AM, Dunstan F, Harrison S, et al. Patterns of skeletal fractures in child thoracotomy: review of published data from the past 25 years. J Am Coll Surg
abuse: systematic review. BMJ 2008;337:a1518. 2000;190:288-98.
6. Rainer TH, Griffith JF, Lam E, et al. Comparison of thoracic ultrasound, clinical 26. Branney SW, Moore EE, Feldhaus KM, et al. Critical analysis of two decades of
acumen, and radiography in patients with minor chest injury. J Trauma 2004; experience with postinjury emergency department thoracotomy in a regional
56:1211-3. trauma center. J Trauma 1998;45:87-94.
7. Jin W, Yang DM, Kim HC, et al. Diagnostic values of sonography for assessment 27. Practice management guidelines for emergency department thoracotomy: Working
of sternal fractures compared with conventional radiography and bone scans. J Group, Ad Hoc Subcommittee on Outcomes, American College of Surgeons
Ultrasound Med 2006;25:1263-1268; quiz 1269-70. Committee on Trauma. J Am Coll Surg 2001;193:303-9.
8. Holmes JF, Ngyuen H, Jacoby RC, et al. Do all patients with left costal margin 28. Wise D, Davies G, Coats T, et al. Emergency thoracotomy: how to do it. Emerg
injuries require radiographic evaluation for intraabdominal injury? Ann Emerg Med J 2005;22:22-4.
Med 2005;46:232-6. 29. Cook CC, Gleason TG. Great vessel and cardiac trauma. Surg Clin North Am
9. Ullman EA, Donley LP, Brady WJ. Pulmonary trauma emergency department 2009;89:797-820, viii.
evaluation and management. Emerg Med Clin North Am 2003;21:291-313. 30. Horton TG, Cohn SM, Heid MP, et al. Identification of trauma patients at risk of
10. Gunduz M, Unlugenc H, Ozalevli M, et al. A comparative study of continuous thoracic aortic tear by mechanism of injury. J Trauma 2000;48:1008-13.
positive airway pressure (CPAP) and intermittent positive pressure ventilation 31. Nagy K, Fabian T, Rodman G, et al. Guidelines for the diagnosis and
(IPPV) in patients with flail chest. Emerg Med J 2005;22:325-9. management of blunt aortic injury: an EAST Practice Management Guidelines
11. EAST management of pulmonary contusion and flail chest practice guidelines Work Group. J Trauma 2000;48:1128-43.
2006. Available at http://www.east.org/. 32. Dyer DS, Moore EE, Ilke DN, et al. Thoracic aortic injury: how predictive is
12. Barton ED. Tension pneumothorax. Curr Opin Pulm Med 1999;5:269-74. mechanism and is chest computed tomography a reliable screening tool? A
13. Bokhari F, Brakenridge S, Nagy K, et al. Prospective evaluation of the sensitivity prospective study of 1,561 patients. J Trauma 2000;48:673-82.
of physical examination in chest trauma. J Trauma 2002;53:1135-8. 33. Stassen NA, Lukan JK, Spain D, et al. Reevaluation of diagnostic procedures for
14. Kirkpatrick AW, Sirois M, Laupland KB, et al. Handheld thoracic sonography transmediastinal gunshot wounds. J Trauma 2002;53:635-8.
for detecting posttraumatic pneumothoraces: the extended focused assessment 34. Eroglu A, Turkyilmaz A, Aydin Y, et al. Current management of esophageal
with sonography for trauma (EFAST). J Trauma 2004;57:288-95. perforation: 20 years experience. Dis Esophagus 2009;22:374-80.
15. Maxwell RA, Campbell DJ, Fabian TC, et al. Use of presumptive antibiotics 35. Reber PU, Schmied B, Seiler CA, et al. Missed diaphragmatic injuries and their
following tube thoracostomy for traumatic hemopneumothorax in the prevention longterm sequelae. J Trauma 1998;44:183-8.
of empyema and pneumoniaa multicenter trial. J Trauma 2004;57:742-8. 36. Wong P, Vendargon SJ. Tension enterothorax. Asian Cardiovasc Thorac Ann 2003;
16. Brasel KJ, Stafford RE, Weigelt JA, et al. Treatment of occult pneumothoraces 11:375.
from blunt trauma. J Trauma 1999;46:987-90. 37. Allen TL, Cummins BF, Bonk RT, et al. Computed tomography without oral
17. Seamon MJ, Medina CR, Pieri PG, et al. Followup after asymptomatic contrast solution for blunt diaphragmatic injuries in abdominal trauma. Am J
penetrating thoracic injury: 3 hours is enough. J Trauma 2008;65:549-53. Emerg Med 2005;23:253-8.
18. Wanek S, Mayberry JC: Blunt thoracic trauma: flail chest, pulmonary contusion, 38. Gangahar R, Doshi D. FAST scan in the diagnosis of acute diaphragmatic rupture.
and blast injury. Crit Care Clin 2004;20:71-81. Am J Emerg Med 2010;28:387.e1-387.e3.
19. Huh J, Milliken JC, Chen JC. Management of tracheobronchial injuries following 39. Blaivas M, Brannam L, Hawkins M, et al. Bedside emergency ultrasonographic
blunt and penetrating trauma. Am Surg 1997;63:896-9. diagnosis of diaphragmatic rupture in blunt abdominal trauma. Am J Emerg Med
20. Maron BJ, Estes NAM. Commotio cordis. N Engl J Med 2010;362:917-27. 2004;22:601-4.
694.e1
Downloaded from ClinicalKey.com at Universitas Hasanuddin April 12, 2016.
For personal use only. No other uses without permission. Copyright 2016. Elsevier Inc. All rights reserved.