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<< Ballistic Injuries In The Emergency Department (Trauma CME)

Management Of Thoracic Gunshot Wounds

Thoracic ballistic wounds often injure multiple structures and require significant hospital resources to manage emergently. (See Table 8.) Major vascular injuries occur in 4% of penetrating chest trauma cases. If tracheobronchial injuries are present, the proportion of patients with major vascular injuries can be as high as 30% (not including cardiac injuries that occur in 3% of cases).78 Many patients with penetrating thoracic injuries do not survive to the ED, and those that do survive to the ED often require immediate interventions such as tube thoracostomy, intubation, and thoracotomy. Thus, the emergency clinician must be able to rapidly diagnose and treat injuries that are immediately life-threatening.

 

Evaluation Of Thoracic Trauma

Focused assessment with sonography in trauma (FAST) examination has become a mainstay of early trauma management, as bedside ultrasound has become readily available in many institutions. The FAST examination should be performed early in the initial assessment of penetrating thoracic trauma as it can help accurately diagnose a pericardial effusion, hemoperitoneum, pneumothorax, and hemothorax and thus direct timely treatment to the most appropriate location. Bedside ED ultrasound of the pericardium has been shown in multiple studies to have excellent sensitivity, specificity, and accuracy (100%, 97%, and 97%, respectively).79,80 A false-negative examination is possible if the cardiac injury is not contained within the pericardium and is causing a massive hemothorax, but false-positive pericardial ultrasounds are rare. Case reports describing false-positive pericardial ultrasounds have been reported most frequently in the setting of a massive hemothorax or mediastinal injury.81 Tube thoracostomy to relieve the hemothorax followed by a repeat pericardial ultrasound may improve the diagnostic accuracy in these cases.

Recent improvements in the performance of bedside ultrasound have led to the expanded FAST (E-FAST) examination to include sonographic evaluation of the chest cavity to assess for pneumothorax and hemothorax. A positive ultrasound for a pneumothorax in a symptomatic patient suggests that decompression is warranted. The findings on ultrasound include a lack of lung sliding and the “seashore” or “bar code” sign.

Chest radiographs are necessary in all thoracic ballistic injuries, regardless of presenting symptoms. In many institutions, portable chest radiographs are frequently ordered on trauma patients, but they are notoriously less accurate than upright posteroanterior and lateral chest films. Nonetheless, portable films are the practical choice for more severely injured patients. Chest films can help determine the presence of most thoracic injuries to the lungs, bony chest wall, and vertebrae, and they can help locate the projectile as well.

In hemodynamically stable patients, CT is warranted if there is still suspicion for intrathoracic injuries after physical examination, FAST examination, and chest films. Computed tomography is highly accurate for diagnosing injuries missed clinically and on chest x-ray. With advances in CT technology and its widespread availability, many clinically important and occult diagnoses may be found only on CT. For example, Ball et al detected an occult pneumothorax on CT in 14.5% of 338 patients with a normal chest radiograph, 47% of whom required drainage.82 Similarly, Stafford found that 21% of 410 trauma patients with a normal chest film had a hemothorax in CT, and half of these patients required tube thoracostomy.83 As always, the emergency clinician should weigh the risks and benefits of CT versus observation based upon ED resources, the potential dangers of irradiation, and the likelihood of complications.

Treatment Of Thoracic Trauma

The management of penetrating thoracic trauma can be complex because so many structures are at risk for injury. Early involvement of a trauma surgeon is recommended, since the final common pathway for many of these patients is surgery or admission for close observation and serial examinations.

When the patient presents in extremis or loses vital signs in the ED, an emergency thoracotomy should be performed, if possible. Indications for emergency thoracotomy include loss of vital signs in the ED (or immediately prior to arrival), evidence of cardiac tamponade, and massive hemothorax. Emergency thoracotomy should not be performed if there are inadequate surgical resources available to definitively manage the patient.

Emergent needle decompression and tube thoracostomy are indicated in the presence of a clinically significant pneumothorax or hemothorax, respectively. Needle decompression should only be performed as a stabilizing procedure while preparing to place a thoracostomy tube. Many needle decompressions fail to get into the pleural space when placed in the classic anterior position of the second intercostal space in the midclavicular line because the chest wall in many adults may be too thick for standard IV catheters.84 The lateral chest wall at the fourth or fifth intercostal spaces in the midaxillary line has been found to be just as thick as the anterior chest wall.84-86 Angiocatheters are longer and stand a greater chance of penetrating the pleural cavity, but there are still many failures when this procedure is attempted.86 Therefore, needle decompression may be ineffective at temporarily relieving a tension pneumothorax, and a thoracostomy tube should be placed immediately if there is truly a concern for a tension pneumothorax. Chest tubes should be placed prior to imaging if there is any suggestion of instability, tension pneumothorax, or hemothorax.28

Fluid resuscitation of the patient with hemorrhagic shock often starts with a crystalloid bolus, but immediate release of blood products (at least 6 units of packed red blood cells [PRBCs] and fresh frozen plasma [FFP]) should be obtained concurrently and started immediately, when available. Literature supports the role of permissive hypotension in the penetrating trauma patient to reduce the possibility of causing increased hemorrhage by dislodging a clot or tamponade that has occurred naturally.87,88 Blood products are recommended at a 1:1 ratio of PRBCs, FFP, and platelets to prevent coagulopathy from developing or worsening. These patients should also be kept warm (> 34oC [> 93.2oF]) to prevent hypothermia from occurring and worsening coagulopathy.89

The recent CRASH-2 trial of over 20,000 bleeding trauma patients from 40 countries worldwide concluded that providing early use of tranexamic acid decreased all-cause mortality and the risk of death due to bleeding compared to placebo and states that this medication may be a useful adjunct in the bleeding trauma patient.90

Administration of prophylactic antibiotics in patients with penetrating chest trauma requiring tube thoracostomy has been debated. Sanabria et al performed a meta-analysis of 5 randomized controlled trials and found that patients given prophylactic antibiotics had a decreased frequency of pneumonia and posttraumatic empyema.91

 
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Last Modified: 07/19/2018
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