By: Jeffrey Rixe, M.D.

Chest Trauma

Rib Fractures
– Chest XR: look for intra-thoracic trauma (no specific rib series indicated)
– Multiple areas of tenderness? Consider CT
– Flail chest: 3 or more rib fractures at 2 points. Flail segment goes IN on inspiration and OUT on expiration
– Isolated sternal fracture? Repeat ECG’s in 6 hours to eval for cardiac injury
– 1st rib fractures: CTA for major vessel injury
– Tx (simple rib fractures): Pain control, incentive spirometry, NO binders
– Elderly patient with 6+ fractures = ICU.
– Anyone with 3+ rib fractures = admission to level 1 trauma center
Tracheobronchial injury
– Dx: CXR will commonly reveal pneumomediastinem. CT and Bronchoscopy also needed.
– Tx: OR necessary for repair.
Pulmonary Contusion
-CT chest: opacification of the lung within 6 hours (pathognomonic)
– Tx: Keep good lung DOWN, aggressive pain control and pulmonary toilet
– Dx: CXR (sensitivity ~40%) to eval for other injuries as well. US more sensitive (~70%).
– Tx: Thoracotomy (make sure to measure)
– Tension Pneumothorax: needle decompress, 2nd intercostal space, mid-clavicular line, large bore and long needle (12 gauge, 3 inch), may have difficulty with standard angiocath (take green needle from central line setup if needed)
-Rare but commonly missed, most commonly on left side
-Definitive Dx: Laparoscopy


EMS: Management of injuries from less-lethal weapons 

Special projectiles (rubber bullets, bean bag rounds)

-Less-lethal can still be lethal (Ex: pepperball shot into the eye)
-Contusions can result in subsequent necrotic ulcers
– Management similar to other major blunt trauma, depends on area hit

Riot control (OC/Pepper spray)
– Tx: Dilute with water, baby shampoo

CEW (Conducted Electrical Weapon) or CED (Conducted Energy Devices) – aka TASER
– DECREASED relative risk of injury to officer and suspect (compared to other devices)
– How does it work? Fires 2 probes, series of electrical impulses – pain and involuntary muscle contractions
– Secondary injuries: falls
– Cardiac effect? 0.36-1.76 J for TASER, way less than 150+ J used for VF
– Elevated lactate in victims (without severe acidosis)
– Who is likely to decompensate after a TASER? Excited Delirium patients
– Consider WHY the patient required a TASER (AMS, psych, intoxication, delirium)
– TASER Barb removal: wear gloves, stabilize skin, position probe perpendicular to skin, pull to disengage (if still connected, cut wires with trauma shears). DEEPER? Lidocaine, 11 blade stab incision
History of “Don’t TASE me bro!”

Ultrasound Findings
– Double barrel shotgun, also “Olive Sandwich” = dilated CBD
– McConnell Sign = Acute PE, deceased/abnormal RV wall motion  (apical 4)
– “D” shaped RV = RV strain, acute PE  (parasternal short)
– Cardiac Tamponade  = effusion in parasternal long, M mode
– SIN (stone in neck) sign = GB stone in neck
-Ying Yang sign = mixed of flow (turbulence) in a AAA
– Spine sign = Pleural effusion (spine should not be visualized through normal lung)
– Lung Point = pneumothorax sliding into view
-Broccoli or Bear claw sign = hydronephrosis
-Hepatization of the lung = pneumonia, air bronchograms also seen
– Cobblestoning = cellulitis
– Anisotropy = appearance of tendons on US, black/white changes with beam change
– Seminal Vesicles = above prostate, well contained, below bladder (normal finding)
– “Aliasing” = velocity of color flow doppler is set to low (adjust sensitivity in settings)
-“Twinkling” = color flow on urinary stone at the UVJ, highlights the stone
– Double line sign = thick line of perinephric fat around the kidney (NOT free fluid)

Community  Corner: Pack ‘n’ ship trauma
Airway: Talking? Mumbling? Anything obstructing airway?
Breathing: bilateral breath sounds and lung sliding
Circulation: HR and BP, obvious bleeding, distal pulses x4, eFAST
Disability: GCS,  pupils, obvious spinal injury?
Exposure: full (axilla, perineum, beneath breasts) – consider rewarming

EM RAP Trauma Transfer:

10 Procedures that must be completed before transfer
1) RSI
2) Chest tube
3) Pelvis Stabilization/binding
4) Splinting
5) Traction Splinting
6) Hemorrhage control
7) Vascular Access
8) Transfusions
9) Surgical Airways

Transfer Call:  Situation, Initial VS, Pertinent Exam, Interventions/Response

Multisystem trauma = Control ABC’s, avoid stay and play or extra imaging
– Hemorrhaging extremity = Tourniquet
– Fracture/dislocation = splint and ship (no more than single reduction attempt)
– Elderly head-strike on Coumadin = CT head will change disposition
-GSW to thorax with loss of pulses =  “If you don’t have a surgeon to fix the mess, call the code, don’t crack the chest.” Consider risks, level of staff experience, evaluate your resources

Resident Author: Jeffrey Rixe, MD

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