Penetrating Chest Trauma

With careful assessment, rapid diagnosis, and relatively simple interventions,

most patients with penetrating chest trauma will recover.
By Rhonda J. Reeder, BSN, CFRN, CEN, MICN, EMT-P,
and Dianne M. Danis, MS, RN, CEN

Chest trauma is the cause of nearly 16,000 deaths in the United States each year
and the cause of death in 25% of all trauma patients. Increased handgun use has
contributed to the rise in penetrating injuries and has accounted for 50% of the
injuries seen in one urban setting. It’s important to note that gunshot wounds are
associated with a mortality rate nearly tenfold that associated with impalement.

MECHANISM OF INJURY
An understanding of the mechanism of injury is critical when caring for patients
with penetrating chest injuries, as it guides resuscitative efforts. Because these
injuries impair airway patency, breathing, and circulation, maintaining a high
degree of vigilance is crucial.

Penetrating chest wounds can be classified as either high- or low-energy injuries.

High-energy injuries include ballistic-type injuries such as gunshot wounds, arrow
wounds, and those resulting from explosions. Low-energy injuries are sustained
from stabbings and slashings. Although the force of the injury is a critical
predictive factor in penetrating chest trauma, the location of the wound is also
significant. A simple stab wound, depending on location, can cause greater injury
than does a peripheral gunshot wound. For example, a stab to the chest can cause a
laceration to the trachea and subclavian artery.

Stabbing wounds generally produce localized tissue damage along the path of the
weapon. The injury pattern is predicted by the location of the wound, as well as by
the size, shape, and length of the object used. Other influential factors are the
positions of and the distance between the victim and the assailant; the sex, height,
and strength of the assailant; as well as the angle of the stab (an upward stab from
an assailant standing behind the victim at arm’s length, for example). Men tend to
stab upward, whereas women stab downward.

Gunshot wounds are high-energy wounds that can be devastating, depending on

the degree of bullet energy and the anatomical position at impact. They are
described as either penetrating or perforating. Whereas penetrating wounds occur
when the bullet enters a body and does not exit it, perforating wounds occur when
the bullet completely passes through the body. Both wound types involve the
crushing and tearing of tissue along the path of the projectile.

Understanding gunshot ballistics helps predict wounds caused by firearms.

Gunshot wounds are classified, according to the kinetic energy (KE) of the
projectile, as either high- or low-energy wounds. KE is the major factor
determining the energy transmitted and is a function of the mass and velocity of
the projectile based on the formula KE equals one-half the mass times the velocity
squared. KE transferred to tissue causes damage as the projectile slows along the
course of the wound. Handgun and shotgun bullets produce tissue destruction
along the path of the projectile. Wounds from high-powered rifles produce local
tissue destruction and cavitation, the creation of a temporary cavity caused by a
pressure wave as the projectile passes through tissue. In turn, this pressure wave
causes stretching, deformation, and, often, tissue death. The amount of cavitation is
contingent on tissue type, the length of the wound, and bullet type.

PRIMARY ASSESSMENT
Identify potentially lethal injuries resulting from penetrating chest trauma during
the initial assessment of traumatized patients. Simple procedures such as airway
management, fluid replacement, and chest tube insertion often correct the
underlying pathophysiology. Start with airway assessment and evaluate the airway
by listening for air movement and watching for chest movement. Either stridor or
penetrating injury to the neck should elicit the assumption of airway compromise.
Spinal immobilization should be maintained throughout the assessment of gunshot
wounds, as vertebral fractures or spinal cord injuries may be present.

Airway maneuvers such as a modified jaw thrust, suction, or airway adjuncts can
be employed to maintain an open airway. Patients with penetrating injury often
require endotracheal intubation, in which case tube placement can be assessed by
listening for breath sounds in both lung fields, and confirmed by end-tidal carbon
dioxide detection and chest radiograph. Remember that the airway has to be
addressed before continuing the assessment.

Also assess for spontaneous breathing, quality of the breathing, chest rise and fall,
skin color, respiratory rate, and pattern. Restlessness, tachypnea, cyanosis, and
diminished breath sounds are indicative of respiratory derangements. Patients
should have continuous pulse oximetry and oxygen delivered by way of a
nonrebreathing mask at a flow rate of 12 to 15 L per minute. If breathing is
ineffective or absent, the patient should be ventilated with 100% oxygen by way of
a bag valve mask device until intubation is accomplished.

Central and peripheral pulses should then be assessed for quality, rate, and
regularity. As a general rule, a carotid pulse indicates a systolic blood pressure of
60 mmHg, femoral pulse indicates 70 mmHg, and brachial pulse, 80 mmHg. Also
look for and control apparent bleeding. Indications of ineffective circulation
include tachycardia, altered level of consciousness, distended or abnormally
flattened external jugular veins, and pale, cool, or diaphoretic skin. Initiate cardiac
monitoring as soon as possible, as well as direct pressure to the source of bleeding
and warm fluid resuscitation through two large-bore IVs. Although current
recommendations call for infusion of 2 L of lactated Ringer’s solution, emerging
data have called into question the use of aggressive fluid resuscitation in the
prehospital setting prior to controlling the hemorrhage. Administer CPR to a
patient without circulation, and if indicated, prepare him for an emergency
thoracotomy.

Perform a brief neurologic survey after initial assessment and, depending on the
type and location of injury, consider spinal cord injury or peripheral nerve injury.
Neurologic injury calls for the Glasgow Coma Scale (GCS) and a brief assessment
of movement in all four extremities, although the latter may be difficult if the
patient is chemically paralyzed or in advanced shock.

It’s particularly important to identify the location of all injuries, and to do this, the
patient should be completely exposed so that none are overlooked. Though not
completely correlative, the pattern of wounds may help predict underlying injuries.
Look closely at the axillae and perineum for concealed injuries. Descriptions of
entrance and exit wounds should be made only by the forensic experts, as
inaccurate ones may adversely affect any legal proceedings that may ensue.

SECONDARY ASSESSMENT
A complete assessment to define the patient’s injuries occurs during the secondary
survey and includes taking a history of the injury, a medical history, identifying
known allergies and medications taken, as well as the patient’s most recent meal.
This information can be gathered from emergency medical service (EMS)
personnel, the patient’s family, and bystanders at the scene of the incident. Since
many patients with penetrating chest trauma are victims of violence, collection of
forensic evidence is important. Collect clothing and place each article in a separate
paper bag. Avoid cutting through bullet or knife holes on clothing and retain any
bullets and weapons found. Promptly notify law enforcement officials according to
local regulations.

SPECIFIC INJURIES AND THEIR TREATMENT

Although penetrating chest trauma carries a significant risk of morbidity and
mortality, many patients can be stabilized or treated with simple interventions.
Most patients with thoracic injuries can be managed with closed chest
thoracotomy, respiratory support, and pain control. Maintain vigilance and
critically evaluate patients for the following lifethreatening injuries associated with
penetrating chest trauma.

Tension pneumothorax.
This occurs when air becomes trapped in the pleural space after damage to the lung
parenchyma. Air flows into the pleural space along a pressure gradient during
inspiration and is prevented from leaving because a clot or other tissue creates a
one-way valve. Continued accumulation of air in the pleural space results in
increasing intrapleural pressure, displacement of the mediastinum to the opposite
side of the chest, consequent compression of the lung and great vessels, and
decreased venous return to the heart. This contributes to hypotension, hypoxia, and
cardiopulmonary collapse.

Symptoms of tension pneumothorax include dyspnea, chest pain, tachypnea,

agitation, and restlessness. Signs include hypotension, decreased breath sounds,
cyanosis, hyperresonation on percussion of the injured side, tracheal deviation (a
late sign), and distant heart sounds. Distended neck veins can be apparent in
tension pneumothorax, and depending on the clinical situation, this may or may not
manifest in hypovolemia. Intubated patients will have increased airway resistance
with bagging and decreased oxygen saturation.

Diagnosis of tension pneumothorax is made by clinical observation, and in patients

in extreme distress, decompression must be performed immediately and is
accomplished by perpendicular insertion of a large-bore IV catheter into the second
intercostal space, at the midclavicular line on the affected side. If this is successful,
a rush of air will be heard through the catheter, and the patient’s vital signs will
stabilize. A Heimlich flutter valve can be connected to the catheter and secured in
place until a chest tube is inserted. Definitive management of the pneumothorax is
completed with a closed thoracostomy tube connected to water seal drainage and
suction.

Open pneumothorax.
Also known as “sucking chest wound,” this occurs on penetrating trauma to the
chest wall, with the wound open to the atmosphere, resulting in equilibration
between intrathoracic and atmospheric pressures. Air will enter the wound rather
than the trachea if the wound is more than two-thirds as wide as the tracheal
diameter. During inspiration, the lung is compressed, the mediastinum is deflected,
and ventilation is ineffective. Entry of outside air on inspiration causes the
characteristic sucking sound noted in this wound.

Patients with open pneumothorax complain of difficulty breathing and chest pain.
Symptoms and signs include tachypnea, hypotension, hypoxia, cyanosis, and air
movement through the wound during respiration. Initial management involves
securing a sterile occlusive dressing of petroleum jelly gauze or plastic wrap over
three edges of the wound, which prevents air from entering the chest during
inspiration but allows it to exit during expiration. Escape of air during expiration is
required to prevent the development of tension pneumothorax, which nevertheless
may develop. In that case, the dressing must be removed, converting the condition
to a simple open pneumothorax. If tension persists, it must be immediately
decompressed. Before surgical closure of the wound, a thoracostomy tube must be
placed or the patient intubated and positive pressure ventilation should be initiated.

Cardiac tamponade occurs as a result of hemorrhage into the pericardial sac

surrounding the heart, and accumulation of blood there prevents venous return to
the heart and causes a decrease in cardiac output.

Symptoms of cardiac tamponade include dyspnea, chest pain, and restlessness. The
classic signs are hypotension, distended neck veins, and muffled heart sounds
(Beck’s triad), all three of which are absent in hypovolemic patients. Pulsus
paradoxus, defined as a decrease of more than 10 mmHg in the systolic arterial
blood pressure upon inspiration, can occur, and electrical alternans, alternating
amplitude seen in the ECG, also may be present.

Diagnosis of cardiac tamponade is based on clinical observation and patient

history. With more frequent use of focused transthoracic trauma ultrasonography,
cardiac tamponade is being more rapidly and accurately confirmed. Although
intravenous fluids may increase cardiac output and stabilize the patient, treatment
requires the removal of blood from the pericardial sac. Pericardiocentesis,
pericardial window, or emergency department thoracotomy can be performed. In
unstable patients, the initial intervention needs to be performed in the emergency
department and surgery in the operating room. Since reaccumulation of blood is
possible, the patient must be monitored for deterioration.
Massive hemothorax affects both the respiratory and circulatory systems. The
accumulation of a significant amount of blood in the thorax causes hemorrhagic
shock and can compress the lungs, which impedes breathing and oxygen exchange.
Hemorrhage results from damage to any of the intercostal, pulmonary, or major
vessels of the chest, or from direct lung or cardiac injury.

Symptoms of massive hemothorax include dyspnea and decreased level of

consciousness, and the signs are comparable to those of hemorrhagic shock,
including hypotension and tachycardia. Other signs include decreased breath
sounds and dullness on percussion. A chest radiograph shows opacity of the lung
field. Pleural effusion may not be identified, as the initial film is taken in the
anterior to posterior projection with the patient supine. Hemorrhage is readily
identified on chest CT scan.

Treatment begins with closed chest thoracostomy. Chest tube placement allows
evacuation of blood and reexpansion of the lung. Massive hemorrhage is defined
by initial return of more than 1,500 mL of blood. If chest tube output remains more
than 200 mL per hour, thoracotomy is often required. The decision to perform a
thoracotomy is based on output, hemodynamic stability, response to interventions,
and associated injuries. Initial resuscitative efforts need to be directed toward fluid
and blood product replacement. Recently there has been increased use of
autotransfusion devices, which collect blood from the chest tube, filter it, and allow
for reinfusion. The blood is relatively uncontaminated, warm, and cross-matched.
In patients with thoracoabdominal trauma one needs to be judicious in the use of
the autotransfusion device because of the possibility of contamination from
gastrointestinal injury.

Cardiac injuries.
Patients with injuries to the heart may present with both massive hemothorax and
tamponade, and interventions additional to those already described may be
required. Cardiac injury is determined by the location of the wound and the path of
the penetration. In one review, the anteriorly located right ventricle was injured in
40% of cases, the left ventricle in 40%, the right atrium in 24%, and the left atrium
in 3%. One method described for managing penetrating cardiac injuries is the use
of a Foley catheter with the balloon inflated to occlude the wound.

Emergency department thoracotomy (EDT) for chest trauma.

The practice of EDT has undergone critical review. One review demonstrated an
overall survival rate in penetrating chest trauma of 8.8%. Indications for EDT in
patients with penetrating chest trauma include those who are pulseless but with
documented cardiac activity, and those who have deteriorating vital signs and fail
to respond to fluid resuscitation. EDT involves left lateral chest incision, control of
hemorrhage, release of the pericardium, clamping of the descending aorta, and
open chest massage. Once stabilized, the patient requires formal surgical
exploration and treatment.

ONGOING MONITORING
Maintain careful cardiovascular and respiratory monitoring during the
postresuscitative phase of evaluation. These patients are at risk for deterioration,
and early recognition and intervention are vital to a favorable outcome. Cardiac
rhythm, blood pressure, and pulse oximetry must be continuously monitored, and
symptoms of tachycardia, hypoxia, or hypotension should alert the health care
team to begin a focused reevaluation of the patient. Pay particular attention to
airway patency, breathing, and circulation. Improvement of base deficit on arterial
blood gas measurement is an additional indication of adequate fluid resuscitation.
A persistent base deficit is an indication of adequate tissue perfusion. Because
urine output is one of the most sensitive indicators of adequate volume
resuscitation, it also must be measured by means of an indwelling urinary catheter.
Serial hematocrit levels must be measured in all patients and measurement of
arterial blood gases is required in all intubated patients. Central venous pressure or
hemodynamic monitoring may guide fluid resuscitation and aid in the
differentiation of hypovolemic shock from one of the mechanical causes of shock
discussed earlier.