■ Sucking chest wound
■ Subcutaneous emphysema
■ Auscultation should reveal diminished breath sounds.
DIAGNOSIS
■ The presence of air movement or bubbles at the site of a chest wound
identifies an open pneumothorax.
TREATMENT
■ Place a three-sided dressing to allow air to exit and not enter the pleural
space while preparing for placement of a chest tube.
■ A dressing that completely occludes the wound may cause a tension PTX.
■ Do not insert a chest tube through the wound because it may push foreign
material into the chest and may also preferentially follow the tract into the
lung parenchyma or across the diaphragm.
Heart
SYMPTOMS/EXAM
■ Consider cardiac injury in patients with:
■ GSW anywhere above the umbilicus
■ Stab wound to the left chest, the right chest medial to the midclavicular
line, or upper abdomen
■ Look for signs of tamponade such as Beck’s triad and pulsus paradoxus
(a reduction in SBP of >10 mmHg on inspiration).
DIAGNOSIS
■ A globular cardiac silhouette on CXR may indicate tamponade, but most
cases of tamponade have a normal CXR.
■ The cardiac view of the fast exam is a quick way to detect pericardial
blood. A subxyphoid view may be necessary in patients with concurrent
pneumothorax.
TREATMENT
■ Traditionally, fluids are given to maximize cardiac output.
■ Thoracotomy should be performed for traumatic effusion/tamponade in
the setting of shock. Removing only 5–10 mL of blood can increase stroke
volume by 25–50%.
Great Vessels
EXAM
Bruits on auscultation of the chest may indicate vascular injury.
DIAGNOSIS
■ Foreign body (eg, bullet) within the chest that appears “fuzzy” on CXR
may indicate vascular injury. Blurring of the borders of the foreign body
may occur because of movement with cardiac pulsations.
■ Never probe a chest wound or remove an impaled FB because you may dis-
lodge a clot and cause massive hemorrhage.
TRAUMABeck’s triad:
■Hypotension
■JVD
■Muffled heart sounds