Emergency Medicine

CHEST INJURIES

Surgical Emergencies 235

(b) other causes of a widened mediastinum include a mediastinal

haematoma from sternal fracture, lower cervical or thoracic

spine fracture, oesophageal injury, local venous oozing and

projection artefact.

(ii) Blurred aortic outline with obliteration of the aortic knuckle.

(iii) Left apical cap of fluid in the pleural space and a left

haemothorax.

(iv) Depressed left main stem bronchus.

(v) Displacement of the trachea to the right.

(vi) Displacement of a nasogastric tube in the oesophagus to the

right.

7 Look for a cervical, thoracic or sternal fracture clinically and on X-ray,
although exclusion of aortic rupture is still necessary irrespective of clinical
findings if the CXR is suggestive.

8 Perform a high-speed helical CT angiogram scan of the chest to look for
blood contiguous with the aorta, or an abnormal aortic wall indicative of
rupture.

MANAGEMENT

1 Administer f luid cautiously.
(i) Initial hypotension responds to modest fluid replacement in
contained aortic rupture.
(ii) Take care to avoid over-transfusion or hypertension from poorly
controlled pain, etc.

2 Refer the patient urgently to the surgical or vascular team for further evalua-
tion, if the patient has a high-risk mechanism of injury and positive radio-
graphic findings.
(i) Urgent thoracotomy and repair are indicated when either of
these show a rupture, or endovascular stenting if the expertise is
available locally.

Diaphragm rupture

DIAGNOSIS

1 This may occur from blunt or penetrating chest or abdominal trauma,
including crush fracture of the pelvis. Left-sided lesions are more common
and allow eventration of the stomach or intestine into the chest.

2 75% of patients with ruptured diaphragm have associated intra-abdominal
injuries.

3 It causes difficulty in breathing, and occasionally bowel sounds are audible
in the chest.