Diagnosis of Thoracic Injuries Symptoms The most frequent symptoms of thoracic trauma are chest pain and shortness

of breath. The pain is most often well localized to the involved area of the chest wall, but sometimes it is referred to the abdomen, neck, shoulder, back, or arms. Dyspnea and tachypnea are nonspecific findings and may also be caused by blood loss or pain from other injuries or by anxiety. Physical Examination The physical examination should be rapidly performed during the primary and secondary surveys to detect life-threatening injuries. Inspection Inspect the chest wall for contusions, abrasions, and other signs of trauma, including a "seat belt sign" that can indicate possible deceleration or vascular injury. Examine the chest for signs of paradoxical segments or flail chest, intrathoracic bleeding, and open chest wounds. Penetrating wounds or flail chest segments may be subtle and not apparent unless the patient is making increased ventilatory efforts. Distended neck veins, especially when the patient is sitting upright, may indicate the presence of pericardial tamponade, tension pneumothorax, cardiac failure, or air embolism. This sign may be absent until hypovolemia has been at least partially corrected. If the face and neck are cyanotic and swollen, severe injury to the superior mediastinum with occlusion or compression of the superior vena cava should be suspected. Subcutaneous emphysema from a torn bronchus or laceration of the lung can also cause severe swelling of the neck and face. A scaphoid abdomen may indicate a diaphragmatic injury with herniation of abdominal contents into the chest. Excessive abdominal movement during breathing may indicate chest wall damage that might not otherwise be apparent. A rocking-horse type of ventilation may indicate a high spinal cord injury with paralysis of intercostal muscles. Palpation Palpate the neck to determine whether the trachea is midline or displaced. Palpation of the chest wall may reveal areas of localized tenderness or crepitus due to fractured ribs or subcutaneous emphysema. Well-localized and consistent tenderness over ribs should be attributed to rib fractures, even in the absence of findings on conventional chest radiography. Severe localized tenderness, crepitus, or mobile segment of the sternum may

be the only objective evidence of a sternal fracture. Palpation of the chest with the patient coughing or straining may detect abnormal motion of an unstable portion of the chest wall better than visual inspection. Percussion Percussion of the chest wall can be of some help in differentiating between a hemothorax and pneumothorax. Dullness to percussion over one side of the chest following trauma may be the first evidence that a hemothorax is present, whereas hyper-resonance may indicate the presence of a pneumothorax. Small hemo- or pneumothoraces may be missed on supine chest radiographs due to layering of air or fluid. Auscultation Breath sounds are most readily heard in the axillae, where the distance from the skin to pulmonary parenchyma is least. Decreased breath sounds unilaterally may indicate the presence of hemothorax or pneumothorax. This finding may also be present if the endotracheal tube is advanced into one (usually the right) mainstem bronchus. Before performing tube thoracostomy in such patients, the depth of the endotracheal tube should be assessed and adjusted to be no more than three times the inner diameter of the endotracheal tube (usually 23 cm in adult males, or 21 cm in adult females). Persistent decreased breath sounds on one side may also be due to a bronchial foreign body or ruptured bronchus. The presence of bowel sounds high in the chest may indicate a diaphragmatic injury. Sensitivity of each specific physical examination finding is not high enough to rule in or out the common injuries in chest trauma. A study of hemodynamically stable chest trauma patients showed that the sensitivities of auscultation and pain or tenderness for the detection of a hemopneumothorax are 50% and 25%, respectively.18 Clinicians should consider patient symptoms, vital signs, and physical examination findings together to detect significant injuries in stable chest trauma patients and to guide further investigation with imaging modalities. Imaging Bedside US can give early clues to life-threatening diagnoses such as hemothorax, pneumothorax, and pericardial tamponade during initial evaluation of the patient. Chest radiographs, especially upright inspiratory and expiratory views, can detect the presence of pneumothorax or hemothorax, as well as identifying rib fractures, pulmonary contusions, and diaphragmatic rupture. However, supine plain radiographs of the chest may miss some significant injuries. CT of the chest is becoming standard in all major blunt torso trauma when clinically indicated.19 Chest Radiographs

Plain chest radiographs are the standard of care to initially evaluate chest trauma patients for intrathoracic injury. Most chest radiographs are initially taken in the supine position at the bedside due to concern for occult spinal cord injuries and to facilitate other procedures being performed on the patient with multiple trauma. They are helpful to screen for abnormal mediastinal contours, hemothorax, pneumothorax, pulmonary contusions, diaphragmatic injury, and osseous trauma. Chest radiographs frequently underestimate the severity and extent of chest trauma and may fail to detect the injury, and up to 50% of blunt chest trauma patients with normal initial chest radiograph have multiple injuries on CT.19,20 Penetrating surface wounds should be marked before imaging. Widening of the upper mediastinal silhouette or evidence of supraclavicular soft tissue swelling may indicate injury to brachiocephalic vessels. Because solid objects tend to pulsate when they lie next to major vessels, a "fuzzy" foreign body (e.g., bullet) may indicate the location of vascular injury. US With experience, emergency physicians may quickly diagnose pneumothorax, hemothorax, pericardial tamponade, rib fractures, and sternal fractures using bedside US. As a part of the focused assessment with sonography for trauma examination, US should be used to evaluate for hemothorax, pneumothorax, and pericardial tamponade or effusion in the chest trauma patient. In trained hands, ultrasonography has a greater sensitivity and equal specificity for detecting hemothorax in patients with chest trauma compared with chest radiography.21 Likewise, the sensitivity of ultrasonography for detecting pneumothorax approaches 92% (as compared with a sensitivity of 52% for chest radiographs) with near 100% specificity. Importantly, ultrasonography in the ED can detect occult pneumothorax as accurately as CT.22 In addition, US has also been found helpful for describing small, medium, or large pneumothoraces with good agreement with CT.23 CT Newer, multidetector CT scanners acquire data rapidly enough to allow breath-holding during the examination, greatly increasing the quality of the image. Computer-controlled contrast injection, helical imaging technology, and multiplanar subtractive reconstruction have made CT angiography an increasingly useful diagnostic tool. Contrast Swallows Thoracic trauma with associated esophageal injury often requires a contrast esophagogram for diagnosis. Water-soluble contrast is preferred over barium-containing contrast in patients with high suspicion for esophageal rupture. Barium swallow imaging has fewer false positives, but may cause significant mediastinitis if there is leakage of contrast out of the esophagus to surrounding tissues.

Endoscopy In selected cases, such as in penetrating wounds of the chest or lower neck, bronchoscopy or esophagoscopy may be indicated to exclude an injury to the aerodigestive tract. Such studies may be deferred until the patient is resuscitated and hemodynamically stable.