Unstable Penetrating Chest Trauma
Annotation for Point C
Resuscitation and assessment follow standard guidelines. If not intubated, the airway is secured, usually with a single-lumen tube. If intubated, placement must be confirmed. Direct visualization of the tube placement by laryngoscopy, auscultation, and confirmation of end-tidal CO2 are simple initial measures. If there are absent breath sounds, indicative of pneumothorax and/or hemothorax, chest tubes are placed on the affected side(s). If there is any doubt, it is safer to place chest tubes on the affected side(s) rather than waiting for confirmatory imaging. Ultrasonography can be used to document pneumothorax/hemothorax if the operator is trained to do so.21 Ultrasonography is now accepted as a tool to rapidly assess for pericardial fluid, although in the presence of hemothorax, a negative study result does not rule out a cardiac injury.22 Needle decompression can be used as an initial step, but inmost dedicated trauma centers, it is almost as expedient to place a chest tube. Circulation is supported by product resuscitation. In the setting of significant hemorrhage from a chest tube, autotransfusion can be used, although in conjunction with ongoing product resuscitation. A quick chest x-ray (CXR) can confirm laterality of injury, rule out transmediastinal and/or multiple injuries, and confirm endotracheal tube placement.