Widening of the mediastinum
Deviation of the trachea to the right
Depression of the left mainstem bronchus
Loss of the aortic knob
Deviation of the nasogastric tube to the right
Fractures of the upper 3 ribs
Fracture of the thoracic spine
If the chest X-ray is equivocal it may be reasonable to screen the aorta with a CT scan. Once a rupture of the thoracic aorta is suspected, the patient's blood pressure should be maintained at 80-100 mmHg systolic in an effort to reduce the risk of further dissection or rupture. The patient must be transferred immediately to the nearest cardiothoracic unit.
Rupture of the diaphragm occurs in about 5% of patients sustaining severe blunt trauma to the trunk. It can be difficult to diagnose initially, particularly when other severe injuries dominate the patient's management. Consequently, the diagnosis of diaphragmatic rupture is often made late. Approximately 75% of ruptures occur on the left side. The stomach or colon commonly herniates into the chest and strangulation of these organs is a significant complication. Signs and symptoms detected during the secondary survey, may include diminished breath sounds on the ipsilateral side, pain in the chest and abdomen, and respiratory distress. Diagnosis can be made on a plain X-ray (elevated hemidiaphragm, gas bubbles above the diaphragm, shift of the mediastinum to the opposite side, nasogastric tube in the chest). The definitive diagnosis is made by instilling contrast media through the nasogastric tube and repeating the X-ray (Figures TT.10 and 11). Once the patient has been stabilised, the diaphragm will require surgical repair.
Figure TT.10 Chest X-ray showing left ruptured diaphragm
X-ray showing contrast media in the stomach (intrathoracic)
A severe blow to the upper abdomen may result in a torn lower oesophagus as gastric contents are forcefully ejected. The conscious patient will complain of severe chest and abdominal pain and mediastinal air may be visible on the chest X-ray. Gastric contents may appear in the chest drain. The diagnosis is confirmed by contrast study of the oesophagus or endoscopy. Urgent surgery is essential since accompanying mediastinitis carries a high mortality.
Laryngeal fractures are, fortunately, rare. Signs of laryngeal injury include hoarseness, subcutaneous emphysema, and palpable fracture crepitus. Total airway obstruction or severe respiratory distress will have been managed by intubation or surgical airway during the primary survey and resuscitation phases. This is the one situation where tracheostomy, rather than cricothyroidotomy, is indicated. Less severe laryngeal injuries may be assessed by CT before any appropriate surgery. Transections of the trachea or bronchi proximal to the pleural reflection cause massive mediastinal and cervical emphysema. Injuries distal to the pleural sheath lead to pneumothoraces. Typically, these will not resolve after chest drainage, since the bronchopleural fistula causes a large air leak. Most bronchial injuries occur within 2.5 cm of the carina and the diagnosis is confirmed by bronchoscopy. Tracheobronchial injuries will require urgent repair through a thoracotomy.
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