Advanced

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Advanced Medics Paramedics Continuing Profess
ional Development Programme
Review of Major Thoracic Trauma Management
Aaron Pennell
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Objectives

• Overview of aetiology and outcomes
• Review normal chest anatomy
• Review normal and altered radiological
  appearances
• Review types of chest injury and altered
  pathology
• Look at current opinions in thoracic trauma
  management
• Review interventions used and technique
• Clinical skills
• Simple thoracostomy
• Tube thoracostomy
• Needle pericardiocentesis
• RSI Procedure
• Thoracotomy

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ional Development Programme
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Aetiology

• Account for 25 30 of trauma deaths most
  are phase 1
• Three mechanisms
• Hypoxia
• Hypovolaemia
• Both
• 85 of chest injuries do not need specialist
  cardiothoracic care
• 15 of chest injuries also include the abdomen
• Presentation can be deceiving fatal injuries
  can occur
• with chest wall damage
• without chest wall damage
• Two of the most specific and useful
  interventions for major chest
• injury are

Advanced Medics Paramedics Continuing Profess
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Advanced Medics Paramedics Continuing Profess
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Normal Anatomy Chest Wall
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Normal chest anatomy
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Normal chest anatomy
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Normal chest anatomy
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Normal chest anatomy
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Normal chest anatomy
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Normal chest anatomy
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Normal chest anatomy
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Normal Anatomy
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Normal Anatomy
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Normal Anatomy
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Advanced Medics Paramedics Continuing Profess
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Normal Anatomy Thoracic content
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Normal Anatomy
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Normal Anatomy
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Normal Anatomy
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Normal Anatomy
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Normal Anatomy
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Normal Anatomy
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Normal Anatomy
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Normal Radiological Appearance
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Altered Physiology
This is a very simple concept !
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Altered Physiology
Ventilation V Perfusion Q
Pa02
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Types of chest injury

• Blunt
• Penetrating
• Those that involve the chest wall
• Those that do not
• Those that are life threatening
• Those that are not
• Those that adversely affect ventilation
• Those that adversely affect perfusion
• Those that affect both

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Types of chest injury

• Some key points to remember
• Rapid removal to hospital
• Role of early ventilation and chest drainage
• Role of adequate analgesia

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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade

• Altered Physiology Management
• Compromised airway from mouth/nose to carina
• Leads to inadequate delivery of 02 (ltp02) Type
  I respiratory failure
• Death from hypoxaemia and hypoxia
• Secure airway
• Ensure adequate oxygen delivery
• Ensure adequate ventilation

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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade

• Most arise from flap laceration of visceral
  pleura
• Most will become fatal within minutes if
  untreated
• IPPV will reduce this time
• Treatment
• Needle decompression ?
• Simple thoracostomy /- Ascherman / tube

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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
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Objectives
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Objectives
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
Advanced Medics Paramedics Continuing Profess
ional Development Programme
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade

• Important considerations
• Concomitant abdominal injury
• Site of bleeding distant from wound
• Retro-insult haemostasis
• Compromises ventilation

• Treatment
• ABCs 02
• Seal wound
• Be vigilant for TP

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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade

• Two problems
• Hypovolaemia reduced perfusion pressure
  shock
• Compromised ventilation
• However
• The problem is nearly always due to air not blood

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Objectives
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Objectives
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Objectives
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Objectives
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ional Development Programme
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
Advanced Medics Paramedics Continuing Profess
ional Development Programme

• Treatment
• Drainage (for air as well as blood)
• Ventilation (for gas exchange)
• Resuscitative thoracotomy
• Surgical repair

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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
Advanced Medics Paramedics Continuing Profess
ional Development Programme

• Compromises ventilation due to VQ mismatch
• Often associated with underlying pneumo /
  haemothorax

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Objectives
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
Advanced Medics Paramedics Continuing Profess
ional Development Programme

• Intercostal block if adequate ventilation
• Elective IPPV if not
• Mandatory chest drainage

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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade

• Normally from penetrating trauma
• Different from haemoparicardium
• Can be DIFFICULT to elicit
• Becks triad
• Muffled heart sounds
• gt JVP
• Shock

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Objectives
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Objectives
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Life threatening Chest injuries Airway
Obstruction Tension Pneumothorax Open
pneumothorax Massive haemothorax Instability of
chest wall Cardiac tamponade
Advanced Medics Paramedics Continuing Profess
ional Development Programme

• Treatment
• Needle pericardiocentesis
• Subxiphoid window drainage
• Thoracotomy if indicated

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• Non Life threatening injuries
• pulmonary contusion
• cardiac contusion
• pneumothorax
• haemothorax

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Advanced Medics Paramedics Continuing Profess
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Specific interventional skills
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Phases of chest injury management
History Mechanism
Subjective
Objective
Assessment
Plan
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Phases of chest injury management
History Mechanism

• Type of incident
• Blunt
• Penetrating
• Weapons used
• Forces involved
• Time of insult

Subjective
Objective
Assessment
Plan
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Phases of chest injury management
History Mechanism
Subjective

• LOC
• Position
• Colour
• Resp effort
• Obvious signs
• gtJVP
• Airway compromise
• Bruising
• Flail segment
• Subcut emphysema
• Wounds
• TWELVE assessment

Objective
Assessment
Plan
Advanced Medics Paramedics Continuing Profess
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Trachea, Wounds, Emphysema, Larynx, Veins,
Examine the back
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Phases of chest injury management
History Mechanism
Subjective

• Expose chest
• Chest expansion gt4cm
• Symmetry
• RR, HR, SBP
• Palpation
• Auscultation
• Percussion
• Sp02
• ECG

Objective
Assessment
Plan
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Phases of chest injury management
History Mechanism
Subjective
Objective

• Non-life threatening
• Haemodynamic compromise
• Life threatening

Assessment
Plan
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Phases of chest injury management
History Mechanism
Subjective
Objective
Assessment
Plan

• Rapid interventions
• Prophylactically
• Responsive
• Triage decision
• Transport decision

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• Aims of treatment
• Establish and maintain airway
• Maximise gasseous exchange
• Release air or blood causing ventilatory /
  circulatory
• compromise
• Assess the need for haemorrhage control

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• Simple thoracostomy
• Tube thoracostomy (chest drain)
• Needle pericardiocentesis
• Resuscitative thoracotomy

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Simple thoracostomy

• Used in INTUBATED patient
• Superior to needle decompression
• Quick, easy and very effective
• Can be converted to tube method

• 4 5th ICS
• Mid Anterior axillary line

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Tube thoracostomy (chest drain)

• Used in intubated and unintubated patients
• Can measure blood loss
• Main complications
• Lung trauma
• Organ trauma
• Infection
• Tube can kink / block

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Technique
Equipment Sterile gloves (2 pairs) Iodine Scalpe
l Tube with introducer Catheter bag Silk suture
elastoplast tape Ascherman chest seal
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Technique
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• Wash area with iodine
• 5th intercostal space mid anterior axillary
  line
• Cut against the 6th rib down to IC muscle (2cm
  long)

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Technique
4th
5th
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Technique
4th
5th
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Technique
4th
5th
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Technique

• Insert tube posteriorly and superiorly
• DO NOT force if path is difficult
• DO NOT LET GO OF THE TUBE !
• Attach catheter bag
• Secure in place
• Suture (with tape and singe suture)
• Via Ascherman seal (need to insert tube first)
• Tape securely with no kinks !

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Pericardiocentesis

• Only really of use in extremis
• Simple procedure but can be difficult to
  interpret results !

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Resuscitative thoracotomy
Resuscitative Thoracotomy (immediate) A chest
opening procedure in order to resuscitate the
patient be means of haemorrhage control,
evacuation of cardiac tamponade, establishing
circulatory preference to vital
organs Emergency Thoracotomy (within 1
hour) A chest opening procedure in order to
control haemorrhage, airleak, tamponade or other
intrathoracic injury. The procedure is planned
and takes place in an operating theatre.
Currently indicated if chest drain shows more
than 1.5 litres of blood loss on insertion or
200mls/hr for the next 3 hours. Planned
Thoracotomy (within 48 hours) For non life
threatening intra-thoracic injury
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Resuscitative thoracotomy

• Indications
• Penetrating thoracic / thoracoabdominal injury
• Casualty lost SOL in your presence / immediately
  before arrival
• PEA arrest

• Considerations
• Decision to open chest needs to be made within 30
  seconds
• What equipment do you need and have
• Where will you triage to

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Resuscitative thoracotomy

• Equipment required
• Scalpel 22 blade
• Tough cut scissors / gigli saw
• Scissors
• 2 small clamps
• 2 large clamps
• 1 rib retractor
• 1 satinski clamp
• 0 silk suture
• Needle holder
• Good light !
• swabs

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Resuscitative thoracotomy

• Left Lateral
• 5th interspace from PAL to near sternum
• Good for evacuation of tamponade, cardiac
  massage, cardiac wound
• Clamshell (Chevron)
• Dramatic but the best for resuscitative use
• 5th interspace on left and right joined up
  through sternum
• Excellent access to heart, hilum, aorta and lung

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Resuscitative thoracotomy
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Resuscitative thoracotomy
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Resuscitative thoracotomy
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• What do you do once the chest is open
• Tamponade
• Cardiac laceration
• Cardiac massage
• Aortic cross clamping
• Hilum clamping

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Resuscitative thoracotomy
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• Summary
• Major thoracic problems are a result of
• Hypoxaemia
• Hypovolaemia
• Both
• An adequate assessment is the key to good
  management
• Meticulous attention to airway and ventilation
  adequacy
• Simple procedures including chest tube insertion
  should be
• mandatory skills for paramedics
• Most chest injuries do not require surgery

Advanced Medics Paramedics Continuing Profess
ional Development Programme