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CHEST TRAUMA

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Title: CHEST TRAUMA


1

Victor Politi, M.D., FACP Medical Director, SVCMC
Division of Allied Health, Physician Assistant
Program
2
Specialty Selection Top Ten Leading Causes of
Death in the U.S.
  • Heart Disease 726,974
  • Cancer 539,577
  • Stroke 159,791
  • Chronic Obstructive Pulmonary Disease 109,029
  • Accidents 95,644
  • Pneumonia/Influenza 86,449
  • Diabetes 62,636
  • Suicide 30,535
  • Nephritis, Nephrotic Syndrome, and Nephrosis
    25,331
  • Chronic Liver Disease and Cirrhosis 25,175

3
Appeal of Emergency Medicine
  • Make an immediate difference
  • Life threatening injuries and illnesses
  • Undifferentiated patient population
  • Challenge of anything coming in
  • Emergency / invasive procedures
  • Safety net of healthcare

4
Appeal of Emergency Medicine
  • Team approach
  • Patient advocacy
  • Open job market
  • Academic opportunities
  • Shift work / set hours
  • Evolving specialty

5
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6
Downside to Emergency Medicine
  • Interaction with difficult, intoxicated, or
    violent patients
  • Finding follow-up or care for uninsured
  • Work in a fishbowl
  • without 20/20 hindsight
  • Working as a patient
  • advocate

7
Subspecialties in Emergency Medicine
  • Pediatric Emergency Medicine
  • Toxicology
  • Emergency Medical Services
  • Sports Medicine

8
Areas of Expertise
  • Toxicology
  • Emergency medical services
  • Mass gatherings
  • Disaster management
  • Wilderness medicine

9
Upcoming Areas of Emergency Medicine
  • Hyperbaric medicine
  • Observation units
  • ED ultrasound
  • International emergency medicine

10
Introduction to Trauma
11
  • Trauma is a major cause of death in young people.
    The cost in human lives and economic terms is
    tremendous

12
  • Trauma is the leading cause of death for all age
    groups under the age of 44
  • In the US - it is the leading cause of death in
    children

13
Trauma Statistics
  • 4th leading cause of death of Americans of all
    ages
  • Nearly 150,000 people of all ages in the US die
    from trauma each year
  • 60 million injuries annually
  • 30 million need medical treatment
  • 3.6 million need hospitalization

14
Trauma Statistics
  • Impact of trauma is greatest in children and
    young adults
  • Trauma cost the American public over 300 billion
    annually including lost wages, medical expenses,
    administrative costs, employer expense
  • Approximately 40 of health care
    monies are spent on trauma

15
Trauma Statistics
  • Traumatic injuries, including unintentional
    injuries cause -
  • 43 of all deaths ages 1 to 4
  • 49 of all deaths ages 5 to 14
  • 64 of all deaths ages 15 to 24

16
Trauma Statistics
  • Leading cause of accidental death in US - motor
    vehicle accidents
  • drinking is a factor in 49 of these cases

17
Trauma Statistics
  • Falls -
  • 2nd leading cause of accidental death for ages 45
    to 75 years and
  • 1 cause of unintentional death for persons age
    75 and older

18
Seatbelt Injury
19
Trauma Statistics
  • Drowning is the 4th most common cause of
    unintentional injury death for all ages
  • It ranks 1st for persons age 25 to 44
  • It ranks 2nd for ages 5 to 44

20
Designated Trauma Centers
  • Designated Trauma Centers
  • Immediate availability of necessary resources
  • Designated -
  • Regional
  • Area
  • Level I
  • Level II

21
Tri-modal distribution of Trauma Death
  • First peak second - minutes
  • brain injury, high spinal cord, large vessels,
    cardiac arrest
  • best treated by prevention
  • Second peak minutes - hours
  • sub/epidurals, HTX/PTX, spleen, liver lac
  • best treated by applying principles of ATLS
  • Third peak days-weeks
  • sepsis, multi-organ failure
  • directly correlated to earlier Rx

22
Primary Evaluation
  • Airway maintenance with c-spine control
  • Breathing and ventilation
  • Circulation with hemorrhage control
  • Disability or neurological status
  • Exposure and environmental control

23
  • Control the airway with basic maneuvers
  • suction
  • administer 100 oxygen
  • hyperventilate
  • prepare to intubate
  • paralyze the patient
  • use appropriate Rx considering ?elevated
    ICP
  • intubate, maintaining in-line traction

24
Circulation
  • Control exsanguinating hemorrhage
  • control external bleeding promptly
  • establish at least 2 R.L. wide-bore Ivs
  • large diameter/short length Ivs
  • ideally 14 ga. 1 1/4
  • add pressure bags

25
Shock Classification
  • Class III
  • percentage loss 30-40
  • amount of loss 1500-2000ml
  • Class IV
  • percentage loss more than 40
  • amount of loss gt200ml
  • Class I
  • percentage loss up to 15
  • amount of loss up to 750ml
  • Class II
  • percentage loss 15-30
  • amount of loss 750-1500ml

26
Treatment of Hemorrhagic Shock due to trauma
  • Defined as B/P less than 90 systolic in an adult
  • The treatment of shock should be directed not
    toward the class of shock but to the response to
    initial therapy

27
Class III Blood Loss
  • Respond to initial fluid bolus
  • was initial bolus inadequate?
  • is patient experiencing ongoing hemorrhage?
  • As fluids are slowed, patient deteriorates

28
Class III Blood Loss
  • Usually indicates 20-40 blood loss
  • Requires continued fluids, blood products
  • The response to blood products dictates speed of
    surgical intervention

29
Fingertip amputation
30
Identify the Site
  • Most obvious source is external hemorrhage
  • Next consider hemothorax
  • Consider abdominal source
  • spleen laceration
  • hemoperitoneum
  • renal hematoma
  • liver laceration
  • injury to a great vessel

31
Identify the Site
  • Consider mechanism of injury
  • Every trauma victim should have a finger or tube
    in every hole

32
Battles sign - base of skull injury
33
'Racoon Eyes' sign of base of skull fracture
34
Minimal or No Response to Fluid Resuscitation
  • Seen in small percentage of patients
  • usually dictates need for immediate surgical
    intervention to control exsanguinating hemorrhage
  • Prepare the OR
  • If penetrating chest trauma -
    consider cardiac injury

35
gunshot wound left fronto-parietal region
entrance wound (close-up)
36
Golden Hour
  • The hemodynamically unstable trauma patient needs
    only two things
  • hot lights
  • cold steel

37
  • Aggressive fluid resuscitation must be initiated
    not when blood pressure is falling/absent but as
    soon as the early signs/symptoms of blood loss
    are suspected

38
  • Decreasing BP increasing pulse
  • Disorientation - confusion
  • Mechanism of injury

39
High voltage wiring injury
40
Blood Transfusion
  • No substitute for the real thing
  • cross match if time permits
  • compatible with ABO and Rh blood types
  • minor antibody incompatibilities may occur

41
cutting two fingers off in a meat slicer
42
Universal Donor
  • Type O negative is available immediately
  • used in exsanguinating hemorrhage
  • used in patient with minimal or no response to
    initial crystalloid fluids bolus
  • Remember -
  • Give Blood Save A Life

43
Radiologic Studies
  • C-spine, chest and pelvis x-rays
  • CAT scan or specific x-rays that are indicated
    based on mechanism of injury and primary exam

44
Right pulmonary contusion, left chest wall defect
with lung hernia
Pulmonary Contusion
45
C-Spine
  • Dont become distracted by trying to clear the
    c-spine
  • A properly applied cervical collar never killed
    anyone!
  • Dont remove cervical collar until c-spine is
    cleared
  • continue to protect c-spine during treatment

46
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47
Fracture-dislocation C7-T1
48
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49
Chest Radiograph
  • Rule-out PTX/HTX - need immediate treatment
  • Provides clues as to condition of -
  • heart, lung, parenchyma, mediastinum, great
    vessels, bronchus, diaphragm
  • Almost unheard of to have significant chest
    injury w/o signs of same on CXR
  • CXR are frequently misinterpreted and
    injuries are frequently overlooked

50
Chest Radiograph
  • Check position of tubes
  • Locate foreign bodies (i.e. bullets)
  • Free air under diaphragm or on lateral means
    perforated viscus
  • Cardiac tamponade

51
Right diaphragm laceration on chest x-ray
52
Abdominal Trauma
  • Remove all clothing including undergarments
  • Perform adequate visual exam for injuries
  • Dont forget the rectal exam

53
Spleen Laceration on CT - Grade III
54
Abdominal Trauma
  • CAT scan with contrast
  • utilizes PO and IV contrast
  • May require NGT for administration of contrast
  • Risk of vomiting and aspiration
  • Risk of allergic reaction to contrast
  • Intubation to protect airway requiring sedation
  • Difficult to obtain CT in unstable patient

55
Renal retroperitoneal hematoma Grade IV
56
Pelvic Trauma
  • Evaluate for pelvic, femoral neck, femur
    fractures
  • Provides clues as to condition of -
  • abdominal viscera
  • bladder
  • Patients can bleed out into thigh
  • Mules and packers -
  • products in distal colon

57
Ultrasound
  • Dynamic study performed in trauma room
  • no need to move patient to x-ray or CT
  • can immediately visualize heart, pericardium
  • can visualize liver, spleen, kidney lacs
  • can visualize 50 cc blood, fluid in abdomen
  • takes approximately 5 minutes
  • highly operator dependent

58
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59
Trauma Code ETA 5 minutes
  • Stick with the basics - remember ABCs
  • Constantly re-evaluate patient not labs
  • Dont raise your voice - remain calm
  • You are not alone, consult the experts
  • dont get in over your head
  • Take a step back -
  • What are you missing ?
  • What did you overlook ?

60
CHEST TRAUMA
61
splinter
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63
Incidence of Chest Trauma
  • Cause 1 of 4 American trauma deaths
  • Contributes to another 1 of 4
  • Many die after reaching hospital - could be
    prevented if recognized
  • lt10 of blunt chest trauma needs surgery
  • 1/3 of penetrating trauma needs surgery
  • Most life-saving procedures do NOT require a
    thoracic surgeon

64
Pathophysiology of Chest Trauma
hypovolemia
ventilation- perfusion mismatch
Inadequate oxygen delivery to tissues
changes in intrathoracic pressure relationships
TISSUE HYPOXIA
65
Pathophysiology of Chest Trauma
  • Tissue hypoxia
  • Hypercarbia
  • Respiratory acidosis - inadequate ventilation
  • Metabolic acidosis - tissue hypoperfusion (e.g.,
    shock)

66
Initial assessment and management
  • Primary survey
  • Resuscitation of vital functions
  • Detailed secondary survey
  • Definitive care

67
Initial assessment and management
  • Hypoxia is most serious problem - early
    interventions aimed at reversing
  • Immediate life-threatening injuries treated
    quickly and simply - usually with a tube or a
    needle
  • Secondary survey guided by high suspicion for
    specific injuries

68
6 Immediate Life Threats
  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • sucking chest wound
  • Massive hemothorax
  • Flail chest
  • Cardiac tamponade

69
6 Potential Life Threats
  • Pulmonary contusion
  • Myocardial contusion
  • Traumatic aortic rupture
  • Traumatic diaphragmatic
  • rupture
  • Tracheobronchial tree
  • injury - larynx, trachea,
  • bronchus
  • Esophageal trauma

70
6 Other Frequent Injuries
  • Subcutaneous emphysema
  • Traumatic asphyxia
  • Simple pneumothorax
  • Hemothorax
  • Scapula fracture
  • Rib fractures

71
Primary Survey
  • Airway
  • Breathing
  • Circulation

72
A Airway
  • Assess for airway patency and air exchange -
    listen at nose mouth
  • Assess for intercostal and supraclavicular muscle
    retractions
  • Assess oropharynx for foreign body obstruction

73
B Breathing
  • Assess respiratory movements and quality of
    respirations - look, listen, feel
  • Shallow respirations are early
    indicator of distress - cyanosis
    is late

74
C Circulation
  • Assess pulses for quality, rate, regularity
  • Assess blood pressure and
    pulse pressure
  • Skin - look and feel for color, temperature,
    capillary refill
  • Look at neck veins - flat vs. distended
  • Cardiac monitor

75
Thoracotomy
  • Closed heart massage is ineffective in a
    hypovolemic patient
  • Left anterior thoracotomy with cross-clamping of
    descending thoracic aorta and open-chest massage
    may be useful in pulseless victim of penetrating
    trauma

76
Thoracotomy
Nipple
77
6 Immediate Life Threats
  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • sucking chest wound
  • Massive hemothorax
  • Flail chest
  • Cardiac tamponade

78
Airway Obstruction
  • Chin-lift - fingers under mandible, lift forward
    so chin is anterior

79
Airway Obstruction
80
Airway Obstruction
  • Jaw thrust - grasp angles of mandible and bring
    the jaw forward

81
Airway Obstruction
  • Oropharyngeal
  • airway inserted in
  • mouth behind tongue.
  • DO NOT push
  • tongue further back.

82
Airway Obstruction
  • Nasopharyngeal airway - well
  • lubricated
  • trumpet
  • gently
  • inserted
  • through
  • nostril

83
Airway Obstruction
  • Definitive
  • management -
  • tube in trachea
  • through vocal cords
  • with balloon
  • inflated.

84
Airway Obstruction
  • Orotracheal intubation
  • Nasotracheal intubation - in breathing patient
    without major facial trauma
  • surgical airways
  • jet insufflation
  • cricothyrotomy
  • tracheostomy

85
Airway Obstruction
Jet insufflation adapters
86
Airway Obstruction
Tracheotomy tubes
87
Tension pneumothorax
  • Air leaks through lung or chest wall
  • One-way valve with lung collapse
  • Mediastinum shifts to opposite side
  • Inferior vena cava kinks on diaphragm, leading
    to decreased venous return and cardiovascular
    collapse

88
Inferior vena cava
89
Tension pneumothorax
  • Tension pneumothorax is not an x-ray diagnosis -
    it MUST be recognized clinically
  • Treatment is decompression
  • - needle into 2nd intercostal
  • space of mid-clavicular line -
  • followed by thoracotomy
  • tube

90
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91
Open pneumothorax
  • Sucking Chest Wound
  • Normal ventilation requires negative
    intra-thoracic pressure
  • Large open chest-wall defect leads to immediate
    equilibration of intra-thoracic and atmospheric
    pressures
  • If hole is gt2/3 tracheal diameter, air prefers
    chest defect

92
Open pneumothorax
  • Initial treatment - seal defect and secure on
    three sides (total occlusion may lead to tension
    pneumothorax
  • Definitive repair of defect in O.R.

93
Massive hemothorax
  • Rapid accumulation of gt1500 cc blood in chest
    cavity
  • Hypovolemia hypoxemia
  • Neck veins may be
  • flat - from hypovolemia
  • distended - intrathoracic blood
  • Absent breath sounds, DULL to percussion

94
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96
Massive hemothorax - treatment
  • Large-bore (32 to 36 F) tube to drain blood
  • If moderate sized - 500 to 1500 ml - and stops
    bleeding, closed drainage usually sufficient
  • If initial drainage gt1500 ml OR continuous
    bleeding gt200 ml / hr, OPEN THORACOTOMY indicated

97
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98
Flail chest
  • Free-floating chest segment, usually from
    multiple ribs fractures
  • Pain and restricted
  • movement
  • Paradoxical
  • movement of
  • chest wall with
  • respiration

99
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100
Flail chest - treatment
  • Adequate ventilation
  • Humidified oxygen
  • Fluid resuscitation
  • PAIN MANAGEMENT
  • Stabilize the chest
  • internal - ventilator
  • external - sand bags

101
Cardiac tamponade
  • Usually from penetrating injuries
  • Classic Becks triad
  • elevated venous pressure - neck veins
  • decreased arterial pressure - BP
  • muffled heart sounds
  • Blood in sac
  • prevents cardiac
  • activity

102
Cardiac tamponade
  • May find pulsus paradoxus - a decrease of 10 mm
    Hg or greater in systolic BP during inspiration
  • Systolic to diastolic gradient of less than 30 mm
    Hg also suggestive

103
Cardiac tamponade
  • Treatment is removal of small amount of blood -
    15 to 20 ml may be sufficient - from pericardial
    sac

104
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105
Stab wound to right ventricle
106
pericardium
epicardial fat
107
6 Potential Life Threats
  • Pulmonary contusion
  • Myocardial contusion
  • Traumatic aortic rupture
  • Traumatic diaphragmatic rupture
  • Tracheobronchial tree injury - larynx, trachea,
    bronchus
  • Esophageal trauma

108
Pulmonary contusion
  • Potentially life-threatening condition with
    insidious onset
  • Parenchymal injury without laceration
  • More than 50 will develop pneumonia, even with
    treatment
  • Up to 50 have only hemoptysis as presenting
    symptom

109
Pulmonary contusion
  • Patients with pre-existing conditions -
    emphysema, renal failure - need early intubation
  • Treatment needs to occur over time
  • as symptoms develop

110
Myocardial contusion
  • Blunt precordial chest trauma
  • Difficult to diagnose
  • Risk for dysrhythmias, sudden death,
  • tamponade, pericarditis, ventricular aneurysm

111
Myocardial contusion
  • Also may see
  • myocardial concussion - stunned myocardium with
    no cell death
  • coronary artery laceration
  • Diagnosis by
  • trans-esophageal echocardiogram
  • serial cardiac enzymes

112
Traumatic aortic rupture
  • 90 or more dead at scene
  • 90 mortality each undiagnosed day
  • Must have high index of suspicion
  • Disruption occurs at ligamentum arteriosum
    (ductus arteriosus)
  • Contained hematoma of 500 to 1000 ml of blood

113
Traumatic aortic rupture
  • Radiographic signs
  • wide mediastinum
  • 1st 2nd rib fx
  • obliteration of aortic knob
  • tracheal deviation to right
  • pleural cap
  • depression left mainstem bronchus
  • elevation and right shift mainstem bronchus
  • obliteration aortic window
  • deviation of esophagus to right

114
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117
Traumatic aortic rupture
  • Treatment -
  • SURGICAL REPAIR

118
Traumatic diaphragmatic rupture
  • Blunt trauma - tears leading to immediate
    herniation
  • Penetrating trauma - small tears which may take
    years to develop herniation
  • Usually on left side

119
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120
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121
Traumatic diaphragmatic rupture
  • Treatment - surgical repair

122
Tracheobronchial tree injury
  • Larynx - rare
  • hoarseness
  • subcutaneous
  • emphysema
  • palpable crepitus
  • Intubation may be difficult
  • tracheostomy (not cricothyroidotomy) is treatment
    of choice

123
Tracheobronchial tree injury
  • Trachea
  • blunt or penetrating
  • esophagus, carotid
  • artery and jugular
  • vein may be involved
  • noisy breathing ?
  • partial airway
  • obstruction

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125
Tracheobronchial tree injury
  • Bronchus
  • rare and lethal
  • usually BLUNT
  • trauma within
  • one inch of
  • carina

126
Esophageal trauma
  • Most commonly penetrating
  • May be lethal if not recognized
  • High suspicion if
  • left pneumothorax and hemothorax without rib
    fracture
  • shock out of proportion to apparent blunt chest
    trauma
  • particulate matter in chest tube

127
Esophageal trauma
  • If blunt trauma, linear tear in lower esophagus
    with leakage of stomach contents into mediastinum

128
6 Other Frequent Injuries
  • Subcutaneous emphysema
  • Traumatic asphyxia
  • Simple pneumothorax
  • Hemothorax
  • Scapula fracture
  • Rib fractures

129
Subcutaneous emphysema
  • Rice Krispies
  • May result from
  • airway injury
  • lung injury
  • blast injury
  • No treatment
  • required - address underlying
  • problem

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131
Traumatic asphyxia
  • Masque ecchymotique - purple face from
    extravasation of blood
  • Major damage is to underlying structures
  • Purple face fades over time in
  • survivors

132
Simple pneumothorax
  • Air enters potential space between visceral and
    parietal pleura
  • Breath sounds down on affected side
  • Percussion shows hyper-resonance
  • Treatment chest tube in 4th or 5th intercostal
    space anterior to mid-axillary line

133
Hemothorax
  • Lung laceration OR disruption of intercostal
    artery or internal mammary artery
  • Most are self-limiting
  • Surgical consultation for
  • initial flow of gt20 cc/kg (1500 cc)
  • continued flow of gt200 cc/hr

134
Scapula fractures
  • Fractures of scapula or 1st 2nd ribs may
    indicate major mechanism of
  • injury

135
Rib fractures
  • Ribs - most frequently injured part of thoracic
    cage
  • Most commonly injured - 4th ? 9th
  • If 10th/11th/12th, be suspicious for liver or
    spleen injuries
  • If 1st/2nd/3rd, worry about injury to head, neck,
    spinal cords, lungs, and great vessels

136
Rib frac tures
  • Treatment consists of
  • intercostal blocks
  • epidural anesthesia
  • systemic analgesics
  • Contraindications include
  • taping
  • rib belts
  • external splints

137
In conclusion...
  • Chest trauma is very common in the multi-injured
    patient
  • Airway management and a judiciously placed needle
    can save many lives

138
Trauma Code ETA 5 minutes
  • Stick with the basics - remember ABCs
  • Constantly re-evaluate patient not labs
  • Dont raise your voice - remain calm
  • You are not alone, consult the experts
  • dont get in over your head
  • Take a step back -
  • What are you missing ?
  • What did you overlook ?

139
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