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CHEST TRAUMA

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Title: CHEST TRAUMA


1
CHEST TRAUMA
  • Victor Politi,M.D., FACP
  • Medical Director, SVCMC Physician Assistant
    Program

2
Statistics
  • Each year there are nearly 150,000 accidental
    deaths in the United States
  • 25 of these deaths are a direct result of
    thoracic trauma
  • An additional 25 of traumatic deaths have chest
    injury as a contributing factor

3
Statistics
  • Chest injuries are the second leading cause of
    trauma deaths each year.
  • Most thoracic injuries (90 of blunt trauma and
    70 to 85 of penetrating trauma) can be managed
    without surgery.

4
splinter
5
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6
CAUSES OF THORACIC TRAUMA
  • Falls
  • 3 times the height of the patient
  • Blast Injuries
  • overpressure, plasma forced into alveoli
  • Blunt Trauma
  • Penetrating trauma 

7
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

8
Classifications of Chest Injuries
  • Skeletal injury
  • Pulmonary injury
  • Heart and great vessel injury
  • Diaphragmatic injury

9
ClassificationMechanism of Injury
  • Blunt thoracic injuries
  • Forces distributed over a large area
  • Deceleration
  • Compression

10
ClassificationMechanism of Injury
  • Penetrating thoracic injuries
  • Forces are distributed over a small area.
  • Organs injured are usually those that lie along
    the path of the penetrating object

11
Injury Patterns
  • General types
  • Open injuries
  • Closed injuries

12
Injury Patterns
  • Cardiovascular
  • Pleural and pulmonary
  • Mediastinal
  • Diaphragmatic
  • Esophageal
  • Penetrating cardiac trauma
  • Blast injury
  • Confined spaces
  • Shock wave
  • Thoracic cage

13
Anatomy
  • Skin
  • Bones
  • Thoracic cage
  • Sternum
  • Thoracic spine

14
Anatomy
  • Muscles
  • The respiratory muscles contract in response to
    stimulation of the phrenic and intercostal
    nerves.
  • Trachea
  • Bronchi
  • Lungs

15
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16
Vascular Anatomy
  • Arteries
  • Aorta
  • Carotid
  • Subclavian
  • Intercostal

17
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18
Vascular Anatomy
  • Veins
  • Superior vena cava
  • Inferior vena cava
  • Subclavian
  • Internal jugular

19
Vascular Anatomy
  • Pulmonary
  • Arteries
  • Veins

20
Vascular Anatomy
  • Heart
  • Ventricles
  • Atria
  • Valves
  • Pericardium

21
Anatomy
  • Mediastinum
  • The area between the lungs
  • Heart
  • Trachea
  • Vena cavae
  • Pulmonary artery
  • Aorta
  • Esophagus
  • Lymph nodes

22
Anatomy
  • Physiology
  • Ventilationthe mechanical
    process of moving air into
    and out of the lungs
  • Respirationthe exchange
    of oxygen and carbon
    dioxide between the outside
    atmosphere and the cells
    of the body

23
Pathophysiology
  • Impairments in cardiac output
  • Blood loss
  • Increased intrapleural pressures
  • Blood in the pericardial sac
  • Myocardial valve damage
  • Vascular disruption

24
Pathophysiology
  • Impairments in cardiac output
  • Blood loss
  • Increased intrapleural pressures
  • Blood in the pericardial sac
  • Myocardial valve damage
  • Vascular disruption

25
Pathophysiology
  • Impairments in gas exchange
  • Atelectasis
  • Contused lung tissue
  • Disruption of the respiratory tract Impairments
    in gas exchange
  • Atelectasis
  • Contused lung tissue
  • Disruption of the respiratory tract

26
Chest TraumaInitial Evaluation
  • Hypoxia and hypoventilation are the primary
    killers of acute trauma patients.
  • Assessment of ventilation is therefore given high
    priority in the primary survey - as the second
    'B' or Breathing stage.

27
Pathophysiology of Chest Trauma
hypovolemia
ventilation- perfusion mismatch
Inadequate oxygen delivery to tissues
changes in intrathoracic pressure relationships
TISSUE HYPOXIA
28
Pathophysiology of Chest Trauma
  • Tissue hypoxia
  • Hypercarbia
  • Respiratory acidosis - inadequate ventilation
  • Metabolic acidosis - tissue hypoperfusion (e.g.,
    shock)

29
Chest TraumaInitial Evaluation
  • Life-threatening injuries should be identified
    and treated immediately.
  • Injuries may develop over time, and become
    life-threatening during the course of a
    resuscitation.
  • Re-assessment and evaluation is therefore
    extremely important, especially if the patient's
    condition deteriorates.

30
Chest Trauma - Initial EvaluationMechanism of
Injury
  • Mechanism of injury is important in so far as
    blunt and penetrating injuries have different
    pathophysiologies and clinical courses.
  • Most blunt injuries are managed non-operatively
    or with simple interventions like intubation and
    ventilation and chest tube insertion.

31
Chest Trauma - Initial EvaluationMechanism of
Injury
  • Diagnosis of blunt injuries may be more difficult
    and require additional investigations such as CT
    scanning.
  • Patients with penetrating trauma may deteriorate
    rapidly, and recover much faster than patients
    with blunt injury.

32
Initial assessment and management
  • Primary survey
  • Resuscitation of vital functions
  • Detailed secondary survey
  • Definitive care

33
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

34
6 Immediate Life Threats
  • Airway obstruction
  • Tension pneumothorax
  • Open pneumothorax
  • sucking chest wound
  • Massive hemothorax
  • Flail chest
  • Cardiac tamponade

35
6 Potential Life Threats
  • Pulmonary contusion
  • Myocardial contusion
  • Traumatic aortic rupture
  • Traumatic diaphragmatic
  • rupture
  • Tracheobronchial tree
  • injury - larynx, trachea,
  • bronchus
  • Esophageal trauma

36
6 Other Frequent Injuries
  • Subcutaneous emphysema
  • Traumatic asphyxia
  • Simple pneumothorax
  • Hemothorax
  • Scapula fracture
  • Rib fractures

37
Chest Trauma Initial EvaluationPrimary Survey
  • Monitoring
  • Oxygen Saturation
  • End-tidal CO2 (if intubated)
  • Diagnostic Studies
  • Chest X-ray
  • FAST ultrasound
  • Arterial Blood Gas
  • Interventions
  • Chest drain
  • ED Thoracotomy

38
Chest Trauma Initial EvaluationSecondary Survey
  • The secondary survey is a more detailed and
    complete examination, aimed at identifying all
    injuries and planning further investigation and
    treatment.
  • Chest injuries identified on secondary survey and
    its adjuncts are
  • Rib fractures and flail chest
  • Pulmonary contusion
  • Simple pneumothorax
  • Simple haemothorax
  • Blunt aortic injury
  • Blunt myocardial injury

39
Primary Survey
  • Airway
  • Breathing
  • Circulation

40
Chest Trauma Initial EvaluationPhysical
examination
  • Physical examination is the primary tool for
    diagnosis of acute thoracic trauma.
  • However, in the noisy ER or in the pre-hospital
    arena, an adequate physical examination may be
    very difficult.
  • Even under ideal conditions, signs of significant
    thoracic injury may be subtle or even absent.
  • It is important also to understand that these
    conditions develop over time.

41
Chest Trauma Initial EvaluationPhysical
examination
  • With the advantages of rapid prehospital
    transport many of these conditions will not have
    fully developed by the time the patient reaches
    the emergency department.
  • While the initial primary survey may identify
    some of these conditions, an initial normal
    examination does not exclude any of them, and
    serial examinations and use of diagnostic
    adjuncts is important.

42
Chest Trauma Initial EvaluationPhysical
examination
  • Look
  • Determine the respiratory rate and depthLook for
    chest wall asymmetry. Paradoxical chest wall
    motion Look for bruising, seat belt or steering
    wheel marks, penetrating wounds
  • Feel
  • Feel for the trachea for deviationAssess whether
    there is adequate and equal chest wall
    movementFeel for chest wall tenderness or rib
    'crunching' indicating rib fracturesFeel for
    subcutaneous emphysema

43
Chest Trauma Initial EvaluationPhysical
examination
  • Listen
  • Listen for normal, equal breath sounds on both
    sides.Listen especially in the apices and
    axillae and at the back of the chest (or as far
    as you can get while supine).
  • Percuss
  • Percuss both sides of the chest looking for
    dullness or resonance (more difficult to
    appreciate in the trauma room).

44
Chest Trauma Initial Evaluation Classic PE
findings
  • The size of the injury, and position of the
    patient will affect the clinical findings.
  • For example, a small hemothorax may have no
    clinical signs at all.
  • A moderate hemothorax will be dull to percussion
    with absent breath sounds at the bases in the
    erect patient, whereas signs will be posterior in
    the supine patient. This is also reflected in
    chest X-ray findings.

45
Chest Trauma Initial Evaluation Classic PE
findings
Trachea Expansion Breath Sounds Percussion
Tension Pneumothorax Away Decreased.Chest may be fixed in hyper-expansion Diminished or absent Hyper-resonant
Simple Pneumothorax Midline Decreased May be diminished May be hyper-resonant. Usually normal
Hemothorax Midline Decreased Diminished if large, normal if small Dull, especially posteriorly
Pulmonary contusion Midline Normal Normal, may have crackles Normal
Lung collapse Towards Decreased May be reduced Normal
46
Chest Trauma Initial Evaluation
  • Note- a collapsed lung on one side can mimic a
    tension pneumothorax on the other side.
  • This is a common error, usually occurring when a
    tracheal tube has been incorrectly placed in the
    right main bronchus, obstructing the right upper
    lobe bronchus.
  • This leads to collapse of the right upper lobe
    and shift of the trachea to the right.
  • The left chest appears hype-resonant compared to
    the left, and breath sounds may be difficult to
    determine.
  • The patient may end up with an unnecessary chest
    drain.

47
Chest Trauma Initial Evaluation
  • Oxygen saturation
  • Pulse oximetry allows continuous, non-invasive
    assessment of arterial hemoglobin oxygen
    saturation.
  • Continuous oxygen saturation monitoring should be
    used during the resuscitation of all trauma
    patients.

48
Chest Trauma Initial Evaluation
  • End-tidal carbon dioxide
  • End-tidal carbon dioxide monitoring (ETCO2)
    should be used in all intubated trauma patients.
  • ETCO2 is the only definitive method of confirming
    placement of a tracheal tube.
  • Other methods, such as watching for chest wall
    movement and listening to breath sounds or for
    air in the stomach are inaccurate, especially in
    the setting of the trauma resuscitation room.
  • ETCO2 also allows for the estimation of the
    arterial PaCO2 level, and for its continuous
    montioring.
  • This is important for all mechanically ventilated
    patients and vital for patients with traumatic
    brain injury.

49
Chest Trauma Initial Evaluation
  • Chest X-ray
  • The plain antero-posterior chest radiograph
    remains the standard initial evaluation for the
    evaluation of chest trauma.
  • Although the indications and techniques are
    slightly different for blunt and penetrating
    trauma.

50
Chest Trauma Initial Evaluation
  • Blunt trauma
  • All blunt trauma patients should have a portable
    chest X-ray performed in the trauma resuscitation
    room.
  • The chest X-ray is a rapid screening examination
    that will identify significant thoracic problems
    requiring intervention.

51
Chest Trauma Initial Evaluation
  • Blunt trauma
  • Chest radiographs in blunt trauma patients are
    taken in the supine position, as unstable spinal
    fractures have not been ruled out at this stage.
  • Chest films should be slightly over-penetrated to
    allow better visualization of the thoracic spine,
    paraspinal lines and aortic outline.

52
Chest Trauma Initial Evaluation
  • Penetrating trauma
  • Patients with a stab wound that may have violated
    the thoracic cavity or mediastinum should have a
    chest X-ray.
  • In practice, this means all patients with stab
    wounds between the neck and the umbilicus (front
    or back!).

53
Chest Trauma Initial Evaluation
  • Penetrating trauma
  • For gunshot wounds, all patients with wounds
    between the neck and the pelvis/buttock area
    should have a chest film.
  • This is especially true if the bullet track is
    unclear, there is a missing bullet or an odd
    number of entry/exit wounds.

54
Chest Trauma Initial Evaluation
  • Penetrating trauma
  • The chest-X-ray in penetrating trauma should be
    taken with the patient sitting upright if
    possible.
  • This will increase the sensitivity for detecting
    a small hemothorax, pneumothorax or diaphragm
    injury.

55
Chest Trauma Initial Evaluation
  • FAST examination
  • Focused abdominal sonography for trauma (FAST) is
    a rapid ultrasound examination performed in the
    trauma resuscitation room looking specifically
    from blood - in the peritoneum, pericardium, or
    hemithorax.
  • Currently, FAST is indicated for all
    hemodynamically unstable blunt trauma patients.
    It may also have a role in some patients with
    penetrating trauma.

56
Chest Trauma Initial Evaluation
  • Arterial Blood Gas analysis
  • Arterial blood gas analyses should be drawn on
    all intubated and ventilated trauma patients, and
    any patient with significant chest trauma or
    evidence of hemodynamic instability.

57
Chest Trauma Initial Evaluation
  • As part of the secondary survey the chest is
    fully examined, front and back.
  • Special attention is paid to identifying any
    missed injuries or progression of previously
    identified injuries.
  • The examination is also directed by findings on
    the chest X-ray or by information from monitoring
    adjuncts.

58
Chest Trauma Initial Evaluation
  • Further investigations may include
  • CT scan
  • Angiography
  • Oesophagoscopy / oesophagram
  • Bronchoscopy
  • Definitive care may include
  • Chest drain
  • Thoracotomy
  • Transfer to ICU area for ventilation /
    observation

59
Assessment Findings
  • Pulse
  • Deficit
  • Tachycardia
  • Bradycardia
  • Blood pressure
  • Narrowed pulse pressure
  • Hypertension
  • Hypotension
  • Pulsus paradoxus

60
Assessment Findings
  • Respiratory rate and effort
  • Tachypnea
  • Bradypnea
  • Labored
  • Retractions
  • Other evidence of respiratory distress

61
Assessment Findings
  • Skin
  • Diaphoresis
  • Pallor
  • Cyanosis
  • Open wounds
  • Ecchymosis
  • Other evidence of trauma

62
Assessment (Neck)
  • Position of trachea
  • Subcutaneous emphysema
  • Jugular venous distention
  • Penetrating wounds

63
Assessment (Chest)
  • Contusions
  • Tenderness
  • Asymmetry
  • Lung sounds
  • Absent or decreased
  • Unilateral
  • Bilateral
  • Location
  • Bowel sounds in hemothorax

64
Abnormal Percussion Finding
  • HyperresonanceAir
  • HyporesonanceFluid

65
Assessment ECG
  • ST/T wave elevation or depression
  • Conduction disturbances
  • Rhythm disturbances

66
History
  • Dyspnea
  • Chest pain
  • Associated symptoms
  • Other areas of pain or discomfort
  • Symptoms before incident
  • Past history of cardiorespiratory disease
  • Use of restraint in motor vehicle crash

67
Management
  • Airway and ventilation
  • High-concentration oxygen
  • Pleural decompression
  • Endotracheal intubation
  • Needle cricothyrotomy
  • Surgical cricothyrotomy
  • Positive-pressure ventilation
  • Occlude open wounds
  • Stabilize chest wall

68
Circulation
  • Manage cardiac dysrhythmias
  • Intravenous access

69
Pharmacological
  • Analgesics
  • Antidysrhythmics

70
Nonpharmacological
  • Needle thoracostomy
  • Tube thoracostomyin hospital management
  • Pericardiocentesisin hospital

71
Skeletal Injury
  • Clavicular fractures
  • Clavicle the most commonly fractured bone
  • Isolated fracture of the clavicle seldom a
    significant injury
  • Common causes
  • Children who fall on their shoulders or
    outstretched arms
  • Athletes involved in contact sports

72
Skeletal Injury
  • Treatment
  • Usually accomplished with a sling and swathe or a
    clavicular strap that immobilizes the affected
    shoulder and arm
  • Usually heals well within 4 to 6 weeks
  • Signs and symptoms
  • Pain
  • Point tenderness
  • Evident deformity

73
Skeletal Injury
  • Complications
  • Injury to the subclavian vein or artery from bony
    fragment penetration, producing a hematoma or
    venous thrombosis (rare)

74
Rib Fractures
  • Incidence
  • Infrequent until adult life
  • Significant force required
  • Most often elderly patients

75
Rib FracturesMorbidity/Mortality
  • Can lead to serious consequences.
  • Older ribs are more brittle and rigid.
  • There may be associated underlying pulmonary or
    cardiovascular injury.

76
Rib FracturesPathophysiology
  • Most often caused by blunt traumabowing effect
    with midshaft fracture
  • Ribs 3 to 8 are fractured most often (they are
    thin and poorly protected)
  • Respiratory restriction as a result of pain and
    splinting

77
Rib FracturesPathophysiology
  • Intercostal vessel injury
  • Associated complications
  • First and second ribs are injured by severe
    trauma
  • Rupture of the aorta
  • Tracheobronchial tree injury
  • Vascular injury

78
Multiple Rib Fractures
  • Atelectasis
  • Hypoventilation
  • Inadequate cough
  • Pneumonia

79
Multiple Rib Fractures
  • Assessment findings
  • Localized pain
  • Pain that worsens with movement, deep breathing,
    coughing
  • Point tenderness
  • Most patients can localize the fracture by
    pointing to the area (confirmed by palpation).
  • Crepitus or audible crunch
  • Splinting on respiration

80
Multiple Rib Fractures Complications
  • Splinting, which leads to atelectasis and
    ventilation-perfusion mismatch (ventilated
    alveoli that are not perfused or perfused alveoli
    that are not ventilated)

81
Rib FracturesManagement
  • Airway and ventilation
  • High-concentration oxygen
  • Positive-pressure ventilation
  • Encourage coughing and deep breathing
  • Pharmacological
  • Analgesics
  • Nonpharmacological
  • Non-circumferential splinting

82
Flail Chest
  • Incidence
  • Most common cause vehicular crash
  • Falls from heights
  • Industrial accidents
  • Assault
  • Birth trauma

83
Flail ChestMorbidity/Mortality
  • Significant chest trauma
  • Mortality rates 20 to 40 due to associated
    injuries
  • Mortality increased with
  • Advanced age
  • Seven or more rib fractures
  • Three or more associated injuries
  • Shock
  • Head injuries

84
Flail ChestPathophysiology
  • Two or more adjacent ribs fractured in two or
    more places producing a free-floating segment of
    chest wall

Flail chest usually results from direct impact.
85
Flail ChestPathophysiology
  • Respiratory failure due to
  • Underlying pulmonary contusion
  • The blunt force of the injury typically produces
    an underlying pulmonary contusion.
  • Associated intrathoracic injury
  • Inadequate bellows action of the chest

86
Flail ChestAssessment Findings
  • Chest wall contusion
  • Respiratory distress
  • Paradoxical chest wall movement
  • Pleuritic chest pain
  • Crepitus
  • Pain and splinting of affected side
  • Tachypnea
  • Tachycardia
  • Possible bundle branch block on ECG

87
Flail ChestManagement
  • Airway and ventilation
  • High-concentration oxygen.
  • Positive-pressure ventilation may be needed.
  • Reverses the mechanism of paradoxical chest wall
    movement
  • Restores the tidal volume
  • Reduces the pain of chest wall movement
  • Assess for the development of a pneumothorax
  • Evaluate the need for endotracheal intubation.
  • Stabilize the flail segment (controversial).

88
Sternal Fractures
  • Incidence
  • Occurs in 5 to 8 of all patients with blunt
    chest trauma
  • A deceleration compression injury
  • Steering wheel
  • Dashboard
  • A blow to the chest massive crush injury
  • Severe hyperflexion of the thoracic cage

89
Sternal FracturesMorbidity/Mortality
  • 25 to 45 mortality rate
  • High association with myocardial or lung injury
  • Myocardial contusion
  • Myocardial rupture
  • Cardiac tamponade
  • Pulmonary contusion

90
Sternal FracturesPathophysiology
  • Associated injuries cause morbidity and
    mortality.
  • Pulmonary and myocardial contusion
  • Flail chest
  • Seriously displaced sternal fractures may produce
    a flail chest.
  • Vascular disruption of thoracic vessels
  • Intra-abdominal injuries
  • Head injuries

91
Sternal FracturesManagement
  • Airway and ventilation
  • High-concentration oxygen
  • Circulationrestrict fluids if pulmonary
    contusion suspected
  • Pharmacologicalanalgesics
  • Non-pharmacologicalallow chest wall
    self-splinting
  • Psychological support/communication strategies

92
Pulmonary Injury
  • Closed (simple) pneumothorax
  • Incidence
  • 10 to 30 in blunt chest trauma
  • Almost 100 with penetrating chest trauma
  • Morbidity/mortality
  • Extent of atelectasis
  • Associated injuries
  • Pathophysiology
  • Caused by the presence of air in the pleural
    space
  • A common cause of pneumothorax is a fractured rib
    that penetrates the underlying lung.

93
Closed (Simple) Pneumothorax
  • May occur in the absence of rib fractures from
  • A sudden increase in intrathoracic pressure
    generated when the chest wall is compressed
    against a closed glottis (the paper-bag effect)
  • Results in an increase in airway pressure and
    ruptured alveoli, which lead to a pneumothorax
  • Small tears self-seal larger ones may progress.
  • The trachea may tug toward the affected side.
  • Ventilation/perfusion mismatch.

94
Closed PneumothoraxAssessment Findings
  • Tachypnea
  • Tachycardia
  • Respiratory distress
  • Absent or decreased breath sounds on the affected
    side
  • Hyperresonance
  • Decreased chest wall movement
  • Dyspnea
  • Chest pain referred to the shoulder or arm on the
    affected side
  • Slight pleuritic chest pain

95
Closed PneumothoraxManagement
  • Airway and ventilation
  • High-concentration oxygen.
  • Positive-pressure ventilation if necessary.
  • If respiration rate is lt12 or gt28 per minute,
    ventilatory assistance with a bag-valve mask may
    be indicated.

96
Closed PneumothoraxManagement
  • Nonpharmacological
  • Needle thoracostomy
  • Transport considerations
  • Position of comfort (usually partially sitting)
    unless contraindicated by possible spine injury

97
Open pneumothorax
  • Develops when penetration injury to the chest
    allows the pleural space to be exposed to
    atmospheric pressure - "Sucking Chest Wound"

98
Open Pneumothorax
  • Incidence
  • Usually the result of penetrating trauma
  • Gunshot wounds
  • Knife wounds
  • Impaled objects
  • Motor vehicle collisions
  • Falls

99
Open Pneumothorax
100
Open pneumothorax
  • WHAT MAY CAUSE A SCW?
  • Examples IncludeGSW, Stab Wounds, Impaled
    Objects, Etc...
  • LARGE VS SMALL
  • Severity is directly proportional to the size of
    the wound
  • Atmospheric pressure forces air through the wound
    upon inspiration

101
Open PneumothoraxMorbidity/Mortality
  • Severity is directly proportional to the size of
    the wound.
  • Profound hypoventilation can result.
  • Death is related to delayed management.

102
Open PneumothoraxPathophysiology
  • An open defect in the chest wall (gt3 cm)
  • If the chest wound opening is greater than
    two-thirds the diameter of the trachea, air
    follows the path of least resistance through the
    chest wall with each inspiration.
  • As the air accumulates in the pleural space, the
    lung on the injured side collapses and begins to
    shift toward the uninjured side.

103
Open pneumothorax
  • Signs Symptoms
  • Shortness of Breath (SOB)
  • Pain
  • Sucking or gurgling sound as air moves in and out
    of the pleural space through the wound

104
Open PneumothoraxAssessment Findings
  • To-and-fro air motion out of the defect
  • A defect in the chest wall
  • A penetrating injury to the chest that does not
    seal itself
  • A sucking sound on inhalation
  • Tachycardia
  • Tachypnea
  • Respiratory distress
  • Subcutaneous emphysema
  • Decreased breath sounds on the affected side

105
Open Pneumothorax
  • Breathing is rapid, shallow and laboured. There
    is reduced expansion of the hemithorax,
    accompanied by reduced breath sounds and an
    increased percussion note.
  • One or all of these signs may not be appreciated
    in a noisy ER.

106
Open PneumothoraxManagement
  • Airway and ventilation
  • High-concentration oxygen.
  • Positive-pressure ventilation if necessary.
  • Assist ventilations with a bag-valve device and
    intubation as necessary.
  • Monitor for the development of a tension
    pneumothorax.
  • Circulationtreat for shock with crystalloid
    infusion.

107
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.

108
Tension pneumothorax
  • Air within thoracic cavity that cannot exit the
    pleural space
  • Fatal if not immediately identified, treated, and
    reassessed for effective management

109
Tension pneumothorax
110
Tension Pneumothorax
  • Associated Injuries
  • A penetrating injury to the chest
  • Blunt trauma
  • Penetration by a rib fracture
  • Many other mechanisms of injury

111
Tension PneumothoraxMorbidity/Mortality
  • Profound hypoventilation can result.
  • Death is related to delayed management.
  • An immediate, life-threatening chest injury.

112
Tension Pneumothorax Pathophysiology
  • 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

113
Early Signs Tension Pneumothorax
  • Extreme anxiety
  • Cyanosis
  • Increasing dyspnea
  • Difficult ventilations while being assisted
  • Tracheal deviation (a late sign)
  • Hypotension

Identification is the most difficult aspect of
field care in a tension pneumothorax.
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Tension Pneumothorax Assessment Findings
  • Bulging of the intercostal muscles
  • Subcutaneous emphysema
  • Jugular venous distention (unless hypovolemic)
  • Unequal expansion of the chest (tension does not
    fall with respiration)
  • Hyperresonnace to percussion

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LATE S/S OF TENSION PNEUMOTHORAX
  • Jugular Venous Distension (JVD)
  • Tracheal Deviation
  • Narrowing pulse pressure
  • Signs of decompensating shock

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MANAGEMENT OF TENSION PNEUMOTHORAX
  • Emergency care is directed at reducing the
    pressure in the pleural space.
  • Airway and ventilation
  • High-concentration oxygen
  • Positive pressure ventilation if necessary
  • Circulationrelieve the tension pneumothorax to
    improve cardiac output.

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Tension Pneumothorax Management
  • Nonpharmacological
  • Occlude open wound
  • Needle thoracostomy
  • Tube thoracostomyin-hospital management

Pleural decompression should only be employed if
the patient demonstrates significant dyspnea and
distinct signs and symptoms of tension
pneumothorax.
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Tension Pneumothorax Management
  • Tension pneumothorax associated with penetrating
    trauma
  • May occur when an open pneumothorax has been
    sealed with an occlusive dressing.
  • Pressure may be relieved by momentarily removing
    the dressing (air escapes with an audible release
    of air).

After the pressure is released, the wound should
be resealed.
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Tension Pneumothorax Management
  • Tension pneumothorax associated with closed
    trauma
  • If the patient demonstrates significant dyspnea
    and distinct signs and symptoms of tension
    pneumothorax
  • Provide thoracic decompression with either a
    large-bore needle or commercially available
    thoracic decompression kit.
  • Insert a 2-inch 14- or 16-gauge hollow needle or
    catheter into the affected pleural space.
  • Usually the second intercostal space in the
    midclavicular line

Insert the needle just above the third rib to
avoid the nerve, artery, and vein that lie just
beneath each rib.
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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

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Tension pneumothorax
  • The classic signs of a tension pneumothorax are
    deviation of the trachea away from the side with
    the tension, a hyper-expanded chest, an increased
    percussion note and a hyper-expanded chest that
    moves little with respiration.
  • The central venous pressure is usually raised,
    but will be normal or low in hypovolemic states.

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Inferior vena cava
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Hemothorax
  • If this condition is associated with
    pneumothorax, it is called a hemopneumothorax.

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Hemothorax
  • Incidence
  • Associated with pneumothorax.
  • Blunt or penetrating trauma.
  • Rib fractures are frequent cause.

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HemothoraxMorbidity/Mortality
  • A life-threatening injury that frequently
    requires urgent chest tube placement and/or
    surgery
  • Associated with great vessel or cardiac injury
  • 50 of these patients will die immediately.
  • 25 of these patients live 5 to 10 minutes.
  • 25 of these patients may live 30 minutes or
    longer.

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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

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HemothoraxAssessment Findings
  • Tachypnea
  • Dyspnea
  • Cyanosis
  • Often not evident in hemorrhagic shock
  • Diminished or decreased breath sounds on the
    affected side

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HemothoraxAssessment Findings
  • Hyporesonance (dullness on percussion) on the
    affected side
  • Hypotension
  • Narrowed pulse pressure
  • Tracheal deviation to the unaffected side (rare)
  • Pale, cool, moist skin

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HemothoraxManagement
  • Airway and ventilation
  • High-concentration oxygen
  • Positive-pressure ventilation if necessary
  • Ventilatory support with bag-valve mask,
    intubation, or both

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HemothoraxManagement
  • Circulation
  • Administer volume-expanding fluids to correct
    hypovolemia
  • Nonpharmacologicaltube thoracostomy

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Hemopneumothorax
  • Pathophysiologypneumothorax with bleeding in the
    pleural space
  • Assessmentfindings and management are the same
    as for hemothorax.
  • Managementmanagement is the same as for
    hemothorax.

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Pulmonary Contusion
  • A pulmonary contusion is the most common
    potentially lethal chest injury.
  • Incidence
  • Blunt trauma to the chest
  • The most common injury from blunt thoracic
    trauma.
  • 30 to 75 of patients with blunt trauma have
    pulmonary contusion.
  • Commonly associated with rib fracture
  • High-energy shock waves from explosion
  • High-velocity missile wounds
  • Rapid deceleration
  • A high incidence of extrathoracic injuries
  • Low velocityice pick

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Pulmonary ContusionMorbidity/Mortality
  • May be missed due to the high incidence of other
    associated injuries

Mortalitybetween 14 and 20
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Pulmonary Contusion Assessment Findings
  • Tachypnea
  • Tachycardia
  • Cough
  • Hemoptysis
  • Apprehension
  • Respiratory distress
  • Dyspnea
  • Evidence of blunt chest trauma
  • Cyanosis

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Pulmonary ContusionManagement
  • Airway and ventilation
  • High-concentration oxygen
  • Positive-pressure ventilation if necessary
  • Circulationrestrict IV fluids (use caution
    restricting fluids in hypovolemic patients).

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Traumatic Asphyxia
  • Incidence
  • A severe crushing injury to the chest and abdomen
  • Steering wheel injury
  • Conveyor belt injury
  • Compression of the chest under a heavy object

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Traumatic Asphyxia Pathophysiology
  • A sudden compressional force squeezes the chest.
  • An increase in intrathoracic pressure forces
    blood from the right side of the heart into the
    veins of the upper thorax, neck, and face.
  • Jugular veins engorge and capillaries rupture.

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Traumatic AsphyxiaAssessment
  • Reddish-purple discoloration of the face and neck
    (the skin below the face and neck remains pink).
  • Jugular vein distention.
  • Swelling of the lips and tongue.

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Traumatic AsphyxiaAssessment
  • Swelling of the head and neck.
  • Swelling or hemorrhage of the conjunctiva
    (subconjunctival petechiae may appear).
  • Hypotension results once the pressure is
    released.

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Traumatic AsphyxiaManagement
  • Airway and ventilation
  • Ensure an open airway.
  • Provide adequate ventilation.
  • Circulation
  • IV access.
  • Expect hypotension and shock once the compression
    is released.

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Heart and Great Vessel Injury
  • Myocardial contusion (blunt myocardial injury)
  • Incidence
  • The most common cardiac injury after a blunt
    trauma to the chest
  • Occurs in 16 to 76 of blunt chest traumas
  • Usually results from motor vehicle collisions as
    the chest wall strikes the dashboard or steering
    column
  • Sternal and multiple rib fractures common

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Heart and Great Vessel Injury Morbidity/Mortality
  • A significant cause of morbidity and mortality in
    the blunt trauma patient
  • Clinical findings are subtle and frequently
    missed due to
  • Multiple injuries that direct attention elsewhere
  • Little evidence of thoracic injury
  • Lack of signs of cardiac injury on initial
    examination

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Heart and Great Vessel Injury Assessment Findings
  • Retrosternal chest pain
  • ECG changes
  • Persistent tachycardia
  • ST elevation, T wave inversion
  • Right bundle branch block
  • Atrial flutter, fibrillation
  • Premature ventricular contractions
  • Premature atrial contractions

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Heart and Great Vessel Injury Assessment Findings
  • New cardiac murmur
  • Pericardial friction rub (late)
  • Hypotension
  • Chest wall contusion and ecchymosis

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Heart and Great Vessel Injury Management
  • Airway and ventilationhigh-concentration oxygen
  • CirculationIV access
  • Pharmacological
  • Antidysrhythmics
  • Vasopressors

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Pericardial Tamponade
  • Incidence
  • Rare in blunt trauma
  • Penetrating trauma
  • Occurs in less than 2 of all chest traumas

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Pericardial Tamponade Morbidity/Mortality
  • Gunshot wounds carry higher mortality than stab
    wounds.
  • Lower mortality rate if isolated tamponade is
    present.

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Pericardial TamponadeAnatomy and Physiology
  • Pericardium
  • A tough fibrous sac that encloses heart
  • Attaches to the great vessels at the base of the
    heart
  • Two layers
  • The visceral layer forms the epicardium.
  • The parietal layer is regarded as the sac
    itself.

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Pericardial Tamponade Pathophysiology
  • A blunt or penetrating trauma may cause tears in
    the heart chamber walls, allowing blood to leak
    from the heart.
  • If the pericardium has been torn sufficiently,
    blood leaks into the thoracic cavity.

If 150 to 200 mL of blood enters the pericardial
space acutely, pericardial tamponade develops.
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Pericardial Tamponade Pathophysiology
  • Increased intrapericardial pressure
  • Does not allow the heart to expand and refill
    with blood
  • Results in a decrease in stroke volume and
    cardiac output
  • Myocardial perfusion decreases due to pressure
    effects on the walls of the heart and decreased
    diastolic pressures.
  • Ischemic dysfunction may result in infarction.
  • Removal of as little as 20 mL of blood may
    drastically improve cardiac output.

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Pericardial Tamponade Assessment Findings
  • Tachycardia
  • Respiratory distress
  • Narrowed pulse pressure
  • Cyanosis of the head, neck, and upper extremities

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Pericardial Tamponade Assessment Findings
  • Becks triad
  • Narrowing pulse pressure
  • Neck vein distention
  • Muffled heart sounds

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Pericardial Tamponade Assessment Findings
  • Kussmauls signa rise in venous pressure with
    inspiration when spontaneously breathing
  • ECG changes

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Pericardial Tamponade Management
  • Airway and ventilation
  • CirculationIV fluid challenge
  • Nonpharmacological pericardiocentesis

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Traumatic Aortic Rupture
  • Incidence
  • Blunt trauma
  • Rapid deceleration in high-speed motor vehicle
    crashes
  • Falls from great heights
  • Crushing injuries

15 of all blunt trauma deaths
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Traumatic Aortic Rupture Morbidity/Mortality
  • 80 to 90 of these patients die at the scene as
    a result of massive hemorrhage.
  • About 10 to 20 of these patients survive the
    first hour.
  • Bleeding is tamponaded by surrounding adventitia
    of the aorta and intact visceral pleura.
  • Of these, 30 have rupture within 6 hours.

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Traumatic Aortic Rupture Pathophysiology
  • Patients who are normotensive should have limited
    replacement fluids to prevent an increase in
    pressure in the remaining aortic wall tissue.

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Traumatic Aortic Rupture Assessment Findings
  • Upper-extremity hypertension with absent or
    decreased amplitude of femoral pulses
  • Thought to result from compression of the aorta
    by the expanding hematoma
  • Generalized hypertension
  • Secondary to increased sympathetic discharge
  • Retrosternal or interscapular pain

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Traumatic Aortic Rupture Assessment Findings
  • About 25 have a harsh systolic murmur over the
    pericardium or interscapular region
  • Paraplegia with a normal cervical and thoracic
    spine (rare)

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Traumatic Aortic Rupture Assessment Findings
  • Dyspnea
  • Dysphagia
  • Ischemic pain of the extremities
  • Chest wall contusion

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Aortic Injury Suspicion
  • Mechanism
  • Fallsgt 3m
  • Major decelaration/acceleration
  • SIGNS
  • Neck hematoma
  • Assymetic pulse or BP
  • Radiofemoral delay
  • Severe searing pain

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Aortic Injury CXR Signs
  • Mediastinum gt 8cm
  • Abnormal Aortic contour
  • Opaque artopulmonary window
  • Apical cap
  • Mediastinal displacement
  • Fracture of first rib or scapula

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Traumatic Aortic Rupture Management
  • Airway and ventilation
  • High-concentration oxygen
  • Ventilatory support with spinal precautions
  • Circulationdo not over-hydrate.

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Diaphragmatic Rupture
  • Incidence
  • Penetrating trauma
  • Blunt trauma
  • Injuries to the diaphragm account for 1 to 8 of
    all blunt injuries.
  • 90 of injuries to the diaphragm are associated
    with high-speed motor vehicle crashes.

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Diaphragmatic RuptureAnatomy Review
  • The diaphragm is a voluntary muscle that
    separates the abdominal cavity from the thoracic
    cavity.
  • The anterior portion attaches to the inferior
    portion of the sternum and the costal margin.
  • Attaches to the 11th and 12th ribs posteriorly.
  • The central portion is attached to the
    pericardium.
  • Innervated via the phrenic nerve.

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Diaphragmatic Rupture
  • Rupture can allow intra-abdominal organs to enter
    the thoracic cavity, which may cause the
    following
  • Compression of the lung with reduced ventilation
  • Decreased venous return
  • Decreased cardiac output
  • Shock

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Diaphragmatic Rupture Pathophysiology
  • Can produce very subtle signs and symptoms
  • Bowel obstruction and strangulation
  • Restriction of lung expansion
  • Hypoventilation
  • Hypoxia
  • Mediastinal shift
  • Cardiac compromise
  • Respiratory compromise

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Diaphragmatic Rupture Management
  • Airway and ventilation
  • High-concentration oxygen
  • Positive-pressure ventilation if necessary
  • Caution positive-pressure may worsen the injury
  • CirculationIV access
  • Nonpharmacologicaldo not place patient in
    Trendelenburg position

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Diaphragmatic Rupture Assessment Findings
  • Tachypnea
  • Tachycardia
  • Respiratory distress
  • Dullness to percussion
  • Scaphoid abdomen (hollow or empty appearance)
  • If a large quantity of the abdominal contents are
    displaced into the chest
  • Bowel sounds in the affected hemithorax
  • Decreased breath sounds on the affected side
  • Possible chest or abdominal pain

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Who gets admitted?
  • Sternal fractures, mediastinal injury
  • Any 1st, 2nd, 3rd rib fractures
  • gt 1 rib fracture in any region
  • Pulmonary contusion
  • Subcutaneous emphysema
  • Traumatic asphyxia
  • Flail segment
  • Arrhythmia or myocardial injury

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In Closing
  • Back to basicsABCDE
  • If you suspect a major chest injury act swiftly
  • Ask for assistance early
  • Practice damage control when necessary
  • Problems with drains? Read the manual or call
    your friendly trauma tream

179
  • QUESTIONS?
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