Download CHEST TRAUMA

CHEST TRAUMA
CHEST TRAUMA
• Second leading cause of trauma death
• 20 % of all trauma deaths
• 50% of trauma patients presenting to ER in
respiratory distress will die
• If in respiratory distress and shock 75% will die
INITIAL SURVEY
• Examine chest immediately after ABC’s
– Inspect: open wounds, tenderness, subcutaneous
emphysema, unequal chest expansion
– Auscultation: decreased breath sounds
– Palpation: pain
– Respiratory rate
• History
– From patients and witnesses
• Seat belts, steering wheel, speed, nature of collision, what
fell on patient, how long was patient crushed
MECHANISM OF INJURY
BLUNT vs PENETRATING
• Blunt: common in all trauma patients
– Injuries are principally a function of the magnitude of force and
the location/direction over which it is applied
– Get a good history
– Support patient while injuries heal
• Penetrating: Consider with suspicious chest wound and
if patient remains hypotensive in spite of fluid therapy
– Knife: Length of the instrument, velocity, angle of entry
– Firearms: Type of gun, Range,
– Limited range of problems
• Hemothorax, pneumothorax, hemopericardium
RIB FRACTURE
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Most common chest injury
Present in 10% of all traumatic injuries
More common in adults than childern
Especially common in elderly
Patients with 1 or 2 rib fractures had a 5%
mortality rate and patients with 7 or more
fractures have a 29% mortality rate
• Ribs form rings
– Consider possibility of break in two places
RIB FRACTURE
• Fractures of the 1st and 2nd ribs require
high force
– Frequently have injury to aorta or bronchi
– 30% will die
• Most commonly
5th to 9th ribs
– Poor protection
RIB FRACTURE
• Fractures of the 8th to 12th ribs can
damage underlying abdominal solid
organs
– Liver
– Spleen
– Kidneys
RIB FRACTURE
• Signs and Symptoms
– Dyspnea
– Localized pain, tenderness
• Increases when patient:
– Coughs
– Moves
– Breathes deeply
– Chest wall
instability
– Deformity, bony
crepitus, ecchymosis
– Associated pneumo
or hemothorax
RIB FRACTURE
• Management
– High concentration oxygen
– Splint using pillow, swathes
– Encourage patient to deep breath
– Monitor elderly and COPD patients carefully
• Broken ribs can cause decompensation
• Patients not breathing deeply will result in poor
clearance of secretions
FLAIL CHEST
• Two or more adjacent ribs broken in two or
more places
• Produces free-floating chest wall segment
– Chest wall becomes unstable
• Usually 2nd to blunt trauma
• More common in older patients
• The incidence of flail segments
is 10-15% in patients with major
chest trauma
FLAIL CHEST
• Signs and Symptoms
– Paradoxical movement
• May NOT be present initially due to intercostal
muscle spasms that splint the segment
• Be suspicious in any patient with chest wall:
– Tenderness
– Crepitus of broken ribs
– Dyspnea
– Hypoxia
• Usually not present unless
underlying lung injury
FLAIL CHEST
• Ramification
– Pain, leading to decreased ventilation
– Increased work of breathing
– Inefficient respirations
– Lung contusion
FLAIL CHEST
• Management
– Establish airway
– Suspect spinal injuries
– Assist ventilation with BVM and oxygen
• Intubate large (>4-6 inches) flail segment and for
underlying acute or chronic lung disease
– Stabilize chest wall
• Towel rolls, tape or sand bags
– Pain relief
• Narcotics, thoracic epidurals
STERNUM FRACTURE
• Extremely painful
• Associated with a steering wheel injury
• Management
– Monitor for cardiac arrhythmias and heart
failure (secondary to myocardial contusion)
PULMONARY CONTUSION
• Bruising of the lung
– Injuries often involve high velocity rather than
slow crushing
– Usually associated with rib fractures/ flail
chest. 20-40% of patients with rib fractures
present with pulmonary contusions
– Always associated with hypoxia
• If tension pneumothorax has been ruled out then
pulmonary contusion is the most likely cause of
respiratory impairment
PULMONARY CONTUSION
• Signs and Symptoms
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Chest pain
Rales
Dyspnea
Tachypnea
Ineffective cough
Hemoptysis
Chest wall contusions
X-ray will show opacity
ABG will worsen in time
due to edema
PULMONARY CONTUSION
• Management
– Oxygen
– Continual reassessment/ Observation
• Oxygenation and ventilation usually deteriorate
over first 4 hours
– Be aggressive if patient has respiratory
distress, severe abdominal injury or COPD.
• Intubate while lung recovers
PNEUMOTHORAX
• Air in pleural space
– Interfers with expansion of lung
• Partial or complete lung collapse occurs
– Respiratory distress is usually not seen until
the pneumo exceeds 40% of lung volume or
pre-existing lung disease
• Patients with pulmonary
disease tolerate
pneumothoraces poorly
PNEUMOTHORAX
• Causes
– Blunt trauma to the chest
– Fractured rib lacerating
lung
– Paper bag effect
– Spontaneously
• Exertion
• Coughing
• Air travel
– Positive pressure
ventilation
PNEUMOTHORAX
• Signs and Symptoms
– Pain on inhalation
– Difficulty breathing
– Tachypnea
– Decreased or
absent breath
sounds
– Hyperresonance
on percussion
– Pleuritic pain
PNEUMOTHORAX
• Management
– Establish airway
– Suspect spinal injury based on mechanism
– High concentration oxygen with NRB
– Assist decreased or rapid respirations with
BVM
– Chest tube if > 20%
– Monitor for tension pnemonthorax
OPEN PNEUMOTHORAX
(SUCKING CHEST WOUND)
• Unusual motion during respiration
– Retraction, shaking, burping
• Hole in chest wall
• Allows air to enter pleural space with
inspiration
• Small wound can form a one way valve
• Larger wound, greater chance air will enter
here than through the trachea
OPEN PNEUMOTHORAX
(SUCKING CHEST WOUND)
• Management
– Cover with occlusive dressing
• Vaseline gauze covered by 4x4’s
• Tape dressing on three sides
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High concentration oxygen
Assist ventilations
Consider transport on injured side
Monitor for tension pneumothorax
• Form one way valve
– Chest tube
• Placed at 2nd site
TENSION PNEUMOTHORAX
• One-way valve forms in lung or chest wall
• Air enters pleural space; cannot leave
• Air is trapped in the
pleural space
• Pressure rises
• Pressure collapses lung
• Mediastinal shift
TENSION PNEUMOTHORAX
• Trapped air pushes heart and lungs away
from injured side
• Vena cava becomes kinked
• Blood cannot return to heart
• Cardiac output falls
• Shock develops
Tension Pneumothorax
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TENSION PNEUMOTHORAX
• Signs and Symptoms
– Extreme dyspnea
– Restlessness, anxiety, agitation
– Decreased breath sounds, unilateral absence
of breath sounds
– Hyperresonance to percussion
– Cyanosis- late
– Subcutaneous emphysema
TENSION PNEUMOTHORAX
• Signs and Symptoms
– Rapid, weak pulse
– Hypotension
– Tracheal shift away from
side
– Jugular vein distension
– Respiratory distress
– Shock
injured
TENSION PNEUMOTHORAX
• Management
– Secure airway
– High concentration oxygen
– Consider ALS for pleural decompression
• Severely compromised patient; insert a 12 g
cannula into the 2nd intercostal space, mid
clavicular line
HEMOTHORAX
• Most common result of major chest wall
trauma
• The incidence of hemopneumothoraces in
patients with rib fractures is 30%.
• Blood in pleura space
– Massive hemothorax due to bleeding from the
major central chest vessels but occasionally
an intercostal artery can bleed enough to
cause a large amount of blood
HEMOTHORAX
• Signs and Symptoms
– Rapid, weak pulse
– Cool clammy skin
– Restlessness, anxiety
– Chills
– Hypotension
– Collapsed neck veins
– Chest pain
HEMOTHORAX
• Signs and Symptoms
– Decreased breath sounds on affected side
– Dullness to percussion
– Dyspnea
– Ventilatory failure
– Up to a liter of blood
may be present and
not seen on portable
supine x-ray
HEMOTHORAX
• Management
– Secure airway
– Assist breathing with high
concentration oxygen
– Rapid transport
– Place a large chest tube
(36-40) aimed posteriorly
TRAUMATIC ASPHYXIA
• Blunt force to chest causes
– Increased intrathoracic pressure
– Backward flow of blood out of the heart into
vessels of upper chest, neck, head
• Name given because patients look like
they have been strangled or hanged
TRAUMATIC ASPHYXIA
• Signs and Symptoms
– Possible sternal fracture or central flail chest
– Shock
– Purplish-red discoloration of head, neck,
shoulders
– Sub-conjunctival haemorrhage (Blood shot)
protruding eyes
– Swollen, cyanotic lips
TRAUMATIC ASPHYXIA
• Management
– Airway with C-spine percautions
– Assist ventilations with high concentration
oxygen
– Spinal stabilization
– Rapid transport
TRAUMATIC AIR EMBOLISM
• Suspect in penetrating chest wounds
where there is sudden deterioration in
cardiac output after intubation
• Immediately life-threatening
• Neurological signs in the absence of a
head injury
• Hemoptysis
TRAUMATIC AIR EMBOLISM
• Management
– 100% O2
– minimise ventilation volumes and pressures
– emergency thoracotomy to clamp ascending
aorta, remove air source (by clamping
pulmonary hilum) and aspirate air from LV
and ascending
TRACHEOBRONCHIAL TREE
RUPTURE
• Relatively rare
• Signs and symptoms
– Dyspnea, Tachypnea
– Hemoptysis
– Subcutaneous emphysema in the neck, face, or suprasternal
area
– Decreased or absent breath sounds
– Persistant pneumothorax
– Potential airway obstruction
• Management
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Control of ventilation (ETT distal to the level of injury)
Bilateral needle decompression may be needed
Two chest tubes inserted on injured side
Bronchoscopy / surgery
CARDIOVASCULAR TRAUMA
• Any patient with significant blunt or
penetrating trauma to chest has
heart/great vessel injury until proven
otherwise
• All patients in shock with penetrating
wound of chest have cardiac injury until
proven otherwise. (Abdominal stab or
gunshot wound may also reach the heart)
MYOCARDIAL CONTUSION
• Bruise of the heart muscle
• Most common cardiac injury
• Usually due to steering wheel impact
MYOCARDIAL CONTUSION
• Behaves like an acute myocardial
infarction
– May produce arrhythmias
– May cause cardiogenic
shock, hypotension
MYOCARDIAL CONTUSION
• Signs and symptoms
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Cardiac arrhythmias after blunt chest trauma
Angina-like pain unresponsive to nitroglycerin
Chest pain independent of respiratory movemen
Chest wall ecchymosist
Tachycardia out of proportion to other injuries
Friction rub may be present
ECG may be normal or ST elevation
Cardiac enzymes may be normal
MYOCARDIAL CONTUSION
• Management
– High concentration oxygen
– ECG
– Transport
– Consider ALS intercept
– Hospitalized for cardiac monitoring and serial
enzymes
CARDIAC TAMPONADE
• Rapid accumulation of blood in space
between heart and pericardium
• Heart is compressed
• Blood entering heart
decreases
• Cardiac output falls
• Obstructive shock can
occur
CARDIAC TAMPONADE
• Signs and symptoms
– Classic Triad
• Hypotension unresponsive to treatment
• Increased central venous pressure (distended
neck/arm veins in presence of decreased arterial
blood pressure)
• Decreased/muffled heart sounds
– Less than ½ the patients present this way
• Neck veins may not be distended if hypovolemic
• Muffled heart sounds often not present
CARDIAC TAMPONADE
• Dyspnea
• Narrowing pulse pressure
• Pulsus paradoxicus
– Radial pulse becomes weak
or disappears when patient
inhales
• Drops >10 mm in SBP
CARDIAC TAMPONADE
• Management
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Secure airway
High concentration oxygen
Rapid fluid administration
Rapid transport
Pericardiocentesis with
removal of 5 to 10 mL
• Leave catheter in place until
the cardiac wound can be
repaired
– Surgery
TRAUMATIC AORTIC ANEURYSM
• 90% die within minutes. Those who arrive
to the hospital alive 90% will die
• Little external evidence of serious chest
trauma
• Caused by sudden decelerations, massive
blunt force:
– Vehicle collisions, Falls from heights, crushing
chest trauma, blunt chest trauma, Animal
kicks
TRAUMATIC AORTIC ANEURYSM
• Rupture usually occurs just
beyond left subclavian, near
the ligamentum arteriosum
• Attachment of aorta to
pulmonary artery at this
point produces shearing
force on aortic arch
TRAUMATIC AORTIC ANEURYSM
• Signs and Symptoms
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Increased BP in arms in absence of head injury
Decreased femoral pulses with full arm pulses
Respiratory distress
New murmur
• More likely in patients with 1st or 2nd rib fracture
– Ache in chest, shoulders (interscapular), back,
abdomen
• Only 25 % of the patients
– X-ray shows a widened upper mediastinum, blurring
of aortic knob, deviation of trachea to the right
TRAUMATIC AORTIC ANEURYSM
• Management
– High concentration oxygen
– Assist ventilation
– Suspect spinal injury
– Rapid fluid resuscitation
– Rapid transport
ASSOCIATED ABDOMINAL
TRAUMA
• Diaphragm forms dome that extends up
into rib cage
• Trauma to chest below 4th rib = Abdominal
injury until proven otherwise
DIAPHRAGMATIC RUPTURE
• Difficult to diagnose and often missed
• Mostly seen on left side
• Suspect when there is
diminished air entry,
bowel sounds in chest
or mediastinal shift
DIAPHRAGMATIC RUPTURE
• Signs and symptoms
– Dyspnea
– Dysphagia
– Abdominal pain
– Sharp epigastric or chest pain radiating to the
left shoudler (Kehr’s Sign)
– Bowel sounds in the lower to middle chest
– Decreased breath sounds on the injuried side
CONCLUSION
• If you only remember one thing…
– NO MATTER WHAT THE INJURY
TREATMENT IS ALWAYS…
ABC’s
THE