Download Thoracic Trauma

Thoracic Trauma
Hossam Hassan
Thoracic Trauma
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Anatomy
Thorax is a hollow cylinder composed of
12 pairs of ribs,10 articulate posteriorly with
the thoracic spine and anteriorly with the
sternum via costal cartilages, the lower 2
pairs are floating ribs
A nerve,and artery and a vein are located a
long the under side of each rib
Intercostal muscles connect each rib to the
one above these muscles with the diaphragm
are the primary muscle of ventilation.
Anatomy
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The pleurae are thin membranes that
consist of 2 distinct layers:
The partial pleurae line the inner side of
the thoracic cavity
The visceral pleurae cover the outer
surface of each lung
Anatomy
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The lungs occupy the right and the left halves
of the thoracic cavity
An area called the mediastinum is located in
the middle of the thoracic cavity within the
mediastinum lie all the other organs and
structures of the chest cavity:the heart,great
vessels,trachea,mainstem bronchi and
esophagus
Any or all of these structures can be injured
by thoracic trauma.
General Assessment
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The signs and symptoms of chest truma
related to the chest wall and lungs are
sob,tachypnea and chest pain
The initial 3 points in general assessment is :
1.Observation ex.bruises,lacerations,distended
neck veins
2.Palpation ex.tenderness,bony crepitus
3.Auscultation ex.presence ,diminished or
absence of breath sounds.
Thoracic injuries can be:
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Rib Fractures
Flail chest
Pulmonary contusion
Pneumothorax(open and close)
Tension pneumothorx
Hemothorax
Blunt cardiac injuries
Pericardial tamponade
Tracheal and bronchial rupture
Aortic rupture
Chest Trauma
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History & PE
ATLS protocol
A,B,C,D,E’s
AMPLE
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A allergies
M Medications (Anticoagulants,
insulin and cardiovascular
medications especially)
Previous medical/surgical history
L Last meal (Time)
E Events /Environment
surrounding the injury; ie. Exactly
what happened
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CXR-fast, easy, least expensive for
initial evaluation
Ultrasound-may soon replace CXR
as initial radiographic study in
chest trauma
CT Scan VS Angiography
EChO VS Transesophogeal
Echocardiography
FAST
Normal CXR
Pneumothorax
Subcutaneous Emphysema
Hemothorax
Management of specific
injuries.
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Rib fracture
Assessment:
Simple rib fracture alone are rarely life
threatening in adults
Signs and symptoms of fractured ribs
include pain with movement,local
tenderness and perhaps bony crepitus
Rib fracture
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Management
The initial management of patient with simple
rib fracture is pain reduction
supplemental oxygen in case hypoxia
Bed rest
Fractured ribs should not be stabilized by
taping or using any other firm bandaging
such attempt can limit ventilation and lead to
atelactasis (collapse of the alveoli or part of
the lung)and pneumonia
Flail Chest
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Flail chest is when 2 or more adjacent
ribs are each fractured in at least 2
places
Assessment :
Tenderness
Bony crepitus
Hypoxia might happen then lead to
increase in respiratory rate as well.
Flail chest
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Management:
The key management is BVM (for
positive pressure ventilation)
All patient who have an obvious flail
segment should supplied with
supplemental O% if not respond then
will require more aggressive
ventilataroy support
Pulmonary contusion
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A pulmonary contusion is an area of the lung
that has been traumatized to the point where
intertitial and leveolar bleeding occur
The amount of intertitial fluids increase in the
area between the wall of the cappilaries and
alveoli resulting in decreased O% transporst
across the thickened membranes
Pulmonary contusion
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Managements
Patient should closely monitored with
special attention to fluid administration
Ensuring adequate ventilation and
enriched O% administration
In inadequate ventilations or altered
LOC or other major injuries BVM and
endotracheal intubation if required.
Pneumothorax
Simple pneumothorax
 Open pneumothorax.
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Simple pneumothorax
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Simple pneumothorax is caused by the
presence of air in the pleural space
Assessment:
Pleuratic chest pain
Difficult and rapid breathing
Decreased or absent breath sounds on
the involved side are classic signs
Percussion is an excellent indicator
Simple pneumothorax
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Management:
High concentration of O% should be
administrated to patients with
pneumothorax
Assisted ventilation might be for those
who display signs of hypoxia
Semi sitting position is preferred.
Open pneumothorax
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Penetrating wounds to the chest can produce
open chest wall injuries(open pneumothorax)
Assessment :
Pain at the injured side
SOB
The sings might included sucking out
bubbling sound as air moves in and out of the
pleural space through the chest wall defected
Open pneumothorax
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Management
Close the wound in the chest
Closing the wound it could be with a Vaseline
gauze by 3 sides taped .
Provide supplemental O%
If signs of increasing respiratory distress are
observed the patient may be developing a
tension pneumothorax and the dressing
should be removed to assess in
decompressing the affected side.
Tension pneumothorax
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It is a life threatening situation
The amount of air trapped in the pleural
space continues to increase not only is the
lung on the affected side collapsed but the
mediastinum is also shifted into the opposite
side
The intra thoracic pressure increase which
decrease the capillaries blood flow and kinks
the vena cava.
Tension pneumothorax
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Assessment:
The presentation of patient with tension
pneumothorax varies according to how much
intrathoracic pressure has developed.
Signs and symptoms can be minimal or
moderate
Anxiety
Cyanosis
Tachypnea
Diminished or absent breath sound on the
injured side
Tension pneumothorax
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Management:
The management of the patient with a
tension pneumothorax involves reducing the
pressure in the pleural space
Needle decompression in the field can be
done by the expert people then
Chest tube .
Hemothorax
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Blood in the pleural space constitutes a
hemothorax
In adult the pleural space on each side
of the thorax can hold 2500 to 3000 ml
of blood
Hemothorax
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Assessment:
The symptoms are related to the blood loss
Signs:
Sob
Tachypnea
Decreased breath sound
Clinical signs of shock
Management: transfer to surgical repair.
Myocardial Contusion
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Occurs in 76% of patients with severe
blunt chest trauma
–Right Atrium and Ventricle is
commonly injured
–Injury may reduce strength of cardiac
contractions Reduced cardiac output
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Electrical Disturbances due to irritability
of damaged myocardial cells
–Progressive Problems
Hematoma
Hemoperitoneum
Myocardial necrosis
Dysrhythmias
CHF & or Cardiogenic shock
Myocardial Contusion Signs &
Symptoms
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Bruising of chest wall
􀂄Tachycardia and/or irregular rhythm
􀂄Retrosternal pain similar to MI
􀂄Associated injuries Rib/ Sternal
fractures
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Chest pain unrelieved by oxygen May
be relieved with rest
 THIS IS TRAUMA-RELATED PAIN
Similar signs and symptoms of medical
chest pain
Blunt Cardiac Injury
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EKG (for any blunt chest injury,
persistent tachycardia, ST-T changes or
ectopy)
􀂄Cardiac enzymes (CPK, CK-MB and
Troponin I)
􀂄Echocardiography (TEE)
Pericardial Tamponade
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Restriction to cardiac filling caused by
blood or other fluid within the
pericardium
–Occurs in <2% of all serious chest
trauma However, very high mortality
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–Results from tear in the coronary
artery or penetration of myocardium
Blood seeps into pericardium and is
unable to escape
200 ml of blood can restrict
effectiveness of cardiac contraction
Pericardial Tamponade
Signs & Symptoms
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Dyspnea
Possible cyanosis
Beck’s Triad
JVD
Distant heart tones
Hypotension or narrowing pulse
pressure
Weak, thready pulse
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Kussmaul’s sign Decrease or absence of
JVD during inspiration
Pulsus Paradoxus Drop in SBP >10
during inspiration
Electrical Alterans P, QRS, & T
amplitude changes in every other
cardiac cycle
PEA
Traumatic Aortic injury
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Aorta most commonly injured in severe
blunt 85-95% mortality
Injury may be confined to areas of
aorta attachment
Signs & Symptoms
Rapid and deterioration of vitals
Pulse deficit between right and left
upper or lower extremities
Traumatic Esophageal
Rupture
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Rare complication of blunt thoracic
trauma
–30% mortality
–Contents in esophagus/stomach may
move into mediastinum
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Serious infection occurs
Chemical irritation
Damage to mediastinal structures
Air enters mediastinum
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Subcutaneous emphysema and
penetrating trauma present
Tracheo-bronchial Injury
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Blunt trauma
Penetrating trauma
50% of patients with injury die within 1
hr of injury
Disruption can occur anywhere in
tracheobronchial tree
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Signs & Symptoms
Dyspnea
Cyanosis
Hemoptysis
Massive subcutaneous emphysema
Suspect/ evaluate for other closed chest
trauma
Treatment summary
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Observe
Palpate
Auscultation
Management always included to provide
supplemental O% then aggressive
method if required.
ATLS protocol: A,B,C,D,E’s
Treatment summary
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Emergency management
Needle thoracentesis
Tube thoracostomy
Subxiphoid pericardotomy
Video assisted thoracic surgery (VATS)
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THANK YOU
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3. Identification of which of the
following is NOT an essential part of the
primary survey?
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A: Tension Pneumothorax
B: Open Pneumothorax
C: Flail Chest
D: Cardiac Tamponade
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4. Upon Identification of a Tension
Pneumothorax, which is the correct
management pathway?
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A: A chest X-ray to confirm the clinical
diagnosis.
B: Insertion of a chest drain in the 5th
intercostals interspace in mid-axillary
line.
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In massive haemothorax, which of the
following is an indication for emergency
thoracotomy?
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A: Production of 500ml of blood on
immediate insertion of a chest drain.
B: Production of 50ml/hour of blood for
two consecutive hours in the chest
drain.
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A pulmonary contusion:
A: Can cause immediate respiratory
difficulties.
B: Results in increased lung compliance
at 24 hours.
C: Does not occur without rib fractures
in children.
D: Can cause ventilation/perfusion
mismatch which evolves over 24 hours.
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When evaluating the chest of a patient
with a chest injury, you note a fine
crackling sensation under the areas that
you palpate. This is best described as:
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pulses paradoxus. subcutaneous
emphysema. hemothorax. none of the
above.
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In which condition would you observe
paradoxical movement of the chest
wall?
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mediastinal shift tension
pneumothorax flail chest Cheyne–
Stokes breathing
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Proper care for a patient with a sucking
chest wound includes:
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pulling the wound open on inhalation
to release trapped air. sealing the
wound with an occlusive dressing.
covering the wound with sterile gauze.
decompression of the chest.
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Which of the following statements
correctly differentiates a simple
pneumothorax from a tension
pneumothorax?
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A tension pneumothorax requires
decompression while a simple
pneumothorax does not. A simple
pneumothorax is caused by air in the
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After placing an occlusive dressing over
a sucking chest wound to the right
chest, you note that the patient has
become extremely dyspneic and
cyanotic with breath sounds absent on
the right side. Your next action would
be to:
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perform a needle cricothyroidotomy.
A 23-year-old woman presents with pain in her right
lateral chest after a low-speed motor vehicle collision.
She is most tender in the fifth rib at the posterior
axillary line. Which of the following is the most
appropriate next step in evaluation?
(A) Chest x-ray
(B) Rib x-rays
(C) CT abdomen/pelvis
(D) CTbrain
(E) Cervical spine radiographs