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Chapter 27 Chest and Abdominal Trauma Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 1 Anatomy and Physiology of the Chest Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 2 Anatomy and Physiology of the Chest Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 3 Thoracic Cavity Subdivided into two smaller spaces Mediastinum – in center • Contains heart, great vessels, esophagus, trachea, nerves Pleural spaces – on either side of mediastinum Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 4 Chest Trauma – Mechanisms of injury Blunt Sudden deceleration of chest wall against a fixed object Penetration Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 5 Rib Fractures Most often the result of blunt trauma Isolated rib fracture usually not a serious emergency Can puncture lung or blood vessel Pneumothorax, hemothorax, flail chest Lower rib fractures may injure abdominal organs Liver, spleen, kidneys Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 6 Case History You respond to an MVC to find a 65-yearold female victim of a front end collision. She is complaining of severe chest pain and dyspnea. She is pale, cyanotic, and diaphoretic. You notice that the steering wheel is deformed. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 7 Flail Chest Two or more ribs fractured in two or more places Paradoxical chest movement Look for signs of underlying injury (e.g., pneumothorax) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 8 Flail Chest – Management Splint chest wall Blanket, towel, sheet Rigid splint Positive-pressure ventilation When hypoventilation is present and patient can tolerate Restores adequate ventilation Otherwise nonrebreather device Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 9 Traumatic Asphyxia Severe compression of thorax High-velocity or steering wheel injuries, heavy weight dropped on chest Heart compressed; blood driven to thorax and neck Ecchymosis and edema Life-threatening injury Look for associated injuries to lungs and chest wall Management: high-concentration oxygen, possible PPV Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 10 Traumatic Asphyxia Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 11 Case History You respond to a call for “difficulty breathing” to find a 19-year-old male complaining of dyspnea and chest pain. He states that it started suddenly while he was running. His breathing difficulty has gotten worse over the last hour. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 12 Pneumothorax Occurs when air enters visceral and parietal pleura Collapses lung Less alveolar surface for diffusion of oxygen Results in hypoxia Two mechanisms Trauma Spontaneous rupture Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 13 Traumatic Penetrating Missile Sharp object Broken rib Blunt Person takes deep breath just before auto collision • “Paper bag effect” Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 14 Spontaneous Ruptured bleb in lung tissue Young, muscular males COPD patients Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 15 Open Pneumothorax Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 16 Open Pneumothorax – Assessment and Recognition Sucking wound Dyspnea Pleuritic chest pain Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 17 Open Pneumothorax – Assessment and Recognition Absent or diminished breath sounds on affected side Signs of respiratory distress Subcutaneous emphysema Historical profile Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 18 Open Pneumothorax – Management Check ABCs. Administer oxygen; positive-pressure ventilation, if needed (carefully). Seal wound with airtight dressing on three sides. Place patient in position of comfort. Transport to definitive care. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 19 Closed Pneumothorax Also called simple pneumothorax Management High-concentration oxygen; possible PPV Transport without delay. • Watch for signs of a developing tension pneumothorax. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 20 Case History You respond to an MVC and find a 32year-old female involved in victim of a front end collision complaining of severe chest pain and dyspnea. She is pale, cyanotic, and diaphoretic. The police on scene says she was fine when they arrived but she suddenly started to become “very sick.” Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 21 Tension Pneumothorax Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 22 Tension Pneumothorax Air trapped within pleural space Acts as a one-way valve Increased intrathoracic pressure Can collapse superior and inferior vena cavae • Reduces blood return to heart Causes profound shock Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 23 Tension Pneumothorax – Assessment and Recognition Increasing respiratory distress and cyanosis Breath sounds absent on affected side Distended neck veins Tracheal shift Signs of shock Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 24 Tension Pneumothorax – Management If airtight dressing was applied, remove dressing Reapply dressing after air escapes. Watch for further tension. Transport immediately. Consider ALS intercept (for needle decompression). Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 25 Hemothorax Blood within the pleural space Thorax has the capacity for massive blood loss. Physiologic effects Primary effect – hypovolemic shock May exist with or without an associated pneumothorax May occur due to penetrating injuries or to rib fractures Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 26 Hemothorax – Assessment and Recognition Signs of hypovolemic shock Delayed or absent capillary refill (children) Pale, cool, sweaty skin Tachycardia Rapid and shallow breathing Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 27 Hemothorax – Assessment and Recognition Breath sounds absent on the affected side Hemoptysis (coughing blood) Hypotension (late sign) Altered mental state (late sign) Cardiovascular collapse (cardiac arrest) Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 28 Hemothorax – Management Establish a patent airway. Suction available to manage hemoptysis High-concentration oxygen; possible PPV Transport immediately. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 29 Pulmonary Contusion From severe blows to chest wall Can result in swelling and fluid buildup Decreases diffusion of oxygen into capillaries Management High-concentration oxygen Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 30 Cardiac Tamponade Fluid accumulation in the pericardial sac caused by bleeding or fluid loss May result from blunt or penetrating trauma Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 31 Cardiac Tamponade — Physiologic Effects Bleeding places pressure on atria, ventricles, and vena cava. Venous return is obstructed. Interferes with the normal dynamics of contraction. Cardiac output is decreased. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 32 Cardiac Tamponade — Assessment and Recognition Penetrating wound or precordial contusion may be present. Signs of shock Decreased pulse pressure Muffled heart sounds Distended neck veins Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 33 Cardiac Tamponade — Management Early recognition and rapid hospital intervention – most essential Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 34 Case History You respond to a “man down” to find a 20-yearold construction worker who fell 30 feet from a rooftop. He is complaining of pain in his chest and back. He is pale and diaphoretic. His pulse is 130 and thready. He is responsive to painful but not verbal stimuli. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 35 Aortic Tear Complete tear results in exsanguination and death. Partial tear causes leak and hemorrhage. Hypovolemic shock is main problem. Mortality is very high from massive hemorrhage. 80% die within first hour Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 36 Abdominal Trauma Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 37 Anatomy and Physiology of the Abdomen Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 38 Anatomy and Physiology of the Abdomen Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 39 Anatomy and Physiology of the Abdomen Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 40 Abdominal Injuries Large vessels and highly vascular organs within abdomen Rapid blood loss and death Maintain high level of suspicion May be from blunt or penetrating trauma Primary goal Recognize life-threatening injuries. Administer essential life support. Transport without delay (requires surgical intervention). Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 41 Mechanism of Injury Blunt trauma Compression injuries Deceleration injuries Seat belt injuries Penetrating trauma Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 42 Assessment Scene size-up Obtain MOI Initial assessment Look for signs of hypovolemia Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 43 Assessment Focused history and physical examination Look for bruises, tire marks, seat belt marks. Is abdomen distended? DCAP-BTLS Palpate abdomen for tenderness and guarding. • Save painful area for last. Palpate iliac crest. • If pelvic bones move, stop examination. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 44 Assessment Focused history and physical examination (continued) Associated head or spinal injuries may present with loss of pain perception. SAMPLE history Elderly? History of medications that slow heart rate? Signs of alcohol or drugs Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 45 Management Management occurs in hospital. Treat for shock. Transport without delay. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 46 Special Considerations Evisceration Do not attempt to put organs back in abdomen. • Cover with moist, sterile dressing or airtight dressing. Transport in supine position with hips and legs flexed with pillow under knees. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 47 Evisceration Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 48 Special Considerations Urinary tract injuries Injuries to male genitalia Look for bruises over flank. Injuries to pelvis can cause bladder or urethral tears. May result in lacerations, bruising, avulsion, or amputation Injuries to female genitalia May occur from direct trauma or straddle injuries Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 49 Acute Abdomen Recent onset of abdominal pain Requires early diagnosis and surgical intervention Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 50 Acute Abdomen – Assessment Identify life threats and transport immediately. Initial assessment If shock present, rapid transport. Establish and maintain patent airway. Administer high-concentration oxygen. Place patient in position of comfort, if not contraindicated. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 51 Acute Abdomen – Assessment Focused history Gather SAMPLE history with O-P-Q-R-S-T approach. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 52 SAMPLE History for Patients with Abdominal Complaints Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 53 SAMPLE History for Patients with Abdominal Complaints Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 54 SAMPLE History for Patients with Abdominal Complaints Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 55 Acute Abdomen – Assessment Focused physical examination Look for findings associated with abdominal complaints. • Jaundice in sclera or skin? • Signs of dehydration? Ask patient to point to area of pain. • Palpate that quadrant last. Copyright © 2007, 2004, by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved. Slide 56
