Transcript Slide 1

CHEST TRAUMA
Victor Politi,M.D., FACP
Medical Director, SVCMC
Physician Assistant Program
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
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.
splinter
CAUSES OF THORACIC TRAUMA
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Falls
3 times the height of the patient
Blast Injuries
overpressure, plasma forced into
alveoli
• Blunt Trauma
• Penetrating trauma
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
• <10% of blunt chest trauma needs surgery
• 1/3 of penetrating trauma needs surgery
• Most life-saving procedures do NOT require a
thoracic surgeon
Classifications of Chest Injuries
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Skeletal injury
Pulmonary injury
Heart and great vessel injury
Diaphragmatic injury
Classification
Mechanism of Injury
• Blunt thoracic injuries
• Forces distributed over a large area
– Deceleration
– Compression
Classification
Mechanism 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
Injury Patterns
• General types
– Open injuries
– Closed injuries
Injury Patterns
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Cardiovascular
Pleural and pulmonary
Mediastinal
Diaphragmatic
Esophageal
Penetrating cardiac trauma
Blast injury
Confined spaces
Shock wave
Thoracic cage
Anatomy
• Skin
• Bones
– Thoracic cage
– Sternum
– Thoracic spine
Anatomy
• Muscles
– The respiratory muscles contract in response
to stimulation of the phrenic and intercostal
nerves.
• Trachea
• Bronchi
• Lungs
Vascular Anatomy
• Arteries
– Aorta
– Carotid
– Subclavian
– Intercostal
Vascular Anatomy
• Veins
– Superior vena cava
– Inferior vena cava
– Subclavian
– Internal jugular
Vascular Anatomy
• Pulmonary
– Arteries
– Veins
Vascular Anatomy
• Heart
– Ventricles
– Atria
– Valves
– Pericardium
Anatomy
• Mediastinum
– The area between the lungs
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Heart
Trachea
Vena cavae
Pulmonary artery
Aorta
Esophagus
Lymph nodes
Anatomy
• Physiology
– Ventilation—the mechanical
process of moving air into
and out of the lungs
– Respiration—the exchange
of oxygen and carbon
dioxide between the outside
atmosphere and the cells
of the body
Pathophysiology
• Impairments in cardiac output
– Blood loss
– Increased intrapleural pressures
– Blood in the pericardial sac
– Myocardial valve damage
– Vascular disruption
Pathophysiology
• Impairments in cardiac output
– Blood loss
– Increased intrapleural pressures
– Blood in the pericardial sac
– Myocardial valve damage
– Vascular disruption
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
Chest Trauma
Initial 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.
Pathophysiology of Chest Trauma
hypovolemia
ventilationperfusion
mismatch
changes in
intrathoracic
pressure
relationships
Inadequate oxygen
delivery to tissues
TISSUE
HYPOXIA
Pathophysiology of Chest Trauma
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Tissue hypoxia
Hypercarbia
Respiratory acidosis - inadequate ventilation
Metabolic acidosis - tissue hypoperfusion
(e.g., shock)
Chest Trauma
Initial 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.
Chest Trauma - Initial Evaluation
Mechanism 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 nonoperatively or with simple interventions like
intubation and ventilation and chest tube
insertion.
Chest Trauma - Initial Evaluation
Mechanism 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.
Initial assessment and management
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Primary survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care
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
6 Immediate Life Threats
• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
“sucking chest wound”
• Massive hemothorax
• Flail chest
• Cardiac tamponade
6 Potential Life Threats
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Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture
Traumatic diaphragmatic
rupture
• Tracheobronchial tree
injury - larynx, trachea,
bronchus
• Esophageal trauma
6 Other Frequent Injuries
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Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures
Chest Trauma – Initial Evaluation
Primary Survey
• Monitoring
– Oxygen Saturation
– End-tidal CO2 (if intubated)
• Diagnostic Studies
– Chest X-ray
– FAST ultrasound
– Arterial Blood Gas
• Interventions
– Chest drain
– ED Thoracotomy
Chest Trauma – Initial Evaluation
Secondary 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:
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Rib fractures and flail chest
Pulmonary contusion
Simple pneumothorax
Simple haemothorax
Blunt aortic injury
Blunt myocardial injury
Primary Survey
• Airway
• Breathing
• Circulation
Chest Trauma – Initial Evaluation
Physical 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.
Chest Trauma – Initial Evaluation
Physical 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.
Chest Trauma – Initial Evaluation
Physical examination
• Look
– Determine the respiratory rate and depth
Look 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 deviation
Assess whether there is adequate and equal chest
wall movement
Feel for chest wall tenderness or rib 'crunching'
indicating rib fractures
Feel for subcutaneous emphysema
Chest Trauma – Initial Evaluation
Physical 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).
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.
Chest Trauma – Initial Evaluation
Classic PE findings
Tension Pneumothorax
Trachea
Expansion
Breath Sounds
Percussion
Away
Decreased.
Diminished or
absent
Hyper-resonant
Chest may be fixed in
hyper-expansion
Simple
Pneumothorax
Midline
Decreased
May be
diminished
May be hyperresonant.
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
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.
Chest Trauma – Initial Evaluation
• Oxygen saturation
– Pulse oximetry allows continuous, noninvasive assessment of arterial hemoglobin
oxygen saturation.
– Continuous oxygen saturation monitoring
should be used during the resuscitation of all
trauma patients.
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.
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.
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.
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.
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!).
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.
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.
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.
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.
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.
Chest Trauma – Initial Evaluation
• Further investigations may include:
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CT scan
Angiography
Oesophagoscopy / oesophagram
Bronchoscopy
• Definitive care may include:
– Chest drain
– Thoracotomy
– Transfer to ICU area for ventilation / observation
Assessment Findings
• Pulse
– Deficit
– Tachycardia
– Bradycardia
• Blood pressure
– Narrowed pulse pressure
– Hypertension
– Hypotension
– Pulsus paradoxus
Assessment Findings
• Respiratory rate and effort
– Tachypnea
– Bradypnea
– Labored
– Retractions
– Other evidence of respiratory distress
Assessment Findings
• Skin
– Diaphoresis
– Pallor
– Cyanosis
– Open wounds
– Ecchymosis
– Other evidence of trauma
Assessment (Neck)
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Position of trachea
Subcutaneous emphysema
Jugular venous distention
Penetrating wounds
Assessment (Chest)
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Contusions
Tenderness
Asymmetry
Lung sounds
– Absent or decreased
– Unilateral
– Bilateral
– Location
– Bowel sounds in hemothorax
Abnormal Percussion Finding
• Hyperresonance–Air
• Hyporesonance–Fluid
Assessment ECG
• ST/T wave elevation or depression
– Conduction disturbances
– Rhythm disturbances
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
Management
• Airway and ventilation
– High-concentration oxygen
– Pleural decompression
– Endotracheal intubation
– Needle cricothyrotomy
– Surgical cricothyrotomy
– Positive-pressure ventilation
– Occlude open wounds
– Stabilize chest wall
Circulation
• Manage cardiac dysrhythmias
• Intravenous access
Pharmacological
• Analgesics
• Antidysrhythmics
Nonpharmacological
• Needle thoracostomy
• Tube thoracostomy—in hospital
management
• Pericardiocentesis—in hospital
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
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
Skeletal Injury
• Complications
– Injury to the subclavian vein or artery from
bony fragment penetration, producing a
hematoma or venous thrombosis (rare)
Rib Fractures
• Incidence
– Infrequent until adult life
– Significant force required
– Most often elderly patients
Rib Fractures
Morbidity/Mortality
• Can lead to serious consequences.
• Older ribs are more brittle and rigid.
• There may be associated underlying
pulmonary or cardiovascular injury.
Rib Fractures
Pathophysiology
• Most often caused by blunt trauma—
bowing 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
Rib Fractures
Pathophysiology
• Intercostal vessel injury
• Associated complications
–First and second ribs are injured by
severe trauma
–Rupture of the aorta
–Tracheobronchial tree injury
–Vascular injury
Multiple Rib Fractures
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Atelectasis
Hypoventilation
Inadequate cough
Pneumonia
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
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)
Rib Fractures
Management
• Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation
– Encourage coughing and deep breathing
• Pharmacological
– Analgesics
• Nonpharmacological
– Non-circumferential splinting
Flail Chest
• Incidence
– Most common cause: vehicular crash
– Falls from heights
– Industrial accidents
– Assault
– Birth trauma
Flail Chest
Morbidity/Mortality
• Significant chest trauma
• Mortality rates 20% to 40% due to associated
injuries
• Mortality increased with
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Advanced age
Seven or more rib fractures
Three or more associated injuries
Shock
Head injuries
Flail Chest
Pathophysiology
• 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.
Flail Chest
Pathophysiology
• 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
Flail Chest
Assessment Findings
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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
Flail Chest
Management
• 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).
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
Sternal Fractures
Morbidity/Mortality
• 25% to 45% mortality rate
• High association with myocardial or lung
injury
– Myocardial contusion
– Myocardial rupture
– Cardiac tamponade
– Pulmonary contusion
Sternal Fractures
Pathophysiology
• 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
Sternal Fractures
Management
• Airway and ventilation
– High-concentration oxygen
• Circulation—restrict fluids if pulmonary contusion
suspected
• Pharmacological—analgesics
• Non-pharmacological—allow chest wall selfsplinting
• Psychological support/communication strategies
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.
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.
Closed Pneumothorax
Assessment Findings
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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
Closed Pneumothorax
Management
• Airway and ventilation
– High-concentration oxygen.
– Positive-pressure ventilation if necessary.
– If respiration rate is <12 or >28 per minute,
ventilatory assistance with a
bag-valve mask may be indicated.
Closed Pneumothorax
Management
• Nonpharmacological
– Needle thoracostomy
• Transport considerations
– Position of comfort (usually partially sitting)
unless contraindicated by possible spine
injury
Open pneumothorax
• Develops when penetration injury to
the chest allows the pleural space to be
exposed to atmospheric pressure "Sucking Chest Wound"
Open Pneumothorax
• Incidence
– Usually the result of penetrating trauma
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Gunshot wounds
Knife wounds
Impaled objects
Motor vehicle collisions
Falls
Open Pneumothorax
Open pneumothorax
• WHAT MAY CAUSE A SCW?
– Examples Include:GSW, 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
Open Pneumothorax
Morbidity/Mortality
• Severity is directly proportional to the size
of the wound.
– Profound hypoventilation can result.
– Death is related to delayed management.
Open Pneumothorax
Pathophysiology
• An open defect in the chest wall (>3 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.
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
Open Pneumothorax
Assessment 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
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.
Open Pneumothorax
Management
• 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.
• Circulation—treat for shock with crystalloid
infusion.
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.
Tension pneumothorax
• Air within thoracic cavity that cannot
exit the pleural space
• Fatal if not immediately identified,
treated, and reassessed for effective
management
Tension pneumothorax
Tension Pneumothorax
• Associated Injuries
– A penetrating injury to the chest
– Blunt trauma
– Penetration by a rib fracture
– Many other mechanisms of injury
Tension Pneumothorax
Morbidity/Mortality
• Profound hypoventilation can result.
• Death is related to delayed management.
• An immediate, life-threatening chest injury.
Tension Pneumothorax
Pathophysiology
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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
Early Signs – Tension
Pneumothorax
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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.
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
LATE S/S OF TENSION
PNEUMOTHORAX
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Jugular Venous Distension (JVD)
Tracheal Deviation
Narrowing pulse pressure
Signs of decompensating shock
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
• Circulation—relieve the tension
pneumothorax to improve cardiac output.
Tension Pneumothorax
Management
• Nonpharmacological
– Occlude open wound
– Needle thoracostomy
– Tube thoracostomy—in-hospital management
Pleural decompression should only be
employed if the patient demonstrates
significant dyspnea and distinct signs and
symptoms of tension pneumothorax.
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.
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.
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
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 hyperexpanded chest that moves little with respiration.
• The central venous pressure is usually raised,
but will be normal or low in hypovolemic states.
Inferior vena cava
Hemothorax
• If this condition is associated with
pneumothorax, it is called a
hemopneumothorax.
Hemothorax
• Incidence
– Associated with pneumothorax.
– Blunt or penetrating trauma.
– Rib fractures are frequent cause.
Hemothorax
Morbidity/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.
Massive hemothorax
• Rapid accumulation of >1500 cc blood in
chest cavity
• Hypovolemia & hypoxemia
• Neck veins may be:
– flat - from hypovolemia
– distended - intrathoracic blood
• Absent breath sounds, DULL to
percussion
Hemothorax
Assessment Findings
• Tachypnea
• Dyspnea
• Cyanosis
– Often not evident in hemorrhagic shock
• Diminished or decreased breath sounds
on the affected side
Hemothorax
Assessment Findings
• Hyporesonance (dullness on percussion)
on the affected side
• Hypotension
• Narrowed pulse pressure
• Tracheal deviation to the unaffected side
(rare)
• Pale, cool, moist skin
Hemothorax
Management
• Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation if necessary
– Ventilatory support with bag-valve mask,
intubation, or both
Hemothorax
Management
• Circulation
– Administer volume-expanding fluids to
correct hypovolemia
– Nonpharmacological—tube
thoracostomy
Hemopneumothorax
• Pathophysiology—pneumothorax with
bleeding in the pleural space
– Assessment—findings and management are
the same as for hemothorax.
– Management—management is the same as
for hemothorax.
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 velocity—ice pick
Pulmonary Contusion
Morbidity/Mortality
• May be missed due to the high incidence
of other associated injuries
Mortality—between 14% and 20%
Pulmonary Contusion
Assessment Findings
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•
•
•
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•
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Tachypnea
Tachycardia
Cough
Hemoptysis
Apprehension
Respiratory distress
Dyspnea
Evidence of blunt chest trauma
Cyanosis
Pulmonary Contusion
Management
• Airway and ventilation:
– High-concentration oxygen
– Positive-pressure ventilation if necessary
• Circulation—restrict IV fluids (use caution
restricting fluids in hypovolemic patients).
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
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.
Traumatic Asphyxia
Assessment
• 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.
Traumatic Asphyxia
Assessment
– Swelling of the head and neck.
– Swelling or hemorrhage of the
conjunctiva (subconjunctival petechiae
may appear).
– Hypotension results once the pressure
is released.
Traumatic Asphyxia
Management
• Airway and ventilation
– Ensure an open airway.
– Provide adequate ventilation.
• Circulation
– IV access.
– Expect hypotension and shock once the
compression is released.
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
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
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
Heart and Great Vessel Injury
Assessment Findings
•
•
•
•
New cardiac murmur
Pericardial friction rub (late)
Hypotension
Chest wall contusion and ecchymosis
Heart and Great Vessel Injury
Management
• Airway and ventilation—high-concentration
oxygen
• Circulation—IV access
• Pharmacological
– Antidysrhythmics
– Vasopressors
Pericardial Tamponade
• Incidence
– Rare in blunt trauma
– Penetrating trauma
– Occurs in less than 2% of all chest traumas
Pericardial Tamponade
Morbidity/Mortality
• Gunshot wounds carry higher mortality
than stab wounds.
• Lower mortality rate if isolated tamponade
is present.
Pericardial Tamponade
Anatomy 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.
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.
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.
Pericardial Tamponade
Assessment Findings
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•
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Tachycardia
Respiratory distress
Narrowed pulse pressure
Cyanosis of the head, neck, and upper
extremities
Pericardial Tamponade
Assessment Findings
• Beck’s triad
– Narrowing pulse pressure
– Neck vein distention
– Muffled heart sounds
Pericardial Tamponade
Assessment Findings
• Kussmaul’s sign—a rise in venous
pressure with inspiration when
spontaneously breathing
• ECG changes
Pericardial Tamponade
Management
• Airway and ventilation
• Circulation—IV fluid challenge
• Nonpharmacological
pericardiocentesis
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
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.
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.
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
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)
Traumatic Aortic Rupture
Assessment Findings
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•
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Dyspnea
Dysphagia
Ischemic pain of the extremities
Chest wall contusion
Aortic Injury : Suspicion
• Mechanism
– Falls> 3m
– Major decelaration/acceleration
• SIGNS
– Neck hematoma
– Assymetic pulse or BP
– Radiofemoral delay
– Severe searing pain
Aortic Injury: CXR Signs
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Mediastinum > 8cm
Abnormal Aortic contour
Opaque artopulmonary window
Apical cap
Mediastinal displacement
Fracture of first rib or scapula
Traumatic Aortic Rupture
Management
• Airway and ventilation:
– High-concentration oxygen
– Ventilatory support with spinal precautions
• Circulation—do not over-hydrate.
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.
Diaphragmatic Rupture
Anatomy 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.
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
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
Diaphragmatic Rupture
Management
• Airway and ventilation
– High-concentration oxygen
– Positive-pressure ventilation if necessary
– Caution: positive-pressure may worsen the
injury
• Circulation—IV access
• Nonpharmacological—do not place patient
in Trendelenburg position
Diaphragmatic Rupture
Assessment Findings
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•
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•
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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
Who gets admitted?
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Sternal fractures, mediastinal injury
Any 1st, 2nd, 3rd rib fractures
> 1 rib fracture in any region
Pulmonary contusion
Subcutaneous emphysema
Traumatic asphyxia
Flail segment
Arrhythmia or myocardial injury
In Closing
• Back to basics:ABCDE
• 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
• QUESTIONS?