Thoracic Trauma

Thoracic Trauma Capt Mike Bevers, PA 173 rd MDF

Thoracic Trauma Second leading cause of trauma deaths after head injury (in USA) Cause of about 10-20% of all trauma deaths Many deaths due to thoracic trauma are preventable

Thoracic Trauma Mechanisms of Injury Blunt Injury Deceleration Compression Penetrating Injury Both

Thoracic Trauma Anatomical Injuries Thoracic Cage (Skeletal) Cardiovascular Pleural and Pulmonary Mediastinal Diaphragmatic Esophageal Penetrating Cardiac What structures may be involved with each injury?

Thoracic Trauma General Pathophysiology Impairments in ventilatory efficiency chest excursion compromise pain air in pleural space asymmetrical movement bleeding in pleural space ineffective diaphragm contraction

Thoracic Trauma General Pathophysiology Impairments in gas exchange atelectasis pulmonary contusion respiratory tract disruption

Thoracic Trauma Initial exam directed toward life threatening: Injuries Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade Conditions Apnea Respiratory Distress

Thoracic Trauma Assessment Findings Mental Status (decreased) Pulse (absent, tachy or brady) BP (narrow PP, hyper- or hypotension, pulsus paradoxus) Ventilatory rate & effort (tachy- or bradypnea, labored, retractions) Skin (diaphoresis, pallor, cyanosis, open injury, ecchymosis)

Thoracic Trauma Assessment Findings Neck (tracheal position, SQ emphysema, JVD, open injury) Chest (contusions, tenderness, asymmetry, absent or decreased lung sounds, bowel sounds, abnormal percussion, open injury, impaled object, crepitus, hemoptysis) Heart Sounds (muffled, distant, regurgitant murmur) Upper abdomen (contusion, open injury)

Thoracic Trauma History Dyspnea Pain Past hx of cardiorespiratory disease Restraint devices used Item/Weapon involved in injury

Rib Fracture Most common chest wall injury from direct trauma More common in adults than children Especially common in elderly Ribs form rings Possibility of break in two places Most commonly 5th - 9th ribs Poor protection

Rib Fracture Fractures of 1st and 2nd second require high force Frequently have injury to aorta or bronchi Occur in 90% of patients with tracheo-bronchial rupture May injure subclavian artery/vein May result in pneumothorax 30% will die

Rib Fracture Fractures of 10 to 12th ribs can cause damage to underlying abdominal solid organs: Liver Spleen Kidneys

Rib Fracture Assessment Findings Localized pain, tenderness Increases on palpation or when patient: Coughs Moves Breathes deeply “ Splinted” Respirations Instability in chest wall, Crepitus Deformity and discoloration Possible pneumo or hemothorax

Rib Fracture Management High concentration O 2 Positive pressure ventilation as needed Splint using pillow or swathes Encourage pt to breath deeply Non-circumferential splinting

Sternal Fracture Uncommon, 5-8% in blunt chest trauma Large traumatic force Direct blow to front of chest by Deceleration steering wheel dashboard Other object

Sternal Fracture 25 - 45% mortality due to associated trauma: Disruption of thoracic aorta Tracheal or bronchial tear Diaphragm rupture Flail chest Myocardial trauma High incidence of myocardial contusion, cardiac tamponade or pulmonary contusion

Sternal Fracture Assessment Findings Localized pain Tenderness over sternum Crepitus Tachypnea, Dyspnea Hx/Mechanism of blunt chest trauma

Sternal Fracture Management Establish airway High concentration oxygen Assist ventilations with BVM as needed IV NS/LR Restrict fluids Emergent Transport Hospital

Flail Chest Two or more adjacent ribs fractured in two or more places producing a free floating segment of the chest wall

Flail Chest Usually secondary to blunt trauma Most commonly in MVC Also results from falls from heights industrial accidents assault More common in older patients

Flail Chest Mortality rates 20-40% due to associated injuries Mortality increased with advanced age seven or more rib fractures three or more associated injuries shock head injuries

Flail Chest Assessment Findings Chest wall contusion Respiratory distress Pleuritic chest pain Splinting of affected side Crepitus Tachypnea, Tachycardia Paradoxical movement (possible)

Flail Chest Management Suspect spinal injuries Establish airway High concentration oxygen Assist ventilation with BVM Treat hypoxia from underlying contusion Promote full lung expansion Consider need for intubation and PEEP Mechanically stabilize chest wall questionable value

Flail Chest Management IV of LR/NS Avoid rapid replacement in hemodynamically stable patient Contused lung cannot handle fluid load Emergent Transport Hospital

Simple Pneumothorax Incidence 10-30% in blunt chest trauma almost 100% with penetrating chest trauma Morbidity & Mortality dependent on extent of atelectasis associated injuries

Simple Pneumothorax Causes Commonly a fx rib lacerates lung Paper bag effect May occur spontaneously in tall, thin young males following: Exertion Coughing

Simple Pneumothorax Assessment Findings Tachypnea, Tachycardia Difficulty breathing or respiratory distress Pleuritic pain may be referred to shoulder or arm on affected side Decreased or absent breath sounds not always reliable patients with multiple ribs fractures may splint injured side by not breathing deeply

Simple Pneumothorax Management Establish airway High concentration O 2 with NRB Assist with BVM decreased or rapid respirations inadequate TV IV of LR/NS Monitor for progression to tension pneumo Usually Non-emergent transport

Open Pneumothorax Assessment Findings Opening in the chest wall Sucking sound on inhalation Tachycardia Tachypnea Respiratory distress SQ Emphysema Decreased lung sounds on affected side

Open Pneumothorax Management Cover chest opening with occlusive dressing High concentration O 2 Assist with positive pressure ventilations prn Monitor for progression to tension pneumothorax IV with LR/NS Emergent Transport Hospital

Tension Pneumothorax Incidence Penetrating Trauma Blunt Trauma Morbidity/Mortality Severe hypoventilation Immediate life-threat if not managed early

Tension Pneumothorax Assessment Findings - Most Likely Severe dyspnea  extreme resp distress Restlessness, anxiety, agitation Decreased/absent breath sounds Worsening or Severe Shock / Cardiovascular collapse Tachycardia Weak pulse Hypotension Narrow pulse pressure

Tension Pneumothorax Assessment Findings - Less Likely Jugular Vein Distension absent if also hypovolemic Subcutaneous emphysema Tracheal shift away from injured side (late) Cyanosis (late)

Tension Pneumothorax Management Recognize & Manage early Establish airway High concentration O 2 Positive pressure ventilations w/BVM prn Needle thoracostomy IV of LR/NS Emergent Transport Consider need to intubate Hospital

Tension Pneumothorax Management Needle Thoracostomy Review Decompress with 14g (lg bore), 2-inch needle Midclavicular line: 2nd intercostal space Midaxillary line: 4-5th intercostal space Go over superior margin of rib to avoid blood vessels Be careful not to kink or bend needle or catheter If available, attach a one-way valve

Hemothorax Assessment Findings Tachypnea or respiratory distress Shock Rapid, weak pulse Hypotension, narrow pulse pressure Restlessness, anxiety Cool, pale, clammy skin Thirst Pleuritic chest pain Decreased lung sounds Collapsed neck veins Dullness on percussion

Hemothorax Management Establish airway High concentration O 2 Assist Ventilations w/BVM prn + MAST in profound hypotension? Needle thoracostomy if tension & unable to differentiate from Tension Pneumothorax IVs x 2 with LR/NS Emergent transport to hospital

Pulmonary Contusion Assessment Findings Tachypnea or respiratory distress Tachycardia Evidence of blunt chest trauma Cough and/or Hemoptysis Apprehension Cyanosis

Pulmonary Contusion Management Supportive therapy Early use of positive pressure ventilation reduces ventilator therapy duration Avoid aggressive crystalloid infusion Severe cases may require ventilator therapy Emergent Transport Hospital

Myocardial Contusion Assessment Findings Cardiac arrhythmias following blunt chest trauma Angina-like pain unresponsive to nitroglycerin Precordial discomfort independent of respiratory movement Pericardial friction rub (late)

Myocardial Contusion Management Establish airway High concentration O 2 IV LR/NS Cautious fluid administration due to injured myocardium Emergent Transport Hospital

Pericardial Tamponade Incidence Usually associated with penetrating trauma Rare in blunt trauma Occurs in < 2% of chest trauma GSW wounds have higher mortality than stab wounds Lower mortality rate if isolated tamponade

Pericardial Tamponade Signs and Symptoms Beck’s Triad Resistant hypotension Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP) Small quiet heart (decreased heart sounds)

Pericardial Tamponade Signs and Symptoms Narrowing pulse pressure Pulsus paradoxicus Radial pulse becomes weak or disappears when patient inhales Increased intrathoracic pressure on inhalation causes blood to be trapped in lungs temporarily

Pericardial Tamponade Management Secure airway High concentration O 2 Pericardiocentesis Out of hospital, primarily reserved for cardiac arrest Rapid transport Hospital IVs of LR/NS

Traumatic Aortic Dissection/Rupture Assessment Findings Retrosternal or interscapular pain Pain in lower back or one leg Respiratory distress Asymmetrical arm BPs Upper extremity hypertension with Decreased femoral pulses, OR Absent femoral pulses Dysphagia

Traumatic Aortic Dissection/Rupture Management Establish airway High concentration oxygen Maintain minimal BP in dissection IV LR/NS TKO minimize fluid administration Avoid PASG Emergent Transport Hospital

Traumatic Asphyxia Name given to these patients because they looked like they had been strangled or hanged

Traumatic Asphyxia Assessment Findings Purplish-red discoloration of: Head and Face Neck Shoulders Blood shot, protruding eyes JVD ? Sternal fracture or central flail Shock when pressure released

Traumatic Asphyxia Management Airway with C-spine control Assist ventilations with high concentration O 2 Spinal stabilization IV of LR + MAST in severely hypotensive patients? Rapid transport Hospital

Diaphragmatic Rupture Assessment Findings Decreased breath sounds Usually unilateral Dullness to percussion Dyspnea or Respiratory Distress Scaphoid Abdomen (hollow appearance) Usually impossible to hear bowel sounds

Diaphragmatic Rupture Management Establish airway Assist ventilations with high concentration O 2 IV of LR NG tube if possible Avoid MAST Trendelenburg position

Diaphragmatic Penetration Suspect intra-abdominal trauma with any injury below 4th ICS Suspect intrathoracic trauma with any abdominal injury above umbilicus

Esophageal Injury Assessment Findings Pain, local tenderness Hoarseness, Dysphagia Respiratory distress Resistance of neck on passive motion Mediastinal esophageal perforation mediastinal emphysema / mediastinal crunch mediastinitis SQ Emphysema splinting of chest wall Shock

Esophageal Injury Management Establish Airway Consider early intubation if possible IV LR/NS titrated to BP 90-100 mm Hg Emergent Transport Hospital Surgical capability

Tracheobronchial Rupture Assessment Findings Respiratory Distress Dyspnea Tachypnea Obvious SQ emphysema Hemoptysis Especially of bright red blood Signs of tension pneumothorax unresponsive to needle decompression

Tracheobronchial Rupture Management Establish airway and ventilations Consider early intubation Emergent Transport Hospital

Pitfalls to Avoid Elderly do not tolerate relatively minor chest injuries Anticipate progression to acute respiratory insufficiency Children may sustain significant intrathoracic injury w/o evidence of thoracic skeletal trauma Maintain a high index of suspicion

Thoracic Trauma

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Thoracic Trauma