thoracic trauma
DESCRIPTION
Capt Mike Bevers, PA173rd MDFTRANSCRIPT
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Thoracic TraumaThoracic Trauma
Capt Mike Bevers, PA
173rd MDF
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Thoracic TraumaThoracic 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
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Thoracic TraumaThoracic Trauma
Mechanisms of Injury Blunt Injury
Deceleration Compression
Penetrating Injury Both
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Thoracic TraumaThoracic Trauma Anatomical Injuries
Thoracic Cage (Skeletal) Cardiovascular Pleural and Pulmonary Mediastinal Diaphragmatic Esophageal Penetrating Cardiac
What structures
may be involved
with each injury?
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Thoracic TraumaThoracic Trauma General Pathophysiology
Impairments in ventilatory efficiency chest excursion compromise
– pain
– air in pleural space
– asymmetrical movement
bleeding in pleural space ineffective diaphragm contraction
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Thoracic TraumaThoracic Trauma General Pathophysiology
Impairments in gas exchange atelectasis pulmonary contusion respiratory tract disruption
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Thoracic TraumaThoracic Trauma Initial exam directed toward life
threatening: Injuries
Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade
Conditions Apnea Respiratory Distress
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Thoracic TraumaThoracic 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)
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Thoracic TraumaThoracic 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)
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Thoracic TraumaThoracic Trauma History
Dyspnea Pain Past hx of cardiorespiratory disease Restraint devices used Item/Weapon involved in injury
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Rib FractureRib 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
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Rib FractureRib 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
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Rib FractureRib Fracture
Fractures of 10 to 12th ribs can cause damage to underlying abdominal solid organs: Liver Spleen Kidneys
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Rib FractureRib 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
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Rib FractureRib Fracture Management
High concentration O2
Positive pressure ventilation as needed Splint using pillow or swathes Encourage pt to breath deeply Non-circumferential splinting
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Sternal FractureSternal Fracture Uncommon, 5-8% in blunt chest trauma Large traumatic force Direct blow to front of chest by
Deceleration steering wheel dashboard
Other object
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Sternal FractureSternal 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
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Sternal FractureSternal Fracture Assessment Findings
Localized pain Tenderness over sternum Crepitus Tachypnea, Dyspnea Hx/Mechanism of blunt chest trauma
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Sternal FractureSternal Fracture Management
Establish airway High concentration oxygen Assist ventilations with BVM as needed IV NS/LR
Restrict fluids Emergent Transport
Hospital
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Flail ChestFlail Chest
Two or more adjacent ribs fractured in two or more places
producing a free floating segment of the chest wall
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Flail ChestFlail Chest Usually secondary to blunt trauma
Most commonly in MVC Also results from
falls from heights industrial accidents assault More common in older patients
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Flail ChestFlail 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
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Flail ChestFlail Chest Assessment Findings
Chest wall contusion Respiratory distress Pleuritic chest pain Splinting of affected side Crepitus Tachypnea, Tachycardia Paradoxical movement (possible)
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Flail ChestFlail 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
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Flail ChestFlail Chest Management
IV of LR/NS Avoid rapid replacement in hemodynamically
stable patient Contused lung cannot handle fluid load
Emergent Transport Hospital
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Simple PneumothoraxSimple Pneumothorax Incidence
10-30% in blunt chest trauma almost 100% with penetrating chest trauma Morbidity & Mortality dependent on
extent of atelectasis associated injuries
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Simple PneumothoraxSimple Pneumothorax Causes
Commonly a fx rib lacerates lung Paper bag effect May occur spontaneously in tall, thin
young males following: Exertion Coughing
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Simple PneumothoraxSimple 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
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Simple PneumothoraxSimple Pneumothorax Management
Establish airway High concentration O2 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
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Open PneumothoraxOpen Pneumothorax Assessment Findings
Opening in the chest wall Sucking sound on inhalation Tachycardia Tachypnea Respiratory distress SQ Emphysema Decreased lung sounds on affected side
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Open PneumothoraxOpen Pneumothorax Management
Cover chest opening with occlusive dressing High concentration O2
Assist with positive pressure ventilations prn Monitor for progression to tension
pneumothorax IV with LR/NS Emergent Transport
Hospital
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Tension PneumothoraxTension Pneumothorax Incidence
Penetrating Trauma Blunt Trauma
Morbidity/Mortality Severe hypoventilation Immediate life-threat if not managed early
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Tension PneumothoraxTension 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
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Tension PneumothoraxTension Pneumothorax Assessment Findings - Less Likely
Jugular Vein Distension absent if also hypovolemic
Subcutaneous emphysema Tracheal shift away from injured side (late) Cyanosis (late)
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Tension PneumothoraxTension Pneumothorax Management
Recognize & Manage early Establish airway High concentration O2 Positive pressure ventilations w/BVM prn Needle thoracostomy IV of LR/NS Emergent Transport
Consider need to intubate Hospital
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Tension PneumothoraxTension 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
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HemothoraxHemothorax 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
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HemothoraxHemothorax Management
Establish airway High concentration O2
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
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Pulmonary ContusionPulmonary Contusion Assessment Findings
Tachypnea or respiratory distress Tachycardia Evidence of blunt chest trauma Cough and/or Hemoptysis Apprehension Cyanosis
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Pulmonary ContusionPulmonary 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
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Myocardial ContusionMyocardial 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)
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Myocardial ContusionMyocardial Contusion Management
Establish airway High concentration O2
IV LR/NS Cautious fluid administration due to injured myocardium
Emergent Transport Hospital
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Pericardial TamponadePericardial 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
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Pericardial TamponadePericardial 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)
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Pericardial TamponadePericardial 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
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Pericardial TamponadePericardial Tamponade Management
Secure airway High concentration O2
Pericardiocentesis Out of hospital, primarily reserved for cardiac arrest
Rapid transport Hospital
IVs of LR/NS
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Traumatic Aortic Traumatic Aortic Dissection/Rupture 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
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Traumatic Aortic Traumatic Aortic Dissection/Rupture 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
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Traumatic AsphyxiaTraumatic Asphyxia
Name given to these patients because they looked like they had been strangled or hanged
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Traumatic AsphyxiaTraumatic 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
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Traumatic AsphyxiaTraumatic Asphyxia Management
Airway with C-spine control Assist ventilations with high concentration O2
Spinal stabilization IV of LR + MAST in severely hypotensive patients? Rapid transport
Hospital
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Diaphragmatic RuptureDiaphragmatic 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
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Diaphragmatic RuptureDiaphragmatic Rupture Management
Establish airway Assist ventilations with high concentration O2
IV of LR NG tube if possible Avoid
MAST Trendelenburg position
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Diaphragmatic PenetrationDiaphragmatic Penetration
Suspect intra-abdominal trauma with any injury below 4th ICS
Suspect intrathoracic trauma with any abdominal injury above umbilicus
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Esophageal InjuryEsophageal 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
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Esophageal InjuryEsophageal Injury Management
Establish Airway Consider early intubation if possible IV LR/NS titrated to BP 90-100 mm Hg Emergent Transport
Hospital Surgical capability
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Tracheobronchial RuptureTracheobronchial Rupture Assessment Findings
Respiratory Distress Dyspnea Tachypnea
Obvious SQ emphysema Hemoptysis
Especially of bright red blood Signs of tension pneumothorax unresponsive
to needle decompression
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Tracheobronchial RuptureTracheobronchial Rupture Management
Establish airway and ventilations Consider early intubation
Emergent Transport
Hospital
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Pitfalls to AvoidPitfalls 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