victor politi, m.d., facp medical director, svcmc division of allied health, physician assistant...
TRANSCRIPT
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1
Introduction to Emergency Medicine
American College of EmergencyPhysicians
Victor Politi, M.D., FACPMedical Director, SVCMC Division of Allied Health, Physician Assistant Program
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Specialty Selection Top Ten Leading Causes of Death in the U.S.
Heart Disease: 726,974 Cancer: 539,577 Stroke: 159,791 Chronic Obstructive Pulmonary Disease: 109,029 Accidents: 95,644 Pneumonia/Influenza: 86,449 Diabetes: 62,636 Suicide: 30,535 Nephritis, Nephrotic Syndrome, and Nephrosis
25,331 Chronic Liver Disease and Cirrhosis: 25,175
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Appeal of Emergency Medicine
Make an immediate differenceLife threatening injuries and
illnessesUndifferentiated patient populationChallenge of “anything” coming inEmergency / invasive proceduresSafety net of healthcare
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Appeal of Emergency Medicine
Team approachPatient advocacyOpen job marketAcademic opportunities Shift work / set hoursEvolving specialty
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Downside to Emergency Medicine
Interaction with difficult, intoxicated, or violent patients
Finding follow-up or care for uninsured
Work in a “fishbowl” without 20/20 hindsight
Working as a patient advocate
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Subspecialties in Emergency Medicine
Pediatric Emergency MedicineToxicologyEmergency Medical ServicesSports Medicine
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Areas of Expertise
ToxicologyEmergency medical servicesMass gatheringsDisaster management Wilderness medicine
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Upcoming Areas of Emergency Medicine
Hyperbaric medicineObservation unitsED ultrasoundInternational emergency medicine
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Introduction to Trauma
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Trauma is a major cause of death in young people. The
cost in human lives and economic terms is
tremendous
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Trauma is the leading cause of death for all age groups under the age of 44
In the US - it is the leading cause of death in children
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Trauma Statistics
4th leading cause of death of Americans of all ages
Nearly 150,000 people of all ages in the US die from trauma each year • 60 million injuries annually• 30 million need medical treatment• 3.6 million need hospitalization
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Trauma Statistics
Impact of trauma is greatest in children and young adults
Trauma cost the American public over $300 billion annually including lost wages, medical expenses, administrative costs, employer expense
Approximately 40% of health care monies are spent on trauma
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Trauma Statistics
Traumatic injuries, including unintentional injuries cause -43% of all deaths ages 1 to 449% of all deaths ages 5 to 1464% of all deaths ages 15 to 24
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Trauma Statistics
Leading cause of accidental death in US - motor vehicle accidentsdrinking is a factor in 49% of
these cases
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Falls - 2nd leading cause of accidental death
for ages 45 to 75 years and
#1 cause of unintentional death for persons age 75 and older
Trauma Statistics
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Seatbelt Injury
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Trauma Statistics
Drowning is the 4th most common cause of unintentional injury death for all agesIt ranks 1st for persons age 25 to 44It ranks 2nd for ages 5 to 44
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Designated Trauma Centers
Designated Trauma CentersImmediate availability of necessary
resourcesDesignated -
• Regional• Area• Level I• Level II
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Tri-modal distribution of Trauma Death
First peak: second - minutesbrain injury, high spinal cord, large vessels,
cardiac arrestbest treated by prevention
Second peak: minutes - hourssub/epidurals, HTX/PTX, spleen, liver lacbest treated by applying principles of ATLS
Third peak: days-weekssepsis, multi-organ failuredirectly correlated to earlier Rx
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Primary Evaluation
Airway maintenance with c-spine control
Breathing and ventilationCirculation with hemorrhage controlDisability or neurological statusExposure and environmental control
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Control the airway with basic maneuverssuctionadminister 100% oxygenhyperventilateprepare to intubateparalyze the patientuse appropriate Rx considering ?elevated
ICPintubate, maintaining in-line traction
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Circulation
Control exsanguinating hemorrhage control external bleeding promptlyestablish at least 2 R.L. wide-bore
Ivslarge diameter/short length Ivsideally 14 ga. 1 1/4”add pressure bags
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Shock Classification
Class I percentage loss up to
15% amount of loss up to
750ml Class II
percentage loss 15-30% amount of loss 750-
1500ml
Class IIIpercentage loss
30-40%amount of loss
1500-2000mlClass IV
percentage loss more than 40%
amount of loss >200ml
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Treatment of Hemorrhagic Shock due to trauma
Defined as B/P less than 90 systolic in an adult
The treatment of shock should be directed not toward the class of shock but to the response to initial therapy
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Class III Blood Loss
Respond to initial fluid boluswas initial bolus inadequate?is patient experiencing ongoing
hemorrhage?As fluids are slowed, patient
deteriorates
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Usually indicates 20-40% blood loss
Requires continued fluids, blood products
The response to blood products dictates speed of surgical intervention
Class III Blood Loss
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Fingertip amputation
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Identify the Site
Most obvious source is external hemorrhage
Next consider hemothoraxConsider abdominal source
spleen lacerationhemoperitoneumrenal hematomaliver lacerationinjury to a great vessel
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Identify the Site
Consider mechanism of injury
Every trauma victim should have a finger or tube in every hole
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Battle’s sign - base of skull injury
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'Racoon Eyes' sign of base of skull fracture
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Minimal or No Response to Fluid Resuscitation
Seen in small percentage of patientsusually dictates need for immediate
surgical intervention to control exsanguinating hemorrhage
Prepare the ORIf penetrating chest trauma -
consider cardiac injury
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gunshot wound left fronto-parietal region
entrance wound (close-up)
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Golden Hour
The hemodynamically unstable trauma patient needs only two things …hot lightscold steel
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Aggressive fluid resuscitation must be initiated not when blood pressure is falling/absent but as soon as the early signs/symptoms of blood loss are suspected
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Decreasing BP increasing pulse
Disorientation - confusion
Mechanism of injury
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High voltage wiring injury
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Blood Transfusion
No substitute for the real thingcross match if time permitscompatible with ABO and Rh blood
typesminor antibody incompatibilities may
occur
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cutting two fingers off in a meat slicer
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Universal Donor
Type O negative is available immediately
used in exsanguinating hemorrhageused in patient with minimal or no
response to initial crystalloid fluids bolus
Remember -“Give Blood Save A Life”
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Radiologic Studies
C-spine, chest and pelvis x-raysCAT scan or specific x-rays that are
indicated based on mechanism of injury and primary exam
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Pulmonary Contusion
Right pulmonary contusion, left chest wall defect with lung hernia
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C-Spine
Don’t become distracted by trying to clear the c-spine
A properly applied cervical collar never killed anyone!
Don’t remove cervical collar until c-spine is clearedcontinue to protect c-spine during
treatment
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Fracture-dislocation C7-T1
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Chest Radiograph
Rule-out PTX/HTX - need immediate treatment
Provides clues as to condition of -heart, lung, parenchyma, mediastinum,
great vessels, bronchus, diaphragmAlmost unheard of to have significant
chest injury w/o signs of same on CXRCXR are frequently misinterpreted and
injuries are frequently overlooked
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Chest Radiograph
Check position of tubesLocate foreign bodies (i.e. bullets)Free air under diaphragm or on
lateral means perforated viscus Cardiac tamponade
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Right diaphragm laceration on chest x-ray
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Abdominal Trauma
Remove all clothing including undergarments
Perform adequate visual exam for injuries
Don’t forget the rectal exam
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Spleen Laceration on CT - Grade III
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Abdominal Trauma
CAT scan with contrast utilizes PO and IV contrast
May require NGT for administration of contrast Risk of vomiting and aspiration Risk of allergic reaction to contrast Intubation to protect airway requiring sedation Difficult to obtain CT in unstable patient
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Renal retroperitoneal hematoma Grade IV
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Pelvic Trauma
Evaluate for pelvic, femoral neck, femur fractures
Provides clues as to condition of -abdominal viscerabladder
Patients can bleed out into thighMules and packers -
products in distal colon
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Ultrasound
Dynamic study performed in trauma roomno need to move patient to x-ray or CTcan immediately visualize heart, pericardiumcan visualize liver, spleen, kidney lacscan visualize ~ 50 cc blood, fluid in abdomentakes approximately 5 minuteshighly operator dependent
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Trauma Code: ETA 5 minutes
Stick with the basics - remember ABC’s Constantly re-evaluate patient not lab’s Don’t raise your voice - remain calm You are not alone, consult the experts
don’t get in over your head Take a step back -
What are you missing ?What did you overlook ?
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CHEST TRAUMACHEST TRAUMA
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splinter
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Incidence of Chest Trauma
Cause 1 of 4 American trauma deathsContributes to another 1 of 4Many die after reaching hospital - could
be prevented if recognized<10% of blunt chest trauma needs
surgery1/3 of penetrating trauma needs surgeryMost life-saving procedures do NOT
require a thoracic surgeon
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Pathophysiology of Chest Trauma
hypovolemia
ventilation-perfusionmismatch
changes in intrathoracic
pressure relationships
Inadequate oxygendelivery to tissues
TISSUE HYPOXIA
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Pathophysiology of Chest Trauma
Tissue hypoxiaHypercarbiaRespiratory acidosis - inadequate
ventilationMetabolic acidosis - tissue
hypoperfusion (e.g., shock)
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Initial assessment and management
Primary surveyResuscitation of vital functionsDetailed secondary surveyDefinitive care
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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
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6 Immediate Life Threats
Airway obstructionTension pneumothoraxOpen pneumothorax “sucking chest wound”Massive hemothoraxFlail chestCardiac tamponade
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6 Potential Life Threats
Pulmonary contusionMyocardial contusionTraumatic aortic ruptureTraumatic diaphragmatic ruptureTracheobronchial tree
injury - larynx, trachea, bronchus
Esophageal trauma
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6 Other Frequent Injuries
Subcutaneous emphysemaTraumatic asphyxiaSimple pneumothoraxHemothoraxScapula fractureRib fractures
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Primary Survey
Airway
Breathing
Circulation
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Assess for airway patency and air exchange - listen at nose & mouth
Assess for intercostal and supraclavicular muscle retractions
Assess oropharynx for foreign body obstruction
A = Airway
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Assess respiratory movements and quality of respirations - look, listen, feel
Shallow respirations are early indicator of distress - cyanosis is late
B = Breathing
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C = Circulation
Assess pulses for quality, rate, regularity
Assess blood pressure and pulse pressure
Skin - look and feel for color, temperature, capillary refill
Look at neck veins - flat vs. distendedCardiac monitor
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Thoracotomy
Closed heart massage is ineffective in a hypovolemic patient
Left anterior thoracotomy with cross-clamping of descending thoracic aorta and open-chest massage may be useful in pulseless victim of penetrating trauma
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Thoracotomy
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6 Immediate Life Threats
Airway obstructionTension pneumothoraxOpen pneumothorax “sucking chest wound”Massive hemothoraxFlail chestCardiac tamponade
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Airway Obstruction
Chin-lift - fingers under mandible, lift forward so chin is anterior
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Airway Obstruction
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Airway Obstruction
Jaw thrust - grasp angles of mandible and bring the jaw forward
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Airway Obstruction
Oropharyngeal airway inserted in mouth behind tongue. DO NOT push tongue further back.
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Airway Obstruction
Nasopharyngeal airway - welllubricated“trumpet”gently insertedthroughnostril
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Airway Obstruction
Definitive management - tube in trachea through vocal cords with balloon inflated.
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Airway Obstruction
Orotracheal intubationNasotracheal intubation - in
breathing patient without major facial trauma
surgical airwaysjet insufflationcricothyrotomytracheostomy
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Airway Obstruction
Jet insufflation adapters
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Airway Obstruction
Tracheotomy tubes
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Tension pneumothorax
Air leaks through lung or chest wall“One-way” valve with lung collapse Mediastinum shifts to opposite sideInferior vena cava “kinks” on
diaphragm, leading to decreased venous return and cardiovascular collapse
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Inferior vena cava
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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
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Open pneumothorax
“Sucking Chest Wound”Normal ventilation requires negative
intra-thoracic pressureLarge open chest-wall defect leads
to immediate equilibration of intra-thoracic and atmospheric pressures
If hole is >2/3 tracheal diameter, air prefers chest defect
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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.
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Massive hemothorax
Rapid accumulation of >1500 cc blood in chest cavity
Hypovolemia & hypoxemiaNeck veins may be:
flat - from hypovolemiadistended - intrathoracic blood
Absent breath sounds, DULL to percussion
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Massive hemothorax - treatment
Large-bore (32 to 36 F) tube to drain blood
If moderate sized - 500 to 1500 ml - and stops bleeding, closed drainage usually sufficient
If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated
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Flail chest
“Free-floating” chest segment, usually from multiple ribs fractures
Pain and restricted movement “Paradoxical movement” of chest wall with respiration
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Flail chest - treatment
Adequate ventilationHumidified oxygenFluid resuscitationPAIN MANAGEMENTStabilize the chest
internal - ventilatorexternal - sand bags
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Cardiac tamponade
Usually from penetrating injuriesClassic “Beck’s triad”
elevated venous pressure - neck veinsdecreased arterial pressure - BPmuffled heart sounds
Blood in sac prevents cardiac activity
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Cardiac tamponade
May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP during inspiration
Systolic to diastolic gradient of less than 30 mm Hg also suggestive
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Cardiac tamponade
Treatment is removal of small amount of blood - 15 to 20 ml may be sufficient - from pericardial sac
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Stab wound toright ventricle
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pericardium
epicardial fat
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6 Potential Life Threats
Pulmonary contusionMyocardial contusionTraumatic aortic ruptureTraumatic diaphragmatic ruptureTracheobronchial tree injury -
larynx, trachea, bronchusEsophageal trauma
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Pulmonary contusion
Potentially life-threatening condition with insidious onset
Parenchymal injury without laceration
More than 50% will develop pneumonia, even with treatment
Up to 50% have only hemoptysis as presenting symptom
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Pulmonary contusion
Patients with pre-existing conditions - emphysema, renal failure - need early intubation
Treatment needs to occur over time
as symptoms develop
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Myocardial contusion
Blunt precordial chest traumaDifficult to diagnoseRisk for dysrhythmias, sudden
death,tamponade, pericarditis, ventricular aneurysm
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Myocardial contusion
Also may see:myocardial concussion - “stunned”
myocardium with no cell deathcoronary artery lacerationDiagnosis by:trans-esophageal echocardiogramserial cardiac enzymes
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Traumatic aortic rupture
90% or more dead at scene90% mortality each undiagnosed
day Must have high index of suspicionDisruption occurs at ligamentum
arteriosum (ductus arteriosus)Contained hematoma of 500 to
1000 ml of blood
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Traumatic aortic rupture
Radiographic signs wide mediastinum1st & 2nd rib fxobliteration of aortic
knob tracheal deviation to
rightpleural capdepression left
mainstem bronchus
elevation and right shift mainstem bronchus
obliteration “aortic window”
deviation of esophagus to right
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Traumatic aortic rupture
Treatment - SURGICAL REPAIR
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Traumatic diaphragmatic rupture
Blunt trauma - tears leading to immediate herniation
Penetrating trauma - small tears which may take years to develop herniation
Usually on left side
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Traumatic diaphragmatic rupture
Treatment - surgical repair
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Tracheobronchial tree injury
Larynx - rarehoarsenesssubcutaneous emphysemapalpable crepitus
Intubation may be difficulttracheostomy (not cricothyroidotomy)
is treatment of choice
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Tracheobronchial tree injury
Tracheablunt or penetratingesophagus, carotid artery and jugular vein may be involvednoisy breathing partial airway obstruction
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Tracheobronchial tree injury
Bronchusrare and lethalusually BLUNT trauma within one inch of carina
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Esophageal trauma
Most commonly penetratingMay be lethal if not recognizedHigh suspicion if
left pneumothorax and hemothorax without rib fracture
shock out of proportion to apparent blunt chest trauma
particulate matter in chest tube
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Esophageal trauma
If blunt trauma, linear tear in lower esophagus with leakage of stomach contents into mediastinum
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6 Other Frequent Injuries
Subcutaneous emphysemaTraumatic asphyxiaSimple pneumothoraxHemothoraxScapula fractureRib fractures
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Subcutaneous emphysema
“Rice Krispies”May result from
airway injurylung injuryblast injury
No treatment required - address underlying problem
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Traumatic asphyxia
“Masque ecchymotique” - purple face from extravasation of blood
Major damage is to underlying structures
Purple face fades over time in survivors
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Simple pneumothorax
Air enters potential space between visceral and parietal pleura
Breath sounds down on affected side
Percussion shows hyper-resonanceTreatment: chest tube in 4th or 5th
intercostal space anterior to mid-axillary line
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Hemothorax
Lung laceration OR disruption of intercostal artery or internal mammary artery
Most are self-limitingSurgical consultation for
initial flow of >20 cc/kg (~1500 cc)continued flow of >200 cc/hr
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Scapula fractures
Fractures of scapula or 1st & 2nd ribs may indicate major mechanism of
injury
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Rib fractures
Ribs - most frequently injured part of thoracic cage
Most commonly injured - 4th 9th
If 10th/11th/12th, be suspicious for liver or spleen injuries
If 1st/2nd/3rd, worry about injury to head, neck, spinal cords, lungs, and great vessels
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Rib frac tures
Treatment consists of…intercostal blocksepidural anesthesiasystemic analgesics
Contraindications include…tapingrib beltsexternal splints
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In conclusion...
Chest trauma is very common in the multi-injured patient
Airway management and a judiciously placed needle can save many lives
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Trauma Code: ETA 5 minutes
Stick with the basics - remember ABC’s Constantly re-evaluate patient not lab’s Don’t raise your voice - remain calm You are not alone, consult the experts
don’t get in over your head Take a step back -
What are you missing ?What did you overlook ?
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Questions