10 Chest Trauma

8/9/2019 10 Chest Trauma

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CHEST TRAUMA CHEST TRAUMA

HOWARD FRIEDLAND DO FACOEPHOWARD FRIEDLAND DO FACOEP

NICOLE MAGUIRE DONICOLE MAGUIRE DO


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OBJECTIVESOBJECTIVES

Anatomical Review of Chest Anatomical Review of Chest Approach to Chest Trauma Approach to Chest Trauma

Identifying and Treating Immediately LifeIdentifying and Treating Immediately Life

Threatening Conditions.Threatening Conditions.

Identifying and Treating Potentially LifeIdentifying and Treating Potentially Life

Threatening Conditions.Threatening Conditions. Diagnostic Studies and Chest TraumaDiagnostic Studies and Chest Trauma


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INCIDENCE OF CHEST TRAUMA INCIDENCE OF CHEST TRAUMA

Trauma is the # 1 cause of death in ages 1Trauma is the # 1 cause of death in ages 1--55.55.

Chest trauma causes 1 in 4 deaths inChest trauma causes 1 in 4 deaths in

America. America.

Less than 10% of Blunt Chest TraumaLess than 10% of Blunt Chest Trauma

requires surgery, where as 15requires surgery, where as 15--30% of30% ofPenetrating Chest Trauma requires anPenetrating Chest Trauma requires anopen thoracotomy.open thoracotomy.


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CAUSES OFCAUSES OF

BLUNT TRAUMA VS CHEST TRAUMA BLUNT TRAUMA VS CHEST TRAUMA

Low VelocityLow Velocity --impalements, knifeimpalements, knife wound. wound.

Medium VelocityMedium Velocity --bullets from mostbullets from mosthand guns and airhand guns and air

powered pellet guns.powered pellet guns. High VelocityHigh Velocity -- riflesrifles

and military weapons.

MVA = 70MVA = 70--80%80%

FALLSFALLS

Act of violence Act of violence -- IE.IE.

•• bat to chest etc.bat to chest etc.

Blast Injuries

and military weapons.Blast Injuries


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THORACIC CAVITY THORACIC CAVITY

Superior Border of ThoraxSuperior Border of Thorax -- Thoracic Inlet whichThoracic Inlet whichholds the major blood supply to and venousholds the major blood supply to and venousdrainage from the neck.drainage from the neck.

SuperiorSuperior--lateral Border of Thoraxlateral Border of Thorax -- ThoracicThoracicOutlet, Brachial Plexus, Axillary Vein, BrachialOutlet, Brachial Plexus, Axillary Vein, Brachial Artery. Artery.

Inferior BorderInferior Border -- hemidiaphragmhemidiaphragm -- holds theholds thediaphragmatic hiatus = Aorta, Esophagus, Vagaldiaphragmatic hiatus = Aorta, Esophagus, VagalNerve, Thoracic Duct and Vena Cava.Nerve, Thoracic Duct and Vena Cava.


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ANATOMY REVIEW CONTINUED ANATOMY REVIEW CONTINUED

Within Chest WallWithin Chest Wall -- Muscles, Ribs,Muscles, Ribs,Sternum,Clavicle, Scapulae.Sternum,Clavicle, Scapulae.

Parietal PleuraParietal Pleura

--

inner lining of chest wall.inner lining of chest wall.

Visceral Pleura Visceral Pleura -- invests major organs.invests major organs.

Pleura SpacePleura Space -- potential space between thepotential space between the

two with a small amount of fluid in it.two with a small amount of fluid in it.


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RESPIRATORY SYSEMRESPIRATORY SYSEM

IN 2 LINES OR LESSIN 2 LINES OR LESS

LungsLungs -- Right has 3 lobes, Left has 2 lobes.Right has 3 lobes, Left has 2 lobes.

Trachea splits into R and L mainstemTrachea splits into R and L mainstembronchi then divides into lobar bronchi.bronchi then divides into lobar bronchi.


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Incase you forgot about the heartIncase you forgot about the heart

Heart is contained within pericardium.Heart is contained within pericardium.

Blood flow:Blood flow:blood is received from the superior andblood is received from the superior and

inferior vena cava ~RA~RV via tricuspidinferior vena cava ~RA~RV via tricuspid

valve ~ lungs via pulmonic valve ~ LA ~ LV valve ~ lungs via pulmonic valve ~ LA ~ LV

via mitral valve ~ thoracic aorta via aortic via mitral valve ~ thoracic aorta via aortic

valve. valve.


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Miscellaneous OrgansMiscellaneous Organs

Esophagus lies posterior to the trachea.Esophagus lies posterior to the trachea. To the right of it is the Aortic Arch.To the right of it is the Aortic Arch.

To the left of it is the Descending Aorta.To the left of it is the Descending Aorta.

Thoracic Duct runs posterior and isThoracic Duct runs posterior and isproximal to the spinal column, it enters theproximal to the spinal column, it enters the

Left Subclavian Vein in the neck.Left Subclavian Vein in the neck.


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Primary Survey (ATLS)Primary Survey (ATLS)

Physician must begin withPhysician must begin with ABC’s Trauma ABC’s Trauma for anyfor anychest trauma patient:chest trauma patient:

A A -- airwayairway

BB -- breathingbreathing

C circulationC circulation

TT -- thoracotomythoracotomy DD -- disabilitydisability -- neuro checkneuro check

EE -- exposureexposure -- remove clothing, roll person.remove clothing, roll person.


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AIRWAY AIRWAY

Listen for airway movement at patient’sListen for airway movement at patient’snose and mouth.nose and mouth.

Access intercostal and supraclavicular Access intercostal and supraclavicular

muscle retractions.muscle retractions.

Assess oropharynx for foreign body Assess oropharynx for foreign body

obstruction, especially in an unconsciousobstruction, especially in an unconsciouspatient.patient.


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BREATHINGBREATHING

Expose patient’s chest.Expose patient’s chest. Observe, palpate and listen for respiratoryObserve, palpate and listen for respiratory

movement.movement.

Rate of breathing.Rate of breathing.

Breathing patternBreathing pattern -- shallow breaths areshallow breaths are

ominous.ominous.

CyanosisCyanosis -- late sign of hypoxia.late sign of hypoxia.


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CirculationCirculation

Check pulse for quality, rate and regularity.Check pulse for quality, rate and regularity. Blood PressureBlood Pressure

Asses and palpate skin for color and Asses and palpate skin for color andtemperature.temperature.

Check neck veins for distentionCheck neck veins for distention -- indicationindication

of cardiac tamponade that may be absent ifof cardiac tamponade that may be absent if

patient is hypovolemic.patient is hypovolemic.

Cardiac MonitorCardiac Monitor -- dysrythmia, PVC, PEA dysrythmia, PVC, PEA


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Pulseless Electrical ActivityPulseless Electrical Activity

HypovolemiaHypovolemia

HypoxiaHypoxia

HH++ -- Acidosis Acidosis

Hemothorax Hemothorax

HypothermiaHypothermia

Hyperkalemia

Tension Pneumothorax Tension Pneumothorax

TamponadeTamponade

ToxinsToxins

Beta BlockersBeta Blockers

DigitalisDigitalis

TCA TCA

CaCa++++ Channel BlockersChannel Blockers

ThrombusThrombus

Pulmonary EmbolusPulmonary Embolus

Myocardial Infarction

Hyperkalemia

Myocardial Infarction


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OPEN THORACOTOMY OPEN THORACOTOMY


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THORACOTOMY THORACOTOMY

Use of emergent resuscitative thoracotomyUse of emergent resuscitative thoracotomyhas been reported to result in survival ashas been reported to result in survival asfollows:follows:

99--57% patients with penetrating57% patients with penetratingcardiac injury.cardiac injury.

00--66% patients with non66% patients with non--cardiaccardiacthoracic injury.thoracic injury.

8% overall survival rate.8% overall survival rate.


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SECONDARY SURVEY SECONDARY SURVEY

Head to foot exam, remember the back.Head to foot exam, remember the back. If the patient is unstable a brief history isIf the patient is unstable a brief history is

applicable at this time =applicable at this time =

A A -- allergiesallergies

MM -- medicationsmedications

PP – – past medical historypast medical history

LL – – last meal eatenlast meal eaten

EE -- events of traumaevents of trauma


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SECONDARY SURVEY (con’t)SECONDARY SURVEY (con’t)

If the patient is stabilized obtain a more in depthIf the patient is stabilized obtain a more in depth

history including:history including:

Time of injury.Time of injury.

Mechanism of InjuryMechanism of Injury -- velocity and deceleration velocity and decelerationfor MVA.for MVA.

Complete Physical ExamComplete Physical Exam -- including evidence ofincluding evidence of

injuries to other systems.injuries to other systems. Preliminary testsPreliminary tests -- CXR, EKG, ABG.CXR, EKG, ABG.

IMMEDIATELY LIFE THREATENINGIMMEDIATELY LIFE THREATENING


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IMMEDIATELY LIFE THREATENINGIMMEDIATELY LIFE THREATENING

CHEST INJURIESCHEST INJURIES

These conditions are evidenced in the primaryThese conditions are evidenced in the primarysurveysurvey::

Airway Obstruction and Traumatic Asphyxia Airway Obstruction and Traumatic Asphyxia

Tension Pneumothorax Tension Pneumothorax

Open Pneumothorax Open Pneumothorax

Massive Hemothorax Massive Hemothorax Flail ChestFlail Chest

Cardiac TamponadeCardiac Tamponade

POTENITALLY LIFE THREATENINGPOTENITALLY LIFE THREATENING


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POTENITALLY LIFE THREATENINGPOTENITALLY LIFE THREATENING

CHEST INJURIESCHEST INJURIES

These conditions are evidenced inThese conditions are evidenced insecondary surveysecondary survey::

Pulmonary ContusionPulmonary Contusion

Myocardial ContusionMyocardial Contusion

Aortic Disruption Aortic Disruption

Traumatic Diaphragmatic RuptureTraumatic Diaphragmatic Rupture

Esophageal RuptureEsophageal Rupture

Blunt injuries to SVC and other major veins.Blunt injuries to SVC and other major veins.

OTHER INJURIES EVIDENCED INOTHER INJURIES EVIDENCED IN


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OTHER INJURIES EVIDENCED INOTHER INJURIES EVIDENCED IN

CHEST TRAUMA CHEST TRAUMA

Rib FracturesRib Fractures

Clavicular FracturesClavicular Fractures

Scapular FracturesScapular Fractures

Blunt injuries to Thoracic Duct.Blunt injuries to Thoracic Duct.


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AIRWAY OBSTRUCTION AIRWAY OBSTRUCTION

Evidenced in blunt trauma, especially MVAEvidenced in blunt trauma, especially MVAand blast injuries.and blast injuries.

Will be seen in primary survey duringWill be seen in primary survey during

airway step.airway step. Readjust head to sniffing position.Readjust head to sniffing position.

•• If CIf C--spine has been cleared.spine has been cleared. Attempt direct visualization and removal. Attempt direct visualization and removal.

May need fiberoptics for visualization.May need fiberoptics for visualization.


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Traumatic AsphyxiaTraumatic Asphyxia

Result of thoracic injury due to strongResult of thoracic injury due to strongcrushing injury.crushing injury.

Signs and Symptoms:Signs and Symptoms:cyanosis of head and neck, subconjuctivalcyanosis of head and neck, subconjuctival

hemorrhage, periorbital ecchymosis,hemorrhage, periorbital ecchymosis,petechiae, edematous moonpetechiae, edematous moon--like face,like face,epistaxis, hemotypmany, LOC, seizure.epistaxis, hemotypmany, LOC, seizure.

TREATMENT OFTREATMENT OF


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TRAUMATIC ASHPYXIA TRAUMATIC ASHPYXIA

Maintain adequate airway.Maintain adequate airway. Elevate head of bed to 30 degrees toElevate head of bed to 30 degrees to

decrease pressure to the head.decrease pressure to the head.

ICU admission with serial neuro checks.ICU admission with serial neuro checks.

Associated injuries of head and torso seen Associated injuries of head and torso seen

with this type of injury often need surgery. with this type of injury often need surgery.

No specific surgery for this condition.No specific surgery for this condition.


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TENSION PNEUMOTHORAX TENSION PNEUMOTHORAX

A one war air leak that collapses the A one war air leak that collapses theaffected lung with mediastinal andaffected lung with mediastinal and

tracheal shift to the opposite side.tracheal shift to the opposite side.

Signs and Symptoms:Signs and Symptoms:

respiratory distress, tachycardia,respiratory distress, tachycardia,hypotension, tracheal deviation, unilateralhypotension, tracheal deviation, unilateral

absent breath sounds, neck veinabsent breath sounds, neck veindistension, cyanosis.distension, cyanosis.



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TENSION PNEUMOTHORAX TENSION PNEUMOTHORAX

Immediate Decompression with a 14”Immediate Decompression with a 14”gauge needle into the second intercostalgauge needle into the second intercostalspace at midclavicular line of affectedspace at midclavicular line of affected

side.side.

Definitive treatmentDefinitive treatment

--

insertion of a chestinsertion of a chest

tube into the fifth intercostal spacetube into the fifth intercostal spaceanterior to midanterior to mid--axillary line.axillary line.


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Pneumothorax Pneumothorax


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S/P CHEST TUBE INSERTIONS/P CHEST TUBE INSERTION

OPEN PNUEMOTHORAXOPEN PNUEMOTHORAX


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OPEN PNUEMOTHORAX OPEN PNUEMOTHORAX

“SUCKING CHEST WOUND”“SUCKING CHEST WOUND”

A large defect of the chest wall causing A large defect of the chest wall causingequilibration between the interthoracicequilibration between the interthoracic

and atmospheric pressure.and atmospheric pressure.

If the opening is 2/3 or more in diameter ofIf the opening is 2/3 or more in diameter of

the trachea, air will prefer to pass throughthe trachea, air will prefer to pass through

the open chest wound.the open chest wound. Signs and Symptoms:Signs and Symptoms:

a large open wound of the chest,a large open wound of the chest,respiratory distress.respiratory distress.



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OPEN PNEUMOTHORAX OPEN PNEUMOTHORAX

Promptly close the defect with a sterilePromptly close the defect with a steriledressing taped on 3 sides creating adressing taped on 3 sides creating a

flutterflutter--type valve.type valve.

Closure of all 4 sides of the dressing couldClosure of all 4 sides of the dressing could

cause a tension pneumothorax if chestcause a tension pneumothorax if chest

tube is not in place.tube is not in place. Definitive surgical closure of the defect isDefinitive surgical closure of the defect is

required.required.


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Massive Hemothorax Massive Hemothorax

Accumulation of more than 1500ml of Accumulation of more than 1500ml ofblood.blood.

Usually secondary to penetrating wound.Usually secondary to penetrating wound.

Signs and Symptoms:Signs and Symptoms:

shock, absent breath sounds, dullness toshock, absent breath sounds, dullness to

percussion on one side of the chest.percussion on one side of the chest.



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MASSIVE HEMOTHORAX MASSIVE HEMOTHORAX

Manage with simultaneous restoration ofManage with simultaneous restoration ofblood volume and decompression of chestblood volume and decompression of chest

cavity.cavity.

CHEST TUBECHEST TUBE -- 38 french or larger38 french or larger

Prepare for autoPrepare for auto--transfusion with massivetransfusion with massive

blood loss.blood loss.

Thoracotomy.Thoracotomy.

THORACOTOMY ANDTHORACOTOMY AND


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THORACOTOMY ANDTHORACOTOMY AND

MASSIVE HEMOTHORAX MASSIVE HEMOTHORAX

Thoracotomy is indicated if there isThoracotomy is indicated if there is>1500ml blood loss or 1500ml blood loss or 200ml/hr.continuous loss > 200ml/hr.

Penetrating anterior wound medial toPenetrating anterior wound medial to

nipple line or posterior wound medial tonipple line or posterior wound medial to

scapula may need thoracotomy due toscapula may need thoracotomy due todamage to great vessels, hilar structuresdamage to great vessels, hilar structures

or heart.or heart.

Surgeon must be present!Surgeon must be present!


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FLAIL CHESTFLAIL CHEST

Secondary to multiple rib fractures.Secondary to multiple rib fractures. A segment of the chest wall does not have A segment of the chest wall does not have

bony continuity with the rest of the thoracicbony continuity with the rest of the thoracic

cage.cage.

Major problem is from the injury to theMajor problem is from the injury to the

underlying lung.underlying lung.

Paradoxical motion alone does not causeParadoxical motion alone does not cause

hypoxia, it is the pain with restricted chesthypoxia, it is the pain with restricted chest wall movement and lung injury . wall movement and lung injury .

SIGNS AND SYMPTOMS OFSIGNS AND SYMPTOMS OF


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Poor inspiratory effort.Poor inspiratory effort.

Asymmetrical movement of thorax. Asymmetrical movement of thorax.

Crepitus of rib or cartilage fractures.Crepitus of rib or cartilage fractures.



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FluidsFluids -- be careful not to overload patient.be careful not to overload patient. Adequate ventilation Adequate ventilation -- some patients maysome patients may

require intubation.require intubation.

Humidified oxygen.Humidified oxygen.

Analgesics. Analgesics.

ReRe--expansion of lung via CT if necessary forexpansion of lung via CT if necessary for

pneumothorax.pneumothorax.


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CARDIAC TAMPONADECARDIAC TAMPONADE

Usually a result of penetrating injuries.Usually a result of penetrating injuries.

Only a small amount of blood in theOnly a small amount of blood in the

pericardial sac is needed to restrictpericardial sac is needed to restrict

cardiac activity.cardiac activity.



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Becks Triad:Becks Triad:

Muffled Heart TonesMuffled Heart Tones

Increased Venous PressureIncreased Venous Pressure – – distendeddistended

neck veins (absent with hypovolemia).neck veins (absent with hypovolemia).Decreased Arterial PressureDecreased Arterial Pressure – – HypotensionHypotension

Pulsus ParadoxusPulsus Paradoxus – – decreased pressure duringdecreased pressure during

inspiration in excess of 10mmHg.inspiration in excess of 10mmHg. Kussmaul’s SignKussmaul’s Sign – – rise in venous pressure withrise in venous pressure with

inspiration while breathing normal.inspiration while breathing normal.



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SECONDARY TO HEMOPERICARDIUMSECONDARY TO HEMOPERICARDIUM



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PericardiocentesisPericardiocentesis – – use a plasticuse a plasticsheathed needle if available and enter viasheathed needle if available and enter viasubxyphoid route.subxyphoid route.

All patients with a positive All patients with a positivepericardiocentesis secondary to traumapericardiocentesis secondary to trauma will require an open thoracotomy. will require an open thoracotomy.

Open pericardiotomy may be required ifOpen pericardiotomy may be required ifblood in pericardial sac is clotted.blood in pericardial sac is clotted.


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POTENTIALLY LETHAL CHEST INJURIESPOTENTIALLY LETHAL CHEST INJURIES

These injuries are not obvious on initialThese injuries are not obvious on initialexam and require a high index of suspicionexam and require a high index of suspicion

to diagnose them.to diagnose them.

They are evaluated through the secondaryThey are evaluated through the secondary

survey and are lethal if not detected andsurvey and are lethal if not detected andtreated promptly.treated promptly.


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MYOCARDIAL CONTUSIONMYOCARDIAL CONTUSION

Patient is at high risk for suddenPatient is at high risk for sudden

dysrythmias.dysrythmias.

ICU admission with cardiac monitor andICU admission with cardiac monitor and

close observation.close observation.

Treat dysrythmias as per ACLS protocols.Treat dysrythmias as per ACLS protocols.


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TRAUMATIC AORTIC RUPTURETRAUMATIC AORTIC RUPTURE

Common cause of death after MVA or fallCommon cause of death after MVA or fallfrom a great height.from a great height.

Usually fatal at scene.Usually fatal at scene.

Viable patient’s usually have a tear near Viable patient’s usually have a tear nearthe ligamentum arteriosum and continuitythe ligamentum arteriosum and continuityof the adventitia layer prevents immediateof the adventitia layer prevents immediatedeath.death.

Considered a contained hematoma.Considered a contained hematoma.

SIGNS, SYMPTOMS, AND DIAGNOSTICSIGNS, SYMPTOMS, AND DIAGNOSTIC


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SIGNS, SYMPTOMS, AND DIAGNOSTICSIGNS, SYMPTOMS, AND DIAGNOSTIC

FINDINGS OF AORTIC RUPTUREFINDINGS OF AORTIC RUPTURE

Signs and Symptoms are usually absent.Signs and Symptoms are usually absent.

Pressure usually drops but responds to fluidPressure usually drops but responds to fluidresuscitation.resuscitation.

Radiology SignsRadiology Signs – – widened mediastinum (most widened mediastinum (mostsignificant finding), fracture of first and secondsignificant finding), fracture of first and secondribs, obliteration of the aortic knob, deviation ofribs, obliteration of the aortic knob, deviation ofthe trachea to the right, presence of pleural cap,the trachea to the right, presence of pleural cap,elevation and R shift of R mainstem bronchus,elevation and R shift of R mainstem bronchus,depression of the L mainstem bronchus, deviationdepression of the L mainstem bronchus, deviationof the esophagus (seen via NGT placement).of the esophagus (seen via NGT placement).



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TREATMENT OFO

TRAUMATIC AORTIC RUPTURETRAUMATIC AORTIC RUPTURE

Angiography should be performed liberally Angiography should be performed liberally

if high index of suspicion of injury.if high index of suspicion of injury.

Direct repair of the aorta or resection of theDirect repair of the aorta or resection of the

injured area and grafting.injured area and grafting.

TRAUMATIC DIAPHRAGMATICTRAUMATIC DIAPHRAGMATIC


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U C G C

RUPTURERUPTURE

More commonly dx on L secondary to liverMore commonly dx on L secondary to liver

obliterating defect on R.obliterating defect on R.

Blunt TraumaBlunt Trauma – – large radial tears that lead tolarge radial tears that lead toherniation.herniation.

Penetrating TraumaPenetrating Trauma – – small perforations that takesmall perforations that take

time even years to develop into hernias.time even years to develop into hernias.

TRAUMATIC DIAPHRAGMATICTRAUMATIC DIAPHRAGMATIC


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RUPTURERUPTURE

If a laceration of the Left diaphragm isIf a laceration of the Left diaphragm issuspected, place a NGT. If this appears insuspected, place a NGT. If this appears inthe thoracic cavity on CXR need for contrastthe thoracic cavity on CXR need for contrast

study is eliminated.study is eliminated. Right diaphragmatic rupture is rarelyRight diaphragmatic rupture is rarely

diagnosed earlydiagnosed early – – suspect if there is ansuspect if there is an

elevated R. diaphragm on CXR.elevated R. diaphragm on CXR. TreatmentTreatment – – Direct Repair.Direct Repair.


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ESOPHAGEAL TRAUMA ESOPHAGEAL TRAUMA

Usually due to penetrating trauma.Usually due to penetrating trauma.

Blunt injury causes a forceful expulsion ofBlunt injury causes a forceful expulsion of

gastric contents into mediastinumgastric contents into mediastinum – –

mediastinitis and may be lethal if notmediastinitis and may be lethal if not

recognized.recognized.

Delayed rupture into pleural space mayDelayed rupture into pleural space maycause an empyema.cause an empyema.



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ESOPHAGEAL TRAUMA ESOPHAGEAL TRAUMA

L. pneumothorax or hemothorax without ribL. pneumothorax or hemothorax without ribfracture.fracture.

Severe blow to the sternum or epigastrumSevere blow to the sternum or epigastrum

with pain or shock out of proportion to with pain or shock out of proportion toinjury.injury.

Particulate matter in the chest tube afterParticulate matter in the chest tube afterblood clears.blood clears.

Presence of mediastinal air on CXRPresence of mediastinal air on CXR


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TREATMENT OF ESOPHAGEAL TRAUMA TREATMENT OF ESOPHAGEAL TRAUMA

Confirm with contrast study orConfirm with contrast study or

esophagoscopy.esophagoscopy.

Wide drainage of the mediastinum andWide drainage of the mediastinum and

pleural space.pleural space.

Direct Repair of injury.Direct Repair of injury.

DIAGNOSTIC STUDIES AND TRAUMA:DIAGNOSTIC STUDIES AND TRAUMA:


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LABSLABS

To aid in confirmation of diagnosis andTo aid in confirmation of diagnosis andmonitor patient.monitor patient.

CBCCBC – – helps gauge blood loss.helps gauge blood loss.

BMPBMP – – patient’s requiring massive fluidpatient’s requiring massive fluidresuscitation should have electrolytesresuscitation should have electrolytesmonitored. Aids with acidmonitored. Aids with acid--base disorders.base disorders.

Coagulation ProfileCoagulation Profile – – for patient’s receivingfor patient’s receivingmassive transfusions (look for DIC).massive transfusions (look for DIC).


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LABSLABS Type and CrossType and Cross

ABG ABG – – allows you to evaluate ventilation,allows you to evaluate ventilation,

oxygenation and acidoxygenation and acid--base status.base status.

Cardiac EnzymesCardiac Enzymes – – correlate with patient’s EKG,correlate with patient’s EKG,abnormalities in patients with blunt cardiacabnormalities in patients with blunt cardiac

injury (Myocardial contusion).injury (Myocardial contusion).

Lactate LevelLactate Level – – measure of tissue perfusion.measure of tissue perfusion.

Levels that clear quickly = better outcomes.Levels that clear quickly = better outcomes.



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IMAGING STUDIESIMAGING STUDIES

CXRCXR – – aids in confirmation ofaids in confirmation of

pneumothorax, hemothorax, cardiac andpneumothorax, hemothorax, cardiac and

great vessel injuries. (Should not wait forgreat vessel injuries. (Should not wait for

one to confirm clinical suspicion of tensionone to confirm clinical suspicion of tensionpneumothorax).pneumothorax).

CT ScanCT Scan – – useful in more occult oruseful in more occult orundetected injury. CT patient’s withundetected injury. CT patient’s with

possible aortic injuriespossible aortic injuries


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IMAGING STUDIESIMAGING STUDIES Aortogram Aortogram – – gold standard in diagnosis of aorticgold standard in diagnosis of aortic

and great vessel injury. If CT is positive for aorticand great vessel injury. If CT is positive for aortic

injury, do aortogram to see exact location andinjury, do aortogram to see exact location and

extent of injury.extent of injury.

Thoracic USThoracic US – – usually done in ED duringusually done in ED during

secondary survey. May visualize pericardium,secondary survey. May visualize pericardium,

heart, thoracic cavity. Pericardial effusions,heart, thoracic cavity. Pericardial effusions,tamponade, and hemothoraces are recognizedtamponade, and hemothoraces are recognized

with sensitivity and specificity of 90%. with sensitivity and specificity of 90%.



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EKGEKG

Aids in identification of new cardiac Aids in identification of new cardiacabnormalities and underlying cardiacabnormalities and underlying cardiacproblems.problems.

Important in patients with clinicallyImportant in patients with clinicallysignificant blunt cardiac injury.significant blunt cardiac injury.

Most common EKG finding in patients withMost common EKG finding in patients with

myocardial contusionmyocardial contusion – – tachyarrhythmia,tachyarrhythmia,first degree blocks, bundle branch blocks.first degree blocks, bundle branch blocks.


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SUMMARY SUMMARY Chest Trauma is common in multiple injuredChest Trauma is common in multiple injured

patients and is often associated with lifepatients and is often associated with lifethreatening problems.threatening problems.

Remember Primary SurveyRemember Primary Survey – – ABCT(rauma) ABCT(rauma)

Always treat first step of ABC’s before proceeding Always treat first step of ABC’s before proceedingto the next, a change in vitals start fromto the next, a change in vitals start frombeginning.beginning.

Have high suspicion for potentially lifeHave high suspicion for potentially lifethreatening condition in secondary survey.threatening condition in secondary survey.

10 Chest Trauma

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