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The ABC’s of Chest Trauma

J Bradley Pickhardt MD, FACS

Providence St Patrick Hospital

What’s the Problem?

2/3 of trauma patients have chest trauma

Responsible for 25% of all trauma deaths

Most injuries can be managed with simple maneuvers

Less than 10% require definitive operative repair

Immediate Priorities in Management of Chest Trauma

AirwayBreathingCirculation

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Case #1

40 year old male has fallen from a scaffold, landing on a pile of wooden pallets

What are your initial thoughts about possible injuries?

How are you going to determine his injuries? How likely are you to miss injuries if you don’t

expose and palpate the patient’s chest? What factors complicate chest assessment? What assessment findings would alert you that

this patient is in acute distress?

What Injuries are Possible?

Always Look at the Back!!

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Rib Fractures

What complications might this patient suffer?

How does pre-morbid status affect onset and severity of complications?

What can we do to prevent these complications from occurring, or at least lessen their severity?

Life Threatening Injuries

Tension Pneumothorax Flail Chest w/ pulmonary

contusion Open chest wounds Massive Pneumo/Hemothorax

Tracheo-bronchial disruption Cardiac Tamponade

Tension Pneumothorax

Common with both blunt an penetrating trauma

Diminished breath sounds (listen laterally)

Subcutaneous emphysema Hypotension

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Subcutaneous Emphysema

Treatment

Needle Thoracostomy

14 to 16 gauge needle

Mid-clavicular

Anterior axillary

Pitfalls of Needle Thoracostomy

May not decompress the tension

Bleeding/lung laceration

May kink

Mandates that patient gets a chest tube

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Case #2

22 year old male stabbed in left chest just lateral to the nipple

BP 120/78, O2 sat 95%

CXR shows 50% pneumothorax

Open Chest Wounds

Loss of chest wall support

Direct pulmonary injury

Magnitude of blood loss may be underappreciated

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Treatment for open chest wounds

Direct pressure to control bleeding

Semi-occlusive dressing

Chest tube

Early intubation to support ventilation

“There is no organ in the chest or abdomen that has not been injured by a chest tube.”

Pitfalls of Chest Tube Placement

Damage to heart/lung/vessels

Intra-abdominal placement with injury to spleen and/or liver

Subcutaneous placement

Last hole not in the thoracic cavity

Pain from the tube being in too far

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Case #2 continued

Heart rate now 130’s, BP upper 90’s

Chest tube output 500cc/2 hours

CXR shows some opacity over the left lung field

Indications for Thoracotomy

Greater than 1000-1500 cc initial output

200-250 cc bleeding over 2-4 hours

Hemodynamic instability

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Case #3

78 year old male driver of vehicle that struck a tree head on

Paradoxical chest wall movement easily seen

Multiple rib fractures seen on CT

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Flail chest/Pulmonary Contusion

3 or more ribs fractured in two or more places

Increased mechanical work of breathing

Impaired gas exchange due to underlying pulmonary contusion

Brad – video, scroll over and click play

Treatment: Flail chest

May require early intubation, mechanical ventilation

Pain control for rib fractures Oxygenation will worsen over

first 24 to 48 hours Rib plating External binding is not

beneficial

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What Does He Need?

Intubation/ventilation support

CVP/A-line

Euvolemia

Pain control

Tracheostomy

PEG

DVT prophylaxis

Consider transfer to higher level of care

Diaphragmatic Rupture

Most commonly presents on the left side

Often a delay in diagnosis if ventilated

Instability usually due to abdominal injury

Blunt Aortic Injury

Free rupture dies prior to the hospital

Most alive on admission are contained hematomas

Operative repair can be delayed with blood pressure control

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Blunt Cardiac Injury (AKA Cardiac Contusion)

Signs and Symptoms Chest pain and tenderness

Broken Steering Column

Arrhythmias

Diagnosis

Treatment- expectant,

monitor for 24-48 hr

Cardiac Tamponade

Most commonly due to penetrating trauma

Early signs may be subtle muffled heart tones

Jugular Venous Distension

hypotension

Requires a high index of suspicion

Case # 4

26 y/o male with GSW to R upper arm and multiple defensive stab wounds

Pt had significant bleeding from GSW site.

HR 81, BP 89/48, RR 20, O2 sats 92%, GCS 15

Actions?

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What injuries are possible?

Tracheobronchial Injuries

Penetrating or blunt injures

Often present with tension pneumothorax

Persistent, massive air leak

May be difficult to ventilate due to loss of tidal volume

Often require several chest tubes

What Next?

Blood, fluids

Chest tube

Intubation

CT if stable

OR if unstable

Bronch

Upper endoscopy

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Case #4

80 y/o male fell off skateboard

Sustained left rib fx 4-12

Admitted at outside facility 7 days--discharged home

Chest x-ray and CT done

Repeat chest x-ray for 2 days then DC x-ray

Discharge on day 7

Case #4 continued

Bounce back to ED a few hours later following DC with difficulty breathing, extreme chest pain and fever

Chest x-ray and CT;

What are these going to show?

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Trauma Center ICU

He was admitted to ICU

Thoracic Injury management Protocol ordered

Worked up for Sepsis

Pigtail drain placed by interventional radiology

No epidural placed

July 2018 started Protocol

Education to respiratory therapy, nursing, trauma advanced practice providers

Inclusion is 3 or more rib fractures

Implementation of Thoracic Injury Management Protocol

Thoracic Injury Management Protocol

Inclusion Criteria (Extubated or recently extubated)

GCS 13-15 (≥14 years of age)+Rib or Sternal fracture (Absence of high spinal cord injury)

ICU and Med Surg Floors

Provider 

On admission order:

Nursing Communication order "pt on Thoracic Injury Protocol"

RT evaluate and treat consult order for Thoracic Injury Protocol

Document recent PIC scores in notesPulmonary Hygiene -IS, cough & DB Q1 hour WA

Minimize IVF

Mobilize at least TID if not contraindicated

HOB 30 degrees if not contraindicatedPain medication plan

Give patient instruction at discharge

RT to assess patient within an hour of consult:

Measure initial IS volumes

Set goal range (male 2500-3500, female 2000-3000, peds 500-2500, ex; 11 yo 1500ml)Routine clinical care:

IS monitoring Q6 & PRN (RT responsible for IS at 0800, 1400, 2000, & 0200)

Chart PIC score, pain & IS Q6 hour in Epic and on score board

Incorporate PIC score, I/S volumes and IS goal in daily rounds

**Notify RN when total PIC score ≤4 and /or a score of 1 point in any category after intervention

Nursing

Notify RT of pt admission

Place PIC score board in visible place in the room

Instruct pt and family on PIC scoring methods and rationale

Provide pt and family  PIC educational handout

Routine clinical care:

Proper IS method and cough & DB Q1 hour WA

Educate and encourage use of splinting

Elevate HOB 30 degrees if not contraindicated

Mobilize at least TID if not contraindicated

Incorporate PIC score, I/S volumes, and goal in daily rounds

**Notify provider if total PIC score ≤4 and or a score of 1 point in any category after interventions

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First PICC Score:Pain: 2 - moderate

Inspiration: 3 – Goal to alert volume

Cough: 2 – weak

Total Score: 7

How will this information guide care?

What if his PICC score was this:Pain: 1-severe

Inspiration: 2 – below alert level

Cough: 2 – weak

Total score: 5

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Last PICC Score done day 3 of 8 transferred to floorPain: 3-controlledInspiration: 4-above goal volumeCough: 2-weakTotal: 9

CXR 6/25

PIC Statistics Improvements in Care

Incentive spirometer consistently in patients room on day one of initiation of PIC protocol

Increased patient education on need for IS, use of IS, deep breath, and cough

ICU readmit d/t respiratory failure decrease

Pain control improved (epidurals placed earlier in care process)

PIC Statistics Improvements in Care

0

50

100

150

200

250

300

350

2017 2018

274

331

Total Patients Seen July-December

0.0% 5.0% 10.0% 15.0% 20.0% 25.0%

% OF PATIENTS RE-ADMIT TO ICU

% OF PATIENTS W/ 3 OR MORE RIB FX

9.4%

19.3%

5.1%

23.9%

Trends Noticed Since Implementation of PIC Protocol

2017 2018

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Summary

Common

Mechanism of injury important

Course often very prolonged

Elderly and/or those with co-morbidities do poorly

Knowledge of natural history essential to anticipate/prevent complications as course evolves