CHEST TRAUMA-CHALLENGES WITH VENTILATIONS/RESPIRATIONS

- Chris Strobach, NREMT-P

• 187,000 deaths per year in the US due to trauma

• That’s approximately 1 person every 3 minutes

• Blunt/penetrating chest trauma is one of the leading causes of trauma death (25+%)

Leading causes of chest trauma include:

▪ MVAs: (70 – 80% of trauma deaths)

▪ Falls from excessive heights (usually >15’ vertically)

▪ Blast injuries (both primary and secondary)

▪ Significant blows to the chest

▪ Chest compression injuries

▪ Gunshot wounds (GSW)

▪ Stab/impalement wounds

Leading Pulmonary Injuries:

• Rib fractures / flail segment

• Pulmonary contusion

• Simple open/closed pneumothorax

• Tension pneumothorax

• Hemothorax

•Rib Fractures:• Most common type of

chest injury

• While painful, the fracture itself is typically not the pathology of concern

• The potential for serious internal injury is what demands your attention.

•Rib Fractures:• 1 – 2 fx. ribs = 5% mortality

rate

• 7+ fx ribs = 29% mortality

• Elderly population mortality rate doubles

• Fx of the 1st or 2nd rib requires significant force

• Ribs are thick and dense

• Often will injure the aorta or bronchi

• 30% mortality rate

• May result in pneumothorax or subclavian artery/vein injuries

•Rib Fractures:• Fractures of the 8th to 12th

ribs can damage underlying abdominal solid organs:

• Liver

• Spleen

• Kidneys

• Laceration of these organs will likely require aggressive volume replacement.

•Rib Fracture’s Best Friend:• Analgesics can often be the

key to improving pulmonary function if painful respirations are the key contributor to poor tidal volumes.

• Flail Chest• A flail chest occurs

when 2 or more ribs are fractured at two or more places, creating a free moving segment of chest wall moving paradoxically to the rest of the chest.• Paradoxical movement may not be

seen early on due to the splinting effect of chest muscle spasms.

• Flail Chest effects:• Work of Breathing

• Increased by the loss of integrity of the chest wall

• Tidal Volume

• Decreases due to the paradoxical movement

• Pulmonary Contusions

• Create atelectasis and poor gas exchange

• Flail Chest Treatment:

“Management should include ventilatorysupport, pain management and monitoring for deterioration. Do not attempt to stabilize flail section.” – TCAD protocol

•Pulmonary Contusion• Bruising of the lung

parenchyma from a high velocity impact

• 20 – 40% of pts with rib fractures will have a PC

•Pulmonary Contusion S/S:• Chest pain

• Adventitious lung sounds

• Lung stiffness

• Hemoptysis or non-productive cough

• Respiratory insufficiency

• Ecchymosis

•Pulmonary Contusion Tx:• High flow O2

• Assist ventilations with BVM as necessary

• Pts will need analgesics to enable them to breathe adequately

• Assess need for advanced airway.

• Pt’s with dyspnea or lung disease should be monitored and managed aggressively

• Emergent transport

•Pneumothorax:• Air in the pleural

space decreases or eliminates the normal negative pressure which is necessary for proper lung expansion.

• Can cause the lung to collapse.

• Can be caused by fxrib(s) which puncture the actual lung tissue (parenchyma).

•Pneumothorax:• Various degrees of

pneumothoracies

• Partial vs. complete

• Respiratory distress typically not seen until 30 – 40% lung involvement.

• Can vary depending on patient’s age and overall health.

•Pneumo S/S:• Decreased/absent

breath sounds.

• Pain with inspiration

• Pain with palpation.

• Dyspnea

• Tachypnea

•Pneumo Tx:• Establish airway

• High flow on NRB or BVM

• Be suspicious of other injuries

• Continuous assessment of ventilations

• Monitor and capnography

• Watch for development of tension pneumo.

•Open Pneumo:• The “sucking chest wound”

• Visible hole in the chest wall (or look for bubbles)

• Small vs. large wound have different pathologies

• Small wounds will likely create a tension pneumo

• Act as a 1-way valve.

• Large wounds will cause air to enter through hole rather than through trachea.

• Decreased tidal volume and gas exchange.

• PPV essential

• Subcutaneous air will likely be seen/felt in chest, neck and axilla.

•Open PneumoTx:• Regardless of hole size,

apply an occlusive dressing taped on 3 sides.

• The Medics should consider cutting a square patch from the dorsal aspect of a clean glove to act as the dressing.

• Clean the area around the wound prior to applying 2” tape.

•Open PneumoTx cont’d:• High flow oxygen with

BVM assist as needed

• Monitor closely for development of tension pneumothorax

• IV and EKG

• Rapid transport to trauma center

• Tension Pneumo:• Air enters the pleural space on

inspiration and becomes trapped.

• Intrapleural pressure rises collapsing the lung on the affected side.

• Increasing pressure push creates a mediastinal shift

• Applies pressure to the heart, superior and inferior vena cava

• Bottoms out pre-load

• Cardiac output falls along with blood pressure.

• Shock will develop rapidly

• True life-threatening emergency!

• Tension Pneumo S/S:• Severe dyspnea / respiratory

distress

• Restlessness, anxiety, agitation

• Decreased/absent breath sounds

• Percussive hyperresonance

• SubQ air

• Assymetrical chest rise

• Cyanosis/late

• JVD (unless hypovolemic as well)

• Rapid/weak pulse

• Hypotension

• Tension Pneumo Tx:• This is obstructive shock!

• Needle Decompression (Thoracostomy)

• Secure airway

• High flow O2

• Capnometry

• Heart monitor

• Rapid transport

• ARS (Air Release System):

• Connect to a 10ml saline flush (make room for air to purge)

• 2nd or 3rd intercostal space, midclavicular (5th intercostal space, mid-axillary as alternate site)

• Prep with aseptic technique

• Insert OVER the top of rib at a 90 angle to chest wall.

• When air escapes (bubbles) stop and advance catheter only until flush with skin.

• Re-assess and repeat as necessary.

• If blood flows continuously, withdraw catheter.

• Hemothorax• Blood in the pleural

space

• Each lung can hold up to 3 liters of blood.

• High incidence with penetrating trauma (knife and gun club)

• Can have hemopneumothoraxconcurrently

• Hemothorax S/S:• Decreased chest rise

and breath sounds

• Dyspnea

• Trachea midline

• No JVD

• AMS

• Hypotension

• Pleuritic chest pain

• Narrow pulse pressure

• Hemothorax Tx:• High flow O2

• 2 large bore IVs with fluid replacement.

• Permissive hypotension

• Rapid Transport

• They need chest tube(s)!

In Summary:

▪ Blunt chest trauma is a leading cause of trauma death (25%)

▪ Simple but aggressive management can truly be the difference between life and death.

▪ Rib Fx’s are not critical, but the damage they can inflict could be.

▪ Good assessment of the physical signs can provide the best clue of what’s going on inside your patient.

▪ Capnometry is an invaluable tool to identify your patient’s current status as well as their response to treatment “real-time”.

▪ Needle decompression is a simple but life-saving procedure

▪ Whether by ground or by air, ensure the patient gets to a Trauma Facility as rapidly as possible.

References:

▪ Center for Disease Control; Injury Prevention and Control; 2011 [Online] http://www.cdc.gov/injury/overview/leading_cod.html.

▪ Casey Thompson RN, CFRN, CCRN, CEN, NREMT; (AirMed) University of Utah Health Care; Trauma Grand Rounds; http://youtu.be/iT5Y2B2zZ1c

▪ Simple Thoracostomy: Moving Beyond Needle Decompression in Traumatic Cardiac Arrest. Andrew Karrer, LP | Brett J. Monroe, MD | Guy R. Gleisberg, MBA, BSEE, NREMT-B, EMS-I | Jared Cosper, BS, LP | Kasia Kimmel, MD | Mark E.A. Escott, MD, MPH, FACEP. s.l. : JEMS, March 2014.