International Trauma Life Support for Emergency Care Providers CHAPTER seventh edition Thoracic...

International Trauma Life Supportfor Emergency Care Providers

CHAPTER

seventh edition

Thoracic Trauma

6

International Trauma Life Support for Emergency Care Providers, Seventh EditionJohn Campbell • Alabama College of Emergency Physicians

Thoracic Trauma

© Pearson


Overview

• Major signs and symptoms– Immediate life-threatening injuries

• Pathophysiology and management– Open pneumothorax– Tension pneumothorax– Massive hemothorax– Flail chest– Cardiac tamponade


Overview

• Cardiac involvement with blunt injury• Other thoracic injuries


Thoracic Trauma

• Thoracic injury is common– 50% of multiple trauma – 25% of trauma deaths

• Potentially fatal thoracic injuries saved by rapid recognition and intervention– Many require surgical intervention


Chest Anatomy


Mechanism of Injury

• Blunt – Direct compression

Fracture of solid organs Blowout of hollow organs

– Deceleration forces Tearing of organs and blood vessels

• Penetrating– Direct trauma to organ and vasculature – Energy transmitted from mass and velocity


Tissue Hypoxia

• Inadequate oxygen delivery• Hypovolemia• Ventilation/perfusion mismatch• Pleural pressure changes• Pump failure


Thoracic Trauma

• Signs and symptoms– Shortness of breath – Chest pain– Hemoptysis – Cyanosis – Neck veins distended– Tracheal deviation– Asymmetrical

movement

– Chest wall contusion– Open wounds– Subcutaneous

emphysema– Shock– Tenderness, instability,

crepitation (TIC)– Breath sounds

abnormal


ITLS Primary Survey

“Deadly Dozen”1. Airway obstruction

2. Flail chest

3. Open pneumothorax

4. Massive hemothorax

5. Tension pneumothorax

6. Cardiac tamponade


ITLS Secondary Survey

“Deadly Dozen”7. Myocardial contusion

8. Traumatic aortic rupture

9. Tracheal or bronchial tree injury

10.Diaphragmatic tears

11.Pulmonary contusion

12.Blast injuries


Primary “Deadly Dozen”

• Airway obstruction– Secondary hypoxia

Common cause of preventable death Foreign body, tongue, aspiration

– Always assume cervical spine injury



• Flail chest



• Flail chest– Assist ventilation– Possible intubation– Load-and-go– Stabilize flail segment– Monitor for:

Pulmonary contusion Hemothorax Pneumothorax

(Courtesy of Stanley Cooper, EMT-P )



• Open pneumothorax– “Sucking chest wound”

Air enters pleural space Ventilation impaired Hypoxia results

– Signs and symptoms Proportional to size of defect



• Open pneumothorax– Close chest wall defect– Load-and-go

Above photo courtesy of Teleflex Incorporated, allrights reserved. No other use shall made of the image without the priorwritten consent of Teleflex Incorporated.



• Massive hemothorax– Anxiety and confusion– Neck veins

Flat: hypovolemia Distended: mediastinal

compression

– Breath sounds decreased Dull if percussed

– Shock



• Massive hemothorax– Load-and-go– Treat for shock– Fluid administration

Titrate to peripheral pulse (80-90 mmHg)

– Monitor for: Tension hemopneumothorax



• Tension pneumothorax– Dyspnea– Anxiety– Tachypnea– Distended neck veins– Tracheal deviation (rare) – Breath sounds diminished

Hypertympany if percussed

– Shock with hypotension



• Tension pneumothorax– Decompress affected side

Respiratory distress and cyanosis

Loss of radial pulse Decreasing

level of consciousness

– Load-and-go

(Courtesy of Louis B. Mallory, MBA, REMT-P)



• Cardiac tamponade– Beck's triad

Hypotension Neck veins distended Heart sounds muffled

– Paradoxical pulse– Breath sounds equal



• Cardiac tamponade– Load-and-go– Treat for shock– Fluid administration

Titrate to peripheral pulse (80–90 mmHg)

– Monitor and treat dysrhythmias– Monitor for:

Hemothorax Pneumothorax


Secondary “Deadly Dozen”

• Myocardial contusion– Most common cardiac injury

Blunt anterior chest injury

– Same as myocardial infarction Chest pain Dysrhythmias Cardiogenic shock (rare)

– Treat as cardiac tamponade



• Traumatic aortic rupture– Most common cause of immediate death

Motor-vehicle collisions or falls from heights 80% die immediately

– Scene Size-up and history extremely important No obvious sign of chest trauma Hypertension in upper extremities

and hypotension in lower extremities (rare)



• Tracheal or bronchial tree injury– Subcutaneous emphysema

Chest, face, neck

– Ensure adequate airway Cuffed ET tube past site of injury

– Monitor for: Pneumothorax Hemothorax



• Diaphragmatic tear– Severe blow to abdomen– Herniation of abdominal organs

More common on left Breath sounds diminished Bowel sounds auscultated in chest (rare) Abdomen appears scaphoid



• Pulmonary contusion– Common from blunt trauma– Hours to develop– Marked hypoxemia



• Blast injury– Penetrating trauma– Difficult to assess in field– If unrecognized, may be lethal


Other Chest Injuries

• Impaled objects– Do not remove– Stabilize the object– Monitor for:

Tension pneumothorax Hemothorax Cardiac tamponade



• Traumatic asphyxia– Severe compression– Ruptures capillaries

Cyanosis above crush Swelling of head, neck Swollen tongue, lips Conjunctival hemorrhage

Courtesy of John Campbell



• Simple pneumothorax– Fractured ribs– Pleuritic chest pain– Dyspnea – Decreased breath sounds – Hypertympany if percussed– Monitor for:

Tension pneumothorax



• Sternal fracture– Significant blunt trauma to anterior chest– Signs of fracture on palpation– Myocardial contusion presumed

• Simple rib fracture– Most frequent chest injury – Monitor for:

Pneumothorax Hemothorax


Summary

• Chest injuries common • Often life-threatening

– Require prompt recognition – Require prompt intervention– Frequently require load-and-go

• Airway and oxygenation always priority• Frequent Ongoing Exams

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