Lecture 5 Chest Trauma
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Transcript of Lecture 5 Chest Trauma
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Chest Trauma
William Schecter, MD
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Rib Fractures
• Control Pain
– Analgesics
• Opiates
• NSAIDS
– Local rib blocks
– Thoracic Epidural
• Admit it patient elderly, > 3 rib fractures,
suspicion of other injury
• Pulmonary toilet
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Pneumothorax
http://health.allrefer.com/health/tension-pneumothorax-pneumothorax-chest-x-ray.html
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Tension Pneumothorax
http://kuriakon00.tripod.com/tension.html http://info.med.yale.edu/intmed/cardio/imaging
/cases/pneumothorax_tension/
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Needle Decompression
http://nursing.umaryland.edu/students/~jkohl/scenario/needle.htm
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Hemothorax
http://health.allrefer.com/health/tension-pneumothorax-chest-tube-insertion-series-2.html
http://nursing.umaryland.edu/students/~jkohl/scenario/needle.htm
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Chest Tube Placement
• Anterior axillary line,
posterior to pectoralis
major muscle
• 5th intercostal space
(opposite the nipple)
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Open Pneumothorax
• Open Penetrating Wound
• Lung Laceration
• Inability to ventilate due
to open chest cavity
http://www.trauma.org/imagebank/imagebank.html
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Sucking Chest Wound-First Aid
Treatment
http://www.vnh.org/FirstAidAnatomy/ChestWound.html
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Sucking Chest Wound-Definitive
Treatment
• Intubation
• Mechanical
Ventilation
• Chest Exploration
http://www.trauma.org/imagebank/imagebank.html
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Flail Chest
• Fractures of two or
more ribs in two or
more places
• Unstable segment of
chest wall
• Paradoxical motion of
chest wall
http://www.trauma.org/imagebank/imagebank.html
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Obsolete Treatment
http://www.trauma.org/imagebank/imagebank.html
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Unstable Chest Wall Treated
with ―Internal Pneumatic
Stabilization‖
http://www.trauma.org/imagebank/imagebank.html
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Same patient after stabilization of
ribs
http://www.trauma.org/imagebank/imagebank.html
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The Main Problem is
usually underlying
Pulmonary Contusion NOT
mechanical chest wall
instability
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Principles of Flail Chest
Treatment
• A,B,C
• Chest Wall Analgesia
– Thoracic Epidural
– Rib Blocks
• Mask CPAP
• Intubation and Mechanical Ventilation
• VERY RARELY – Internal Fixation
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Pulmonary Contusion
• A bruise to the lung
• Airspace opacification
• No air bronchogram
http://medweb.bham.ac.uk/wmaet/presentations
/Pulmonary%20Contusion.ppt
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Components of Pulmonary
Contusion
http://www.cvmbs.colostate.edu/clinsci/wing/trauma/pulmcont.htm
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http://medweb.bham.ac.uk/wmaet/presentations/Pulmonary%20Contusion.ppt
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Treatment of Pulmonary
Contusion
• ABC
• Oxygen
• Analgesia
– Parenteral
– Chest wall
• Rib blocks
• Thoracic epidural
• Mask CPAP/BIPAP
• Intubation and
Mechanical
Ventilation
• Fluid Restriction
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Indications for Endotracheal
Intubation
• Hypoventilation
• Hypoxia
• Pulmonary Toilet
• Airway Protection
• ―Semi-stable‖ Trauma Victim requiring mulitiple radiologic procedures (relative indication)
• ―Prophylactic Intubation‖ – eg. A big burn
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Pulmonary Blast Injury
• 74 yo woman injured in a bus bombing Jan. 29, 2004
• Admitted with rt rib fxs, pulmonary contusion, hemothorax and amputations rt and lt 2nd digits.
• Required 10 days of mechanical ventilation
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Pulmonary Blast Injury
• 14 yo boy injured in
bus bombing Jan 29,
2004
• Admitted with
profound hypoxia,
acidosis and
hypercarbia
• Intubation/mechanical
ventilation
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Pulmonary Blast Injury
• HD 3 Respiratory
Status improved but
sudden deterioration in
abdominal findings
and right lateral
decubitus suggestive
of free air
• Exploratory
laparotomy: negative
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Pulmonary Blast Injury
• Left hemiparesis
• Hyperagitation
• Question air embolus +/- blast injury to brain
• Head CT negative
• Outcome: extubated, disposition: rehab center
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Pulmonary Blast Injury at SZMC
January 29, 2004, Bus Bombing
• 23 patients evaluated
• 11 patients admitted
• 10/11 admissions had radiographic evidence of pulmonary blast injury
• 4/10 patients with blast injury patients required intubation and mechanical ventilation
• Deaths: 0
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Case Presentation
• 17 year old girl struck by car
• Presents to ER hemodynamically stable, awake and alert with RR = 22 with CXR similar to the one on the right
• Pneumomediastinum is present
http://www.amershamhealth.com/
medcyclopaedia/Volume
%20V%201/TRAUMATIC%20RUPTURE%
20TRACHEOBRONCHIAL%20TREE.asp#
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http://www.cyber-nurse.com/veetac/horrorctam.htm
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Chronic Tamponade
http://www.emedicine.com/med/topic283.htm
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Cardiac Tamponade
•
http://www.trauma.org/imagebank/imagebank.html
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http://www.trauma.org/imagebank/imagebank.html
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http://www.cyber-nurse.com/veetac/horrorctam.htm
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Beck’s Triad
• Hypotension
• Jugular Venous Distension
• Muffled Heart Sounds
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Additional Signs of Cardiac
Tamponade
• Pulsus Paradoxicus
• Kussmaul’s Sign: Elevated Jugular Venous
Pressure on Inspiration
• Water bottle heart on chest x-ray
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Case Presentation
• Patient with stab wound to the chest in the
box
• BP on admission 70 systolic
• BP rises to 90 systolic with fluid
• FAST exam: no blood in abdomen.
Examiner thinks heart is ok
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Blunt Cardiac Injury
http://www.vh.org/adult/provider/surgery/bluntcardiacinjury/
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Blunt Cardiac Injury
• Spectrum of Disease ranging from
―concussion‖ manifested by arrhythmias to
cardiac rupture
• Cardiac Contusion a problematic term
– EKG evidence
– Ultrasound evidence
– Technician Scan--NO
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Cardiac Contusion
• Patients with a normal EKG in the ER do
not need ICU admission to R/O a diagnosis
of myocardial contusion (They may need
ICU admission for other reasons)
• Patients who have an abnormal EKG in the
ER should be admitted to a monitored bed
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http://www.vh.org/adult/provider/surgery/bluntcardiacinjury/withoutrupture/management.html
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Thoracic Aortic Injury
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Spectrum of Injury • Intimal Tear
• Tear of Intima and Media
• Free Rupture
http://www.visualsunlimited.com/browse/vu978/vu97852.html
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Ruptured Thoracic Aorta
• 90% of patients dead at the scene
• 50% of the patients who arrive at the
hospital are dead within 24 hours without
proper diagnosis and Rx.
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Radiologic Signs Suggesting
Ruptured Thoracic Aorta
• Widened Mediastinum
• Blurring of the Aorta Knob
• Extrapleural cap
• Depression of left mainstem
bronchus
• Ng tube shifted to the right
• 1st and 2nd rib fractures
• Fractured sternum/scapulaSSS
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Diagnosis and Rx of Ruptured
Thoracic Aorta
• High Index of Suspicion
– Mechanism of Injury
– Associated Radiologic Findings
• Arterial Line
• Beta Blockade
• Additional blood pressure control
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Methods of Diagnosis
Arteriogram
Helical CT TEE
http://radiology.rsnajnls.org/
cgi/content/full/227/2/434 http://www.trauma.org/imagebank/imagebank.html
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Methods of Treatment
• Observation with blood pressure and wall
tension control
• Repair
– With or without graft
– With or without cardiopulmonary bypass
• Stent placement
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Ruptured Left Hemidiaphragm
http://www.worldwidewounds.com/2002/october/Bowley/Patterns-Of-Injury-MVAS.html
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Ruptured Diaphragm
http://www.trauma.org/imagebank/imagebank.html
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Transmediastinal Penetrating
Trauma
• Unstable – OR
• Stable—CT
• R/O injury to
– Aorta
– Esophagus
– Heart
– Tracheobronchial tree
– Lung
– Great Vessels
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Summary
• ABCDE
• Diagnoses to make in the Primary Survey
– Simple/Tension Pneumothorax
– Open Pneumothorax
– Hemothorax
– Flail Chest
– Cardiac Tamponade
• Stage of Resuscitation
– Pulmonary contusion
– Ruptured Diaphragm
– Ruptured bronchus
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Summary
• Diagnoses to make in the Secondary Survey
– Blunt Cardiac Injury
– Blunt Injury to the Aorta
– Esophageal Injury (rare)