Presentation 3: TRAUMA

Emergency Care

CLS 243 Dr.Bushra Bilal

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INTRODUCTION

The life-threatening chest injuries are:

Tension Pneumothorax Massive Hemothorax Open Pneumothorax Cardiac Tamponade Flail chest

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Diagnostic Adjuncts

Chest X-ray FAST ultrasound Arterial Blood Gas Interventions Chest drain ED Thoracotomy

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PNEUMOTHORAX

• Pneumothorax is the medical term for a collapsed lung.

• Pneumothorax occurs when air becomes trapped in the space around the lungs—the pleural space.

• This can cause the lung to collapse and put pressure on the heart.

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Types:1- traumatic pneumothorax. This occurs when an injury to the chest

(as from a car wreck or gun or knife wound) causes the lung to collapse.

2- tension pneumothorax: can be fatal. It occurs when pressure inside the pleural cavity is greater than the outside atmospheric pressure. It can force the entire lung to collapse and can push the heart toward the lung, putting pressure on both.

3- primary spontaneous pneumothorax. This happens when a small air bubble on the lung ruptures. These may happen for no obvious reason or while undergoing changes in air pressure (like when scuba diving or mountain climbing).

4- secondary spontaneous pneumothorax. This typically happens to those who already have lung disease.

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Symptoms

A sudden attack of chest pain is typically the first symptom. Other symptoms may include: steady ache in the chest shortness of breath (dyspnea) breaking out in a cold sweat tightness in the chest turning blue (cyanosis) severe tachycardia (fast heart rate)

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Diagnosis:

Imaging tests commonly used to diagnose pneumothorax include:

upright poster anterior (PA) chest radiograph computed tomography (CT) lung sonography thoracic ultrasound

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Treatment:

Nonsurgical treatments include: bed rest oxygen supplementation needle aspiration chest tube insertion

There are several types of surgery for pneumothorax. They include: thoracotomy—an incision into the pleural space simple thoracoscopy—insertion of a small scope through the

chest wall lobectomy—removal of part of the lung

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SIMPLE PNEUMOTHORAX

• Does not result in major changes in the patient’s physiology

• Can often worsen, deteriorate into tension pneumothorax, or develop complications

Classic signs of simple pneumothorax Trachea ┴ Expansion ↓ Percussion Note ↑ Breath sounds ↓

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OPEN PNEUMOTHORAX

• Also known as communicating pneumothorax or sucking chest wound)

• Usually involves a traumatic chest wound.

• Air enters the pleural cavity from the atmosphere.

• The lung collapses due to equilibration of pressure within the pleural cavity with atmospheric pressure.

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Diagnosis:

Diagnosis should be made clinically during the primary survey. A wound in the chest wall is identified that appears to be 'sucking air' into the chest and may be visibly bubbling - this is diagnostic.

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Classic signs of open pneumothorax

(+ sucking chest wound)

Trachea ┴ Expansion ↓ Percussion Note ↑ Breath sounds↓

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TENSION PNEUMOTHORAX

• A condition in which there is a one-way movement of air into but not out of the pleural cavity.

• May involve a hole or wound to the pleural cavity that allows air to enter and the lung to collapse. Upon expiration, the hole or opening closes, which prevents the movement of air back out of the pleural cavity.

• A life-threatening condition because pressure in the pleural cavity continues to increase and may result in further lung compression or compression of large blood vessels in the thorax or the heart

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Classic signs of tension pneumothorax

Trachea → Expansion ↓ Percussion Note ↑ Breath sounds ↓ Neck veins ↑

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Signs/symptoms:

dyspnea, tachypnea, tachycardia anxiety/restlessness cyanosis pallor/diaphoresis( signs of shock) hypotension diminished/absent heart sounds on affected side bulging intercostal muscles on the affected side Jugular vein distension Asymmetrical chest wall movement Tracheal deviation away from the affected side

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Emergency care for a tension Pneumothorax:

ensure a patent airway provide 100% supplemental oxygen perform a needle thoracentesis to evacuate air from the pleural

space Chest drain placement promptly transport the patient to a trauma center

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FLAIL CHEST

• A flail chest occurs when a segment of the thoracic cage is separated from the rest of the chest wall.

• This is usually defined as at least two fractures per rib (producing a free segment), in at least two ribs.

• A segment of the chest wall that is flail is unable to contribute to lung expansion.

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Diagnosis:

A flail chest is identified as paradoxical movement of a segment of the chest wall – i.e. in-drawing on inspiration and moving outwards on expiration. This is often better appreciated by palpation than by inspection.

Chest X-ray

The antero-posterior chest radiograph will identify most significant chest wall injuries, but will not identify all rib fractures.

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Management:

Analgesia Ventilation and intubation Chest tube insertion Rib fracture fixation

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HAEMOTHORAX

Haemothorax is a collection of blood in the pleural space and may be caused by blunt or penetrating trauma.

Diagnosis

Most small-moderate haemothoraces are not detectable by physical examination and will be identified only on Chest X-ray, FAST or CT scan. However, larger and more clinically significant haemothoraces may be identified clinically.

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Management: Chest drain Thoracotomy

Classic signs of haemothorax Trachea ┴ Expansion ↓ Percussion Note ↓ Breath sounds↓

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TRACHEA EXPANSION BREATH SOUNDS

PERCUSSION

Tension pneumothorax

Away Decreased Diminished/absent

Hyper resonant

Simple pneumothorax

Midline Decreased Maybe diminished

Usually normal

Haemothorax Midline Decreased Diminished if large/ normal if small

Dull

Open Pneumothorax

Midline Decreased Decreased Increased

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