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4/18/2011
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Thoracic Trauma
The Dirty DozenThe Dirty Dozen
Beyond the Basics of Thoracic Trauma
Steven “Kelly” Grayson, CCEMT-P
Thoracic Trauma
ObjectivesObjectives
Review the epidemiology of thoracic trauma.Review the pathophysiology of thoracic trauma resulting from blunt and penetrating mechanisms.Discuss and describe clinical syndromes in various types of thoracic trauma.Discuss current treatment and management of the various types of thoracic trauma.
Thoracic Trauma
EpidemiologyEpidemiology
Second leading cause of trauma deaths25% of all trauma deaths45 – 50% of unrestrained drivers have thoracic injuries50% of all trauma patients have associated thoracic injuries2/3 reach the Emergency Department aliveOnly 15% require surgery
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Thoracic Trauma
Anatomy and PhysiologyAnatomy and Physiology
Thoracic Trauma
Anatomy and PhysiologyAnatomy and Physiology
Thoracic Trauma
Anatomy and PhysiologyAnatomy and Physiology
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Thoracic Trauma
Anatomy and PhysiologyAnatomy and Physiology
Thoracic Trauma
The Big SixThe Big SixLife-threatening conditions that must be identified and treated immediately:
Airway obstructionTension pneumothoraxOpen pneumothorax (sucking chest wound)Flail chestMassive hemothoraxCardiac tamponade
Thoracic Trauma
The Dirty DozenThe Dirty Dozen
Lung contusionMyocardial contusionAortic ruptureDiaphragmatic ruptureTracheobronchialruptureEsophageal injury
Airway obstructionTension pneumothoraxOpen pneumothoraxFlail chestMassive hemothoraxCardiac tamponade
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Thoracic Trauma
AssessmentAssessment
Thoracic Trauma
AssessmentAssessmentInspection
BruisingAbrasionsParadoxical motion
PalpationCrepitusDeformityBilateral expansionTactile vocal fremitus
Thoracic Trauma
AssessmentAssessmentAuscultation
Presence/quality of breath soundsHeart tones
PercussionDullness/fullnessHyperresonance
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Thoracic Trauma
Airway ObstructionAirway ObstructionFollow the Airway Continuum
SuctionBLS adjunctsSupraglottic airwaysEndotracheal intubationCricthyoidotomy
Remember, supraglottic airways only manage a supraglottic obstruction!
Thoracic Trauma
ManagementManagement
The Gold Standard of airway management is not a tool, it’s an outcome.The goal is effective oxygenation and ventilation.
Thoracic Trauma
Tension PneumothoraxTension Pneumothorax
Blunt or penetrating traumaHypoventilation
HypoxiaHypercapnea
Cardiovascular compromiseShockCardiovascular collapse
Life-threatening if not treated early
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Thoracic Trauma
Tension PneumothoraxTension Pneumothorax
Thoracic Trauma
Simple Pneumothorax vsTension Pneumothorax
Simple Pneumothorax vsTension Pneumothorax
SimpleDegree of hypoxia directly related to size of lung area affectedResponds well to supplemental oxygenLittle or no hemodynamic compromiseRequires no EMS intervention other than oxygenation
TensionSevere hypoxiaWorsens despite supplemental oxygenPoor ventilatorycomplianceSevere hemodynamic compromiseLife-threatening if not treated immediately
Thoracic Trauma
Likely Assessment FindingsLikely Assessment FindingsSevere respiratory distressRestlessness, anxiety, agitationDecreased or absent breath soundsShockSubcutaneous emphysema
AxillaeNeck
Cardiovascular collapseTachycardiaWeak pulseHypotensionNarrow pulse pressure
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Thoracic Trauma
Unlikely Assessment FindingsUnlikely Assessment Findings
Jugular venous distensionabsent if also hypovolemic
Hyper-resonance to percussion Contralateral tracheal deviation
Late signSubtle finding
Cyanosis (late)
Thoracic Trauma
Progression of Tension Pneumothorax
Progression of Tension Pneumothorax
EarlyUnilaterally decreased breath soundsWorsening dyspnea despite treatment
Middle:Increased respirationsSubcutaneous emphysemaPoor ventilatory compliance
Late:Jugular venous distentionTracheal deviation Acute hypoxiaNarrowing pulse pressureDecompensated shock
Thoracic Trauma
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Thoracic Trauma
PathophysiologyPathophysiology
Air trapped in pleural space from damaged lung or chest wall Pressure collapses ipsilaterallungContralateral mediastinal shiftReduction in cardiac output
Increased intrathoracicpressureVena cava kinks, reducing preload
Thoracic Trauma
ManagementManagement
Maintain airwayConsider ETI
High flow O 2Ventilate PRNNeedle thoracentesis
2nd or 3 rd ICSAngle of LouisNo flutter valve necessaryCatheter length < 2 inches resulted in failure to reach pleural cavity in 65% of cases
Treat shock
Thoracic Trauma
Open PneumothoraxOpen Pneumothorax
Penetrating traumaSucking chest wounds
Air enters pleural space via hole in chest wallHole has to be large to suck air
Impaled objectsAvulsed wounds and open rib fractures due to blunt or crushing trauma.
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Thoracic Trauma
AssessmentAssessment
Opening in the chest wallSucking sound on inhalationTachycardiaTachypneaRespiratory distressSQ emphysemaDecreased lung sounds on affected side
Thoracic Trauma
PathophysiologyPathophysiologyAllows communication between pleural space and atmospherePrevents development of negative intrathoracicpressure
Profound hypoventilationV/Q mismatch
Shuntinghypoxialarge functional dead space
Pressure may build within pleural spaceReturn from Vena cava may be impaired
Results in ipsilateral lung collapse due to ineffect ive ventilation
Thoracic Trauma
ManagementManagement
Occlusive dressingHigh flow O 2
Assisted ventilations PRNBe alert for tension pneumothorax
Burp dressingNeedle decompression
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Thoracic Trauma
ManagementManagement
Thoracic Trauma
Flail ChestFlail Chest
3 or more ribs broken in 2 or more placesFree floating segment of chest wallParadoxical motionPulmonary contusionMortality rate 20-40% due to associated injuries
Thoracic Trauma
Assessment FindingsAssessment Findings
Chest wall contusionRespiratory distressPleuritic chest painSplinting of affected sideCrepitusTachypnea, tachycardiaParadoxical movement (possible)
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Thoracic Trauma
PathophysiologyPathophysiology
Impairment of bellows systemInadequate diaphragmatic movementPain and increased work of breathingIntra-alveolar bleedingHypoventilation:
HypoxiaHypercapnea
Thoracic Trauma
ManagementManagement
Suspect spinal injuriesEstablish airwayHigh flow O 2Assisted ventilations
Treat hypoxiaPromote full lung expansionConsider ETI and PEEP
Mechanical stabilization does not work
Thoracic Trauma
Massive HemothoraxMassive Hemothorax
If due to great vessel or cardiac injury:
50% die immediately25% live 5-10 minutes25% may live > 30 minutes
Blood loss results inHypovolemiaDecreased ventilation of affected lung
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Thoracic Trauma
Assessment FindingsAssessment FindingsTachypnea /dyspneaTachycardiaShock
Directly correlates to amount of blood loss
Pleuritic chest painDecreased lung soundsCollapsed neck veinsDullness on percussionBleeding may be severe enough to mimic tension pneumothorax
Thoracic Trauma
PathophysiologyPathophysiologyAccumulation of blood in pleural space
Each side can hold up to 3000 ml bloodPenetrating or blunt lung injury
Laceration of:Chest wall vesselsintercostal vesselsMyocardium
Massive hemothorax indicates great vessel or cardiac injuryIntercostal artery can bleed 50 cc/minResults in collapse of lung
Thoracic Trauma
ManagementManagement
Establish airwayHigh flow O 2Assisted ventilation PRNNeedle thoracentesis if tension suspectedChest tube or surgery in hospital
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Thoracic Trauma
Cardiac TamponadeCardiac Tamponade
Rapid accumulation of blood in the inelastic pericardiumUsually associated with penetrating traumaRare in blunt traumaOccurs in < 2% of thoracic traumaGSW wounds have higher mortality than stab woundsLower mortality rate if isolated tamponade
Thoracic Trauma
AssessmentAssessment
Beck’s Triad (hallmark sign)HypotensionJugular venous distensionMuffled heart sounds
Narrowing pulse pressurePulsus paradoxus
Radial pulse weakens on inhalation
Pulsus alternansElectrical alternans
Thoracic Trauma
Electrical AlternansElectrical Alternans
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Thoracic Trauma
PathophysiologyPathophysiology
Heart is compressed, resulting in:Impairment of Frank Starling mechanism
Decreased preloadDecreased stroke volume
Myocardial perfusion decreased due topressure effects on walls of heartdecreased diastolic pressures
Ischemic dysfunction may result in injuryRemoval of as little as 20 ml of blood may drastically improve cardiac output
Thoracic Trauma
ManagementManagementSecure airwayHigh flow O 2
PericardiocentesisRarely done by EMS, primarily reserved for cardiac arrestNeedle-guidedEchocardiogram-guidedRemoval of as little as 20 ml blood can improve CO greatly
Thoracic Trauma
Pulmonary ContusionPulmonary Contusion
Blunt trauma to the chest from:
Rapid deceleration forcesHigh energy shock waveshigh velocity projectilesLow velocity projectileMost common injury from blunt thoracic trauma30-75% of blunt traumaMortality 14-20%
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Thoracic Trauma
Assessment FindingsAssessment Findings
Tachypnea or respiratory distressTachycardiaEvidence of blunt chest traumaCough and / or hemoptysisApprehensionCyanosis
Thoracic Trauma
PathophysiologyPathophysiology
Rib fractures in many but not all casesRib fractures less common in children
Alveolar rupture with hemorrhage and edemaincreased capillary membrane permeability
Large vascular shunts developGas exchange disturbancesHypoxemiaHypercapnea
Thoracic Trauma
ManagementManagement
Supportive therapyEarly use of positive pressure ventilation reduces ventilator therapy durationAvoid aggressive crystalloid infusionSevere cases may require ventilator therapyEmergent transport
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Thoracic Trauma
PEEP/CPAPPEEP/CPAP
Thoracic Trauma
Myocardial ContusionMyocardial Contusion
Most common blunt injury to heartUsually due to steering wheelSignificant cause of morbidity and mortality in the blunt trauma patient
Thoracic Trauma
Assessment FindingsAssessment Findings
Cardiac arrhythmias following blunt chest traumaAngina-like pain unresponsive to nitroglycerinPrecordial discomfort independent of respiratory movementPericardial friction rub (late)
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Thoracic Trauma
EKG FindingsEKG Findings
Persistent tachycardiaST elevation, T wave inversionAtrial flutter or fibrillationRBBBPVCsPACs
Thoracic Trauma
ManagementManagement
Establish airwayHigh flow O 2Be cautious with fluid boluses12 Lead ECG if time permitsStandard antiarrhythmic therapy as neededConsider vasopressors for hypotensionEmergent transport
Thoracic Trauma
Aortic DissectionAortic Dissection
15% of all blunt trauma deaths1 of 6 MVC fatalities had aortic rupture
85% die on scene10-15% survive to hospital
1/3 die within 6 hours1/3 die within 24 hours1/3 survive 3 days or longer
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Thoracic Trauma
Assessment FindingsAssessment Findings
Retrosternal or interscapular painPain in lower back or one legRespiratory distressAsymmetrical perfusion
BP difference between armsIpsilateral pulse deficit
Upper extremity hypertension withDecreased femoral pulses, ORAbsent femoral pulses
Dysphagia
Thoracic Trauma
PathophysiologyPathophysiology
Separation of the tunica intima and mediaTears due to high-speed decelerationDescending aorta at the isthmus distal to left subc lavianartery is most common site
Fixation point – ligamentum arteriosumBlood enters tunica media through a small intimal te ar
Forms a false lumen between layersLumen expands and lengthens with each beat
Rupture results in circulatory collapse within seco nds
Thoracic Trauma
ManagementManagement
Establish airwayHigh flow O 2
Vascular access, but…… NS at TKO rate only!… the only fluid you should bolus is diesel!Transport to trauma center with vascular surgery
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Thoracic Trauma
Diaphragmatic HerniationDiaphragmatic Herniation
Thoracic Trauma
Assessment FindingsAssessment Findings
Decreased breath soundsUsually unilateralDullness to percussion
DyspneaScaphoid abdomen (hollow appearance)Suspect with lower rib fracturesBowel sounds resemble a diesel engine
Thoracic Trauma
PathophysiologyPathophysiology
Compression to abdomen resulting in increased intra-abdominal pressure
Abdominal contents rupture through diaphragm into chestBowel obstruction and strangulationRestriction of lung expansionMediastinal shift
90% occur on left side due to protection of right side by liver
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Thoracic Trauma
ManagementManagementEstablish airwayAssist ventilations with high flow O 2
Vascular accessMonitor ECGNasogastric tube if possible
Distal tip in pleural space on CXR is diagnosticAvoid
PASGTrendelenburg
Thoracic Trauma
Tracheobronchial RuptureTracheobronchial Rupture
< 3% of thoracic traumaBlunt or penetrating injuryHigh mortality rate (>30%)Associated with fracture of upper 3 ribs
Thoracic Trauma
Assessment FindingsAssessment FindingsTachypneaDyspneaObvious SQ emphysemaBright red hemoptysisSigns of tension pneumothoraxunresponsive to needle decompression
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Thoracic Trauma
PathophysiologyPathophysiology
Majority (80%) occur at or near carinaRapid movement of air into pleural spaceTension pneumothorax refractory to needle decompressionContinuous flow of air from needle of decompressed chest
Thoracic Trauma
ManagementManagement
Establish airwayAssisted ventilationConsider early ETIIntubate the mainstem bronchus!
Thoracic Trauma
Esophageal InjuryEsophageal InjuryPenetrating injury most frequent cause
Iatrogenic (Boerhaave Syndrome)Rare in blunt traumaCan perforate spontaneously
Violent emesis (Mallory Weiss tear)Carcinoma
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Thoracic Trauma
Assessment FindingsAssessment FindingsPain and local tendernessHoarseness and dysphagiaRespiratory distressResistance of neck on passive motionMediastinal esophageal perforation
Mediastinal emphysemaMediastinitisPneumomediastinumSQ emphysemaSplinting of chest wall
Shock
Thoracic Trauma
ManagementManagementEstablish airway
ETIAvoid supraglottic airways
IV crystalloids titrated to BP 90-100 systolicEmergent transport
Trauma center with surgical capability
Thoracic Trauma
SummarySummary
Thoracic trauma results in significant morbidity and mortality.Rapid recognition and treatment of the Big Six can save lives.Airway management and ventilation are the keys to proper care.
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Thoracic Trauma
Questions?
Thoracic Trauma
www.kellygrayson.com
www.ambulancedriverfiles.com
Thoracic Trauma
ReferencesReferencesInadequate needle thoracostomy rate in the prehospit al setting for presumed pneumothorax: an ultrasound study. Bla ivas M.J Ultrasound Med . 2010 Sep;29(9):1285-9.
Thoracic needle decompression for tension pneumotho rax: clinical correlation with catheter length. Ball CG, et al. Can J Surg . 2010 June; 53(3): 184–188. Needle thoracostomy in the prehospital setting. Ecks tein M, Suyehara D. Prehosp Emerg Care . 1998 Apr-Jun;2(2):132-5.
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