Approach to Chest TraumaApproach to Chest Trauma
Mary OsingaMary Osinga
Comprehensive ReviewComprehensive Review
Fleming CollegeFleming College
Traumatic InjuriesTraumatic Injuries
Airway injuriesAirway injuries Chest and BreathingChest and Breathing Circulation – shockCirculation – shock Disability – neurologicalDisability – neurological E- expose and extremityE- expose and extremity
Airway ProblemsAirway Problems
Problem in trauma is that the Problem in trauma is that the airway may not look or behave as airway may not look or behave as normalnormal
Forces onto the head and/or neck Forces onto the head and/or neck may provide significant changes to may provide significant changes to the anatomy of the airwaythe anatomy of the airway
Lets review normal airway Lets review normal airway anatomyanatomy
Abnormal AirwayAbnormal Airway
EdemaEdema Presence of fluidPresence of fluid Loss of bony Loss of bony
structure integritystructure integrity Foreign objectsForeign objects
Airway managementAirway management
Use a modified jaw thrust to avoid C Use a modified jaw thrust to avoid C spine displacementspine displacement
Watch for nasal airway insertion in Watch for nasal airway insertion in patients with….?patients with….?
Oral airways in patients GCS<8Oral airways in patients GCS<8 Suction blood and secretions, Suction blood and secretions,
remember patients supine on boardremember patients supine on board Watch for vomiting –beer and pizzaWatch for vomiting –beer and pizza
IntroductionIntroduction
Chest trauma is often sudden and Chest trauma is often sudden and dramaticdramatic
Accounts for 25% of all trauma deathsAccounts for 25% of all trauma deaths 2/3 of deaths occur after reaching 2/3 of deaths occur after reaching
hospitalhospital Serious pathological consequences:Serious pathological consequences:
-hypoxia, hypovolemia, myocardial-hypoxia, hypovolemia, myocardial failure failure
Mechanism of InjuryMechanism of Injury
Penetrating injuriesPenetrating injuries E.g. stab wounds etc.E.g. stab wounds etc. Primarily peripheral lungPrimarily peripheral lung HaemothoraxHaemothorax PneumothoraxPneumothorax Cardiac, great vessel or Cardiac, great vessel or
oesophageal injuryoesophageal injury
Either:Either: - direct blow (e.g. - direct blow (e.g. rib fracture)rib fracture) - deceleration injury - deceleration injury oror - compression - compression injuryinjury
Rib fracture is the most common sign Rib fracture is the most common sign of blunt thoracic traumaof blunt thoracic trauma
Fracture of scapula, sternum, or first Fracture of scapula, sternum, or first rib suggests massive force of injuryrib suggests massive force of injury
Blunt injuriesBlunt injuries
Deadly Dozen from ITLSDeadly Dozen from ITLS
Airway obstructionAirway obstruction Open PneumoOpen Pneumo Flail ChestFlail Chest Tension PneumoTension Pneumo Massive HemothoraxMassive Hemothorax Cardiac TamponadeCardiac Tamponade
Detected in the primary survey
Deadly Dozen from ITLSDeadly Dozen from ITLS
Myocardial contusionMyocardial contusion Traumatic aortic ruptureTraumatic aortic rupture Tracheal bronchial tearTracheal bronchial tear Diagphragmatic injuryDiagphragmatic injury Esophageal injuryEsophageal injury Pulmonary contusionPulmonary contusion
Detected in the secondary survey
Chest wall injuries Chest wall injuries
Rib fractures Rib fractures
Flail chestFlail chest
Open pneumothoraxOpen pneumothorax
Rib fracturesRib fractures
Most common thoracic injuryMost common thoracic injury Localised pain, tenderness, crepitusLocalised pain, tenderness, crepitus CXR to exclude other injuriesCXR to exclude other injuries Analgesia..avoid tapingAnalgesia..avoid taping Underestimation of effectUnderestimation of effect Upper ribs, clavicle or scapula Upper ribs, clavicle or scapula
fracture: suspect vascular injuryfracture: suspect vascular injury
Flail chestFlail chest
Multiple rib fractures produce a Multiple rib fractures produce a mobile fragment which moves mobile fragment which moves paradoxically with respirationparadoxically with respiration
2 or more ribs in 2 or more places2 or more ribs in 2 or more places Significant force requiredSignificant force required Palpate carefully and laterallyPalpate carefully and laterally Rx: ABCRx: ABC s and analgesias and analgesia +/- splint the flail segment+/- splint the flail segment
Lung injuryLung injury
Pulmonary contusionPulmonary contusion Pneumothorax Pneumothorax HaemothoraxHaemothorax Parenchymal injuryParenchymal injury Trachea and bronchial injuriesTrachea and bronchial injuries PneumomediastinumPneumomediastinum
Open pneumothoraxOpen pneumothorax Defect in chest wall provides a direct Defect in chest wall provides a direct
communication between the pleural communication between the pleural space and the environmentspace and the environment
Lung collapse and paroxysmal shifting Lung collapse and paroxysmal shifting of mediastinum with each respiratory of mediastinum with each respiratory effort ± tension pneumothoraxeffort ± tension pneumothorax
““Sucking chest wound”Sucking chest wound” Rx: ABCs…closure of wound…chest Rx: ABCs…closure of wound…chest
drain drain
PneumothoraxPneumothorax
Air in the pleural cavityAir in the pleural cavity Blunt or penetrating injury that Blunt or penetrating injury that
disrupts the parietal or visceral pleuradisrupts the parietal or visceral pleura Unilateral signs: Unilateral signs: movement and movement and
breath sounds, resonant to percussionbreath sounds, resonant to percussion Confirmed by CXRConfirmed by CXR Rx: chest drainRx: chest drain
Tension pneumothorax Tension pneumothorax
Air enters pleural space and cannot Air enters pleural space and cannot escapeescape
P/C: chest pain, dyspnoeaP/C: chest pain, dyspnoea Dx: - respiratory distress Dx: - respiratory distress
- tracheal deviation (away) - tracheal deviation (away) - absence of breath - absence of breath
soundssounds - distended neck - distended neck veinsveins - hypotension - hypotension
Surgical emergencySurgical emergency
Needle decompression required-ACPNeedle decompression required-ACP
In hospital-Either large bore cannula In hospital-Either large bore cannula
in 2nd ICS, MCL or insert chest tubein 2nd ICS, MCL or insert chest tube
Reassess post needleReassess post needle
HemothoraxHemothorax
Blunt or penetrating traumaBlunt or penetrating trauma Requires rapid decompression and Requires rapid decompression and
fluid resuscitationfluid resuscitation May require surgical interventionMay require surgical intervention Clinically: hypovolemiaClinically: hypovolemia
absence of breath sounds absence of breath sounds dullness to percussion dullness to percussion
Can lose entire blood volume in chestCan lose entire blood volume in chest
Some problems with Some problems with HemothoraxHemothorax
Significant blood loss-how much?Significant blood loss-how much? AtelactasisAtelactasis V/Q MismatchV/Q Mismatch So what problems can your So what problems can your
patients have?patients have?
Heart, Aorta & DiaphragmHeart, Aorta & Diaphragm
Blunt cardiac injuryBlunt cardiac injury- contusion- contusion- ventricular, septal or valvular - ventricular, septal or valvular
rupture rupture Cardiac tamponade Cardiac tamponade Ruptured thoracic aortaRuptured thoracic aorta Diaphragmatic ruptureDiaphragmatic rupture
Cardiac TamponadeCardiac Tamponade Blood in the pericardial sac Blood in the pericardial sac Most frequently penetrating injuriesMost frequently penetrating injuries Shock, Shock, JVP, PEA, pulsus paradoxusJVP, PEA, pulsus paradoxus Classically, Beck’s triad:Classically, Beck’s triad:
- distended neck veins- distended neck veins- muffled heart sounds- muffled heart sounds
- hypotension- hypotension Rx: Volume resuscitationRx: Volume resuscitation
Pericardiocentesis Pericardiocentesis
Aortic ruptureAortic rupture
Usually blunt trauma involving Usually blunt trauma involving deceleration forces; deceleration forces;
~90% die within minutes~90% die within minutes Most common site near ligamentum Most common site near ligamentum
arteriosumarteriosum Treat like an aneurysm if still alive, Treat like an aneurysm if still alive,
blunt trauma VSA if dead (?pronounce)blunt trauma VSA if dead (?pronounce) Rx: surgical…poor prognosisRx: surgical…poor prognosis
Ruptured Hemi diaphragmRuptured Hemi diaphragm
Etiology? Etiology? Side??Side?? OutcomeOutcome Diagnosis- how can you tell??Diagnosis- how can you tell?? Treatment?Treatment?
Chest trauma: summaryChest trauma: summary CommonCommon SeriousSerious Primary goal is to provide oxygen Primary goal is to provide oxygen
to vital organsto vital organs RememberRemember
AAirwayirwayBBreathingreathing
CCirculationirculation Be alert to change in clinical Be alert to change in clinical
condition condition
Chest TraumaChest Trauma Identify earlyIdentify early Rapid transportRapid transport Auscultate frequentlyAuscultate frequently Consider tertiary care centreConsider tertiary care centre Watch for shock and treat Watch for shock and treat
– IV fluids (bolus is…?)IV fluids (bolus is…?)– Large bore IV’sLarge bore IV’s– TrendelenbergTrendelenberg
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