Approach to Thoracoabdominal Trauma Dan O’Donnell IUSOM Dept. of Emergency Medicine Beech Grove A&R 7/10/07

Goals  Review the basic approach to thoracoabdominal trauma  Review the major killers  Discuss prehopsital approach to thoracoabdominal trauma  Dispel some myths about needle decompression

6 Traumatic Causes of Early Death in Thoracic Trauma  Tension Pneumothorax  Cardiac Tamponade  Open Pneumothorax  Hemothorax  Flail Chest  Airway Obstruction

Case 1  Dispatched to scene  22y/o male outside night club  Reports of gun shots - 2 dudes  Respiratory distress  Chest pain

Case Cont  HR 120, BP 120/64, RR 35, Sa02 94% on NRB  Lungs: Decreased Breath Sounds on right side  Rest of exam WNL

What to Do?  Who wants to put there finger in it?  Who wants to put a needle in his chest?  Who wants to make sure that nobody is coming back for this guy?

Penetrating Chest Trauma  Cover open chest wounds with an occlusive dressing  Apply on exhalation  Three sided best  If increased respiratory distress?  Lift one edge of the dressing

When Do We Needle?  If tension pneumothorax suspected  Decreased breath sounds  Tracheal deviation  Loss of vital signs  Not when we suspect pneumothorax

Tension Pneumothorax

Case 2  Called for injured person  32 y/o male walking around at fair  Got too close to the archery exhibit

Treatment of impaled objects  Don’t poke at it  Stabilize impaled objects with Vaseline gauze  ABCs as indicated  Will need to be explored in the OR

Penetrating Chest  Assume cardiac injury (low BP)  Pneumothorax is the rule  Diaphragmatic injury  Associated abdominal injury  Great vessel injury

Case 3  Dispatched to scene  42 y/o male construction worker  Fell off ladder onto his tool box  Respiratory distress  Chest pain

Case Continued  Vitals P 135, BP 110/p, RR 32 88% NRB  ABCs intact, GCS 15  As you watch him breath you notice something funny

Continued  You note asymmetry to chest wall  One piece of his chest actually sucks in while he takes a breath  What's the story

Flail Chest  Free-floating segment of rips that are no longer connected to the rest of the thorax  Caused by fracture in two or more locations of the same rib, usually involving three adjacent ribs

Flail Chest Continued  Often have underlying lung contusion  Require positive pressure ventilation +/- chest tube  Sign of more serious injuries

Treatment  ABCs  O2  Put them on the NRB  Will need adequate pain control  Don’t hesitate on fentanyl  To nearest trauma center  Preferably level 1

Case 4  Called for MVA  22 y/o female with no PMHx was unrestrained driver involved in MVA  Patient remembers hitting steering wheel with chest  C/o Pain with palpation of chest

Case Cont..  P 96, BP 135/90, RR 20, 98% on RA  Equal breath sounds  PE significant for severe pain with palpation of sternum  Questionable bruising

On the monitor

Cardiac Contusion  From blunt trauma to chest  Can cause variety of rhythm disturbances  Sinus tachy (most common)  PVCs  Atrial fib, SVT  Usually monitored  No consensus on treatment

Case 4  Dispatched for MVC  32 year old male restrained driver involved in high speed MVC  Patient complains only of belly pain  PE unremarkable except for

Continued  Patient hurts but wants to SOR  Who is fine with this?  Why not?

“Seatbelt sign”  Abdominal wall ecchymosis  Pain with associated injury  Small bowel injury  Chance fracture of L1,L2 Common  Fx/dislocation of thoracolumbar spine  Hollow viscous injury Rare  Aortic intimal disruption/transection  Iliac wing fx  Avulsion of appendix

Patterns of Injury  Subcostal/Upper abdomen  LiverSmall Bowel  SpleenDiaphragm  KidneysVascular  Lower abdomen  VascularPelvic Bones  BladderL spine

Case 4  Dispatched to scene  24 y/o female  Driver of stopped car rear-ended at 20 mph  No complaints  34 weeks pregnant  Desires SOR

Trauma in Pregnancy  High risk in even minor trauma for complications  Placental abruption  Placental fracture  All pregnant patients with trauma should be transported  <20wks will be evaluated  Not much to do  >20wks will be monitored by OB for at least 4 hours

Take it Home  Remember the causes of sudden decompensation in thoracic trauma  Occlusive dressings for penetrating chest wounds  Not every decreased breath sound needs a needle

Summary Cont…  Don’t poke at the thing sticking out of the chest  Be aware of cardiac contusions  Beware the seatbelt sign  Pregnant trauma patients are scary