Thoracic Trauma Chapter 4

Objectives Identify and treat life-threatening injuries found during the primary survey Identify and treat injuries found during the secondary survey This lecture focuses on the ABCDE approach to the initial assessment and management process of identifying and treating patients who sustain thoracic trauma.

Thoracic Trauma Significant cause of mortality Blunt: <10% require operation Penetrating: 15-30% require operation Majority: require simple procedures Most life-threatening injuries identified in primary survey Chest injuries remain a significant cause of morbidity and mortality among trauma patients.

Key Questions What life-threatening chest injuries should I recognize as causing major patho- physiologic events? What are the significant pathophysiologic effects of chest injury that I should identify in the primary survey? When and how do I correct the problem identified in the primary survey? It is important to think in terms of ABCDE.

Life-threatening injuries? Airway obstruction Tension pneumothorax Open pneumothorax Flail chest Massive hemothorax Cardiac tamponade These life-threatening injuries are treated as they are identified.

Major pathophysiologic events? Hypoxia Hypoventilation Acidosis Respiratory Metabolic Inadequate tissue perfusion Treatment is directed at these events. These are the important pathophysiologic events.

When do I correct the problem? When the problem is identified in the Primary Survey The problem should be corrected when the problem is identified in the Primary Survey.

Life-threatening chest injuries? What life-threatening injuries might occur in the event below? 28 year-old male involved in high speed car wreck Prolonged extrication from driver’s seat Significant deformation to car and steering column This scenario is used to stimulate the in-depth discussions of the various life-threatening chest injuries.

Life-threatening injuries Airway obstruction Tension pneumothorax Open pneumothorax Flail chest Massive hemothorax Cardiac tamponade The patient in the previous scenario could have sustained any one or various combinaitons of these life-threatening injuries.

Laryngeal Injury Causing airway obstruction Rare Hoarseness Subcutaneous emphysema Treatment: intubate cautiously, tracheostomy Treatment is establishing a definitive airway.

Tension Pneumothorax Respiratory distress Distended neck veins Unilateral decrease in breath sounds Hyperresonance Cyanosis (late) Blunt injury is a more likely cause of tension pneumothroax. Cardiac tamponade occurs more often with penetrating trauma.

Tension pneumothorax Immediate decompression Clinical diagnosis, not by X-ray A tension pneumothorax must be immediately decompressed by inserting a needle, followed by insertion of a chest tube.

Open pneumothorax 3-sided cover over defect Chest tube Definitive operation The photo illustrates a chest tube.

Flail chest/pulmonary contusion Reexpand lung Oxygen Judicious fluids Intubate as indicated Analgesia The flail segment serves as a marker for pulmonary contusion. The treatment goal is to reexpand the lung, and avoid progressive atelectasis.

Massive hemothorax Systemic/pulmonary vessel disruption >1500 mL blood loss Flat vs distended neck veins Shock with no breath sounds and/or percussion dullness Treatment: Restore volume Chest decompression X-ray Operation This injury results in a circulation problem.

Cardiac Tamponade Most survivors of cardiac tamponade have an anterior or posterior penetrating wound to the chest Decrease arterial pressure Distended neck veins Muffled heart sounds PEA Cardiac tamponade is suspected if the patient has a penetrating peristernal wound, is hypotensive and dyspneic, and may even verbalize that he/she senses she/she is dying.

Cardiac Tamponade Treatment: Surgery Airway Breathing: ventilate/Oxygen Pericardiocentesis/FAST Surgery Thoracoctomy Not on PEA Pericardiocentesis is performed to confirm the diagnosis.

Key Questions What potentially lethal chest injuries should I recognize as causing patho-physiologic events? What are the pathophysiologic effects of chest injury that I should identify in the secondary survey? When and how do I correct the problem identified in the secondary survey? It is important to think in terms of ABCDE.

Potentially lethal chest injuries Simple pneumothorax Hemothorax Tracheobronchial tree injury Blunt cardiac injury Traumatic aortic disruption Mediastinal traversing wound These are injuries addressed during secondary survey.

Pathophysiologic events? Hypoxia Hypoventilation Acidosis Respiratory Metabolic Inadequate tissue perfusion Treatment is directed at these events in the secondary survey. These are the important pathophysiologic events.

Pneumothorax Penetrating/blunt trauma Ventilation/perfusion Hyperresonance Decreased breath sounds Treatment: Chest tube Obtaining a chest X-ray as part of the initial assessment process can help identify this injury.

Hemothorax Chest wall injury Lung/vessel laceration Treatment: Chest tube Hemothorax is suspected by hypotension without obvious sources of blood loss or by decreased breath sounds and dullness to percussion over a hemithorax.

Pulmonary Contusion Common Treatment: Oxygenate and ventilate Selective intubation Late X-ray change A pulmonary contusion can be mild to severe and may cause very little hypoxia to severe hypoxia.

Tracheobronchial Injury Often missed Blunt or penetrating Persistent pneumothorax Treatment: Bronchoscopy Airway/Ventilation Chest tube Operation Strong suspicion of a tracheobronchial injury is raised if the lung does not properly inflate after insertion of a chest tube, or there is a persistent air leak after tube thoracocstomy.

Blunt Cardiac Injury Injury spectrum Abnormal ECG Treatment: Echocardiography Treat dysrhythmias Perfusion Complications Blunt cardiac injury is rare. Patient usually presents with an abnormal ECG within the first 24 hours from injury.

Traumatic Aortic Disruption Rapid acceleration/ deceleration mechanism High index of suspicion Rapid surgical consult A patient involved in a rapid acceleration or deceleration situation is at risk for an aortic injury. The Xiray may show a widened mediastinum.

Diaphragmatic Rupture Most diagnosed on left Blunt: large tears Penetrating: small perforations Misinterpreted X-ray Contrast radiography Operation An elevated diaphragm on the chest X-ray should raise suspicion for a ruptured diaphragm.

Mediastinal Traversing Wound Hemodynamically abnormal Multiple mediastinal injuries Bilateral chest tubes Emergent surgical consult Hemodynamically normal Diagnostic studies Surgical consult Penetrating wounds traversing the mediastinum present unique challenges to the doctor caring for the patient with this type of injury.

Subcutaneous Emphysema Airway injury Pneumothorax Blast injury Latrogenic Such an appearance usually indicates an airway injury.

Traumatic Asphyxia Acute, temporary compression of the superior vena cava Brain edema Petechiae Traumatic asphyxia occurs when a powerful compressive force is applied to the thoracic cavity. This is most often seen in motor vehicle accidents, as well as industrial and farming accidents. However, it can present anytime a significant pressure is applied to the thorax. The sudden impact on the thorax causes an increase in intrathoracic pressure. In order for traumatic asphyxia to occur, a Valsalva maneuver is required when the traumatic force is applied. Exhalation against the closed glottis along with the traumatic event causes air that cannot escape from the thoracic cavity. Instead, the air causes increased venous back-pressure, which is transferred back to through the right atrium, to the superior vena cava and to the head and neck veins and capillaries. Traumatic asphyxia is characterized by cyanosis in the upper extremities, neck, and head as well as petechiae in the conjunctiva. Patients can also display jugular venous distention and facial edema. Associated injuries include pulmonary contusion, myocardial contusion, hemo/pneumothorax, and broken ribs.

Fracture Pathophysiology Sternum, scapular, and rib Pain Associated injuries Complications Atelectasis Pneumonia Patient tends to breath shallow due to pain Need adequate pain relief.

Associated Injuries Ribs 1-3 = severe force Ribs 4-9 = pulmonary contusion and pneumothorax The location of the fracture can provide clues about other possible injuries. Ribs 10-12 = suspect abdominal injury

Esophageal injury Blunt/penetrating Severe blow Pain/shock out of proportion of injury Signs: Chest tube discharging particulate matter Mediastinal air Treatment: Contrast swallow Operative intervention Esophageal injury is more common with penetrating injuries.

Pitfalls? Application of an occlusive dressing over a wound associated with a simple pneumothorax can produce a tension pneumothorax Chest tube placement is important to clear pleural space and reduce iatrogenic injury Adequate pain relief Extremes of age These are pitfalls to avoid.

Summary Common in multiple injured Life-threatening injuries Potentially lethal injuries Initial stabilzation by simple techniques in the majority of cases Goal: restore normal gas exchange and perfusion This is the summary.

Questions?