1. Advanced Trauma Life Support Thoracic Trauma

2. Objectives
A-Identify and manage the following immediately life-threatening chest injuries evidenced in the primary survey:
1.Airway obstruction
2.Tension pneumothorax
3.Open pneumothorax (sucking chest wound)
4.Massive hemothorax
5.Flail chest
6.Cardiac tamponade

3. B-Identify and initiate treatment of the following potentially life-threatening injuries assessed during the secondary survey:
1.Pulmonarycontusion
2.Aortic disruption
3.Tracheobronchial disruption
4.Esophageal disruption
5.Traumatic diaphragmatic hernia
6.Myocardial contusion

4. Chest Trauma 1 out of 4 deaths
Thoracic Injuries 85% Require :
Correct hypoxia
Improve circulation
Alleviate ventilatory obstruction

5. Etiology of Hypoxia Hypovolemia tissue hypoxia
Perfusion unventilated lung
Ventilation of unperfused lung
Abnormal pleural airway relationships

6. Primary Survey Life threatening chest trauma Airway Breathing
Circulation

7. Tension Pneumothorax Air enters pleural space without exit
Collapse of affected lung
Impaired ventilation-unaffected lung
Mechanical ventilation with PEEP
Nonsealing
Emphysematous bullae lung injury
Tracheal deviation
Respiratory distress
Unilateral absence of breath sounds
Distended neck veins
Cyanosis - late

8. Treatment
Immediate decompression
Clinical diagnosis not radiologic
Open Pneumothorax Management
Immediate covering of defect
Chest tube
Definitive operation

9. Massive Hemothorax 1500 ml + blood loss
Systemic of pulmonary vessel disruption
Flat vs. distended neck veins
Shock / no breath sounds or percussion dullness

10. Management Rapid volume restoration Chest decompression & X-ray
Auto-transfusion
Operative intervention
Re-expand lung
Oxygen
Judicious fluid management
Selective intubation
Analgesia

11. Classic Findings
Narrowed pulse pressure
Elevated CVP
Muffled heart sounds
Distended neck veins
Management
Patient airway
IV therapy
Pericardiocentesis
Open thoracotomy with repair

12. Secondary Survey In-depth physical exam Upright chest film ABGs ECG
Pulmonary contusion
Aortic disruption
Tracheo-bronchial injury
Myocardial contusion

13. Pulmonary Contusion Most common Selective intubation & ventilation
Maintain adequate oxygenation

14. Major Intrathoracic Vascular Injury
90% fatal at scene
50% mortality each day treatment delayed
Common site: ligamentum arteriosum

15. Widened Mediastinum On X-ray
Management
Direct repair
Resection & graft
Treatment by qualified surgeon

16. Tracheal Injuries Penetrating : ♦STAT surgical ♦repair ♦Associated
Blunt :
♦Subtle
♦History
♦Important

17. Laryngeal Fractures Tracheal Injuries Bronchial Injury
Hoarseness
Subcutaneous emphysema
Palpable fracture creptius
Tracheal Injuries
Partial vs. complete airway obstruction
Endoscopy-diagnostic aid
Bronchial Injury
Frequently missed
Blunt trauma
50% of deaths in 1 hour

18. Management
Airway maintenance
Surgical intervention
Esophageal Trauma
Blunt vs. penetrating
Severe epigastric blow
Pain/shock, injury
Pneumo/hemothorax without fracture

19. Esophageal Trauma Chest tube-particulate matter
Chest tube-bubbles continuously
Mediastinal air/empyema
Gastrografin swallow/esophagoscopy
Management of Surgical Intervention

20. Traumatic Diaphragmatic Hernia
Diagnosed left side
Blunt: large tears
Penetration: small perforation
Misinterpreted X-ray
Contrast radiography

21. Subcutaneous Emphysema
Myocardial Contusion
Blunt trauma
History
ECG changes
Serial enzyme changes
Treatment: observe/monitor
Subcutaneous Emphysema
Airway injury
Pneumothorax
Blast injury

22. Pneumothorax Blunt trauma Ventilation/perfusion defect Hyper-resonance
Decreased breath sounds
Treatment- tube thoracostomy

23. Hemothorax Etiology ♦Lung laceration ♦Vessel laceration Treatment
♦Tube Thoracostomy for continued bleeding

24. Rib Fractures
Pain/splinting
Impaired ventilation
Increased secretions
Atelectasis/pneumonia
Ribs # 1-3
Severe force
Associated injuries
50% mortality

25. Ribs # 5-9
Majority - blunt trauma
Bowing effect
Midshaft fracture
Intrathoracic
Management
Obtain chest X-ray
Avoid
♦Systemic analgesics
♦Constrictive devices

26. Indications for Chest Tube Insertion
1. Pneumothorax
2. Hemothorax
3. Selected cases, suspected severe lung injury
4. Prophylaxis

27. Summary Common in multiple injured patient
Cognitive knowledge to diagnose
Develop skills
ECG monitoring

28. Pitfalls in Thoracic Injuries
Failure to obtain a chest X-ray soon after admission and again within 4-8 hours may result in significant intrathoracic injuries being overlooked
Excessive reliance on chest X-rays may lead to diagnostic errors
Without careful inspection of the chest wall, contusions, flail chest, intrathoracic bleeding, and open or "sucking" chest wounds may be overlooked

29. A fractured sternum can be easily missed unless the sternum is palpated carefully or special X-ray views are obtained
Cardiac arrest may occur suddenly and rapidly if there is any delay in relieving a suspected tension pneumothorax in a hypotensive patient. X-rays are not needed before treatment under such circumstances
Inserting a chest tube while the patient is lying flat increases the chances for injury to the diaphragm

30. If an air leak and pneumothorax space are allowed to persist together, the patient is apt to develop an empyema or bronchopleural fistula
If a patient with multiple injuries which include a flail chest is not given ventilatory assistance with a respirator soon after admission, he is apt to die of respiratory failure
If a diaphragmatic injury is not suspected and looked for in all patients with chest trauma, the diagnosis will probably be missed

31. If it is assumed that bleeding from the chest wound in a hypotensive patient is superficial in origin, the diagnosis and treatment of severe intrathoracic bleeding may be delayed
Repeated attempts to completely aspirate a small hemothorax with a needle or a syringe may cause a pneumothorax or empyema
Use of high ventilatory pressures to inflate the lungs following penetrating chest wounds may result in systemic air emboli

32. Failure to obtain an aortogram when there is superior mediastinal widening following blunt chest trauma may result in an inaccurate diagnosis and an unnecessary thoracotomy
Hypotension following blunt chest trauma is frequently due to intra-abdominal bleeding
Delay in closure or drainage of esophageal injuries result in a high morbidity and mortality; hence, early diagnosis and treatment are vital

33. Any delay in providing adequate ventilatory support greatly increases the risk of irreversible respiratory failure
Excessive administration of crystalloids greatly increases the risk of respiratory failure
Failure to empty the stomach with a tube soon after chest trauma greatly increases the risk of aspiration and severe ileus