2 CHEST TRAUMA Second leading cause of trauma death 20 % of all trauma deaths50% of trauma patients presenting to ER in respiratory distress will dieIf in respiratory distress and shock 75% will dieSecond to brain and spinal cord injuries
4 INITIAL SURVEY Examine chest immediately after ABC’s History Inspect: open wounds, tenderness, subcutaneous emphysema, unequal chest expansionAuscultation: decreased breath soundsPalpation: painRespiratory rateHistoryFrom patients and witnessesSeat belts, steering wheel, speed, nature of collision, what fell on patient, how long was patient crushedIf a life threatening injury is discovered during this examination treat it before going on.Initial survey is directed towards open pneumo, flail chest, tension pneumo, massive hemo, cadiac tamponadeFollowing any intervention, reexamine the chest to determine the effects of treatmentIf in doubt about whether to intubate… intubateSevere internal injury may be present with external tendernessChest injuries are often associated with other injuries so a high index of suspicion should be maintained
6 BLUNT vs PENETRATING Blunt: common in all trauma patients Injuries are principally a function of the magnitude of force and the location/direction over which it is appliedGet a good historySupport patient while injuries healPenetrating: Consider with suspicious chest wound and if patient remains hypotensive in spite of fluid therapyKnife: Length of the instrument, velocity, angle of entryFirearms: Type of gun, Range,Limited range of problemsHemothorax, pneumothorax, hemopericardiumBlunt most common 70% of chest traumaget a good history – point to diagnostic alternativesIsolated blunt thoracic injury is uncommon. Head, extremity, and abdominal injuries frequently occur concurrentlyPenetrating: are frequently associated with abdominal trauma because of the anatomical proximity of the chest and abdomen.Knife: Tissue injury is related to the length of the instrument, the velocity at which the force was applied, and the angel of entry. Although the puncture site may apparently follow a straight path, this is not always true. Tissues may be disrupted and pushed aside by the penetrating instrument, thus causing damage to adjacent structures.Gun:Tissue damage inflicted by bullets is related to their velocity, shape, construction, and mass. The range, or distance between the barrel of the weapon and the victim, affects the velocity at which the bullet strikes the body tissues.
8 RIB FRACTURE Most common chest injury Present in 10% of all traumatic injuriesMore common in adults than childernEspecially common in elderlyPatients with 1 or 2 rib fractures had a 5% mortality rate and patients with 7 or more fractures have a 29% mortality rateRibs form ringsConsider possibility of break in two placesThe injured arrea of lung underlying the fib fracture is usually of more clinical significance than the fracture.
9 RIB FRACTURE Fractures of the 1st and 2nd ribs require high force Frequently have injury to aorta or bronchi30% will dieMost commonly th to 9th ribsPoor protection
10 RIB FRACTUREFractures of the 8th to 12th ribs can damage underlying abdominal solid organsLiverSpleenKidneys
11 RIB FRACTURE Signs and Symptoms Dyspnea Localized pain, tenderness Increases when patient:CoughsMovesBreathes deeplyChest wall instabilityDeformity, bony crepitus, ecchymosisAssociated pneumo or hemothorax
12 RIB FRACTURE Management High concentration oxygen Splint using pillow, swathesEncourage patient to deep breathMonitor elderly and COPD patients carefullyBroken ribs can cause decompensationPatients not breathing deeply will result in poor clearance of secretions
14 FLAIL CHEST Two or more adjacent ribs broken in two or more places Produces free-floating chest wall segmentChest wall becomes unstableUsually 2nd to blunt traumaMore common in older patientsThe incidence of flail segments is 10-15% in patients with major chest trauma
15 FLAIL CHEST Signs and Symptoms Paradoxical movement Dyspnea Hypoxia May NOT be present initially due to intercostal muscle spasms that splint the segmentBe suspicious in any patient with chest wall:TendernessCrepitus of broken ribsDyspneaHypoxiaUsually not present unless underlying lung injury
16 FLAIL CHEST Ramification Pain, leading to decreased ventilation Increased work of breathingInefficient respirationsLung contusion
17 FLAIL CHEST Management Establish airway Suspect spinal injuries Assist ventilation with BVM and oxygenIntubate large (>4-6 inches) flail segment and for underlying acute or chronic lung diseaseStabilize chest wallTowel rolls, tape or sand bagsPain reliefNarcotics, thoracic epiduralsMechanical ventilation reserved for patients who do not respond to conservative therapy.
21 PULMONARY CONTUSION Bruising of the lung Injuries often involve high velocity rather than slow crushingUsually associated with rib fractures/ flail chest % of patients with rib fractures present with pulmonary contusionsAlways associated with hypoxiaIf tension pneumothorax has been ruled out then pulmonary contusion is the most likely cause of respiratory impairment
22 PULMONARY CONTUSION Signs and Symptoms Chest pain Rales Dyspnea TachypneaIneffective coughHemoptysisChest wall contusionsX-ray will show opacityABG will worsen in time due to edema
23 PULMONARY CONTUSION Management Oxygen Continual reassessment/ ObservationOxygenation and ventilation usually deteriorate over first 4 hoursBe aggressive if patient has respiratory distress, severe abdominal injury or COPD.Intubate while lung recovers
25 PNEUMOTHORAX Air in pleural space Interfers with expansion of lungPartial or complete lung collapse occursRespiratory distress is usually not seen until the pneumo exceeds 40% of lung volume or pre-existing lung diseasePatients with pulmonary disease tolerate pneumothoraces poorly
26 PNEUMOTHORAX Causes Blunt trauma to the chest Fractured rib lacerating lungPaper bag effectSpontaneouslyExertionCoughingAir travelPositive pressure ventilation
27 PNEUMOTHORAX Signs and Symptoms Pain on inhalation Difficulty breathingTachypneaDecreased or absent breath soundsHyperresonance on percussionPleuritic pain
28 PNEUMOTHORAX Management Establish airway Suspect spinal injury based on mechanismHigh concentration oxygen with NRBAssist decreased or rapid respirations with BVMChest tube if > 20%Monitor for tension pnemonthorax
30 OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) Unusual motion during respirationRetraction, shaking, burpingHole in chest wallAllows air to enter pleural space with inspirationSmall wound can form a one way valveLarger wound, greater chance air will enter here than through the tracheaOpen wound allows air to be sucked into the chest with inspiration, if large enough it may interfere with air motion in the lungs by decreasing the amount of negative pressure that can be generated during inspiration. Small wounds can form one-way valves, leading to tension pneumothorax.
31 OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) ManagementCover with occlusive dressingVaseline gauze covered by 4x4’sTape dressing on three sidesHigh concentration oxygenAssist ventilationsConsider transport on injured sideMonitor for tension pneumothoraxForm one way valveChest tubePlaced at 2nd siteTape on 3 sides so it can act as a one-way valve allowing air to exit with expiration but prevent sucking in during inspiration. If tension pneumo develops remove drsgingChest tube in 2nd location due to contamination of wound
33 TENSION PNEUMOTHORAX One-way valve forms in lung or chest wall Air enters pleural space; cannot leaveAir is trapped in the pleural spacePressure risesPressure collapses lungMediastinal shift
34 TENSION PNEUMOTHORAXTrapped air pushes heart and lungs away from injured sideVena cava becomes kinkedBlood cannot return to heartCardiac output fallsShock developsCompresses the heart, great vessels, trachea, and the uninjuried lungVenous blood return to the heart slows and shock develops
36 TENSION PNEUMOTHORAX Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitationDecreased breath sounds, unilateral absence of breath soundsHyperresonance to percussionCyanosis- lateSubcutaneous emphysema
37 TENSION PNEUMOTHORAX Signs and Symptoms Rapid, weak pulse Hypotension Tracheal shift away from injured sideJugular vein distensionRespiratory distressShock
38 TENSION PNEUMOTHORAX Management Secure airway High concentration oxygenConsider ALS for pleural decompressionSeverely compromised patient; insert a 12 g cannula into the 2nd intercostal space, mid clavicular line
40 HEMOTHORAX Most common result of major chest wall trauma The incidence of hemopneumothoraces in patients with rib fractures is 30%.Blood in pleura spaceMassive hemothorax due to bleeding from the major central chest vessels but occasionally an intercostal artery can bleed enough to cause a large amount of bloodPresent in % of penetrating, major non-penetrating chest traumaThere are usually nine pairs of aortic intercostal arteries. They arise from the back of the aorta, and a redistributed to the lower nine intercostal spaces, the first two spaces being supplied by the highest intercostal artery, a branch of the costocervical trunk of the subclavian
45 TRAUMATIC ASPHYXIA Blunt force to chest causes Increased intrathoracic pressureBackward flow of blood out of the heart into vessels of upper chest, neck, headName given because patients look like they have been strangled or hangedsudden increase in venous pressure occurring as a result of sudden or severe compression of the thorax or upper abdomen, or both.
46 TRAUMATIC ASPHYXIA Signs and Symptoms Possible sternal fracture or central flail chestShockPurplish-red discoloration of head, neck, shouldersSub-conjunctival haemorrhage (Blood shot) protruding eyesSwollen, cyanotic lips
47 TRAUMATIC ASPHYXIA Management Airway with C-spine percautions Assist ventilations with high concentration oxygenSpinal stabilizationRapid transport
49 TRAUMATIC AIR EMBOLISM Suspect in penetrating chest wounds where there is sudden deterioration in cardiac output after intubationImmediately life-threateningNeurological signs in the absence of a head injuryHemoptysisPatients with penetrating chest trauma are at high risk of traumatic air embolism and positive pressure ventilation of the affected lung will cause rapid death if the condition is not immediately recognized. Early aggressive treatment is therefore necessary for survival.
50 TRAUMATIC AIR EMBOLISM Management100% O2minimise ventilation volumes and pressuresemergency thoracotomy to clamp ascending aorta, remove air source (by clamping pulmonary hilum) and aspirate air from LV and ascending
51 TRACHEOBRONCHIAL TREE RUPTURE Relatively rareSigns and symptomsDyspnea, TachypneaHemoptysisSubcutaneous emphysema in the neck, face, or suprasternal areaDecreased or absent breath soundsPersistant pneumothoraxPotential airway obstructionManagementControl of ventilation (ETT distal to the level of injury)Bilateral needle decompression may be neededTwo chest tubes inserted on injured sideBronchoscopy / surgeryBlunt ruptures or tears of the lower trachea or mainstem bronchus may be caused by such mechanisms of injury as striking the dash board or steering wheel, karate-type blows, or “clothesline-type” injuriesTears or lacerations in the tracheobronchial tree interrupt the integrity of the lower airway because air dissects through the tear into the pleural space or the mediastinum. Patients with these injuries manifest dramatic symptoms early during resuscitaiton with massive air leaks into the subcutaneous tissue.
53 CARDIOVASCULAR TRAUMA Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwiseAll patients in shock with penetrating wound of chest have cardiac injury until proven otherwise. (Abdominal stab or gunshot wound may also reach the heart)
54 MYOCARDIAL CONTUSION Bruise of the heart muscle Most common cardiac injuryUsually due to steering wheel impact
55 MYOCARDIAL CONTUSION Behaves like an acute myocardial infarction May produce arrhythmiasMay cause cardiogenic shock, hypotension
56 MYOCARDIAL CONTUSION Signs and symptoms Cardiac arrhythmias after blunt chest traumaAngina-like pain unresponsive to nitroglycerinChest pain independent of respiratory movemenChest wall ecchymosistTachycardia out of proportion to other injuriesFriction rub may be presentECG may be normal or ST elevationCardiac enzymes may be normalThe sound that a pleural friction rub makes is a leather-on-leather type of sound. These sounds can be heard at the same points in the inhalatory and the exhalatory cyclesPleural Friction Rubs are created when the visceral and parietal pleurae become inflammed and roughened. The inflammed membranes will stick together
57 MYOCARDIAL CONTUSION Management High concentration oxygen ECG TransportConsider ALS interceptHospitalized for cardiac monitoring and serial enzymes
59 CARDIAC TAMPONADERapid accumulation of blood in space between heart and pericardiumHeart is compressedBlood entering heart decreasesCardiac output fallsObstructive shock can occur
60 CARDIAC TAMPONADE Signs and symptoms Classic Triad Hypotension unresponsive to treatmentIncreased central venous pressure (distended neck/arm veins in presence of decreased arterial blood pressure)Decreased/muffled heart soundsLess than ½ the patients present this wayNeck veins may not be distended if hypovolemicMuffled heart sounds often not present
61 CARDIAC TAMPONADE Dyspnea Narrowing pulse pressure Pulsus paradoxicus Radial pulse becomes weak or disappears when patient inhalesDrops >10 mm in SBP
62 CARDIAC TAMPONADE Management Secure airway High concentration oxygen Rapid fluid administrationRapid transportPericardiocentesis with removal of 5 to 10 mLLeave catheter in place until the cardiac wound can be repairedSurgery
64 TRAUMATIC AORTIC ANEURYSM 90% die within minutes. Those who arrive to the hospital alive 90% will dieLittle external evidence of serious chest traumaCaused by sudden decelerations, massive blunt force:Vehicle collisions, Falls from heights, crushing chest trauma, blunt chest trauma, Animal kicksThe mechanism of injury is associated with a combination of shearing forces, compression of the aorta on the vertebral column, and an increase in pressure inside the vessel during the episode of the trauma
65 TRAUMATIC AORTIC ANEURYSM Rupture usually occurs just beyond left subclavian, near the ligamentum arteriosumAttachment of aorta to pulmonary artery at this point produces shearing force on aortic arch
66 TRAUMATIC AORTIC ANEURYSM Signs and SymptomsIncreased BP in arms in absence of head injuryDecreased femoral pulses with full arm pulsesRespiratory distressNew murmurMore likely in patients with 1st or 2nd rib fractureAche in chest, shoulders (interscapular), back, abdomenOnly 25 % of the patientsX-ray shows a widened upper mediastinum, blurring of aortic knob, deviation of trachea to the right
69 ASSOCIATED ABDOMINAL TRAUMA Diaphragm forms dome that extends up into rib cageTrauma to chest below 4th rib = Abdominal injury until proven otherwise
70 DIAPHRAGMATIC RUPTURE Difficult to diagnose and often missedMostly seen on left sideSuspect when there is diminished air entry, bowel sounds in chest or mediastinal shift
71 DIAPHRAGMATIC RUPTURE Signs and symptomsDyspneaDysphagiaAbdominal painSharp epigastric or chest pain radiating to the left shoudler (Kehr’s Sign)Bowel sounds in the lower to middle chestDecreased breath sounds on the injuried side
73 CONCLUSION If you only remember one thing… NO MATTER WHAT THE INJURY THE TREATMENT IS ALWAYS… ABC’sIf in doubt about airway: intubateIf in doubt about chest movement: ventilateResuscitate and assess simultaneously