CHEST TRAUMA

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Victor Politi, M.D., FACP Medical Director, SVCMC
Division of Allied Health, Physician Assistant
Program
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Specialty Selection Top Ten Leading Causes of
Death in the U.S.

• Heart Disease 726,974
• Cancer 539,577
• Stroke 159,791
• Chronic Obstructive Pulmonary Disease 109,029
• Accidents 95,644
• Pneumonia/Influenza 86,449
• Diabetes 62,636
• Suicide 30,535
• Nephritis, Nephrotic Syndrome, and Nephrosis
  25,331
• Chronic Liver Disease and Cirrhosis 25,175

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Appeal of Emergency Medicine

• Make an immediate difference
• Life threatening injuries and illnesses
• Undifferentiated patient population
• Challenge of anything coming in
• Emergency / invasive procedures
• Safety net of healthcare

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Appeal of Emergency Medicine

• Team approach
• Patient advocacy
• Open job market
• Academic opportunities
• Shift work / set hours
• Evolving specialty

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Downside to Emergency Medicine

• Interaction with difficult, intoxicated, or
  violent patients
• Finding follow-up or care for uninsured
• Work in a fishbowl
• without 20/20 hindsight
• Working as a patient
• advocate

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Subspecialties in Emergency Medicine

• Pediatric Emergency Medicine
• Toxicology
• Emergency Medical Services
• Sports Medicine

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Areas of Expertise

• Toxicology
• Emergency medical services
• Mass gatherings
• Disaster management
• Wilderness medicine

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Upcoming Areas of Emergency Medicine

• Hyperbaric medicine
• Observation units
• ED ultrasound
• International emergency medicine

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Introduction to Trauma
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• Trauma is a major cause of death in young people.
  The cost in human lives and economic terms is
  tremendous

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• Trauma is the leading cause of death for all age
  groups under the age of 44
• In the US - it is the leading cause of death in
  children

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Trauma Statistics

• 4th leading cause of death of Americans of all
  ages
• Nearly 150,000 people of all ages in the US die
  from trauma each year
• 60 million injuries annually
• 30 million need medical treatment
• 3.6 million need hospitalization

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Trauma Statistics

• Impact of trauma is greatest in children and
  young adults
• Trauma cost the American public over 300 billion
  annually including lost wages, medical expenses,
  administrative costs, employer expense
• Approximately 40 of health care
  monies are spent on trauma

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Trauma Statistics

• Traumatic injuries, including unintentional
  injuries cause -
• 43 of all deaths ages 1 to 4
• 49 of all deaths ages 5 to 14
• 64 of all deaths ages 15 to 24

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Trauma Statistics

• Leading cause of accidental death in US - motor
  vehicle accidents
• drinking is a factor in 49 of these cases

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Trauma Statistics

• Falls -
• 2nd leading cause of accidental death for ages 45
  to 75 years and
• 1 cause of unintentional death for persons age
  75 and older

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Seatbelt Injury
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Trauma Statistics

• Drowning is the 4th most common cause of
  unintentional injury death for all ages
• It ranks 1st for persons age 25 to 44
• It ranks 2nd for ages 5 to 44

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Designated Trauma Centers

• Designated Trauma Centers
• Immediate availability of necessary resources
• Designated -
• Regional
• Area
• Level I
• Level II

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Tri-modal distribution of Trauma Death

• First peak second - minutes
• brain injury, high spinal cord, large vessels,
  cardiac arrest
• best treated by prevention
• Second peak minutes - hours
• sub/epidurals, HTX/PTX, spleen, liver lac
• best treated by applying principles of ATLS
• Third peak days-weeks
• sepsis, multi-organ failure
• directly correlated to earlier Rx

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Primary Evaluation

• Airway maintenance with c-spine control
• Breathing and ventilation
• Circulation with hemorrhage control
• Disability or neurological status
• Exposure and environmental control

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• Control the airway with basic maneuvers
• suction
• administer 100 oxygen
• hyperventilate
• prepare to intubate
• paralyze the patient
• use appropriate Rx considering ?elevated
  ICP
• intubate, maintaining in-line traction
  

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Circulation

• Control exsanguinating hemorrhage
• control external bleeding promptly
• establish at least 2 R.L. wide-bore Ivs
• large diameter/short length Ivs
• ideally 14 ga. 1 1/4
• add pressure bags

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Shock Classification

• Class III
• percentage loss 30-40
• amount of loss 1500-2000ml
• Class IV
• percentage loss more than 40
• amount of loss gt200ml

• Class I
• percentage loss up to 15
• amount of loss up to 750ml
• Class II
• percentage loss 15-30
• amount of loss 750-1500ml

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Treatment of Hemorrhagic Shock due to trauma

• Defined as B/P less than 90 systolic in an adult
• The treatment of shock should be directed not
  toward the class of shock but to the response to
  initial therapy

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Class III Blood Loss

• Respond to initial fluid bolus
• was initial bolus inadequate?
• is patient experiencing ongoing hemorrhage?
• As fluids are slowed, patient deteriorates

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Class III Blood Loss

• Usually indicates 20-40 blood loss
• Requires continued fluids, blood products
• The response to blood products dictates speed of
  surgical intervention

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Fingertip amputation
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Identify the Site

• Most obvious source is external hemorrhage
• Next consider hemothorax
• Consider abdominal source
• spleen laceration
• hemoperitoneum
• renal hematoma
• liver laceration
• injury to a great vessel

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Identify the Site

• Consider mechanism of injury
• Every trauma victim should have a finger or tube
  in every hole

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Battles sign - base of skull injury
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'Racoon Eyes' sign of base of skull fracture
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Minimal or No Response to Fluid Resuscitation

• Seen in small percentage of patients
• usually dictates need for immediate surgical
  intervention to control exsanguinating hemorrhage
• Prepare the OR
• If penetrating chest trauma -
  consider cardiac injury

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gunshot wound left fronto-parietal region
entrance wound (close-up)
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Golden Hour

• The hemodynamically unstable trauma patient needs
  only two things
• hot lights
• cold steel

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• Aggressive fluid resuscitation must be initiated
  not when blood pressure is falling/absent but as
  soon as the early signs/symptoms of blood loss
  are suspected

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• Decreasing BP increasing pulse
• Disorientation - confusion
• Mechanism of injury

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High voltage wiring injury
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Blood Transfusion

• No substitute for the real thing
• cross match if time permits
• compatible with ABO and Rh blood types
• minor antibody incompatibilities may occur

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cutting two fingers off in a meat slicer
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Universal Donor

• Type O negative is available immediately
• used in exsanguinating hemorrhage
• used in patient with minimal or no response to
  initial crystalloid fluids bolus
• Remember -
• Give Blood Save A Life

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Radiologic Studies

• C-spine, chest and pelvis x-rays
• CAT scan or specific x-rays that are indicated
  based on mechanism of injury and primary exam

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Right pulmonary contusion, left chest wall defect
with lung hernia
Pulmonary Contusion
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C-Spine

• Dont become distracted by trying to clear the
  c-spine
• A properly applied cervical collar never killed
  anyone!
• Dont remove cervical collar until c-spine is
  cleared
• continue to protect c-spine during treatment

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Fracture-dislocation C7-T1
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Chest Radiograph

• Rule-out PTX/HTX - need immediate treatment
• Provides clues as to condition of -
• heart, lung, parenchyma, mediastinum, great
  vessels, bronchus, diaphragm
• Almost unheard of to have significant chest
  injury w/o signs of same on CXR
• CXR are frequently misinterpreted and
  injuries are frequently overlooked

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Chest Radiograph

• Check position of tubes
• Locate foreign bodies (i.e. bullets)
• Free air under diaphragm or on lateral means
  perforated viscus
• Cardiac tamponade

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Right diaphragm laceration on chest x-ray
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Abdominal Trauma

• Remove all clothing including undergarments
• Perform adequate visual exam for injuries
• Dont forget the rectal exam

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Spleen Laceration on CT - Grade III
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Abdominal Trauma

• CAT scan with contrast
• utilizes PO and IV contrast
• May require NGT for administration of contrast
• Risk of vomiting and aspiration
• Risk of allergic reaction to contrast
• Intubation to protect airway requiring sedation
• Difficult to obtain CT in unstable patient

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Renal retroperitoneal hematoma Grade IV
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Pelvic Trauma

• Evaluate for pelvic, femoral neck, femur
  fractures
• Provides clues as to condition of -
• abdominal viscera
• bladder
• Patients can bleed out into thigh
• Mules and packers -
• products in distal colon

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Ultrasound

• Dynamic study performed in trauma room
• no need to move patient to x-ray or CT
• can immediately visualize heart, pericardium
• can visualize liver, spleen, kidney lacs
• can visualize 50 cc blood, fluid in abdomen
• takes approximately 5 minutes
• highly operator dependent

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Trauma Code ETA 5 minutes

• Stick with the basics - remember ABCs
• Constantly re-evaluate patient not labs
• Dont raise your voice - remain calm
• You are not alone, consult the experts
• dont get in over your head
• Take a step back -
• What are you missing ?
• What did you overlook ?

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CHEST TRAUMA
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splinter
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Incidence of Chest Trauma

• Cause 1 of 4 American trauma deaths
• Contributes to another 1 of 4
• Many die after reaching hospital - could be
  prevented if recognized
• lt10 of blunt chest trauma needs surgery
• 1/3 of penetrating trauma needs surgery
• Most life-saving procedures do NOT require a
  thoracic surgeon

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Pathophysiology of Chest Trauma
hypovolemia
ventilation- perfusion mismatch
Inadequate oxygen delivery to tissues
changes in intrathoracic pressure relationships
TISSUE HYPOXIA
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Pathophysiology of Chest Trauma

• Tissue hypoxia
• Hypercarbia
• Respiratory acidosis - inadequate ventilation
• Metabolic acidosis - tissue hypoperfusion (e.g.,
  shock)

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Initial assessment and management

• Primary survey
• Resuscitation of vital functions
• Detailed secondary survey
• Definitive care

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Initial assessment and management

• Hypoxia is most serious problem - early
  interventions aimed at reversing
• Immediate life-threatening injuries treated
  quickly and simply - usually with a tube or a
  needle
• Secondary survey guided by high suspicion for
  specific injuries

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6 Immediate Life Threats

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• sucking chest wound
• Massive hemothorax
• Flail chest
• Cardiac tamponade

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6 Potential Life Threats

• Pulmonary contusion
• Myocardial contusion
• Traumatic aortic rupture
• Traumatic diaphragmatic
• rupture
• Tracheobronchial tree
• injury - larynx, trachea,
• bronchus
• Esophageal trauma

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6 Other Frequent Injuries

• Subcutaneous emphysema
• Traumatic asphyxia
• Simple pneumothorax
• Hemothorax
• Scapula fracture
• Rib fractures

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Primary Survey

• Airway
• Breathing
• Circulation

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A Airway

• Assess for airway patency and air exchange -
  listen at nose mouth
• Assess for intercostal and supraclavicular muscle
  retractions
• Assess oropharynx for foreign body obstruction

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B Breathing

• Assess respiratory movements and quality of
  respirations - look, listen, feel
• Shallow respirations are early
  indicator of distress - cyanosis
  is late

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C Circulation

• Assess pulses for quality, rate, regularity
• Assess blood pressure and
  pulse pressure
• Skin - look and feel for color, temperature,
  capillary refill
• Look at neck veins - flat vs. distended
• Cardiac monitor

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Thoracotomy

• Closed heart massage is ineffective in a
  hypovolemic patient
• Left anterior thoracotomy with cross-clamping of
  descending thoracic aorta and open-chest massage
  may be useful in pulseless victim of penetrating
  trauma

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Thoracotomy
Nipple
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6 Immediate Life Threats

• Airway obstruction
• Tension pneumothorax
• Open pneumothorax
• sucking chest wound
• Massive hemothorax
• Flail chest
• Cardiac tamponade

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Airway Obstruction

• Chin-lift - fingers under mandible, lift forward
  so chin is anterior

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Airway Obstruction
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Airway Obstruction

• Jaw thrust - grasp angles of mandible and bring
  the jaw forward

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Airway Obstruction

• Oropharyngeal
• airway inserted in
• mouth behind tongue.
• DO NOT push
• tongue further back.

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Airway Obstruction

• Nasopharyngeal airway - well
• lubricated
• trumpet
• gently
• inserted
• through
• nostril

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Airway Obstruction

• Definitive
• management -
• tube in trachea
• through vocal cords
• with balloon
• inflated.

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Airway Obstruction

• Orotracheal intubation
• Nasotracheal intubation - in breathing patient
  without major facial trauma
• surgical airways
• jet insufflation
• cricothyrotomy
• tracheostomy

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Airway Obstruction
Jet insufflation adapters
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Airway Obstruction
Tracheotomy tubes
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Tension pneumothorax

• Air leaks through lung or chest wall
• One-way valve with lung collapse
• Mediastinum shifts to opposite side
• Inferior vena cava kinks on diaphragm, leading
  to decreased venous return and cardiovascular
  collapse

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Inferior vena cava
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Tension pneumothorax

• Tension pneumothorax is not an x-ray diagnosis -
  it MUST be recognized clinically
• Treatment is decompression
• - needle into 2nd intercostal
• space of mid-clavicular line -
• followed by thoracotomy
• tube

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Open pneumothorax

• Sucking Chest Wound
• Normal ventilation requires negative
  intra-thoracic pressure
• Large open chest-wall defect leads to immediate
  equilibration of intra-thoracic and atmospheric
  pressures
• If hole is gt2/3 tracheal diameter, air prefers
  chest defect

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Open pneumothorax

• Initial treatment - seal defect and secure on
  three sides (total occlusion may lead to tension
  pneumothorax
• Definitive repair of defect in O.R.

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Massive hemothorax

• Rapid accumulation of gt1500 cc blood in chest
  cavity
• Hypovolemia hypoxemia
• Neck veins may be
• flat - from hypovolemia
• distended - intrathoracic blood
• Absent breath sounds, DULL to percussion

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Massive hemothorax - treatment

• Large-bore (32 to 36 F) tube to drain blood
• If moderate sized - 500 to 1500 ml - and stops
  bleeding, closed drainage usually sufficient
• If initial drainage gt1500 ml OR continuous
  bleeding gt200 ml / hr, OPEN THORACOTOMY indicated

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Flail chest

• Free-floating chest segment, usually from
  multiple ribs fractures
• Pain and restricted
• movement
• Paradoxical
• movement of
• chest wall with
• respiration

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Flail chest - treatment

• Adequate ventilation
• Humidified oxygen
• Fluid resuscitation
• PAIN MANAGEMENT
• Stabilize the chest
• internal - ventilator
• external - sand bags

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Cardiac tamponade

• Usually from penetrating injuries
• Classic Becks triad
• elevated venous pressure - neck veins
• decreased arterial pressure - BP
• muffled heart sounds
• Blood in sac
• prevents cardiac
• activity

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Cardiac tamponade

• May find pulsus paradoxus - a decrease of 10 mm
  Hg or greater in systolic BP during inspiration
• Systolic to diastolic gradient of less than 30 mm
  Hg also suggestive

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Cardiac tamponade

• Treatment is removal of small amount of blood -
  15 to 20 ml may be sufficient - from pericardial
  sac

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Stab wound to right ventricle
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pericardium
epicardial fat
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6 Potential Life Threats

• Pulmonary contusion
• Myocardial contusion
• Traumatic aortic rupture
• Traumatic diaphragmatic rupture
• Tracheobronchial tree injury - larynx, trachea,
  bronchus
• Esophageal trauma

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Pulmonary contusion

• Potentially life-threatening condition with
  insidious onset
• Parenchymal injury without laceration
• More than 50 will develop pneumonia, even with
  treatment
• Up to 50 have only hemoptysis as presenting
  symptom

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Pulmonary contusion

• Patients with pre-existing conditions -
  emphysema, renal failure - need early intubation
• Treatment needs to occur over time
• as symptoms develop

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Myocardial contusion

• Blunt precordial chest trauma
• Difficult to diagnose
• Risk for dysrhythmias, sudden death,
• tamponade, pericarditis, ventricular aneurysm

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Myocardial contusion

• Also may see
• myocardial concussion - stunned myocardium with
  no cell death
• coronary artery laceration
• Diagnosis by
• trans-esophageal echocardiogram
• serial cardiac enzymes

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Traumatic aortic rupture

• 90 or more dead at scene
• 90 mortality each undiagnosed day
• Must have high index of suspicion
• Disruption occurs at ligamentum arteriosum
  (ductus arteriosus)
• Contained hematoma of 500 to 1000 ml of blood

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Traumatic aortic rupture

• Radiographic signs
• wide mediastinum
• 1st 2nd rib fx
• obliteration of aortic knob
• tracheal deviation to right
• pleural cap
• depression left mainstem bronchus

• elevation and right shift mainstem bronchus
• obliteration aortic window
• deviation of esophagus to right

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Traumatic aortic rupture

• Treatment -
• SURGICAL REPAIR

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Traumatic diaphragmatic rupture

• Blunt trauma - tears leading to immediate
  herniation
• Penetrating trauma - small tears which may take
  years to develop herniation
• Usually on left side

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Traumatic diaphragmatic rupture

• Treatment - surgical repair

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Tracheobronchial tree injury

• Larynx - rare
• hoarseness
• subcutaneous
• emphysema
• palpable crepitus
• Intubation may be difficult
• tracheostomy (not cricothyroidotomy) is treatment
  of choice

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Tracheobronchial tree injury

• Trachea
• blunt or penetrating
• esophagus, carotid
• artery and jugular
• vein may be involved
• noisy breathing ?
• partial airway
• obstruction

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Tracheobronchial tree injury

• Bronchus
• rare and lethal
• usually BLUNT
• trauma within
• one inch of
• carina

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Esophageal trauma

• Most commonly penetrating
• May be lethal if not recognized
• High suspicion if
• left pneumothorax and hemothorax without rib
  fracture
• shock out of proportion to apparent blunt chest
  trauma
• particulate matter in chest tube

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Esophageal trauma

• If blunt trauma, linear tear in lower esophagus
  with leakage of stomach contents into mediastinum

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6 Other Frequent Injuries

• Subcutaneous emphysema
• Traumatic asphyxia
• Simple pneumothorax
• Hemothorax
• Scapula fracture
• Rib fractures

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Subcutaneous emphysema

• Rice Krispies
• May result from
• airway injury
• lung injury
• blast injury
• No treatment
• required - address underlying
• problem

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Traumatic asphyxia

• Masque ecchymotique - purple face from
  extravasation of blood
• Major damage is to underlying structures
• Purple face fades over time in
• survivors

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Simple pneumothorax

• Air enters potential space between visceral and
  parietal pleura
• Breath sounds down on affected side
• Percussion shows hyper-resonance
• Treatment chest tube in 4th or 5th intercostal
  space anterior to mid-axillary line

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Hemothorax

• Lung laceration OR disruption of intercostal
  artery or internal mammary artery
• Most are self-limiting
• Surgical consultation for
• initial flow of gt20 cc/kg (1500 cc)
• continued flow of gt200 cc/hr

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Scapula fractures

• Fractures of scapula or 1st 2nd ribs may
  indicate major mechanism of
• injury

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Rib fractures

• Ribs - most frequently injured part of thoracic
  cage
• Most commonly injured - 4th ? 9th
• If 10th/11th/12th, be suspicious for liver or
  spleen injuries
• If 1st/2nd/3rd, worry about injury to head, neck,
  spinal cords, lungs, and great vessels

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Rib frac tures

• Treatment consists of
• intercostal blocks
• epidural anesthesia
• systemic analgesics
• Contraindications include
• taping
• rib belts
• external splints

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In conclusion...

• Chest trauma is very common in the multi-injured
  patient
• Airway management and a judiciously placed needle
  can save many lives

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Trauma Code ETA 5 minutes

• Stick with the basics - remember ABCs
• Constantly re-evaluate patient not labs
• Dont raise your voice - remain calm
• You are not alone, consult the experts
• dont get in over your head
• Take a step back -
• What are you missing ?
• What did you overlook ?

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Questions