Thoracic Trauma

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Chapter 6 Thoracic Trauma
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Thoracic Trauma
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Overview

• Major signs and symptoms
• Immediate life-threatening injuries
• Pathophysiology and management
• Open pneumothorax
• Tension pneumothorax
• Massive hemothorax
• Flail chest
• Cardiac tamponade
• Cardiac involvement with blunt injury
• Other thoracic injuries

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Thoracic Trauma

• Thoracic injury is common.
• 50 of multiple trauma
• 25 of trauma deaths
• Potentially fatal thoracic injuries saved by
  rapid recognition and intervention.
• Many require surgical intervention

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Chest Anatomy
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Mechanism of Injury

• Blunt
• Direct compression
• Fracture of solid organs
• Blowout of hollow organs
• Deceleration forces
• Tearing of organs and blood vessels
• Penetrating
• Direct trauma to organ and vasculature
• Energy transmitted from mass and velocity

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Tissue Hypoxia

• Inadequate oxygen delivery
• Hypovolemia
• Ventilation/perfusion mismatch
• Pleural pressure changes
• Pump failure

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Thoracic Trauma

• Signs and symptoms

• Shortness of breath
• Chest pain
• Hemoptysis
• Cyanosis
• Neck veins distended
• Tracheal deviation
• Asymmetrical movement

• Chest wall contusion
• Open wounds
• Subcutaneous emphysema
• Shock
• Tenderness, instability, crepitation (TIC)
• Breath sounds abnormal

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ITLS Primary Survey

• Deadly Dozen
• Airway obstruction
• Open pneumothorax
• Flail chest
• Tension pneumothorax
• Massive hemothorax
• Cardiac tamponade

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ITLS Secondary Survey

• Deadly Dozen
• Myocardial contusion
• Traumatic aortic rupture
• Tracheal or bronchial tree injury
• Diaphragmatic tears
• Esophageal injury
• Pulmonary contusion

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Primary Deadly Dozen

• Airway obstruction
• Secondary hypoxia
• Common cause of preventable death
• Foreign body, tongue, aspiration
• Always assume cervical spine injury

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Primary Deadly Dozen

• Open pneumothorax
• Sucking chest wound
• Air enters pleural space
• Ventilation impaired
• Hypoxia results
• Signs and symptoms
• Proportional to size of defect

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Primary Deadly Dozen

• Open pneumothorax
• Close chest wall defect
• Load-and-go

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Primary Deadly Dozen

• Flail chest

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Primary Deadly Dozen

• Flail chest
• Assist ventilation
• Possible intubation
• Load-and-go
• Stabilize flail segment
• Monitor for
• Pulmonary contusion
• Hemothorax
• Pneumothorax

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Primary Deadly Dozen

• Tension pneumothorax
• Dyspnea
• Anxiety
• Tachypnea
• Distended neck veins
• Tracheal deviation (rare)
• Breath sounds diminished
• Hypertympany if percussed
• Shock with hypotension

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Primary Deadly Dozen

• Tension pneumothorax
• Decompress affected side
• Respiratory distress and cyanosis
• Loss of radial pulse
• Decreasing level of consciousness
• Load-and-go

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Primary Deadly Dozen

• Massive hemothorax
• Anxiety and confusion
• Neck veins
• Flat hypovolemia
• Distended mediastinal compression
• Breath sounds decreased
• Hypotympany if percussed
• Shock

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Primary Deadly Dozen

• Massive hemothorax
• Load-and-go
• Treat for shock
• Fluid administration
• Titrate to peripheral pulse (90100 mmHg)
• Monitor for
• Hemopneumothorax

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Primary Deadly Dozen

• Cardiac tamponade
• Becks triad
• Hypotension
• Neck veins distended
• Heart sounds muffled
• Paradoxical pulse
• Breath sounds equal

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Primary Deadly Dozen

• Cardiac tamponade
• Load-and-go
• Treat for shock
• Fluid administration
• Titrate to peripheral pulse (90100 mmHg)
• Monitor and treat dysrhythmias
• Monitor for
• Hemothorax
• Pneumothorax

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Secondary Deadly Dozen

• Myocardial contusion
• Most common cardiac injury
• Blunt anterior chest injury
• Same as myocardial infarction
• Chest pain
• Dysrhythmias
• Cardiogenic shock (rare)
• Treat as cardiac tamponade

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Secondary Deadly Dozen

• Traumatic aortic rupture
• Most common cause of immediate death
• Motor-vehicle collisions or falls from heights
• 90 die immediately
• Scene Size-up and history extremely important
• No obvious sign of chest trauma
• Hypertension in upper extremities and
  hypotension in lower extremities (rare)

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Secondary Deadly Dozen

• Tracheal or bronchial tree injury
• Subcutaneous emphysema
• Chest, face, neck
• Ensure adequate airway
• Cuffed ET tube past site of injury
• Monitor for
• Pneumothorax
• Hemothorax

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Secondary Deadly Dozen

• Diaphragmatic tear
• Severe blow to abdomen
• Herniation of abdominal organs
• More common on left
• Breath sounds diminished
• Bowel sounds auscultated in chest (rare)
• Abdomen appears scaphoid

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Secondary Deadly Dozen

• Esophageal injury
• Penetrating trauma
• Difficult to assess in field
• If unrecognized, may be lethal

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Secondary Deadly Dozen

• Pulmonary contusion
• Common from blunt trauma
• Hours to develop
• Marked hypoxemia
• Impaled object
• Do not remove
• Gently stabilize object
• Avoid movement

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Other Chest Injuries

• Traumatic asphyxia
• Severe compression
• Ruptures capillaries
• Cyanosis above crush
• Swelling of head, neck
• Swollen tongue, lips
• Conjunctival hemorrhage

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Other Chest Injuries

• Simple pneumothorax
• Fractured ribs
• Pleuritic chest pain
• Dyspnea
• Decreased breath sounds
• Hypertympany if percussed
• Monitor for
• Tension pneumothorax

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Other Chest Injuries

• Sternal fracture
• Significant blunt trauma to anterior chest
• Signs of fracture on palpation
• Myocardial contusion presumed
• Simple rib fracture
• Most frequent chest injury
• Monitor for
• Pneumothorax
• Hemothorax

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Summary

• Chest injuries common
• Often life-threatening
• Require prompt recognition
• Require prompt intervention
• Frequently require load-and-go
• Airway and oxygenation always priority
• Frequent Ongoing Exams

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Discussion
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