Thoracic Trauma

1
Thoracic Trauma

• Tintinalli Chapter 259

2
Introduction to Thoracic Trauma

• 25 of civilian deaths
• Hospital mortality lt5
• Mechanism predicts mortality

3
Initial Resuscitation

• Respiratory effort
• Poor effort / poor movement
• Good effort / poor movement
• Listen to neck

4
Initial Resuscitation

• Cardiac arrest during / after intubation
• Inadequate preintubation oxygenation
• Esophageal intubation
• Mainstem intubation
• Excess ventilation
• Developed tension pneumothorax
• Systemic air embolism
• Vasovagal response
• Sudden severe respiratory alkalosis

5
Initial Survey

• Treat life threatening injuries
• Airway obstruction
• Tension pneumothorax
• Cardiac tamponade
• Massive hemothorax
• Open pneumothorax
• Flail chest

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Initial Survey

• Airway obstruction

7
Initial Survey

• Tension Pneumothorax
• Exam
• Treatment

8
Initial Survey

• Tension Pneumothorax
• Exam
• Treatment

9
Initial Survey

• Cardiac Tamponade
• Blunt or penetrating trauma
• Presentation
• Diagnosis
• Treatment

10
Initial Survey

• Cardiac Tamponade
• Blunt or penetrating trauma
• Presentation
• Diagnosis
• Treatment

11
Initial Survey

• Cardiac Tamponade
• Blunt or penetrating trauma
• Presentation
• Diagnosis
• Treatment

12
Initial Survey

• Massive Hemothorax
• Mechanisms of lethality
• Hypovolemia
• Hypoxia
• Vena cava compression
• Treatment

13
Initial Survey

• Open Pneumothorax
• Pathophysiology
• Treatment

14
Initial Survey

• Open Pneumothorax
• Pathophysiology
• Treatment

15
Initial Survey

• Flail Chest
• Definition
• Examination
• Treatment

16
Ventilatory Support

• Consider when
• Impaired ventilation that persists despite
  primary care treatment measures
• Respiratory failure with flail chest
• Shock
• Multiple injuries
• Comatose
• Elderly

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Shock

• Goal Maintain tissue perfusion
• Splanchnic perfusion
• Capnometry
• PETCO2 lt28 mm Hg
• P(a ET)CO2 gt10 mmHg
• Hypovolemic Hypoptension
• Blunt
• Penetrating

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Treatment

• Fluids
• Correct hypotension ASAP
• Access
• Site choice
• Stabilize intravascular volume

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Treatment

• Chest tube and thoracotomy

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Cardiac Arrest

• External massage (compressions)
• Internal massage / thoracotomy
• For all blunt injuries with thoracotomy
• No SOL at scene mortality 100
• Loose SOL on scene or enroute mortality 97.5
• Lost SOL in ER mortality 96
• For penetrating injuries with thoracotomy
• Stab wounds mortality 85
• GSW mortality 96

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Diagnosis of Thoracic Injuries

• Symptoms
• Physical
• Inspection
• Percussion
• Auscultation
• Imaging

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Injuries to the Chest Wall

• Bleeding
• Open chest wounds
• Tissue loss
• Subcutaneous emphysema

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Injuries to the Chest Wall

• Bleeding
• Open chest wounds
• Tissue loss
• Subcutaneous emphysema

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Injuries to the Chest Wall

• Bleeding
• Open chest wounds
• Tissue loss
• Subcutaneous emphysema

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Injuries to the Chest Wall

• Bleeding
• Open chest wounds
• Tissue loss
• Subcutaneous emphysema

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Bony Injuries

• Clavicular fractures
• Rib fractures
• First and second
• Multiple
• Flail Chest
• Sternum fracture
• Traumatic asphyxia

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Bony Injuries

• Clavicular fractures
• Rib fractures
• First and second
• Multiple
• Flail Chest
• Sternum fracture
• Traumatic asphyxia

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Bony Injuries

• Clavicular fractures
• Rib fractures
• First and second
• Multiple
• Flail Chest
• Sternum fracture
• Traumatic asphyxia

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Bony Injuries

• Clavicular fractures
• Rib fractures
• First and second
• Multiple
• Flail Chest
• Sternum fracture
• Traumatic asphyxia

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Bony Injuries

• Clavicular fractures
• Rib fractures
• First and second
• Multiple
• Flail Chest
• Sternum fracture
• Traumatic asphyxia

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Injuries to the Lungs

• Pulmonary contusion
• Pathphysiology
• Diagnosis
• Treatment

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Injuries to the Lungs

• Hemothorax
• Etiology
• Pathophysiology
• Diagnosis
• Treatment

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Injuries to the Lungs

• Pneumothorax
• Pathophysiology
• Diagnosis
• Treatment
• Complications

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Injuries to the Lungs

• Pneumomediastinum
• Pulmonary hematoma
• Pulmonary laceration
• Systemic air embolism
• Intrabronchial bleeding
• Aspiration

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Injuries to the Lungs

• Pneumomediastinum
• Pulmonary hematoma
• Pulmonary laceration
• Systemic air embolism
• Intrabronchial bleeding
• Aspiration

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Injuries to the Lungs

• Pneumomediastinum
• Pulmonary hematoma
• Pulmonary laceration
• Systemic air embolism
• Intrabronchial bleeding
• Aspiration

37
Injuries to the Lungs

• Pneumomediastinum
• Pulmonary hematoma
• Pulmonary laceration
• Systemic air embolism
• Intrabronchial bleeding
• Aspiration

38
Injuries to the Lungs

• Pneumomediastinum
• Pulmonary hematoma
• Pulmonary laceration
• Systemic air embolism
• Intrabronchial bleeding
• Aspiration

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Injuries to the Lungs

• Pneumomediastinum
• Pulmonary hematoma
• Pulmonary laceration
• Systemic air embolism
• Intrabronchial bleeding
• Aspiration

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Tracheobronchial Injury

• Lower trachea and major bronchi
• Deceleration
• Forced expiration
• Cervical tracheal injuries

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Diaphragm Injury

• Etiology
• History
• Diagnosis
• Treatment

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Penetrating Heart Injuries

• Considerations
• Diagnosis
• Treatment

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Blunt Heart Injuries

• Etiology
• Types
• Diagnosis table 259-4

44
Blunt Heart Injuries

• Blunt myocardial injury (BMI)
• Patho
• Diagnosis
• Clinical
• Radiological
• EKG
• Enzymes
• Echo
• Treatment

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Pericardial Inflammation Syndrome

• Etiology
• Diagnosis
• Treatment

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Great Vessels of the Chest

• Penetrating trauma
• Stab gt GSW
• Diagnosis
• History
• Exam
• Radiography
• Treatment

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Great Vessels of the Chest

• Blunt trauma
• Diagnosis
• History chart 259-5
• Exam
• CXR
• CT
• Treatment

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Special Considerations

• Ascending aorta
• Descending aorta
• Innominate artery
• Subclavian artery

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Espohageal and Thoracic Duct Injuries

• Esophageal laceration
• Thoracic duct

50
Questions?