CHEST TRAUMA

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CHEST TRAUMA

• Victor Politi,M.D., FACP
• Medical Director, SVCMC Physician Assistant
  Program

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Statistics

• Each year there are nearly 150,000 accidental
  deaths in the United States
• 25 of these deaths are a direct result of
  thoracic trauma
• An additional 25 of traumatic deaths have chest
  injury as a contributing factor

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Statistics

• Chest injuries are the second leading cause of
  trauma deaths each year.
• Most thoracic injuries (90 of blunt trauma and
  70 to 85 of penetrating trauma) can be managed
  without surgery.

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CAUSES OF THORACIC TRAUMA

• Falls
• 3 times the height of the patient
• Blast Injuries
• overpressure, plasma forced into alveoli
• Blunt Trauma
• Penetrating trauma 

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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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Classifications of Chest Injuries

• Skeletal injury
• Pulmonary injury
• Heart and great vessel injury
• Diaphragmatic injury

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ClassificationMechanism of Injury

• Blunt thoracic injuries
• Forces distributed over a large area
• Deceleration
• Compression

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ClassificationMechanism of Injury

• Penetrating thoracic injuries
• Forces are distributed over a small area.
• Organs injured are usually those that lie along
  the path of the penetrating object

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Injury Patterns

• General types
• Open injuries
• Closed injuries

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Injury Patterns

• Cardiovascular
• Pleural and pulmonary
• Mediastinal
• Diaphragmatic
• Esophageal
• Penetrating cardiac trauma
• Blast injury
• Confined spaces
• Shock wave
• Thoracic cage

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Anatomy

• Skin
• Bones
• Thoracic cage
• Sternum
• Thoracic spine

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Anatomy

• Muscles
• The respiratory muscles contract in response to
  stimulation of the phrenic and intercostal
  nerves.
• Trachea
• Bronchi
• Lungs

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Vascular Anatomy

• Arteries
• Aorta
• Carotid
• Subclavian
• Intercostal

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Vascular Anatomy

• Veins
• Superior vena cava
• Inferior vena cava
• Subclavian
• Internal jugular

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Vascular Anatomy

• Pulmonary
• Arteries
• Veins

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Vascular Anatomy

• Heart
• Ventricles
• Atria
• Valves
• Pericardium

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Anatomy

• Mediastinum
• The area between the lungs
• Heart
• Trachea
• Vena cavae
• Pulmonary artery
• Aorta
• Esophagus
• Lymph nodes

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Anatomy

• Physiology
• Ventilationthe mechanical
  process of moving air into
  and out of the lungs
• Respirationthe exchange
  of oxygen and carbon
  dioxide between the outside
  atmosphere and the cells
  of the body

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Pathophysiology

• Impairments in cardiac output
• Blood loss
• Increased intrapleural pressures
• Blood in the pericardial sac
• Myocardial valve damage
• Vascular disruption

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Pathophysiology

• Impairments in cardiac output
• Blood loss
• Increased intrapleural pressures
• Blood in the pericardial sac
• Myocardial valve damage
• Vascular disruption

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Pathophysiology

• Impairments in gas exchange
• Atelectasis
• Contused lung tissue
• Disruption of the respiratory tract Impairments
  in gas exchange
• Atelectasis
• Contused lung tissue
• Disruption of the respiratory tract

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Chest TraumaInitial Evaluation

• Hypoxia and hypoventilation are the primary
  killers of acute trauma patients.
• Assessment of ventilation is therefore given high
  priority in the primary survey - as the second
  'B' or Breathing stage.

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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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Chest TraumaInitial Evaluation

• Life-threatening injuries should be identified
  and treated immediately.
• Injuries may develop over time, and become
  life-threatening during the course of a
  resuscitation.
• Re-assessment and evaluation is therefore
  extremely important, especially if the patient's
  condition deteriorates.

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Chest Trauma - Initial EvaluationMechanism of
Injury

• Mechanism of injury is important in so far as
  blunt and penetrating injuries have different
  pathophysiologies and clinical courses.
• Most blunt injuries are managed non-operatively
  or with simple interventions like intubation and
  ventilation and chest tube insertion.

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Chest Trauma - Initial EvaluationMechanism of
Injury

• Diagnosis of blunt injuries may be more difficult
  and require additional investigations such as CT
  scanning.
• Patients with penetrating trauma may deteriorate
  rapidly, and recover much faster than patients
  with blunt injury.

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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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Chest Trauma Initial EvaluationPrimary Survey

• Monitoring
• Oxygen Saturation
• End-tidal CO2 (if intubated)
• Diagnostic Studies
• Chest X-ray
• FAST ultrasound
• Arterial Blood Gas
• Interventions
• Chest drain
• ED Thoracotomy

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Chest Trauma Initial EvaluationSecondary Survey

• The secondary survey is a more detailed and
  complete examination, aimed at identifying all
  injuries and planning further investigation and
  treatment.
• Chest injuries identified on secondary survey and
  its adjuncts are
• Rib fractures and flail chest
• Pulmonary contusion
• Simple pneumothorax
• Simple haemothorax
• Blunt aortic injury
• Blunt myocardial injury

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Primary Survey

• Airway
• Breathing
• Circulation

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Chest Trauma Initial EvaluationPhysical
examination

• Physical examination is the primary tool for
  diagnosis of acute thoracic trauma.
• However, in the noisy ER or in the pre-hospital
  arena, an adequate physical examination may be
  very difficult.
• Even under ideal conditions, signs of significant
  thoracic injury may be subtle or even absent.
• It is important also to understand that these
  conditions develop over time.

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Chest Trauma Initial EvaluationPhysical
examination

• With the advantages of rapid prehospital
  transport many of these conditions will not have
  fully developed by the time the patient reaches
  the emergency department.
• While the initial primary survey may identify
  some of these conditions, an initial normal
  examination does not exclude any of them, and
  serial examinations and use of diagnostic
  adjuncts is important.

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Chest Trauma Initial EvaluationPhysical
examination

• Look
• Determine the respiratory rate and depthLook for
  chest wall asymmetry. Paradoxical chest wall
  motion Look for bruising, seat belt or steering
  wheel marks, penetrating wounds
• Feel
• Feel for the trachea for deviationAssess whether
  there is adequate and equal chest wall
  movementFeel for chest wall tenderness or rib
  'crunching' indicating rib fracturesFeel for
  subcutaneous emphysema

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Chest Trauma Initial EvaluationPhysical
examination

• Listen
• Listen for normal, equal breath sounds on both
  sides.Listen especially in the apices and
  axillae and at the back of the chest (or as far
  as you can get while supine).
• Percuss
• Percuss both sides of the chest looking for
  dullness or resonance (more difficult to
  appreciate in the trauma room).

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Chest Trauma Initial Evaluation Classic PE
findings

• The size of the injury, and position of the
  patient will affect the clinical findings.
• For example, a small hemothorax may have no
  clinical signs at all.
• A moderate hemothorax will be dull to percussion
  with absent breath sounds at the bases in the
  erect patient, whereas signs will be posterior in
  the supine patient. This is also reflected in
  chest X-ray findings.

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Chest Trauma Initial Evaluation Classic PE
findings
Trachea Expansion Breath Sounds Percussion
Tension Pneumothorax Away Decreased.Chest may be fixed in hyper-expansion Diminished or absent Hyper-resonant
Simple Pneumothorax Midline Decreased May be diminished May be hyper-resonant. Usually normal
Hemothorax Midline Decreased Diminished if large, normal if small Dull, especially posteriorly
Pulmonary contusion Midline Normal Normal, may have crackles Normal
Lung collapse Towards Decreased May be reduced Normal
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Chest Trauma Initial Evaluation

• Note- a collapsed lung on one side can mimic a
  tension pneumothorax on the other side.
• This is a common error, usually occurring when a
  tracheal tube has been incorrectly placed in the
  right main bronchus, obstructing the right upper
  lobe bronchus.
• This leads to collapse of the right upper lobe
  and shift of the trachea to the right.
• The left chest appears hype-resonant compared to
  the left, and breath sounds may be difficult to
  determine.
• The patient may end up with an unnecessary chest
  drain.

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Chest Trauma Initial Evaluation

• Oxygen saturation
• Pulse oximetry allows continuous, non-invasive
  assessment of arterial hemoglobin oxygen
  saturation.
• Continuous oxygen saturation monitoring should be
  used during the resuscitation of all trauma
  patients.

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Chest Trauma Initial Evaluation

• End-tidal carbon dioxide
• End-tidal carbon dioxide monitoring (ETCO2)
  should be used in all intubated trauma patients.
• ETCO2 is the only definitive method of confirming
  placement of a tracheal tube.
• Other methods, such as watching for chest wall
  movement and listening to breath sounds or for
  air in the stomach are inaccurate, especially in
  the setting of the trauma resuscitation room.
• ETCO2 also allows for the estimation of the
  arterial PaCO2 level, and for its continuous
  montioring.
• This is important for all mechanically ventilated
  patients and vital for patients with traumatic
  brain injury.

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Chest Trauma Initial Evaluation

• Chest X-ray
• The plain antero-posterior chest radiograph
  remains the standard initial evaluation for the
  evaluation of chest trauma.
• Although the indications and techniques are
  slightly different for blunt and penetrating
  trauma.

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Chest Trauma Initial Evaluation

• Blunt trauma
• All blunt trauma patients should have a portable
  chest X-ray performed in the trauma resuscitation
  room.
• The chest X-ray is a rapid screening examination
  that will identify significant thoracic problems
  requiring intervention.

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Chest Trauma Initial Evaluation

• Blunt trauma
• Chest radiographs in blunt trauma patients are
  taken in the supine position, as unstable spinal
  fractures have not been ruled out at this stage.
• Chest films should be slightly over-penetrated to
  allow better visualization of the thoracic spine,
  paraspinal lines and aortic outline.

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Chest Trauma Initial Evaluation

• Penetrating trauma
• Patients with a stab wound that may have violated
  the thoracic cavity or mediastinum should have a
  chest X-ray.
• In practice, this means all patients with stab
  wounds between the neck and the umbilicus (front
  or back!).

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Chest Trauma Initial Evaluation

• Penetrating trauma
• For gunshot wounds, all patients with wounds
  between the neck and the pelvis/buttock area
  should have a chest film.
• This is especially true if the bullet track is
  unclear, there is a missing bullet or an odd
  number of entry/exit wounds.

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Chest Trauma Initial Evaluation

• Penetrating trauma
• The chest-X-ray in penetrating trauma should be
  taken with the patient sitting upright if
  possible.
• This will increase the sensitivity for detecting
  a small hemothorax, pneumothorax or diaphragm
  injury.

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Chest Trauma Initial Evaluation

• FAST examination
• Focused abdominal sonography for trauma (FAST) is
  a rapid ultrasound examination performed in the
  trauma resuscitation room looking specifically
  from blood - in the peritoneum, pericardium, or
  hemithorax.
• Currently, FAST is indicated for all
  hemodynamically unstable blunt trauma patients.
  It may also have a role in some patients with
  penetrating trauma.

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Chest Trauma Initial Evaluation

• Arterial Blood Gas analysis
• Arterial blood gas analyses should be drawn on
  all intubated and ventilated trauma patients, and
  any patient with significant chest trauma or
  evidence of hemodynamic instability.

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Chest Trauma Initial Evaluation

• As part of the secondary survey the chest is
  fully examined, front and back.
• Special attention is paid to identifying any
  missed injuries or progression of previously
  identified injuries.
• The examination is also directed by findings on
  the chest X-ray or by information from monitoring
  adjuncts.

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Chest Trauma Initial Evaluation

• Further investigations may include
• CT scan
• Angiography
• Oesophagoscopy / oesophagram
• Bronchoscopy
• Definitive care may include
• Chest drain
• Thoracotomy
• Transfer to ICU area for ventilation /
  observation

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Assessment Findings

• Pulse
• Deficit
• Tachycardia
• Bradycardia
• Blood pressure
• Narrowed pulse pressure
• Hypertension
• Hypotension
• Pulsus paradoxus

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Assessment Findings

• Respiratory rate and effort
• Tachypnea
• Bradypnea
• Labored
• Retractions
• Other evidence of respiratory distress

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Assessment Findings

• Skin
• Diaphoresis
• Pallor
• Cyanosis
• Open wounds
• Ecchymosis
• Other evidence of trauma

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Assessment (Neck)

• Position of trachea
• Subcutaneous emphysema
• Jugular venous distention
• Penetrating wounds

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Assessment (Chest)

• Contusions
• Tenderness
• Asymmetry
• Lung sounds
• Absent or decreased
• Unilateral
• Bilateral
• Location
• Bowel sounds in hemothorax

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Abnormal Percussion Finding

• HyperresonanceAir
• HyporesonanceFluid

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Assessment ECG

• ST/T wave elevation or depression
• Conduction disturbances
• Rhythm disturbances

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History

• Dyspnea
• Chest pain
• Associated symptoms
• Other areas of pain or discomfort
• Symptoms before incident
• Past history of cardiorespiratory disease
• Use of restraint in motor vehicle crash

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Management

• Airway and ventilation
• High-concentration oxygen
• Pleural decompression
• Endotracheal intubation
• Needle cricothyrotomy
• Surgical cricothyrotomy
• Positive-pressure ventilation
• Occlude open wounds
• Stabilize chest wall

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Circulation

• Manage cardiac dysrhythmias
• Intravenous access

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Pharmacological

• Analgesics
• Antidysrhythmics

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Nonpharmacological

• Needle thoracostomy
• Tube thoracostomyin hospital management
• Pericardiocentesisin hospital

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Skeletal Injury

• Clavicular fractures
• Clavicle the most commonly fractured bone
• Isolated fracture of the clavicle seldom a
  significant injury
• Common causes
• Children who fall on their shoulders or
  outstretched arms
• Athletes involved in contact sports

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Skeletal Injury

• Treatment
• Usually accomplished with a sling and swathe or a
  clavicular strap that immobilizes the affected
  shoulder and arm
• Usually heals well within 4 to 6 weeks
• Signs and symptoms
• Pain
• Point tenderness
• Evident deformity

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Skeletal Injury

• Complications
• Injury to the subclavian vein or artery from bony
  fragment penetration, producing a hematoma or
  venous thrombosis (rare)

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Rib Fractures

• Incidence
• Infrequent until adult life
• Significant force required
• Most often elderly patients

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Rib FracturesMorbidity/Mortality

• Can lead to serious consequences.
• Older ribs are more brittle and rigid.
• There may be associated underlying pulmonary or
  cardiovascular injury.

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Rib FracturesPathophysiology

• Most often caused by blunt traumabowing effect
  with midshaft fracture
• Ribs 3 to 8 are fractured most often (they are
  thin and poorly protected)
• Respiratory restriction as a result of pain and
  splinting

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Rib FracturesPathophysiology

• Intercostal vessel injury
• Associated complications
• First and second ribs are injured by severe
  trauma
• Rupture of the aorta
• Tracheobronchial tree injury
• Vascular injury

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Multiple Rib Fractures

• Atelectasis
• Hypoventilation
• Inadequate cough
• Pneumonia

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Multiple Rib Fractures

• Assessment findings
• Localized pain
• Pain that worsens with movement, deep breathing,
  coughing
• Point tenderness
• Most patients can localize the fracture by
  pointing to the area (confirmed by palpation).
• Crepitus or audible crunch
• Splinting on respiration

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Multiple Rib Fractures Complications

• Splinting, which leads to atelectasis and
  ventilation-perfusion mismatch (ventilated
  alveoli that are not perfused or perfused alveoli
  that are not ventilated)

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Rib FracturesManagement

• Airway and ventilation
• High-concentration oxygen
• Positive-pressure ventilation
• Encourage coughing and deep breathing
• Pharmacological
• Analgesics
• Nonpharmacological
• Non-circumferential splinting

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Flail Chest

• Incidence
• Most common cause vehicular crash
• Falls from heights
• Industrial accidents
• Assault
• Birth trauma

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Flail ChestMorbidity/Mortality

• Significant chest trauma
• Mortality rates 20 to 40 due to associated
  injuries
• Mortality increased with
• Advanced age
• Seven or more rib fractures
• Three or more associated injuries
• Shock
• Head injuries

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Flail ChestPathophysiology

• Two or more adjacent ribs fractured in two or
  more places producing a free-floating segment of
  chest wall

Flail chest usually results from direct impact.
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Flail ChestPathophysiology

• Respiratory failure due to
• Underlying pulmonary contusion
• The blunt force of the injury typically produces
  an underlying pulmonary contusion.
• Associated intrathoracic injury
• Inadequate bellows action of the chest

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Flail ChestAssessment Findings

• Chest wall contusion
• Respiratory distress
• Paradoxical chest wall movement
• Pleuritic chest pain
• Crepitus
• Pain and splinting of affected side
• Tachypnea
• Tachycardia
• Possible bundle branch block on ECG

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Flail ChestManagement

• Airway and ventilation
• High-concentration oxygen.
• Positive-pressure ventilation may be needed.
• Reverses the mechanism of paradoxical chest wall
  movement
• Restores the tidal volume
• Reduces the pain of chest wall movement
• Assess for the development of a pneumothorax
• Evaluate the need for endotracheal intubation.
• Stabilize the flail segment (controversial).

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Sternal Fractures

• Incidence
• Occurs in 5 to 8 of all patients with blunt
  chest trauma
• A deceleration compression injury
• Steering wheel
• Dashboard
• A blow to the chest massive crush injury
• Severe hyperflexion of the thoracic cage

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Sternal FracturesMorbidity/Mortality

• 25 to 45 mortality rate
• High association with myocardial or lung injury
• Myocardial contusion
• Myocardial rupture
• Cardiac tamponade
• Pulmonary contusion

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Sternal FracturesPathophysiology

• Associated injuries cause morbidity and
  mortality.
• Pulmonary and myocardial contusion
• Flail chest
• Seriously displaced sternal fractures may produce
  a flail chest.
• Vascular disruption of thoracic vessels
• Intra-abdominal injuries
• Head injuries

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Sternal FracturesManagement

• Airway and ventilation
• High-concentration oxygen
• Circulationrestrict fluids if pulmonary
  contusion suspected
• Pharmacologicalanalgesics
• Non-pharmacologicalallow chest wall
  self-splinting
• Psychological support/communication strategies

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Pulmonary Injury

• Closed (simple) pneumothorax
• Incidence
• 10 to 30 in blunt chest trauma
• Almost 100 with penetrating chest trauma
• Morbidity/mortality
• Extent of atelectasis
• Associated injuries
• Pathophysiology
• Caused by the presence of air in the pleural
  space
• A common cause of pneumothorax is a fractured rib
  that penetrates the underlying lung.

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Closed (Simple) Pneumothorax

• May occur in the absence of rib fractures from
• A sudden increase in intrathoracic pressure
  generated when the chest wall is compressed
  against a closed glottis (the paper-bag effect)
• Results in an increase in airway pressure and
  ruptured alveoli, which lead to a pneumothorax
• Small tears self-seal larger ones may progress.
• The trachea may tug toward the affected side.
• Ventilation/perfusion mismatch.

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Closed PneumothoraxAssessment Findings

• Tachypnea
• Tachycardia
• Respiratory distress
• Absent or decreased breath sounds on the affected
  side
• Hyperresonance
• Decreased chest wall movement
• Dyspnea
• Chest pain referred to the shoulder or arm on the
  affected side
• Slight pleuritic chest pain

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Closed PneumothoraxManagement

• Airway and ventilation
• High-concentration oxygen.
• Positive-pressure ventilation if necessary.
• If respiration rate is lt12 or gt28 per minute,
  ventilatory assistance with a bag-valve mask may
  be indicated.

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Closed PneumothoraxManagement

• Nonpharmacological
• Needle thoracostomy
• Transport considerations
• Position of comfort (usually partially sitting)
  unless contraindicated by possible spine injury

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Open pneumothorax

• Develops when penetration injury to the chest
  allows the pleural space to be exposed to
  atmospheric pressure - "Sucking Chest Wound"

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Open Pneumothorax

• Incidence
• Usually the result of penetrating trauma
• Gunshot wounds
• Knife wounds
• Impaled objects
• Motor vehicle collisions
• Falls

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Open Pneumothorax
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Open pneumothorax

• WHAT MAY CAUSE A SCW?
• Examples IncludeGSW, Stab Wounds, Impaled
  Objects, Etc...
• LARGE VS SMALL
• Severity is directly proportional to the size of
  the wound
• Atmospheric pressure forces air through the wound
  upon inspiration

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Open PneumothoraxMorbidity/Mortality

• Severity is directly proportional to the size of
  the wound.
• Profound hypoventilation can result.
• Death is related to delayed management.

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Open PneumothoraxPathophysiology

• An open defect in the chest wall (gt3 cm)
• If the chest wound opening is greater than
  two-thirds the diameter of the trachea, air
  follows the path of least resistance through the
  chest wall with each inspiration.
• As the air accumulates in the pleural space, the
  lung on the injured side collapses and begins to
  shift toward the uninjured side.

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Open pneumothorax

• Signs Symptoms
• Shortness of Breath (SOB)
• Pain
• Sucking or gurgling sound as air moves in and out
  of the pleural space through the wound

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Open PneumothoraxAssessment Findings

• To-and-fro air motion out of the defect
• A defect in the chest wall
• A penetrating injury to the chest that does not
  seal itself
• A sucking sound on inhalation
• Tachycardia
• Tachypnea
• Respiratory distress
• Subcutaneous emphysema
• Decreased breath sounds on the affected side

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Open Pneumothorax

• Breathing is rapid, shallow and laboured. There
  is reduced expansion of the hemithorax,
  accompanied by reduced breath sounds and an
  increased percussion note.
• One or all of these signs may not be appreciated
  in a noisy ER.

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Open PneumothoraxManagement

• Airway and ventilation
• High-concentration oxygen.
• Positive-pressure ventilation if necessary.
• Assist ventilations with a bag-valve device and
  intubation as necessary.
• Monitor for the development of a tension
  pneumothorax.
• Circulationtreat for shock with crystalloid
  infusion.

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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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Tension pneumothorax

• Air within thoracic cavity that cannot exit the
  pleural space
• Fatal if not immediately identified, treated, and
  reassessed for effective management

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Tension pneumothorax
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Tension Pneumothorax

• Associated Injuries
• A penetrating injury to the chest
• Blunt trauma
• Penetration by a rib fracture
• Many other mechanisms of injury

111
Tension PneumothoraxMorbidity/Mortality

• Profound hypoventilation can result.
• Death is related to delayed management.
• An immediate, life-threatening chest injury.

112
Tension Pneumothorax Pathophysiology

• 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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Early Signs Tension Pneumothorax

• Extreme anxiety
• Cyanosis
• Increasing dyspnea
• Difficult ventilations while being assisted
• Tracheal deviation (a late sign)
• Hypotension

Identification is the most difficult aspect of
field care in a tension pneumothorax.
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Tension Pneumothorax Assessment Findings

• Bulging of the intercostal muscles
• Subcutaneous emphysema
• Jugular venous distention (unless hypovolemic)
• Unequal expansion of the chest (tension does not
  fall with respiration)
• Hyperresonnace to percussion

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LATE S/S OF TENSION PNEUMOTHORAX

• Jugular Venous Distension (JVD)
• Tracheal Deviation
• Narrowing pulse pressure
• Signs of decompensating shock

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MANAGEMENT OF TENSION PNEUMOTHORAX

• Emergency care is directed at reducing the
  pressure in the pleural space.
• Airway and ventilation
• High-concentration oxygen
• Positive pressure ventilation if necessary
• Circulationrelieve the tension pneumothorax to
  improve cardiac output.

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Tension Pneumothorax Management

• Nonpharmacological
• Occlude open wound
• Needle thoracostomy
• Tube thoracostomyin-hospital management

Pleural decompression should only be employed if
the patient demonstrates significant dyspnea and
distinct signs and symptoms of tension
pneumothorax.
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Tension Pneumothorax Management

• Tension pneumothorax associated with penetrating
  trauma
• May occur when an open pneumothorax has been
  sealed with an occlusive dressing.
• Pressure may be relieved by momentarily removing
  the dressing (air escapes with an audible release
  of air).

After the pressure is released, the wound should
be resealed.
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Tension Pneumothorax Management

• Tension pneumothorax associated with closed
  trauma
• If the patient demonstrates significant dyspnea
  and distinct signs and symptoms of tension
  pneumothorax
• Provide thoracic decompression with either a
  large-bore needle or commercially available
  thoracic decompression kit.
• Insert a 2-inch 14- or 16-gauge hollow needle or
  catheter into the affected pleural space.
• Usually the second intercostal space in the
  midclavicular line

Insert the needle just above the third rib to
avoid the nerve, artery, and vein that lie just
beneath each rib.
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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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Tension pneumothorax

• The classic signs of a tension pneumothorax are
  deviation of the trachea away from the side with
  the tension, a hyper-expanded chest, an increased
  percussion note and a hyper-expanded chest that
  moves little with respiration.
• The central venous pressure is usually raised,
  but will be normal or low in hypovolemic states.

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Inferior vena cava
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Hemothorax

• If this condition is associated with
  pneumothorax, it is called a hemopneumothorax.

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Hemothorax

• Incidence
• Associated with pneumothorax.
• Blunt or penetrating trauma.
• Rib fractures are frequent cause.

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HemothoraxMorbidity/Mortality

• A life-threatening injury that frequently
  requires urgent chest tube placement and/or
  surgery
• Associated with great vessel or cardiac injury
• 50 of these patients will die immediately.
• 25 of these patients live 5 to 10 minutes.
• 25 of these patients may live 30 minutes or
  longer.

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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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HemothoraxAssessment Findings

• Tachypnea
• Dyspnea
• Cyanosis
• Often not evident in hemorrhagic shock
• Diminished or decreased breath sounds on the
  affected side

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HemothoraxAssessment Findings

• Hyporesonance (dullness on percussion) on the
  affected side
• Hypotension
• Narrowed pulse pressure
• Tracheal deviation to the unaffected side (rare)
• Pale, cool, moist skin

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HemothoraxManagement

• Airway and ventilation
• High-concentration oxygen
• Positive-pressure ventilation if necessary
• Ventilatory support with bag-valve mask,
  intubation, or both

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HemothoraxManagement

• Circulation
• Administer volume-expanding fluids to correct
  hypovolemia
• Nonpharmacologicaltube thoracostomy

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Hemopneumothorax

• Pathophysiologypneumothorax with bleeding in the
  pleural space
• Assessmentfindings and management are the same
  as for hemothorax.
• Managementmanagement is the same as for
  hemothorax.

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Pulmonary Contusion

• A pulmonary contusion is the most common
  potentially lethal chest injury.
• Incidence
• Blunt trauma to the chest
• The most common injury from blunt thoracic
  trauma.
• 30 to 75 of patients with blunt trauma have
  pulmonary contusion.
• Commonly associated with rib fracture
• High-energy shock waves from explosion
• High-velocity missile wounds
• Rapid deceleration
• A high incidence of extrathoracic injuries
• Low velocityice pick

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Pulmonary ContusionMorbidity/Mortality

• May be missed due to the high incidence of other
  associated injuries

Mortalitybetween 14 and 20
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Pulmonary Contusion Assessment Findings

• Tachypnea
• Tachycardia
• Cough
• Hemoptysis
• Apprehension
• Respiratory distress
• Dyspnea
• Evidence of blunt chest trauma
• Cyanosis

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Pulmonary ContusionManagement

• Airway and ventilation
• High-concentration oxygen
• Positive-pressure ventilation if necessary
• Circulationrestrict IV fluids (use caution
  restricting fluids in hypovolemic patients).

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Traumatic Asphyxia

• Incidence
• A severe crushing injury to the chest and abdomen
• Steering wheel injury
• Conveyor belt injury
• Compression of the chest under a heavy object

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Traumatic Asphyxia Pathophysiology

• A sudden compressional force squeezes the chest.
• An increase in intrathoracic pressure forces
  blood from the right side of the heart into the
  veins of the upper thorax, neck, and face.
• Jugular veins engorge and capillaries rupture.

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Traumatic AsphyxiaAssessment

• Reddish-purple discoloration of the face and neck
  (the skin below the face and neck remains pink).
• Jugular vein distention.
• Swelling of the lips and tongue.

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Traumatic AsphyxiaAssessment

• Swelling of the head and neck.
• Swelling or hemorrhage of the conjunctiva
  (subconjunctival petechiae may appear).
• Hypotension results once the pressure is
  released.

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Traumatic AsphyxiaManagement

• Airway and ventilation
• Ensure an open airway.
• Provide adequate ventilation.
• Circulation
• IV access.
• Expect hypotension and shock once the compression
  is released.

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Heart and Great Vessel Injury

• Myocardial contusion (blunt myocardial injury)
• Incidence
• The most common cardiac injury after a blunt
  trauma to the chest
• Occurs in 16 to 76 of blunt chest traumas
• Usually results from motor vehicle collisions as
  the chest wall strikes the dashboard or steering
  column
• Sternal and multiple rib fractures common

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Heart and Great Vessel Injury Morbidity/Mortality

• A significant cause of morbidity and mortality in
  the blunt trauma patient
• Clinical findings are subtle and frequently
  missed due to
• Multiple injuries that direct attention elsewhere
  
• Little evidence of thoracic injury
• Lack of signs of cardiac injury on initial
  examination

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Heart and Great Vessel Injury Assessment Findings

• Retrosternal chest pain
• ECG changes
• Persistent tachycardia
• ST elevation, T wave inversion
• Right bundle branch block
• Atrial flutter, fibrillation
• Premature ventricular contractions
• Premature atrial contractions

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Heart and Great Vessel Injury Assessment Findings

• New cardiac murmur
• Pericardial friction rub (late)
• Hypotension
• Chest wall contusion and ecchymosis

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Heart and Great Vessel Injury Management

• Airway and ventilationhigh-concentration oxygen
• CirculationIV access
• Pharmacological
• Antidysrhythmics
• Vasopressors

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Pericardial Tamponade

• Incidence
• Rare in blunt trauma
• Penetrating trauma
• Occurs in less than 2 of all chest traumas

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Pericardial Tamponade Morbidity/Mortality

• Gunshot wounds carry higher mortality than stab
  wounds.
• Lower mortality rate if isolated tamponade is
  present.

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Pericardial TamponadeAnatomy and Physiology

• Pericardium
• A tough fibrous sac that encloses heart
• Attaches to the great vessels at the base of the
  heart
• Two layers
• The visceral layer forms the epicardium.
• The parietal layer is regarded as the sac
  itself.

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Pericardial Tamponade Pathophysiology

• A blunt or penetrating trauma may cause tears in
  the heart chamber walls, allowing blood to leak
  from the heart.
• If the pericardium has been torn sufficiently,
  blood leaks into the thoracic cavity.

If 150 to 200 mL of blood enters the pericardial
space acutely, pericardial tamponade develops.
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Pericardial Tamponade Pathophysiology

• Increased intrapericardial pressure
• Does not allow the heart to expand and refill
  with blood
• Results in a decrease in stroke volume and
  cardiac output
• Myocardial perfusion decreases due to pressure
  effects on the walls of the heart and decreased
  diastolic pressures.
• Ischemic dysfunction may result in infarction.
• Removal of as little as 20 mL of blood may
  drastically improve cardiac output.

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Pericardial Tamponade Assessment Findings

• Tachycardia
• Respiratory distress
• Narrowed pulse pressure
• Cyanosis of the head, neck, and upper extremities

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Pericardial Tamponade Assessment Findings

• Becks triad
• Narrowing pulse pressure
• Neck vein distention
• Muffled heart sounds

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Pericardial Tamponade Assessment Findings

• Kussmauls signa rise in venous pressure with
  inspiration when spontaneously breathing
• ECG changes

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Pericardial Tamponade Management

• Airway and ventilation
• CirculationIV fluid challenge
• Nonpharmacological pericardiocentesis

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Traumatic Aortic Rupture

• Incidence
• Blunt trauma
• Rapid deceleration in high-speed motor vehicle
  crashes
• Falls from great heights
• Crushing injuries

15 of all blunt trauma deaths
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Traumatic Aortic Rupture Morbidity/Mortality

• 80 to 90 of these patients die at the scene as
  a result of massive hemorrhage.
• About 10 to 20 of these patients survive the
  first hour.
• Bleeding is tamponaded by surrounding adventitia
  of the aorta and intact visceral pleura.
• Of these, 30 have rupture within 6 hours.

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Traumatic Aortic Rupture Pathophysiology

• Patients who are normotensive should have limited
  replacement fluids to prevent an increase in
  pressure in the remaining aortic wall tissue.

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Traumatic Aortic Rupture Assessment Findings

• Upper-extremity hypertension with absent or
  decreased amplitude of femoral pulses
• Thought to result from compression of the aorta
  by the expanding hematoma
• Generalized hypertension
• Secondary to increased sympathetic discharge
• Retrosternal or interscapular pain

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Traumatic Aortic Rupture Assessment Findings

• About 25 have a harsh systolic murmur over the
  pericardium or interscapular region
• Paraplegia with a normal cervical and thoracic
  spine (rare)

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Traumatic Aortic Rupture Assessment Findings

• Dyspnea
• Dysphagia
• Ischemic pain of the extremities
• Chest wall contusion

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Aortic Injury Suspicion

• Mechanism
• Fallsgt 3m
• Major decelaration/acceleration
• SIGNS
• Neck hematoma
• Assymetic pulse or BP
• Radiofemoral delay
• Severe searing pain

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Aortic Injury CXR Signs

• Mediastinum gt 8cm
• Abnormal Aortic contour
• Opaque artopulmonary window
• Apical cap
• Mediastinal displacement
• Fracture of first rib or scapula

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Traumatic Aortic Rupture Management

• Airway and ventilation
• High-concentration oxygen
• Ventilatory support with spinal precautions
• Circulationdo not over-hydrate.

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Diaphragmatic Rupture

• Incidence
• Penetrating trauma
• Blunt trauma
• Injuries to the diaphragm account for 1 to 8 of
  all blunt injuries.
• 90 of injuries to the diaphragm are associated
  with high-speed motor vehicle crashes.

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Diaphragmatic RuptureAnatomy Review

• The diaphragm is a voluntary muscle that
  separates the abdominal cavity from the thoracic
  cavity.
• The anterior portion attaches to the inferior
  portion of the sternum and the costal margin.
• Attaches to the 11th and 12th ribs posteriorly.
• The central portion is attached to the
  pericardium.
• Innervated via the phrenic nerve.

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Diaphragmatic Rupture

• Rupture can allow intra-abdominal organs to enter
  the thoracic cavity, which may cause the
  following
• Compression of the lung with reduced ventilation
• Decreased venous return
• Decreased cardiac output
• Shock

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Diaphragmatic Rupture Pathophysiology

• Can produce very subtle signs and symptoms
• Bowel obstruction and strangulation
• Restriction of lung expansion
• Hypoventilation
• Hypoxia
• Mediastinal shift
• Cardiac compromise
• Respiratory compromise

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Diaphragmatic Rupture Management

• Airway and ventilation
• High-concentration oxygen
• Positive-pressure ventilation if necessary
• Caution positive-pressure may worsen the injury
• CirculationIV access
• Nonpharmacologicaldo not place patient in
  Trendelenburg position

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Diaphragmatic Rupture Assessment Findings

• Tachypnea
• Tachycardia
• Respiratory distress
• Dullness to percussion
• Scaphoid abdomen (hollow or empty appearance)
• If a large quantity of the abdominal contents are
  displaced into the chest
• Bowel sounds in the affected hemithorax
• Decreased breath sounds on the affected side
• Possible chest or abdominal pain

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Who gets admitted?

• Sternal fractures, mediastinal injury
• Any 1st, 2nd, 3rd rib fractures
• gt 1 rib fracture in any region
• Pulmonary contusion
• Subcutaneous emphysema
• Traumatic asphyxia
• Flail segment
• Arrhythmia or myocardial injury

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In Closing

• Back to basicsABCDE
• If you suspect a major chest injury act swiftly
• Ask for assistance early
• Practice damage control when necessary
• Problems with drains? Read the manual or call
  your friendly trauma tream

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• QUESTIONS?