Approach to Chest Trauma Mary Osinga Comprehensive Review

Approach to Chest Trauma Mary Osinga Comprehensive Review Fleming College

Traumatic Injuries Airway injuries n Chest and Breathing n Circulation – shock n Disability – neurological n E- expose and extremity n

Airway Problems Problem in trauma is that the airway may not look or behave as normal n Forces onto the head and/or neck may provide significant changes to the anatomy of the airway n Lets review normal airway anatomy n

Normal airway

Abnormal Airway n n Edema Presence of fluid Loss of bony structure integrity Foreign objects

Airway management Use a modified jaw thrust to avoid C spine displacement n Watch for nasal airway insertion in patients with…. ? n Oral airways in patients GCS<8 n Suction blood and secretions, remember patients supine on board n Watch for vomiting –beer and pizza n

Chest Trauma

Introduction Chest trauma is often sudden and dramatic n Accounts for 25% of all trauma deaths n 2/3 of deaths occur after reaching hospital n Serious pathological consequences: -hypoxia, hypovolemia, myocardial failure n

Mechanism of Injury Penetrating injuries E. g. stab wounds etc. n Primarily peripheral lung n Haemothorax n Pneumothorax n Cardiac, great vessel or oesophageal injury n

Blunt injuries Either: - direct blow (e. g. rib fracture) - deceleration injury or - compression injury n Rib fracture is the most common sign of blunt thoracic trauma n Fracture of scapula, sternum, or first rib suggests massive force of injury n

Deadly Dozen from ITLS Airway obstruction n Open Pneumo n Flail Chest n Tension Pneumo n Massive Hemothorax n Cardiac Tamponade n Detected in the primary survey

Deadly Dozen from ITLS Myocardial contusion n Traumatic aortic rupture n Tracheal bronchial tear n Diagphragmatic injury n Esophageal injury n Pulmonary contusion n Detected in the secondar survey

Mechanism!

Chest wall injuries n Rib fractures n Flail chest n Open pneumothorax

Rib fractures Most common thoracic injury n Localised pain, tenderness, crepitus n CXR to exclude other injuries n Analgesia. . avoid taping n Underestimation of effect n Upper ribs, clavicle or scapula fracture: suspect vascular injury n

Flail chest Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration n 2 or more ribs in 2 or more places n Significant force required n Palpate carefully and laterally n Rx: ABC s and analgesia n +/- splint the flail segment n

Flail chest

Flail Chest - detail

Lung injury Pulmonary contusion n Pneumothorax n Haemothorax n Parenchymal injury n Trachea and bronchial injuries n Pneumomediastinum n

Open pneumothorax Defect in chest wall provides a direct communication between the pleural space and the environment n Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax n “Sucking chest wound” n Rx: ABCs…closure of wound…chest drain n

Pneumothorax Air in the pleural cavity n Blunt or penetrating injury that disrupts the parietal or visceral pleura n Unilateral signs: movement and breath sounds, resonant to percussion n Confirmed by CXR n Rx: chest drain n

Pneumothorax

Tension pneumothorax Air enters pleural space and cannot escape n P/C: chest pain, dyspnoea n Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension n

n Surgical emergency n Needle decompression required-ACP n In hospital-Either large bore cannula in 2 nd ICS, MCL or insert chest tube n Reassess post needle

Hemothorax Blunt or penetrating trauma n Requires rapid decompression and fluid resuscitation n May require surgical intervention n Clinically: hypovolemia absence of breath sounds dullness to percussion n Can lose entire blood volume in chest n

Knife wound

Some problems with Hemothorax Significant blood loss-how much? n Atelactasis n V/Q Mismatch n So what problems can your patients have? n

Heart, Aorta & Diaphragm Blunt cardiac injury - contusion - ventricular, septal or valvular rupture n Cardiac tamponade n Ruptured thoracic aorta n Diaphragmatic rupture n

Cardiac Tamponade Blood in the pericardial sac n Most frequently penetrating injuries n Shock, JVP, PEA, pulsus paradoxus n Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension n Rx: Volume resuscitation Pericardiocentesis n

Cardiac tamponade

Aortic rupture Usually blunt trauma involving deceleration forces; n ~90% die within minutes n Most common site near ligamentum arteriosum n Treat like an aneurysm if still alive, blunt trauma VSA if dead (? pronounce) n Rx: surgical…poor prognosis n

Aortic rupture

Ruptured Hemi diaphragm Etiology? n Side? ? n Outcome n Diagnosis- how can you tell? ? n Treatment? n

Chest trauma: summary Common n Serious n Primary goal is to provide oxygen to vital organs n Remember Airway Breathing Circulation n Be alert to change in clinical condition n

Chest Trauma Identify early n Rapid transport n Auscultate frequently n Consider tertiary care centre n Watch for shock and treat n – IV fluids (bolus is…? ) – Large bore IV’s – Trendelenberg