Approach to Chest TraumaApproach to Chest Trauma

Mary OsingaMary Osinga

Comprehensive ReviewComprehensive Review

Fleming CollegeFleming College

Traumatic InjuriesTraumatic Injuries

Airway injuriesAirway injuries Chest and BreathingChest and Breathing Circulation – shockCirculation – shock Disability – neurologicalDisability – neurological E- expose and extremityE- expose and extremity

Airway ProblemsAirway Problems

Problem in trauma is that the Problem in trauma is that the airway may not look or behave as airway may not look or behave as normalnormal

Forces onto the head and/or neck Forces onto the head and/or neck may provide significant changes to may provide significant changes to the anatomy of the airwaythe anatomy of the airway

Lets review normal airway Lets review normal airway anatomyanatomy

Normal Normal airwayairway

Abnormal AirwayAbnormal Airway

EdemaEdema Presence of fluidPresence of fluid Loss of bony Loss of bony

structure integritystructure integrity Foreign objectsForeign objects

Airway managementAirway management

Use a modified jaw thrust to avoid C Use a modified jaw thrust to avoid C spine displacementspine displacement

Watch for nasal airway insertion in Watch for nasal airway insertion in patients with….?patients with….?

Oral airways in patients GCS<8Oral airways in patients GCS<8 Suction blood and secretions, Suction blood and secretions,

remember patients supine on boardremember patients supine on board Watch for vomiting –beer and pizzaWatch for vomiting –beer and pizza

Chest TraumaChest Trauma

IntroductionIntroduction

Chest trauma is often sudden and Chest trauma is often sudden and dramaticdramatic

Accounts for 25% of all trauma deathsAccounts for 25% of all trauma deaths 2/3 of deaths occur after reaching 2/3 of deaths occur after reaching

hospitalhospital Serious pathological consequences:Serious pathological consequences:

-hypoxia, hypovolemia, myocardial-hypoxia, hypovolemia, myocardial failure failure

Mechanism of InjuryMechanism of Injury

Penetrating injuriesPenetrating injuries E.g. stab wounds etc.E.g. stab wounds etc. Primarily peripheral lungPrimarily peripheral lung HaemothoraxHaemothorax PneumothoraxPneumothorax Cardiac, great vessel or Cardiac, great vessel or

oesophageal injuryoesophageal injury

Either:Either: - direct blow (e.g. - direct blow (e.g. rib fracture)rib fracture) - deceleration injury - deceleration injury oror - compression - compression injuryinjury

Rib fracture is the most common sign Rib fracture is the most common sign of blunt thoracic traumaof blunt thoracic trauma

Fracture of scapula, sternum, or first Fracture of scapula, sternum, or first rib suggests massive force of injuryrib suggests massive force of injury

Blunt injuriesBlunt injuries

Deadly Dozen from ITLSDeadly Dozen from ITLS

Airway obstructionAirway obstruction Open PneumoOpen Pneumo Flail ChestFlail Chest Tension PneumoTension Pneumo Massive HemothoraxMassive Hemothorax Cardiac TamponadeCardiac Tamponade

Detected in the primary survey

Deadly Dozen from ITLSDeadly Dozen from ITLS

Myocardial contusionMyocardial contusion Traumatic aortic ruptureTraumatic aortic rupture Tracheal bronchial tearTracheal bronchial tear Diagphragmatic injuryDiagphragmatic injury Esophageal injuryEsophageal injury Pulmonary contusionPulmonary contusion

Detected in the secondary survey

MechanismMechanism!!

Chest wall injuries Chest wall injuries

Rib fractures Rib fractures

Flail chestFlail chest

Open pneumothoraxOpen pneumothorax

Rib fracturesRib fractures

Most common thoracic injuryMost common thoracic injury Localised pain, tenderness, crepitusLocalised pain, tenderness, crepitus CXR to exclude other injuriesCXR to exclude other injuries Analgesia..avoid tapingAnalgesia..avoid taping Underestimation of effectUnderestimation of effect Upper ribs, clavicle or scapula Upper ribs, clavicle or scapula

fracture: suspect vascular injuryfracture: suspect vascular injury

Flail chestFlail chest

Multiple rib fractures produce a Multiple rib fractures produce a mobile fragment which moves mobile fragment which moves paradoxically with respirationparadoxically with respiration

2 or more ribs in 2 or more places2 or more ribs in 2 or more places Significant force requiredSignificant force required Palpate carefully and laterallyPalpate carefully and laterally Rx: ABCRx: ABC s and analgesias and analgesia +/- splint the flail segment+/- splint the flail segment

Flail chestFlail chest

Flail Chest - detail

Lung injuryLung injury

Pulmonary contusionPulmonary contusion Pneumothorax Pneumothorax HaemothoraxHaemothorax Parenchymal injuryParenchymal injury Trachea and bronchial injuriesTrachea and bronchial injuries PneumomediastinumPneumomediastinum

Open pneumothoraxOpen pneumothorax Defect in chest wall provides a direct Defect in chest wall provides a direct

communication between the pleural communication between the pleural space and the environmentspace and the environment

Lung collapse and paroxysmal shifting Lung collapse and paroxysmal shifting of mediastinum with each respiratory of mediastinum with each respiratory effort ± tension pneumothoraxeffort ± tension pneumothorax

““Sucking chest wound”Sucking chest wound” Rx: ABCs…closure of wound…chest Rx: ABCs…closure of wound…chest

drain drain

PneumothoraxPneumothorax

Air in the pleural cavityAir in the pleural cavity Blunt or penetrating injury that Blunt or penetrating injury that

disrupts the parietal or visceral pleuradisrupts the parietal or visceral pleura Unilateral signs: Unilateral signs: movement and movement and

breath sounds, resonant to percussionbreath sounds, resonant to percussion Confirmed by CXRConfirmed by CXR Rx: chest drainRx: chest drain

PneumothoraxPneumothorax

Tension pneumothorax Tension pneumothorax

Air enters pleural space and cannot Air enters pleural space and cannot escapeescape

P/C: chest pain, dyspnoeaP/C: chest pain, dyspnoea Dx: - respiratory distress Dx: - respiratory distress

- tracheal deviation (away) - tracheal deviation (away) - absence of breath - absence of breath

soundssounds - distended neck - distended neck veinsveins - hypotension - hypotension

Surgical emergencySurgical emergency

Needle decompression required-ACPNeedle decompression required-ACP

In hospital-Either large bore cannula In hospital-Either large bore cannula

in 2nd ICS, MCL or insert chest tubein 2nd ICS, MCL or insert chest tube

Reassess post needleReassess post needle

HemothoraxHemothorax

Blunt or penetrating traumaBlunt or penetrating trauma Requires rapid decompression and Requires rapid decompression and

fluid resuscitationfluid resuscitation May require surgical interventionMay require surgical intervention Clinically: hypovolemiaClinically: hypovolemia

absence of breath sounds absence of breath sounds dullness to percussion dullness to percussion

Can lose entire blood volume in chestCan lose entire blood volume in chest

Knife woundKnife wound

Some problems with Some problems with HemothoraxHemothorax

Significant blood loss-how much?Significant blood loss-how much? AtelactasisAtelactasis V/Q MismatchV/Q Mismatch So what problems can your So what problems can your

patients have?patients have?

Heart, Aorta & DiaphragmHeart, Aorta & Diaphragm

Blunt cardiac injuryBlunt cardiac injury- contusion- contusion- ventricular, septal or valvular - ventricular, septal or valvular

rupture rupture Cardiac tamponade Cardiac tamponade Ruptured thoracic aortaRuptured thoracic aorta Diaphragmatic ruptureDiaphragmatic rupture

Cardiac TamponadeCardiac Tamponade Blood in the pericardial sac Blood in the pericardial sac Most frequently penetrating injuriesMost frequently penetrating injuries Shock, Shock, JVP, PEA, pulsus paradoxusJVP, PEA, pulsus paradoxus Classically, Beck’s triad:Classically, Beck’s triad:

- distended neck veins- distended neck veins- muffled heart sounds- muffled heart sounds

- hypotension- hypotension Rx: Volume resuscitationRx: Volume resuscitation

Pericardiocentesis Pericardiocentesis

Cardiac Cardiac tamponadetamponade

Aortic ruptureAortic rupture

Usually blunt trauma involving Usually blunt trauma involving deceleration forces; deceleration forces;

~90% die within minutes~90% die within minutes Most common site near ligamentum Most common site near ligamentum

arteriosumarteriosum Treat like an aneurysm if still alive, Treat like an aneurysm if still alive,

blunt trauma VSA if dead (?pronounce)blunt trauma VSA if dead (?pronounce) Rx: surgical…poor prognosisRx: surgical…poor prognosis

Aortic ruptureAortic rupture

Ruptured Hemi diaphragmRuptured Hemi diaphragm

Etiology? Etiology? Side??Side?? OutcomeOutcome Diagnosis- how can you tell??Diagnosis- how can you tell?? Treatment?Treatment?

Chest trauma: summaryChest trauma: summary CommonCommon SeriousSerious Primary goal is to provide oxygen Primary goal is to provide oxygen

to vital organsto vital organs RememberRemember

AAirwayirwayBBreathingreathing

CCirculationirculation Be alert to change in clinical Be alert to change in clinical

condition condition

Chest TraumaChest Trauma Identify earlyIdentify early Rapid transportRapid transport Auscultate frequentlyAuscultate frequently Consider tertiary care centreConsider tertiary care centre Watch for shock and treat Watch for shock and treat

– IV fluids (bolus is…?)IV fluids (bolus is…?)– Large bore IV’sLarge bore IV’s– TrendelenbergTrendelenberg