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CHEST TRAUMAHEST TRAUMAHEST TRAUMAHEST TRAUMAJoe Lex, MD, FAAEMoe Lex, MD, FAAEMTemple University Hospitalemple University Hospital
Philadelphia, PAhiladelphia, PAJuly 20uly 20 thh, 20062006
Joe Lex, MD, FAAEMoe Lex, MD, FAAEMTemple University Hospitalemple University HospitalPhiladelphia, PAhiladelphia, PAJuly 20uly 20 thh, 20062006
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Incidence of Chest TraumaIncidence of Chest Trauma
Incidence of Chest TraumaIncidence of Chest Trauma
1/4 American trauma deaths
Contributes to another 1 of 4
Many die after reaching hospital -preventable if recognized
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Pathophysiology of Chest TraumaPathophysiology of Chest Trauma
Pathophysiology of Chest TraumaPathophysiology of Chest Trauma
hypovolemia
ventilation-
perfusionmismatch
changes inintrathoracic
pressure
relationships
TISSUEHYPOXIA
Inadequate oxygendelivery to tissues
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Pathophysiology of Chest TraumaPathophysiology of Chest Trauma
Pathophysiology of Chest TraumaPathophysiology of Chest Trauma
Tissue hypoxia
Hypercarbia
Respiratory acidosis: inadequate ventilation
Metabolic acidosis: tissue hypoperfusion(e.g., shock)
Tissue hypoxia
Hypercarbia
Respiratory acidosis: inadequate ventilation
Metabolic acidosis: tissue hypoperfusion(e.g., shock)
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Blunt traumaBlunt trauma
Blunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Blunt traumaBlunt traumaBlunt traumaBlunt trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Splinter
Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma
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6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
sucking chest wound
Massive hemothorax Flail chest
Cardiac tamponade
Airway obstruction
Tension pneumothorax
Open pneumothorax
sucking chest wound
Massive hemothorax Flail chest
Cardiac tamponade
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6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats
Lung contusion
Heart contusion
Aorta rupture
Diaphragm rupture
Tracheobronchial tree injury -larynx, trachea, bronchus
Esophagus trauma
Lung contusion
Heart contusion
Aorta rupture
Diaphragm rupture
Tracheobronchial tree injury -larynx, trachea, bronchus
Esophagus trauma
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6 Other Frequent Injuries6 Other Frequent Injuries6 Other Frequent Injuries6 Other Frequent Injuries
Subcutaneousemphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures
Subcutaneousemphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures
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Primary SurveyPrimary SurveyPrimary SurveyPrimary Survey
Airway
Breathing
Circulation
Airway
Breathing
Circulation
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A = AirwayA = AirwayA = AirwayA = Airway
Assess for airway patency and airexchange - listen at nose & mouth
Assess for intercostal and supraclavicularmuscle retractions
Assess oropharynx for foreign body
obstruction
Assess for airway patency and airexchange - listen at nose & mouth
Assess for intercostal and supraclavicularmuscle retractions
Assess oropharynx for foreign body
obstruction
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B = BreathingB = BreathingB = BreathingB = Breathing
Assess respiratory movements and qualityof respirations look, listen, feel
Shallow respirations are early indicator ofdistress cyanosis is late
Assess respiratory movements and qualityof respirations look, listen, feel
Shallow respirations are early indicator ofdistress cyanosis is late
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C = CirculationC = CirculationC = CirculationC = Circulation
Assess pulses for quality, rate, regularity
Assess blood pressure and pulse pressure
Skin - look and feel for color,temperature, capillary refill
Look at neck veins - flat vs. distended
Cardiac monitor
Assess pulses for quality, rate, regularity
Assess blood pressure and pulse pressure
Skin - look and feel for color,temperature, capillary refill
Look at neck veins - flat vs. distended
Cardiac monitor
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Where can adults hide blood and goWhere can adults hide blood and go
into shock?into shock?Where can adults hide blood and goWhere can adults hide blood and go
into shock?into shock?
Chest: listen, do chest x-ray
Abdomen: do DPL or CT or US
Retroperitoneum: do CT
Thigh: physical examination
Street: ask paramedic...and in children, add
Head
Chest: listen, do chest x-ray
Abdomen: do DPL or CT or US
Retroperitoneum: do CT
Thigh: physical examination
Street: ask paramedic...and in children, add
Head
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Initial assessment and managementInitial assessment and managementInitial assessment and managementInitial assessment and management
Primary survey
Resuscitation of vital functions Detailed secondary survey
Definitive care
Primary survey
Resuscitation of vital functions Detailed secondary survey
Definitive care
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Initial assessment and managementInitial assessment and managementInitial assessment and managementInitial assessment and management
Hypoxia most serious problem: earlyinterventions aimed at reversing
Immediate life-threatening injuriestreated quickly and simply, usually withtube or a needle
Secondary survey guided by highsuspicion for specific injuries
Hypoxia most serious problem: earlyinterventions aimed at reversing
Immediate life-threatening injuriestreated quickly and simply, usually withtube or a needle
Secondary survey guided by highsuspicion for specific injuries
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ThoracotomyThoracotomyThoracotomyThoracotomy
Closed heart massage is ineffective in ahypovolemic patient
Left anterior thoracotomy with cross-clamping of descending thoracic aorta andopen-chest massage may be useful in
pulseless victim of penetrating trauma
Closed heart massage is ineffective in ahypovolemic patient
Left anterior thoracotomy with cross-clamping of descending thoracic aorta andopen-chest massage may be useful in
pulseless victim of penetrating trauma
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ThoracotomyThoracotomyThoracotomyThoracotomy
Emergency departmentthoracotomy for patientswithout cardiac activity who
are victims of blunt thoracicinjuries is ineffective
Emergency departmentthoracotomy for patientswithout cardiac activity who
are victims of blunt thoracicinjuries is ineffective
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ThoracotomyThoracotomyThoracotomyThoracotomy
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ThoracotomyThoracotomyThoracotomyThoracotomy
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ThoracotomyThoracotomyThoracotomyThoracotomy
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ThoracotomyThoracotomyThoracotomyThoracotomy
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6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
sucking chest wound
Massive hemothorax Flail chest
Cardiac tamponade
Airway obstruction
Tension pneumothorax
Open pneumothorax
sucking chest wound
Massive hemothorax Flail chest
Cardiac tamponade
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Airway obstruction at alveolar level:assessed and managed during 2o survey
Upper airway obstruction immediatelife threat which must be dealt with inprimary survey
Most common cause: patients tongue
Airway obstruction at alveolar level:assessed and managed during 2o survey
Upper airway obstruction immediatelife threat which must be dealt with inprimary survey
Most common cause: patients tongue
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Chin-lift: fingersunder mandible,
lift forward sochin is anterior
Chin-lift: fingersunder mandible,
lift forward sochin is anterior
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Jaw thrust: grasp angles of mandible andbring jaw forward
Jaw thrust: grasp angles of mandible andbring jaw forward
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Oropharyngealairway: insert into
mouth behind tongue DO NOT push tongue
further back
Oropharyngealairway: insert into
mouth behind tongue DO NOT push tongue
further back
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Nasopharyngealairway: gently
insert well-lubricated
trumpet
through nostril
Nasopharyngealairway: gently
insert well-lubricated
trumpet
through nostril
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Definitive Airway
Management: tubein trachea throughvocal cords with
balloon inflated
Definitive Airway
Management: tubein trachea throughvocal cords with
balloon inflated
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Orotracheal intubation
Nasotracheal intubation: in breathing
patient without major facial trauma
Surgical airways
jet insufflation
retrograde
cricothyrotomy
tracheostomy
Orotracheal intubation
Nasotracheal intubation: in breathing
patient without major facial trauma
Surgical airways
jet insufflation
retrograde
cricothyrotomy
tracheostomy
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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction
Jet insufflation adapters
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How to perform cricothyroidotomyHow to perform cricothyroidotomyHow to perform cricothyroidotomyHow to perform cricothyroidotomy
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Tension pneumothoraxTension pneumothoraxTension pneumothoraxTension pneumothorax
Air leak through lung or chest wall
One-way valve lung collapse
Mediastinum shifts to opposite side Inferior vena cava kinks on diaphragmdecreased venous return
cardiovascular collapse
Air leak through lung or chest wall
One-way valve lung collapse
Mediastinum shifts to opposite side Inferior vena cava kinks on diaphragmdecreased venous return
cardiovascular collapse
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Inferior vena cava
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Tension pneumothoraxTension pneumothoraxTension pneumothoraxTension pneumothorax
Tension pneumothorax is not an x-raydiagnosis it MUST be recognizedclinically
Treatment is decompression needle into2nd intercostal space of mid-clavicular line
- followed by thoracotomy tube
Tension pneumothorax is not an x-raydiagnosis it MUST be recognizedclinically
Treatment is decompression needle into2nd intercostal space of mid-clavicular line
- followed by thoracotomy tube
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Insert needle here
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Open pneumothoraxOpen pneumothoraxOpen pneumothoraxOpen pneumothorax
Sucking Chest Wound
Normal ventilation requires negative intra-
thoracic pressure
Large open chest-wall defectimmediate equilibration of intra-thoracic
and atmospheric pressures If hole >2/3 tracheal diameter, air prefers
chest defect
Sucking Chest Wound
Normal ventilation requires negative intra-
thoracic pressure
Large open chest-wall defectimmediate equilibration of intra-thoracic
and atmospheric pressures If hole >2/3 tracheal diameter, air prefers
chest defect
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Open pneumothoraxOpen pneumothoraxOpen pneumothoraxOpen pneumothorax
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Open pneumothoraxOpen pneumothoraxOpen pneumothoraxOpen pneumothorax
Initial treatment: seal defect and secureon three sides (total occlusion may lead to
tension pneumothorax Definitive repair of defect in O.R.
Initial treatment: seal defect and secureon three sides (total occlusion may lead to
tension pneumothorax Definitive repair of defect in O.R.
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Massive hemothoraxMassive hemothoraxMassive hemothoraxMassive hemothorax
Rapid accumulation of >1500 cc blood inchest cavity
Hypovolemia & hypoxemia
Neck veins may be:
Flat: from hypovolemia
Distended: intrathoracic blood
Absent breath sounds, DULL to percussion
Rapid accumulation of >1500 cc blood inchest cavity
Hypovolemia & hypoxemia
Neck veins may be:
Flat: from hypovolemia
Distended: intrathoracic blood
Absent breath sounds, DULL to percussion
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Massive hemothorax: treatmentMassive hemothorax: treatmentMassive hemothorax: treatmentMassive hemothorax: treatment
Large-bore (32 to 36 F) tube to drainblood
If moderate sized (500 to 1500 ml) andstops bleeding, closed drainage usuallysufficient
If initial drainage >1500 ml ORcontinuous bleeding >200 ml / hr, OPENTHORACOTOMY indicated
Large-bore (32 to 36 F) tube to drainblood
If moderate sized (500 to 1500 ml) andstops bleeding, closed drainage usuallysufficient
If initial drainage >1500 ml ORcontinuous bleeding >200 ml / hr, OPENTHORACOTOMY indicated
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Chest tube
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How to place a chest tubeHow to place a chest tubeHow to place a chest tubeHow to place a chest tube
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Pleural space
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l l hFl il h t
Fl il hFl il h t
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Flail chestFlail chestFlail chestFlail chest
Free-floating chestsegment, usually from
multiple ribs fractures Pain and restricted
movement paradoxical
movement of chest wallwith respiration
Free-floating chestsegment, usually from
multiple ribs fractures Pain and restricted
movement paradoxical
movement of chest wallwith respiration
Fl il hFl il h t
Fl il h tFl il h t
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Flail chestFlail chestFlail chestFlail chest
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Fl il t t t ( ld)Fl il t t t ( ld)
Fl il t t t ( ld)Fl il t t t ( ld)
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Flail treatment (old)Flail treatment (old)Flail treatment (old)Flail treatment (old)
Fl il t t t ( ld)Fl il t t t ( ld)
Fl il t t t ( ld)Fl il t t t ( ld)
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Flail treatment (old)Flail treatment (old)Flail treatment (old)Flail treatment (old)
Fl il t t tFl il t t t
Fl il t t tFl il t t t
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Flail treatmentFlail treatmentFlail treatmentFlail treatment
Ventilate well
Humidify oxygen
Resuscitate with fluids
Manage pain (!!)
Stabilize chest
Internal ventilator
External sand bags(rare)
Ventilate well
Humidify oxygen
Resuscitate with fluids
Manage pain (!!)
Stabilize chest
Internal ventilator
External sand bags(rare)
C di t dC di t d
C di t dC di t d
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Cardiac tamponadeCardiac tamponadeCardiac tamponadeCardiac tamponade
Usually from penetrating injuries
Classic Becks triad
elevated venous pressure - neck veins
decreased arterial pressure - BP
muffled heart sounds
Blood in sac
prevents cardiac
activity
Usually from penetrating injuries
Classic Becks triad
elevated venous pressure - neck veins
decreased arterial pressure - BP
muffled heart sounds
Blood in sac
prevents cardiac
activity
C di t dC di t d
C di t dCa diac tamponade
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Cardiac tamponadeCardiac tamponadeCardiac tamponadeCardiac tamponade
May find pulsus paradoxus - a decreaseof 10 mm Hg or greater in systolic BP
during inspiration Systolic to diastolic gradient of less than
30 mm Hg also suggestive
May find pulsus paradoxus - a decreaseof 10 mm Hg or greater in systolic BP
during inspiration Systolic to diastolic gradient of less than
30 mm Hg also suggestive
C di t dCa diac tamponade
C di t dCardiac tamponade
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Cardiac tamponadeCardiac tamponadeCardiac tamponadeCardiac tamponade
Treatment is removalof small amount of
blood 15 to 20 mlmay be sufficient from pericardial sac
Treatment is removalof small amount of
blood 15 to 20 mlmay be sufficient from pericardial sac
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Pericardiocentesis
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Stab wound toright ventricle
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pericardium
epicardial fat
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Ten-m inutebreakTen-m inutebreak
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The Flock of Birds
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behind the heart
Esophagoose
Azygoose v.
Vagoose n.
Thoracic duck
6 Potential Life Threats6 Potential Life Threats
6 Potential Life Threats6 Potential Life Threats
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6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats
Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture (TAR)
Traumatic diaphragmatic rupture
Tracheobronchial tree injury: larynx,trachea, bronchus
Esophageal trauma
Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture (TAR)
Traumatic diaphragmatic rupture
Tracheobronchial tree injury: larynx,trachea, bronchus
Esophageal trauma
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Pulmonary contusionPulmonary contusion
Pulmonary contusionPulmonary contusion
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Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion
Potentially life-threatening condition withinsidious onset
Parenchymal injury without laceration More than 50% will develop pneumonia,
even with treatment
Up to 50% have only hemoptysis aspresenting symptom
Potentially life-threatening condition withinsidious onset
Parenchymal injury without laceration More than 50% will develop pneumonia,
even with treatment
Up to 50% have only hemoptysis aspresenting symptom
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Pulmonary contusionPulmonary contusion
Pulmonary contusionPulmonary contusion
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Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion
Patients with pre-existing conditions(emphysema, renal failure) need early
intubation Treatment needs
to occur over time
as symptoms develop
Patients with pre-existing conditions(emphysema, renal failure) need early
intubation Treatment needs
to occur over time
as symptoms develop
Myocardial contusionMyocardial contusion
Myocardial contusionMyocardial contusion
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Myocardial contusionMyocardial contusionMyocardial contusionMyocardial contusion
Blunt precordial chesttrauma
Difficult to diagnose Risk for dysrhythmia,
sudden death,
tamponade,pericarditis,ventricular aneurysm
Blunt precordial chesttrauma
Difficult to diagnose Risk for dysrhythmia,
sudden death,
tamponade,pericarditis,ventricular aneurysm
Myocardial contusionMyocardial contusion
Myocardial contusionMyocardial contusion
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Myocardial contusionMyocardial contusionMyocardial contusionMyocardial contusion
Myocardial contusionMyocardial contusion
Myocardial contusionMyocardial contusion
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Myocardial contusionMyocardial contusionMyocardial contusionMyocardial contusion
Also may see:
myocardial concussion stunned
myocardium with no cell death coronary artery laceration
Diagnosis by:
trans-esophageal echocardiogram (TEE)
serial cardiac enzymes / markers
Also may see:
myocardial concussion stunned
myocardium with no cell death coronary artery laceration
Diagnosis by:
trans-esophageal echocardiogram (TEE)
serial cardiac enzymes / markers
Myocardial contusionMyocardial contusion
Myocardial contusionMyocardial contusion
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Myocardial contusionMyocardial contusionMyocardial contusionMyocardial contusion
Question: Does it matter?
New nomenclature: Anterior Chest Wall
Syndrome
Question: Does it matter?
New nomenclature: Anterior Chest Wall
Syndrome
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Traumatic aortic ruptureTraumatic aortic rupture
Traumatic aortic ruptureTraumatic aortic rupture
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Traumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic rupture
90% or more dead at scene
90% mortality each undiagnosed day
Must have high index of suspicion
Disruption occurs at ligamentumarteriosum (ductus arteriosus)
Contained hematoma of 500 to 1000 mlof blood
90% or more dead at scene
90% mortality each undiagnosed day
Must have high index of suspicion
Disruption occurs at ligamentumarteriosum (ductus arteriosus)
Contained hematoma of 500 to 1000 mlof blood
Traumatic aortic ruptureTraumatic aortic rupture
Traumatic aortic ruptureTraumatic aortic rupture
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Traumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic rupture
Radiographic signs
Wide mediastinum
(>8cm) Fractured 1st & 2nd rib
Obliterated aorticknob
Trachea deviated toright
Pleural cap
Radiographic signs
Wide mediastinum
(>8cm) Fractured 1st & 2nd rib
Obliterated aorticknob
Trachea deviated toright
Pleural cap
Elevated mainstembronchus with shift toright
Obliterated aorticwindow
Esophagus shifted to
right (NG at T4) Depressed left
mainstem bronchus
Elevated mainstembronchus with shift toright
Obliterated aorticwindow
Esophagus shifted to
right (NG at T4) Depressed left
mainstem bronchus
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dye leakage
Traumatic aortic ruptureTraumatic aortic rupture
Traumatic aortic ruptureTraumatic aortic rupture
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Traumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic rupture
CT becoming imaging of choice
Must know site!
NPV of normal chest x-ray (good quality,upright): 98% (CT will find mediastinalhemorrhage in 3%, TAR in 0.4%)
78% of patients with post-traumatic widemediastinum on chest film have normalCT
CT becoming imaging of choice
Must know site!
NPV of normal chest x-ray (good quality,upright): 98% (CT will find mediastinalhemorrhage in 3%, TAR in 0.4%)
78% of patients with post-traumatic widemediastinum on chest film have normalCT
Traumatic aortic ruptureTraumatic aortic rupture
Traumatic aortic ruptureTraumatic aortic rupture
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Traumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic rupture
Treatment -SURGICAL REPAIR
Treatment -SURGICAL REPAIR
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Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture
Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture
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Traumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureTraumatic diaphragmatic rupture
Blunt trauma: tears leading to immediateherniation
Penetrating trauma: small tears whichmay take years to develop herniation
Usually on left side
Blunt trauma: tears leading to immediateherniation
Penetrating trauma: small tears whichmay take years to develop herniation
Usually on left side
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Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture
Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture
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Traumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureau at c d ap ag at c uptu e
Treatment: surgical repair Treatment: surgical repair
Tracheobronchial tree injuryTracheobronchial tree injury
Tracheobronchial tree injuryTracheobronchial tree injury
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Tracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injury
Larynx - rare
Hoarseness
Subcutaneous emphysema
Palpable crepitus
Intubation may be difficult: tracheostomy
(not cricothyroidotomy) is treatment ofchoice
Larynx - rare
Hoarseness
Subcutaneous emphysema
Palpable crepitus
Intubation may be difficult: tracheostomy
(not cricothyroidotomy) is treatment ofchoice
Tracheobronchial tree injuryTracheobronchial tree injury
Tracheobronchial tree injuryTracheobronchial tree injury
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Tracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injury
Trachea
Blunt or penetrating
Esophagus, carotidartery and jugular
vein may be involved
Noisy breathing partial airway
obstruction
Trachea
Blunt or penetrating
Esophagus, carotidartery and jugular
vein may be involved
Noisy breathing partial airway
obstruction
Tracheobronchial tree injuryTracheobronchial tree injury
Tracheobronchial tree injuryTracheobronchial tree injury
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Tracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injury
Bronchus
1.5% blunt chest
trauma 80% due to
BLUNT trauma
within one inch ofcarina (tethered)
Bronchus
1.5% blunt chest
trauma 80% due to
BLUNT trauma
within one inch ofcarina (tethered)
Esophageal traumaEsophageal trauma
Esophageal traumaEsophageal trauma
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Esophageal traumaEsophageal traumaEsophageal traumaEsophageal trauma
Penetrating > blunt
Lethal if not recognized
High suspicion if
left pneumothorax and hemothoraxwithout rib fracture
shock out of proportion to apparent bluntchest trauma
particulate matter in chest tube
Penetrating > blunt
Lethal if not recognized
High suspicion if
left pneumothorax and hemothoraxwithout rib fracture
shock out of proportion to apparent bluntchest trauma
particulate matter in chest tube
Esophageal traumaEsophageal trauma
Esophageal traumaEsophageal trauma
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Esophageal traumaEsophageal traumaEsophageal traumasop agea t au a
Esophageal traumaEsophageal trauma
Esophageal traumaEsophageal trauma
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Esophageal traumasop agea t au aEsophageal traumap g
Blunt trauma,most tears
superiorIf low esophagus leakage ofstomach contentsinto mediastinum
Blunt trauma,most tears
superiorIf low esophagus leakage of
stomach contentsinto mediastinum
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6 Other Frequent Injuries6 Other Frequent Injuries
6 Other Frequent Injuries6 Other Frequent Injuries
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6 Other Frequent Injuriesq j6 Ot e eque t ju esq j
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture Rib fractures
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture Rib fractures
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Subcutaneous emphysemaSubcutaneous emphysema
Subcutaneous emphysemaSubcutaneous emphysema
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ub u a ou p y ap yp yp y
Rice Krispies
May result from
airway injury lung injury
blast injury
No treatmentrequired address underlying problem
Rice Krispies
May result from
airway injury lung injury
blast injury
No treatmentrequired address underlying problem
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Traumatic asphyxiaTraumatic asphyxia
Traumatic asphyxiaTraumatic asphyxia
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p yp yp yp y
Purple face fromextravasation of blood
(Masqueecchymotique)
Major damage is to
underlying structures Purple face fades over
time in survivors
Purple face fromextravasation of blood
(Masqueecchymotique)
Major damage is to
underlying structures Purple face fades over
time in survivors
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Simple pneumothoraxSimple pneumothorax
Simple pneumothoraxSimple pneumothorax
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p pp pp pp p
Air enters potential space betweenvisceral and parietal pleura
Breath sounds down on affected side Percussion hyper-resonance
Treatment: chest tube in 4th or 5th
intercostal space anterior to mid-axillaryline
Air enters potential space betweenvisceral and parietal pleura
Breath sounds down on affected side Percussion hyper-resonance
Treatment: chest tube in 4th or 5th
intercostal space anterior to mid-axillaryline
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Medialpneumothorax
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Pocket shooter
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HemothoraxHemothorax
HemothoraxHemothorax
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Lacerated lung OR disrupted intercostalartery or internal mammary artery
Most are self-limiting Surgical consultation if
initial drainage of >20 cc/kg (~1500 cc)
continued flow of >200 cc/hr
Lacerated lung OR disrupted intercostalartery or internal mammary artery
Most are self-limiting Surgical consultation if
initial drainage of >20 cc/kg (~1500 cc)
continued flow of >200 cc/hr
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Scapula fracturesScapula fractures
Scapula fracturesScapula fractures
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p
Fractured scapulaor 1st & 2nd ribs
indicates majormechanism ofinjury; consider
underlyingdamage
Fractured scapulaor 1st & 2nd ribs
indicates majormechanism ofinjury; consider
underlyingdamage
Rib fracturesRib fractures
Rib fracturesRib fractures
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Most frequent thoracic cage injury
Most commonly injured: 4th 9th
If 10th/ 11th/ 12th suspect liver or spleeninjury
If 1st/ 2nd/ 3rdworry about injury to head,
neck, spinal cords, lungs, great vessels
Most frequent thoracic cage injury
Most commonly injured: 4th 9th
If 10th/ 11th/ 12th suspect liver or spleeninjury
If 1st/ 2nd/ 3rdworry about injury to head,
neck, spinal cords, lungs, great vessels
Rib fractures treatmentRib fractures treatment
Rib fractures treatmentRib fractures treatment
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Intercostal blocks
Epidural anesthesia
Systemic analgesicsDo not use
taping
rib belts
external splints
Intercostal blocks
Epidural anesthesia
Systemic analgesicsDo not use
taping
rib belts
external splints
Rib fracturesRib fractures
Rib fracturesRib fractures
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Ribs x-rays
are expensive
are inaccurate for diagnosis (~50%sensitivity)
add nothing to treatment
require painful positioning of the patient
are, in general, not useful
Ribs x-rays
are expensive
are inaccurate for diagnosis (~50%sensitivity)
add nothing to treatment
require painful positioning of the patient
are, in general, not useful
In conclusion...In conclusion...
In conclusion...In conclusion...
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Chest trauma is common in themultiply-injured patient
Most conditions can be treated by theevaluating physician and do notrequire emergent thoracotomy
Airway management and ajudiciously placed needle can savemany lives
Chest trauma is common in themultiply-injured patient
Most conditions can be treated by theevaluating physician and do notrequire emergent thoracotomy
Airway management and ajudiciously placed needle can savemany lives
Next timeNext time
Next timeNext time
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February 27th, 2004February 27th, 2004
RespiratoryRespiratoryEmergenciesEmergencies
Joe LexJoe Lex
February 27th, 2004February 27th, 2004
RespiratoryRespiratoryEmergenciesEmergencies
Joe LexJoe Lex