Objectives
• Describe chest wall trauma and concomitant injuries
• Compare and Contrast Standards of Care with Novel Pharmacologic Therapies
• Identify Indications, Advantages, and Disadvantages of Surgical Fixation of Fractured Ribs
Successful Completion
• To successfully complete this course, participants must attend the entire event and complete/submit the evaluation at the end of the session.
• Society of Trauma Nurses is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's Commission on Accreditation.
Protecting Important Structures
• Heart• Aorta and its branches• Pulmonary Artery• Vena Cava• Lungs• Trachea• Bronchi• Esophagus• Diaphragm
Lethal Injuries
AirwayAirway
O2/VentO2/Vent
HemorrhageHemorrhageCardiac FailureCardiac Failure
Cardiac TamponadeCardiac
Tamponade
Concomitant Injuries
• Simple pneumothorax• Tension Pneumothorax• Blunt cardiac injury• Pulmonary contusion• Aortic transection• Tracheobronchial injury• Livers Laceration• Kidney Laceration
• Hemothorax• Open pneumothorax• Traumatic Chylothorax• Cardiac Tamponade• Cardiac laceration• Ruptured diaphragm • Splenic Laceration
Case I – EMS call in
• 37 F• Motorcycle crash• Decreased breath sounds on right• Right knee deformity
Primary Survey
• A – Speaking, in cervical collar• B – Right sided crepitus, chest wall instability• C – palpable left radial pulse, HR 90, SBP 110, sat 96% on 2L, no gross hemorrhage
• D – GCS 15, PERRL, MAE• E – Road rash
Pain in trauma
TransductionTransduction TransmissionTransmission PerceptionPerception ModulationModulation
Pain• Opioids
– Morphine– Hydromorphone– Fentanyl
• Route– IV, PO, etc.– PCA
• With/without basal• AACA
• Non‐opioids– Regional blocks– Ketamine– Acetaminophen– NSAIDs, COX‐2 inhibitors– Gabapentin– Alpha‐2 agonists– Muscle relaxants– Transdermal Lidocaine– Non‐pharmacologic
Opioids
Advantages• Rapid• Effective• Numerous routes• Inexpensive
Limitations• Respiratory• CNS• GI• Heme• Derm• GU
Personally Controlled Analgesia
PCA• Saves time• Empowers patients• Provides data
AACA• Improves pain control• Saves time• Prevents higher doses
Ketamine
Category?• General anesthetic
Mechanism? Pd? Pk?• NMDA receptor antagonist• Onset: 30 seconds when IV• Duration: 5‐10 mins IV• Metabolized Hepatically
Ketamine
Adverse Reactions?• Emergence Reaction
Contraindications?• Schizophrenia• Age < 3 months• Elevated ICP?
Thoracic Epidural Anesthesia
Pros• Ease of placement• Effective• Can include personally
controlled component
Cons• Hemodynamics• Coagulopathy limitations• Sympathectomy• Mobility impairment
Intercostal Nerve Blocks
• Single injection vscontinuous
• Can be tedious• Not limited by anticoagulation
Truitt 2011
Non‐pharmacologic
• Heat• Ice• Reiki Therapy• Physical and Occupational Therapy• Repositioning• Distraction
Nursing ImplicationsNursing
Implications
Incentive SpirometryIncentive Spirometry
Out of bedOut of bed
PT/OTPT/OT
Chest PTChest PT
TheravestTheravest
TCDBTCDB
RibScore
6 or more rib fx 1 pointBilateral rib fx 1 pointFlail chest 1 point3 or more bicortical fx 1 point1st rib fx 1 point1 or more fx in each of 3 anatomic areas 1 point
Contraindications
Pulmonary Contusions?Pulmonary Contusions?
Severe Injuries?Severe Injuries? Instability?Instability?
Acute Resp. Failure?
Acute Resp. Failure? Infection?Infection?
Case I ‐ Rib Plating
• Hospital Day 2• Ribs 5‐9 plated through an 8 cm transverse thoracic incision
• Procedure time 1 hour 45 minutes• Extubated same day
Case II
• 71M Ped Struck• Polytrauma
• Ketamine infusion• AACA hydromorphone• Gabapentin• Transdermal lidoderm• Lidocaine infusion• Paravertebral blockade
Local Anesthetic Systemic Toxicity
Prodromal Symptoms
SeizuresLOCAgitation
CNSCNSHR changesEctopyST segment changes
Hypo/Hypertension
CVCV
Case III
• 85 yo female presents after choking on food• CPR with ROSC and normal MS• Extubated• Injuries: flail sternum, bilateral rib fractures of 2‐8
Take home messages
• Value the clinical exam• Advocate for our patients• Promote patient recovery• Provide multimodal pain therapy + regional blocks
• We need more data needed on SSRF, but early results promising
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