TCAR

mortality rate off tension pneumothorax

100% of patients will die w/o intervention

how much blood can be in one hemothroax

500 - 3L

important thing to remember when you are evaluating a patient for pulmonary contusions

70% of pulmonary contusions aren't initial on the initial CXR

Q - in a pneumothorax, no ligaments attach the lung to the wall. so what holds it up?

A - a thin layer of pleural fluid & negative pressure. the liquid helps it stick like how a spilled liquid forms a seal between a glass and a smooth table top

parameters to assess ventilation

ETCO2, PaCO2, clinical assessment

% blood loss that is tolerable versus not tolerable

most people can tolerate a 10% blood volume loss but most can't tolerate 40%

what is the significance of posterior rib fractures

unusual direction of injury shorter stubby ribs good muscle profection **posterior rib fractures have a lot of force so need a high dose. ***PRF need a lot of force so high dose of energy. big red flag for t-spine injury

primary goal of GSW surgery

usually damage repair & not bullet removal -if superficial, it may migrate the surface with time

effect of tension pneumothorax on heart function

increases intrathoracic pressure decreases preload/CO increases afterload

how to convert a tension pneumothorax to a simple pneumo

"needle D"

needle "d" for tension pneumo

"pop the bubble" with needle/finger. to restore CO. life saving

definition of flail chest

+2 adjacent rib fracture free floating sternum

3 questions to ask in trauma

-what was the dose of energy? -where did it go? -what injuries are likely?

considered too much chest tube drainage

1-1.5L at initial palcement 50-200ml over 2-4hrs

problem of using CXR as a definitive clinical dx tool

CXR may lag behind clinical status *b/c 70% of pulmonary contusions aren't present on initial CXR. they "blossom" over time

IVF in hemorrhage

IVF is not a substitution for aggressive hemorrhage control and can be harmful

definitive bleeding management

OR

tension pnumothorax

air enters under pressure but doesn't exit at the same rate. = accumulation of air under pressure

intrathroacic pressure in simple pneumothorax

air that enters the pleural cavity leaves at the same rate lungs are deflated but no increase in pressure air in/out at the same rate

all contusions over time

all contusions "blossom" over time. the full extent of the injury is not initially apparent

best parameter of serial monitoring for pt's who have risk factors for pulmonary contusions

anticipate "blossoming" over time b/c 70% of pulmonary contusions aren't present on the initial CXR P:F ratio

what is a simple pneumothorax

any air that enters the pleural cavity can also leave at the same rate. lungs deflated but no increase in intrathroacic pressure. air in/out exits at the same rate. pt might be able to tolerate a simple pneumothraox causes a problem at the ventilation point at the tissue oxygen cascade

benefit of chest tube in trauam

autotransufsion

why is flail chest a problem

b/c breathing is a mechanical process

what happens to the lungs in pulmonary contusions

big boggy bruise on the lungs diffusion problems when it becomes contused & edematous, it becomes difficult for oxygen to move from the alveoli into the capillaries

how to tell if something is blood or air on a CXR

blood = white black = air

what type of injuries occur when the lungs are subjected to force?

bruise = contusion tear = lacerations pop = punctures inhalation injury

c spine versus t spine fractures

c-spine doesn't need a big energy blow. just some shaking around t-spine needs a great strong direct blow (not just a shock_

aka diameter of a bullet

caliber

2 q's to ask in GSW

caliber type of gun # of entrance/exit wounds high/low velocity

risk of rib fractures

can puncture liver, spleen,, diaphragm pop lungs

coagulopathy control in hemorrhage

can't clot if we only give RBC/crystallids needs plasma, cry, plt

what attaches the ribs to the sternum

cartliage

aka chest tube

chest thoacotomy

keeps blood in blood products from clotting

citrate

added to blood products that may cause low Ca

citrate.

what should you monitor when a pt has trauma to the throax

closely monitor for pulmonary contustiobs = 70% not present on the initial CXR and "blossom" over time -monitor for progress e deterioration in hours/days post injury *might look ok in ER

assessment of the site of a chest tube site

consider how it might be a potential site of an open pneumo

purpose of "needle d"

convert tension pneumo to a simple pneumo. then put in chest tube

how to tell a pt has a pneumonia from a CXR

dark spot that is not equal to the opposite side

what is the caliber of a bullet?

diameter

where on the tissue oxygenation cascade do pulmonary contusions cause their problems

diffusion

+2 adjacent rib fractures

flail chest

free floating sternum

flail chest

field care for bleeding management

helping blood loss > replacing fludis

cause of 30 - 40% of all patients who die of trauma

hemorrhage

leading cause of early mortality in trauma

hemorrhage

hemothorax causes problems at what point of the tissue oxygen cascade

hgb availability ventilation issue b/c lung collapses CO problem if enough blood is lost small venin/arteries below each fib so a broken rib could cause hemothraox bleeding from intercostal vessels should not be extensive and taper off quickly so continuous bleeding is likely a different vessel

causes of pulmonary contusions

high speed blunt or penetrating injury

too much black on CXR

hyperlucency

paradoxical chest movements

in flail chest

why is it important to keep a hemorrhage pt warm

keep a trauma pt warm helps stop bleeding b/c you can't clot well if cold

treatment for rib fractures

largely supportive nursing care like pulmonary toilet

when do you get tracheal deviation

late sign of tension pneumothrax

how high does the diaphragm rise on inspiration

level of 4th ICS

example of tension pneumothorax

like using a bicycle pump to put more and more air into the lungs over time. no escape *pressure means no lung function on the side of the injury and compromises function on the un injured heart and great vessel compression (decreases preload/CO increases afterload

consider if a pt has a lower rib fracture

liver & spleen injury acts like BBQ/marshmellow skewers

late s/s of tension pneumothrax

low bp JVD tracheal deviation

what happens in penumothorax

lungs are collapsed/deflated aire enters space between the visceral & parietal

intervention if hemothorax

needs CT later will need intrapleura tPA or VATS

intervention if you suspect tension pneumothrax

needs FAST do immediate needle D w/o imaging

normal pressure in the vena cavas

normally is low similar to the central venous pressure which is similar to right atrial pressure (2-8mm hg) so very little increase in pressure to impede venous return to the heart

when isn't JVD & tracheal deviation obvious in tension pneumothroax

not obvious if obese, low bp, cervical collar also - it is a super late s/s

open pneumothorax

object penetrates or a rib pokes out

identify a previous rib fracture on CXR

once healed, rib fractures form bony callouses and become more visible on CXR

pleuritic chest pain

pain with breathing

s/s of flail chest

paradoxical chest wall movement

chest pain w/breathign

pleuritic

assessment of t. pneumothraox

pleuritic chest pain (hurts to breathe) respiratory distress increased HR hyppoxemia agitation decreased LS chest dyspmetry hyperresonance

considerations of chest trauma

pneumonia, great vessel trauma, pressure so low CO

what can rapidly convert a simple pneumothorax to a tension pneumothraox

positive pressure can rapidly convert a simple pneumothorax to a tension pneumothorax (BVM or m. ventilation) or if a chest tube is kinked/clamped/occluded

what happens to projectiles when they enter the body

projectiles don't travel in a straight line consider temporary cavity wound

bruise on the lungs

pulmonary contusion

tear in lung tissue

pulmonary laceration

ribs that are the most frequently broken

ribs 4-9 b/c long, thin, and poorly protecte it is harder to break a short pencil (T1-2) and easier to break a longer one *ask how many and where to understand the force involved

problem of pulmonary lacerations

risk of massive hemothoax b/c those vessels are very vascular

what breaks thoracic bones

significant force -1-2nd ribs, posterior ribs, sternum, scapulae, T2-10 gives us info about the force aka "dose" of energy received consider injury to internal structures b/c force

CXR and rib fractures

simple rib fractures are difficult to see on CXR and can be commonly missed (1/2 of all rib fractures aren't identified at the POI CXR)

aka brestbone

sternum

priority in bleeding episodes

stop bleeding CABC

what should you consider about tissue a projectile enounters

temporary cavitation

why is tension pneumothorax more life threatening than simple pneumothorax

tension pneuma is more life threatening than simple b/c of the pressure it puts on the great vessels so decreased CO

important thing to remember about retained projectiles

they may migrate over time. bullett migration might explain unexplained clinical findings (VP Cheney accidentally shot his friend while hunting in 2006. ICU and did great. moved to an inpatient unit. had a silent MI bc a shot gun pellets migrated into a canary artery causing an infract. so had a MI but fibrinolytic not the answer in this case b/c it was a "projectile embolus"

purpose of using a chest tube in simple pneumothorax

to allow for negative pressure to reestablish .

indication of c-spine injury

to injure c-spine, you don't need a big energy blow. all it takes is shaking around.

where is the problem in the tissue oxygenation cascade in simple pneumothroax

ventilation

where on the tissue oxygenation cascade is thoracic cage fractures a problem

ventilation

what part on the tissue oxygenation cascade is affected by tension pneumothorax

ventilation r/t collapsed lung CO b/c pressure

VATS

video-assisted thoracic surgery

two layers of the lungs

visceral & parietal

purpose of citrate in blood products

w/o citrate, blood will clot

1st question to ask in any traumatic injury?

what was the dose of energy involved? (was it high or low?)

when is a hospitalized chest patient the most likely to develop tension pneumothrax

when we initiate positive pressure ventilation

intervention for an ope. pneumothroax

xeroform, gasoline bandage, chest seal.