Thoracic Trauma
Beck's triad
Associated w/ Cardiac Tamponade -Hypotension - JVD - Muffled heart sounds
Sternal, Scapular, Clavicular Fxs diagnostics
CXR CT Chest
Rib fxs diagnostics
CXR CT chest
Simple PTX Diagnostics
CXR (frequently missed due to diffuse distribution of air over anterior chest on supine film) CT (gold standard)
About 85% of patients w/ thoracic injuries only require ______, ______, and ______.
chest tube, observation, and pain management
Traumatic Diaphragmatic Injury occurs on right or left side in 65-80% cases
left b/c of the protective effect of the liver on the right side (if right hemidiaphragmatic injury is present, suspect liver injury
MOI Massive HTX
penetrating trauma
Pulmonary contusion (in children)
pulmonary contusion may be isolated w/o rib fxs due to resiliency of the chest wall
Sternal flail chest
separation of the sternum from adjacent broken ribs or costochondral joints
pericardiocentesis
surgical puncture to aspirate fluid from the sac surrounding the heart - can be performed as a temporary intervention until pericardial window is performed - 16 or 18g into the left side of xiphoid ("popping" sound if usually when pericardium has been entered)
Tension PNA MOI
- barotrauma (most common) from + pressure - penetrating injury to chest - untreated simple PNA - rib fxs - barotrauma
Traumatic Diaphragmatic Injury interventions
- exploratory laparotomy
Traumatic Aortic Disruption interventions
- hemorrhage control #1 - neuro stabilization - OR - Reduce risk of rupture by controlling BP (120 mmHg>) ex: Esmolol gtt
Common findings in a patient with chest trauma
- hypotension - hypoxia - tachycardia - SOB - tachypnea - pleuritic chest pain - diminished breath sounds - subcutaneous emphysema
Tracheobronchial Tree Injury S/S
- lung does not properly inflate after chest tube or w/ persistent air leak after chest thoracotomy - subcutaneous emphysema - pneumomediastinum - full thickness injury is fatal
Blunt Cardiac Injury S/S
- may or may not have CP - tenderness over chest - dysrhythmias (esp. tachyarrhythmias, conduction disturbances like heart block and BBB)
Pulmonary contusion interventions
- oxygen - analgesia - carefully control fluids in absence of shock to prevent volume overload - Intubate w/ PEEP (pressure control, APRV)
Sternal, Scapular, Clavicular Fxs Interventions
- pain control - operative repair needed occasionally - cardiac dysrhythmias associated w. 1.5% of sternal fxs - monitor for great vessel injuries
Rib fxs interventions
- pain control (analgesia, intracostal block, etc.) - surgical fixation (plating) is only indicated for severe cases (ex: flail chest, severe chest wall deformity, or symptomatic fxs of 3 < ribs
Fail chest S/S
- paradoxical chest movements - accessory muscle use - Shallow respirations - hypoxemia (may require intubation) - hypoventilation - labored breathing - often associated w/ pulmonary contusion
Open PTX MOI
- penetrating trauma - large defects of the chest wall that remains open
Esophageal Injuries complications
- peritoneal irritation - respiratory compromise - fistula formation - peritonitis -esophageal stricture
Esophageal Injuries Interventions
- surgical repair is gold standard - minimize bacterial contamination and enzyme erosion - gastric decompression - IV ABX - wound drainage - GI tube
MOI for Thoracic Trauma
1) Blunt - MVC - MCC - Ped struck 2) Penetrating -GSW (less predictable pattern) - Knife - Blast injury
diagnostic tension PNA
1) CXR 2) Clinical exam
Tension PNA interventions
1) Needle decompression (12g-14g) into the 2nd or 3rd ICS in the MCL 2) chest tube placement at the 4th or 5th ICS, midaxillary line
Massive HTX interventions
- 36F-40F chest tube - Autotransfusion - thoracotomy (want 200ml > / hour)
Tracheobronchial Tree Injury Diagnostics
- Bronchoscopy (definitive diagnosis) - CT (intubated pts can have ett tube covering injury...pay special attention)
Tension PNA S/S
- CP - Restlessness - Severe agitation - Dyspnea - hyperresonance on percussion - Tachycardia - Hypotension - Unilateral breath sounds - Deviated trachea (late sign) - cyanosis (late sign)
Diagnostics for chest trauma
- CXR - FAST - CT
Traumatic Diaphragmatic Injury Diagnostics
- CXR - FAST - CT
Esophageal Injuries Diagnostics
- CXR (pneumomediastinum, pleural effusion, or gas bubble in the NG tube) - Endoscopy - Esophagography - CT
Traumatic Aortic Disruption diagnostics
- CXR :Widened mediastinum (> 8 cm), loss of aortic knob, pleural cap, tracheal deviation to the right, depression of left main stem bronchus - CT (gold standard- stable pts only)
Interventions for open PTX
- Close w/ 3-sided cover in absence of chest tube - Intubate - Chest tube (avoid inserting near or through defect) - Thoracotomy
Blunt Cardiac Injury Interventions
- EKG - Echo - Serum Trops - Serum CK levels
Cardiac Tamponade Diagnostics
- FAST - Sonography (gold standard) - Echocardiogram - Pericardial window (if clinical symptoms correlate)
Esophageal Injuries S/S
- Fluid loss may cause respiratory compromise - dyspnea - pleuritic pain
Massive HTX assessment
- Hemorrhagic Shock (hilar or great vessel disruption in severe shock) - no breath sounds - percussion dullness
Cardiac Tamponade S/S
- Hypotension (despite adequate fluid resuscitation) - Tachycardia - Dyspnea - Impending doom - Muffled heart sounds - Narrow pulse pressure (SBP falls so DSB rises to compensate) - PEA (late sign) - Kussmaul's sign (late sign): distended superficial neck veins more prominent during respiration
Hemothorax S/S
- Hypotension w/o obvious source of blood loss w/ decreased breath sounds and dullness to percussion
Pulmonary contusion S/S
- Hypoxemia - Respiratory compromise - Bloody sputum - Secretions - CXR: patchy infiltrates or consolidation (hrs after injury)
Cardiac Tamponade Interventions
- Oxygen - Volume resuscitation - Intubation - Decompensating pt: left thoracotomy - Stable pt: pericardial window over pericardiocentesis (if + pt needs a sternotomy)
Traumatic Diaphragmatic Injury S/S
- Peristaltic sounds in the chest on auscultation - abnormal position of the NG tube - ipsilateral hemidiaphragm elevation - abdominal visceral herniation into chest - delayed rupture (expect CP and tachypnea) * masked by positive pressure ventilation - can happen YEARS later
Flail chest interventions
- Ventilate - carefully control fluids in absence of shock to prevent volume overload - intubate for any signs of shock or respiratory distress - thoracotomy & fixation of ribs using wires if extreme s/s
Traumatic Aortic Disruption S/S
- Widened mediastinum on CXR - Difficulty breathing - Intrascapular pain - New onset murmur - Upper extremity HTN - BL femoral pulse deficit
Massive HTX
1500 mL < in the pleural space w/ signs of shock and hypo perfusion (Each HTX can hold 3L of blood- class 3 or 4 hemorrhage)
normal fluid level of pericardial sac
20-30 mLs
Hemothorax
Blood accumulates in the plural cavity due to laceration of lung/ intercostal vessels, internal mammary artery laceration or thoracic spine fx/ dislocation
Simple PTX MOI
Blunt Penetrating
Traumatic Aortic Disruption MOI
Blunt (ex MVC) Deceleration (fall from height)
Blunt Cardiac Injury MOI
Blunt trauma (ex: compression, deceleration, blast, direct forces to the chest)
Flail chest MOI
Blunt trauma: direct high energy impact
Pulmonary contusion MOI
Blunt trauma: direct high energy impact (usually MVC)
Hemothorax Interventions
Chest tube
Simple PTX
Collection of air in the pleural space, visceral pleura, or parietal pleura
Pulmonary contusion
Diffuse hemorrhage w/ interstitial and alveolar edema
What intervention must be done w/ anyone having significant chest trauma and can be determined unnecessary after the H/P and clinical exam?
EKG
Tracheobronchial Tree Injury
Injury b/w cricoid and lobar bronch - Rare, but potentially life threatening
Esophageal Injuries MOI
Penetrating trauma (rupture incidence is higher in the cervical and thoracic areas)
Traumatic Diaphragmatic Injury MOI
Penetrating trauma Blunt trauma (ex: MVC or severe blow to abdomen)
Rib fxs
Ribs 1-3: severe force, high mortality Ribs 4-9: pulmonary contusion and PTX Ribs 10-12: suspect intraabdominal injuries
Deep Sulcus Sign
This is a sign seen on SUPINE radiograph that indicates a pneumothorax The costophrenic angle is going to look DEEP which represent air accumulation Image shows a right sided deep sulcus sign
Most penetrating wounds to the chest require what intervention?
Thoracostomy tube
Cardiac Tamponade MOI
Usually in penetrating trauma (especially parasternal wounds) (can be seen in blunt trauma)
Cardiac Tamponade
acute compression of the heart caused by fluid accumulation in the pericardial cavity
Death w/i 3 hrs of blunt chest trauma is related to ...
airway obstruction, cardiac tamponade, aortic disruption, or continued hemorrhage
What should be considered if a pt's status does not improve after a chest tube is placed for a tension PNA w/ increasing RR and hypoxemia w/ a continuous air leak?
injury of the tracheobronchial tree
Flail chest
fracture of two or more adjacent ribs in two or more places that allows for free movement of the fractured segment
Immediate death from blunt chest trauma are usually related to ...
heart or thoracic aorta disruption