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