WK 3 Thoracic Trauma

Complications of Flail Chest

(a) Pneumonia may occur due to hypoventilation, intubation, aspiration, inadequate pain management, atelectasis, and/or pooling of secretions. (b) Flail chest is a red flag for significant underlying intra- thoracic injury, usually pulmonary contusion. Also suspect injuries such as hemothorax and pneumothorax. (c) Prolonged tracheal intubation can lead to associated complications such as tracheal stenosis, vocal cord paralysis, and vocal cord ulceration. (d) Long-term: complaints of dyspnea and chest pain.

Flail Chest Interventions/goals

(a) Promote oxygenation and gas exchange. (b) Achieve and maintain adequate pain control. (c) Achieve and maintain euvolemia. (d) Selective use of tracheal intubation and ventilation is currently recommended. Mechanical ventilation is not always needed in these patients. It should be used to correct abnormalities of gas exchange rather than to overcome instability of the chest wall. (e) Alert patients with marginal respiratory status should be considered for a trial of continuous positive airway pressure (CPAP) mask in combination with optimal regional anesthesia. (f) Clinical signs of progressive fatigue and deterioration should prompt intubation and mechanical ventilations: (i) Respiratory rate > 35 or < 8 breaths/min (ii) PaO2 < 60 mmHg at FiO2 > 50% (iii) PaCO2 or EtCO2> 50 mmHg at FiO2 > 50% (iv) Other ventilatory parameters: Vital capacity < 15 mL/kg, pO2/FiO2 ratio 200. (v) Early ventilatory support may be recommended in the following patients who sustain a flail chest: (a) Concomitant shock (b) Associated severe head injury (c) Assoc. injury requiring OR intervention (d) Previous pulmonary disease (e) Age > 65 years (f) Fracture of eight or more ribs (g) Patients requiring mechanical ventilation should be supported in a manner based on institutional and physician preference and separated from the ventilator at the earliest possible time. (h) Independent lung ventilation may be considered in severe unilateral pulmonary contusion when shunt cannot be otherwise corrected due to maldistribution of ventilation or when crossover bleeding is problematic. (i) Patients should not be excessively fluid restricted, but rather should be resuscitated per protocol to maintain signs of adequate tissue perfusion. Once adequately resuscitated, unnecessary fluid administration should be meticulously avoided. A pulmonary artery catheter may be useful to avoid fluid overload". (j) Pain management is essential to promote pulmonary hygiene and to prevent complications of undertreated pain (splinting, atelectasis, hypoxia, and hypoventilation). Some patients may desaturate purely from inadequate pain management. Narcotic administration may decrease the ventilatory drive and cause worsening hypoxia and hypotension, and therefore should be avoided or used with extreme caution in the presence of chest trauma. Providing optimal pain relief and aggressive chest physiotherapy will lessen the likelihood of respiratory failure and ensuring ventilatory support. Epidural catheter is the preferred mode of analgesia delivery in severe flail chest injury If epidural analgesia is contraindicated, paravertebral analgesia may be equally effective. (k) Diuretics may be ordered if hydrostatic fluid overload is evidenced by elevated pulmonary capillary wedge pressures in hemodynamically stable patients or in the setting of known concurrent CHF. (l) There is no evidence that steroids are effective in the treatment of pulmonary contusion. (m) Rib fractures are being increasingly fixed surgically with a 10-fold increase in surgical procedures during the last decade. The benefits of rib fixation over mechanical ventilation include a decrease in chest infections and chest wall deformity with an increase in pulmonary function tests. Open reduction and internal fixation also result in decreased ICU days, a trend toward a lower rate of pneumonia, and an increase in forced vital capacity. Indications for surgical fixation of a flail chest include persistent pain and decreased pulmonary function tests. Surgical fixation can be done non-urgently, and the average time to fixation in many cases is about 6 days post- injury. The most common technique for surgical fixation includes plates with cortical locking screws. (n) Areas needing further study: effect of hypertonic saline resuscitation on PC, anti-inflammatory "anti-cytokine" treatment, modes of ventilator support, non-invasive ventilatory support, and long-term outcomes.

Blunt Cardiac Injury Management/ Complications

e. Management (1) Supportive care if hemodynamically stable (2) Invasive monitoring with a pulmonary artery catheter may be used in certain populations with suspected BCI: patients >60 years of age, hemodynamically unstable, multisystem trauma, those with abnormal ECGs, and those who will undergo general anesthesia. f. Complications (1) Cardiac tamponade (2) Constrictive pericarditis (3) Valvular rupture

Myocardial rupture

(1) Associated with immediate trauma or may be delayed for 2-3 weeks (2) Mechanisms: Blunt trauma due to heart being compressed between the sternum and vertebrae; penetrating trauma to heart due to fractured ribs, a missile, or sternal bone (3) Hx of trauma with a presentation of HF or cardiac tamponade. Immediate onset of heart failure following trauma suggests rupture of cardiac valves or interventricular septal rupture. (4) Management is supportive

Zonal injuries of the neck

A. Kinematics: Zonal neck injury most commonly occurs due to penetrating trauma. In today's society with increasing violence due to guns and knives, it becomes imperative that the TNS recognize the different types of zonal injuries, the vital structures located within each zone and the evaluation and treatment of injury in the different zones. 1. The neck is a small and vulnerable area that contains a large number of complex and vital structures. Injury to these structures does not always present with obvious signs and symptoms, especially with penetrating trauma. Zone 1, 2, and 3.

Physical Assessment of Zone 2 Injuries

Physical assessment is possible due to the accessibility of the structures within the zones. The most common finding in this zone from penetrating injuries is a vascular injury. a. Obvious hemorrhage b. Sub-q emphysema c. Hoarseness/stridor d. Dysphasia e. Neuro deficit f. Occasionally may also exhibit hematemesis and a bruit

Blunt aortic injury (BAI) Diagnosis/ Management/ Complications

d. Diagnostic tests (1) Chest x-ray in penetrating trauma performed to detect: (a) Hemothorax/pneumothorax (b) Bullet trajectory (c) Proximity of trauma to the great vessels (d) Possible intracardiac location (e) Missing projectile in a patient who has sustained a gun shot wound to the chest (2) Chest x-ray findings with blunt trauma to thoracic aorta (a) Widening of the mediastinum > 8 cm (b) Obscure or indistinct aortic knob (c) Opacification of the aorto-pulmonary window (d) Depression or deviation of the left mainstem bronchus (e) "Funny" looking mediastinum (f) Deviation of the NG tube, TT, or trachea to the right (g) Left apical hematoma (capping) (h) Calcium layering in the aortic knob (i) Double contour of the aorta or of the aorto-pulmonary window (3) Angiography (aortography) is a very sensitive, specific and accurate test for the presence of blunt aortic injury. Standard by which other diagnostic tests are compared. (4) Computed tomography (CT) is taking more of a role especially for screening. CT is a useful diagnostic tool for both screening and diagnosis of blunt aortic injury. Spiral or Helical CT scanners have an extremely high negative predictive value and may be used alone to role out blunt aortic injury. When these scanners are used, angiography may be reserved for patients with indeterminate scans. (5) Other diagnostic studies (a) Magnetic resonance imaging (MRI) (b) Transesophageal echocardiography (TEE) e. Management/interventions (1) Initial trauma care supporting ABCDEs (2) "Techniques of endovascular repair are rapidly evolving as an alternate approach for surgical repair of blunt traumatic aortic injury" (3) HR and BP control can decrease the likelihood of rupture of a traumatic aortic aneurysm. If no contraindications exist, recommend HR control with a short-acting beta-blocker to a goal HR of <80 and BP control with a MAP of 60-70 mm Hg f. Complications (1) Neurologic insults (a) Cerebral injury may occur from emboli during surgical repair of the aorta (b) Vocal cord paralysis may occur secondary to injury of the laryngeal nerve during aortic surgery (2) Paraplegia (a) Occurs resulting from aortic injury that may compromise the patient's vascular supply to the thoracic cord. (b) A small percentage of patients become paraplegic from traditional surgical repair of the descending thoracic aorta. Clamp time of the aorta is carefully monitored as vascular supply distal to the clamp is halted during the procedure. (3) Hemorrhage (a) Common complication following aortic surgery which may present as bleeding from the surgical incisions or grafts. (b) Monitor all potential openings i.e., IV insertion sites, surgical incisions, and chest tube output, etc. (c) Other postoperative complications such as hypothermia and coagulopathy need to be addressed to prevent exacerbation of the bleeding. (4) Renal insult: Renal insufficiency can occur as a result of ischemia due to prolonged aortic cross clamping during traditional surgical repair. Careful monitoring of urinary output is essential.

Definitive management of thoracic trauma/zonal injuries of the neck: Nursing diagnoses related to patients with thoracic trauma/zonal injuries of the neck

1. Alteration in airway clearance 2. Ineffective breathing pattern 3. Decreased cardiac output related to ... 4. Pain related to ... 5. Potential for infection related to invasive lines, chest tube insertion 6. Knowledge deficit related to injury; follow up care 7. Anxiety related to hospitalization, injury, ICU stay

Mechanisms of chest injury

Deceleration, shearing, acceleration, acceleration-deceleration, compression

Cardiovascular trauma

Blunt Cardiac Injury(BCI) and Blunt aortic injury (BAI)

Flail chest

(1) Most severe form of blunt chest wall injury with mortality rates of 10-20%. (2) Mechanism of injury: usually due to blunt chest trauma such as high speed MVC, falls, auto-pedestrian trauma, motorcycle trauma, and severe compression. (3) Pathophysiology (a) Occurs when two or more adjacent ribs and/or cartilages on both sides of an impact point are broken at two points resulting in a freely mobile or "floating" segment. (b) May be identified by location or size (i) Anterior, posterior, or lateral (ii) Parasternal: Separation of the sternum from adjacent broken ribs or costochondral joints: sternal flail chest (c) Free segment moves separately and in the opposite direction (paradoxically) to the contiguous thoracic wall during the ventilatory cycle. (d) Paradoxical motion of the flail segment interferes with the normal inspiratory/expiratory cycle due to the lack of bony support and changes in intrathoracic pressures. (e) Subatmospheric intrathoracic pressure during inspiration pulls the segment inward. Positive intrathoracic pressures during expiration move the segment outward. (f) Paradoxical movement is not always apparent in an awake patient with muscle spasm, shallow respirations, and splinting secondary to pain. This is seen as patient tires, usually in first 24 hours. (4) The most significant life-threat with this injury is the accompanying damage to the lung parenchyma: pulmonary contusion. Contused lung produces more interstitial and intra-alveolar fluid resulting in impaired gas exchange. Pulmonary contusion occurs in 30-50% of all blunt thoracic trauma and is the major cause of respiratory compromise. (a) Evidence from animal studies indicates that pulmonary contusion is not only a localized process, but has global pulmonary and systemic effects when occurring in a sufficient portion of the lung. The following may be seen: (i) Local effects (a) Laceration to lung tissue (b) Hemorrhage-filled alveoli (c) Reduced compliance leading to reduced ventilation (d) Increased shunting with decreased pO2, increased AaDO2 (alveolar-arterial oxygen difference) (e) Increased pulmonary vascular resistance (f) Decreased pulmonary blood flow (ii) Injured and uninjured lung (a) Thickened alveolar septa with impaired diffusion (b) Decreased alveolar diameter (c) Vacuolation of pulmonary tissues (development of small cavities or spaces containing air or fluid) (d) Delayed capillary leak with increased bronchoalveolar lavage protein (e) Increased neutrophils in lung tissue (iii) Systemic (a) Increased terminal complement complex (b) Decreased complement (b) The pain of multiple rib fractures discourages the effort to breathe and even if made initially, fatigue, CNS depression, or increased tracheobronchial secretions will eventually outweigh any patient efforts. (c) Hypoventilation, impaired O2 diffusion, pulmonary physiologic shunting and venous admixture results in a decreased PaO2 and SpO2, decreased lung compliance, tidal volume and vital capacity; and decreased venous return with VA/Q mismatch. CO2 retention results in hypercarbia. Impaired cough results in atelectasis. (5) Mortality rates are estimated to be 10% to 20% with a significant pulmonary contusion. Pulmonary contusion/flail chest particularly affect the elderly population.

Chest tube insertion

Chest drainage systems work by combining three functions: (a) Expiratory positive pressure helps push air and fluid out of the chest (such as cough, Valsalva maneuver) (b) Gravity helps fluid to drain as long as the chest drainage system is below the level of the patient's chest (c) Suction can improve the speed at which air and fluid are pulled from the chest (d) Chest tubes are available in multiple diameters in multiples of 4 on the French scale (12 Fr up to 36 Fr). Side holes allow drainage and length markers note the distance of the lowest hole from the skin surface. (e) A radiopaque strip allows visualization on chest films. (f) Multifunction chest drainage systems allow single or multi- catheter drainage and work for gravity-assisted and suction-assisted drainage. The collection container contains the following: (i) Collection chamber calibrated in mL. (ii) Water seal: U-tube design that acts as a one-way valve that prevents air from reentering the chest with inspiration. It can monitor air leaks and changes in intrathoracic pressure. (iii) Suction control chamber: Contains an atmospheric vent. The suction chamber helps monitor intrathoracic pressure. Dry-suction and water-suction units are set to the prescribed amount of suction either by rotating a dial to the prescribed amount, or, in the case of water- suction, are filled with sterile water to the prescribed level. (g) Set up/prep: Connect the long patient tube to the thoracic catheter. (h) Follow manufacturer's instructions regarding setting of the wall suction unit to obtain the appropriate amount of suction. Slowly increase vacuum until gentle bubbling appears in the suction control chamber. (i) Observe for normal tidaling in the water seal chamber as it reflects the air leaving the chest. Immediately report absence of fluid oscillations suggesting obstruction of the drainage system by clots or kinks, loss of subatmospheric pressure, or complete reexpansion of the lung. Report continuous bubbling indicating an on-going air leak in the lung. Also report increasing sub-q emphysema in the neck and upper chest or near the tube insertion site, indicating a continuous leak. (j) Clamping a chest tube with a continuing air leak may result in a tension pneumothorax. (k) Monitor amount and nature of chest tube drainage per local procedure. (l) Apply an occlusive dressing to the site per institutional policy and secure tube to patient's chest. (m) Obtain chest x-ray. (n) Evaluate the effectiveness of chest tube placement by assessing patient's respiratory status, lung sounds, vital signs, and clinical presentation. (o) Ensure that all connections are secure. A single layer of tape across the long axis of each joint is better than layers of circular tape over the joints. (p) Avoid tubing kinks. (q) The collection chamber must remain lower than the patient's chest to prevent fluid from being siphoned into the pleural space. (r) Chest drains can be painful. Provide adequate analgesia as prescribed. Options may include opioid PCA, parenteral, oral or epidural analgesic medications.

management of a sucking chest wound

(a) If detectable, there is an immediate life-threat. Convert to a closed pneumothorax by covering wound with a gloved hand and then an occlusive dressing. Dressings should be at least 3 or 4 times the size of the defect. (b) Past recommendations were to place an occlusive dressing taped on 3 of 4 sides to allow air to egress and prevent a tension pneumothorax. These guidelines have not proven to be effective or realistic. Covering the wound improves respiratory mechanics, but the three-sided occlusive dressing is no longer recommended. Tactical Combat Casualty Care Guidelines recommend a vented chest seal and a non-vented seal if a vented one is unavailable (c) Oxygen 12-15 L/NRM; assist with bag-mask ventilation as necessary. Positive pressure ventilations should be used with caution in penetrating chest wounds. High ventilatory pressures may force air from an injured bronchus into an adjacent open pulmonary vein, producing systemic air emboli. This may account for many of the dysrhythmias and sudden deaths that occur in patients with severe penetrating chest wounds. (d) Administer analgesics and sedatives as prescribed to allow for control of pain and ventilation. (e) Prepare for chest tube insertion (not placed through the injury site). After chest tube insertion, place an occlusive dressing over the open wound. (f) Anticipate surgical exploration/closure of the chest wound. (8) Expected outcomes (a) Respiratory rate 12-20 breaths/min (b) PaO2 > 80 on RA; SpO2 > 95-99%; EtCO2 35-45 mmHg (c) Chest x-ray demonstrating lung re-expansion (d) Tidal volume at least 5-8 mL/kg (9) Complications (a) Once the wound is closed and prior to chest tube placement, monitor for tension pneumothorax due to ongoing internal air leaks. If patient develops increasing hypoxia, respiratory distress, or hypotension, and a tension pneumothorax is suspected, treat by burping or removing the dressing followed by by needle decompression prn. (b) Post chest tube insertion: inadequate drainage, air leak, and empyema

Pleural injuries

Closed (simple) pneumothorax and Small hemothorax

Zone I

Base of the neck from the clavicles to the cricoid cartilage a. Subclavian and vertebral arteries b. Subclavian and innominate veins c. Carotid artery (common and internal) d. Jugular veins e. Trachea f. Esophagus g. Spinal cord h. Lungs

Commotio cordis

Blow to the chest producing cardiac arrest. Any blow to the chest, regardless of intensity or velocity or force is capable of producing cardiac arrest, especially in younger children whose rib cages are narrow and have underdeveloped chest muscles.

Secondary survey

Bony fractures, Pleural injuries, Thoracic tissues, Cardiovascular trauma

Primary survey: Immediate life-threat recognition and intervention

Early recognition and treatment of thoracic trauma is crucial in decreasing potentially preventable mortality. Detect and resuscitate clinically evident, immediately life-threats. "A": Assess and secure airway patency "B": Assess breathing; ventilatory and gas exchange status "C": Assess perfusion/cardiac status

Zone III

From the inferior border of the mandible to the base of the skull a. Carotid arteries (external and internal) b. Internal jugular veins c. Vertebral arteries d. Basilar arteries e. Spinal cord f. Cervical vertebrae g. Cranial nerves IX-XII h. Salivary & parotid glands i. Esophagus j. Trachea

"A": Assess and secure airway patency

If agitation is present, assume that the patient has an airway, breathing, and/or perfusion problem (oxygen debt) especially if objective criteria support these findings, (such as weak radial pulses, decreased oxygen saturation). Do not initially attribute altered mental status (AMS) to drugs or ethanol abuse until life-threatening pathologies have been ruled out. 3. Conventional resuscitative measures supersede more invasive procedures. For example, a patient requires intubation and oxygen prior to emergency thoracotomy. 4. Immediate life-threat - airway obstruction: Laryngeal injury and skeletal injury to the upper chest may cause airway impairment. a. Reposition mandible b. Suction as necessary c. NP/OP airways d. Intubation e. Alternate airways f. Cricothyrotomy 5. If intubation is needed, prepare tube thoracostomy trays in the event the patient has a tear to the trachea or a bronchus that could result in barotrauma, pneumothorax, and/or tension pneumothorax after positive pressure ventilation. 6. Maintain spine motion restriction until the cervical spine is cleared.

Physical Assessment of Zone 3 Injuries

The injuries in this zone are difficult to assess without the aid of ancillary diagnostic tests a. Assess for neurological deficit b. Assess for other signs & symptoms of shock and presence of a bruit, however, shock and bruit are usually very subtle

Physical assessment of Zonal injuries of the Neck

This is the most important and may be the most reliable tool to evaluate penetrating neck trauma. As many as 10% of neck wounds may lead to respiratory compromise. This assessment should be performed quickly and accurately. Treatment will depend on assessment findings. The physical exam often helps classify signs of hard vs. soft vascular trauma. 1. Hard signs: Active bleeding, large expanding hematoma, distal ischemia and/or a bruit/thrill. 2. Soft signs: Shock responding to fluid resuscitation, a small stable hematoma, associated nerve injuries, dyspnea, sub-q emphysema, hoarseness, dysphagia or minor hematemesis.

Thoracic tissues

Tracheobronchial tree injury and Pulmonary contusion

Physical Assessment of Zone 1 Injuries

Unable to palpate and observe due to the bony skeleton. Of the 3 zones, penetrating trauma to this zone has the highest mortality due to vascular injury. a. Evaluate for signs and symptoms of shock b. Hematoma resulting in respiratory compromise c. Hoarseness/stridor d. Sub-q emphysema e. Dysphasia f. Neuro deficit g. Occasionally may also exhibit hematemesis and a bruit

D: Disability

rapid neuro assessment (GCS); pupils; glucose if AMS

Diagnostic clues based on mechanism of injury: Blunt chest trauma

A. Consideration of the MOI may be essential in identifying potentially life-threatening injuries. The mechanism of energy transfer may suggest the degree of patient acuity and may also help the nurse anticipate needed diagnostic tests and potential interventions e.g. high speed mvc- angiography? B. Blunt chest trauma: Patient stability determines further intervention and workup 1. If patient is unstable, emergent resuscitation is provided based on the patient's clinical status and responses to interventions 2. If patient's vital signs are stable, the patient may have an ECG and chest radiograph 3. Chest x-ray findings positive? a. If chest x-ray shows evidence of a hemo/pneumothorax a chest tube is placed b. If there is evidence of a massive hemothorax, an operative thoracotomy is performed and autotransfusion is employed in the interim c. If there is evidence of a traumatic rupture, a transesophageal echocardiogram (TEE) or aortography is done d. Esophageal or tracheobronchial studies may be done if indicated. Operative intervention may be needed if positive 4. Anterior chest tenderness present? a. If ECG positive: blunt cardiac injury protocol may be initiated b. If ECG negative: the patient may be observed

Blunt Cardiac Injury(BCI)

Ceased use of myocardial contusion as a term after a consensus statement was published in the J of Trauma in 1992 by Mattox et al. a. Definition: Bruising of the heart from blunt chest trauma which may produce myocardial hemorrhage, dysrhythmias, and hemodynamic compromise. b. Epidemiology: Reported incidence of BCI ranges from 8% to 71% in those with blunt chest trauma. c. Signs and symptoms (1) Nonspecific chest pain due to associated injuries is common (2) Evidence of physical signs of trauma (a) Anterior chest wall abrasions or contusions (b) The presence of a sternal fracture with normal ECG and troponin levels does not predict the presence of BCI. (3) Maintain a high index of suspicion in those with an appropriate MOI or in those who have an inappropriate or abnormally poor cardiovascular response to their injury. d. Diagnostic tests (1) All patients who are suspect for BCI should have an admission ECG performed having a negative predictive value of >95%. Dysrhythmias usually associated with blunt cardiac trauma include sinus tachycardia, premature ventricular contractions, ventricular fibrillation, atrial fibrillation, and atrial flutter. Pulseless electrical activity (PEA) may be present. (2) Blunt cardiac injury can be ruled out only if both ECG and troponin I levels are normal. (3) If the admission ECG is abnormal (arrhythmia, ST changes, ischemia, heart block, unexplained ST changes), the patient should be admitted for cardiac monitoring. If the patient has pre-existing abnormalities, a review and comparison of previous ECGs is needed to determine the need for continued monitoring. (4) If the patient is unstable or presents with persistent, new dysrhythmia, an echocardiogram should be completed. It is preferred that a transthoracic echocardiogram be performed, but if this cannot be done, the patient should have a transesophageal echocardiogram. Nuclear medicine studies (MUGA, thallium-201 scanning) should not be performed as they add little information compared to echocardiography. (5) Creatinine phosphokinase with isoenzymes should not be used to screen for BCI patients. (6) CT or MRI may be used to differentiate between BCI and acute myocardial infarction in patients with abnormal troponins, ECG or echocardiogram results. (7) Pericardial friction rub, S3 gallop, crackles, or an ↑ CVP in a patient who sustains blunt chest trauma may also suggest myocardial insult.

Zone II

Area between the cricoid cartilage to the inferior border of the mandible a. Subclavian arteries b. Carotid arteries (external and internal) c. Internal jugular veins d. Vertebral arteries e. Trachea f. Esophagus g. Larynx h. Pharynx i. Spinal cord

Complications of Massive Hemothorax

(a) Decreased cardiac output (b) Fibrosis (c) Empyema

Detect/resuscitate immediate life-threats r/t "C" perfusion/cardiac status

a. Pulseless electrical activity (PEA) (this is a condition, not a rhythm) (1) Patient will present with an organized rhythm but pulseless (2) Follow current ACLS guidelines for treatment (3) Attempt to identify the cause including tension pneumothorax, cardiac tamponade, hypovolemia, hypoxia (4) Treat the cause as directed by injury-specific interventions b. pericardial tamponade c. massive hemothorax

Penetrating chest trauma

a. Usually occur in an urban setting due to violent crime b. Commonly due to gun shot and stabbing wounds

Pulmonary Contusion Management/ Complications

e. Management/interventions (1) Airway/ventilatory therapy will vary depending on the degree of lung insult and respective ventilatory management, i.e. assist control, SIMV, jet ventilation, etc. Chemical paralysis with intubation may be needed to support the patient's oxygenation/ ventilatory status. (2) O2 therapy and aggressive pulmonary hygiene are important. Prone positioning with the affected lung down may facilitate lung oxygenation to the unaffected lung but studies have not indicated improvement in mortality rates. (3) Administer fluid resuscitation as prescribed to maintain tissue and organ perfusion. However, if the patient does not require fluid resuscitation, judicious administration of fluids is advocated. f. Complications (1) Pneumonia remains one of the most common complications occurring in thoracic trauma patients. Antibiotics are indicated with positive sputum cultures that are sensitive to treatment. Prophylactic antibiotics are not currently advocated. (2) Pneumothorax or tension pneumothorax may occur with ventilator therapy especially in patients who require high PEEP.

E: Exposure/Environment

remove clothing, inspect back, and maintain body temperature

Bony fractures found on secondary survey

rib fractures and Sternal fracture and dislocation

Definitive management of thoracic trauma/zonal injuries of the neck: Pain management

related to blunt chest wall trauma: rib fx, flail chest, contusions. 1. Have patient quantify pain severity using an objective scale such as 0 - 10. Also consider findings from the pulmonary exam/function tests and ABGs. 2. Administer analgesia as prescribed, monitor the ECG and SpO2, evaluate the effectiveness of medications given and repeat as necessary. 3. Intravenous narcotics, by divided doses or demand modalities may be used as initial management for lower risk patients presenting with stable and adequate pulmonary performance as long as the desired clinical response is achieved. The disadvantages of IV narcotics are the tendency to cause sedation, cough suppression, respiratory depression and hypoxemia. 4. Use of epidural analgesia (EA) for pain control after severe blunt injury and non-traumatic surgical thoracic pain significantly improves subjective pain perception and critical pulmonary function tests compared to intravenous narcotics and is the preferred technique after severe blunt thoracic trauma. A combination of a narcotic (i.e., fentanyl) and a local anesthetic (i.e., bipivicaine) provides the most effective EA and are the preferred drug combinations for use by this route. a. Patients with 4 or more rib fractures (mortality is shown to markedly increase in those with 4 or more fractures) who are ≥65 years of age should be provided with EA unless this treatment is contraindicated. b. Younger patients with 4 or more rib fractures or patients aged ≥65 with lesser injuries should also be considered for EA. The presence in elderly patients of cardiopulmonary disease or diabetes should provide additional impetus for EA as these co-morbidities may increase mortality once respiratory complications have occurred. c. EA is associated with less respiratory depression, somnolence and gastrointestinal symptoms than IV narcotics. EA is safe with permanent disability being extremely rare and negligible mortality attributable to treatment. d. EA may improve outcome as measured by ventilator days, ICU length of stay, and hospital lengths of stay. 5. Paravertebral or extrapleural infusions are effective in improving subjective pain perception and may improve pulmonary function in high-risk patients who are not candidates for EA. 6. Anticipate evaluation by pain service (if one exists) for patients who require aggressive pain management, e.g. multiple rib fractures, flail chest.

Closed (simple) pneumothorax Management/ Complications

f. Management/interventions (1) Observation and/or aspiration of an asymptomatic pneumothorax may be appropriate but should be determined by a qualified physician, otherwise placement of chest tube should be performed. (2) Observation with serial x-rays may be the only treatment needed for a small, closed pneumothorax (< 1-2 cm) that will reabsorb spontaneously. (3) Other indications for chest tube insertion (a) Transfer to another facility (b) General anesthesia (c) Ventilatory support g. Complication: Empyema: An inadequately drained pneumothorax or hemothorax usually results in an empyema due to a pleural infection. Various factors contribute to the formation of a posttraumatic empyema: (1) Conditions under which the tube was inserted (emergent or urgent): Staphylococcal infections that occur secondary to contamination (2) Mechanism of injury (3) Internal bronchopleural fistulas (4) Gastrointestinal injury with associated diaphragmatic injury (5) Pneumonia or subphrenic abscess which progress to an infected pleural effusion (6) Clotted or retained hemothorax (7) Ventilator care

Massive hemothorax

(1) Definition: Accumulation of 1500 mL (or more) of blood into the pleural space (Class III or IV hemorrhage). Pleural spaces can hold the entire blood volume. (2) Etiology: Blunt or penetrating trauma. Sources of bleeding: (a) Rib fractures (b) Lung parenchyma injury (c) Intercostal and Internal mammary artery disruption (d) Hilar injury (e) Great vessel injury (pulmonary/aortic) (f) Heart laceration (g) Diaphragmatic tear (h) Splenic laceration (with associated diaphragm injury) (i) Liver laceration (associated diaphragm injury) (3) Pathophysiology (a) Blood accumulates in the pleural cavity causing partial to total lung collapse, possible mediastinal shift and impaired venous return to the right heart. (b) Patient presents in hypovolemic shock and respiratory distress. Cause of death: exsanguination leading to cardiac arrest. (4) Assessment (a) Inspect for signs of hypovolemic shock, dyspnea, tachypnea, respiratory distress; asymmetric chest expansion, complaint of chest tightness, ecchymosis/contusion over affected chest wall, hemoptysis or bloody sputum. Neck veins are flat. (b) Palpate for tracheal deviation toward unaffected side (late sign), diminished pulse quality and tachycardia. (c) Percuss for dullness on affected side. (d) Auscultate for diminished or absent breath sounds

Pericardial tamponade

(1) Definition: Acute increase in fluid accumulation in the pericardial sac causing hemodynamic compromise. Tamponade comes from the French word "tampon" meaning "to plug". Pericardial tamponade literally means a plug in the pericardial sac. (2) Epidemiology: Can occur with blunt and penetrating trauma, however, penetrating is more common. Approximately 80%-90% of patients with stab wounds to the heart show evidence of tamponade. (3) Anatomy considerations (See Cardiac A&P module) (a) Pericardium: tough, fibrous sac, enclosing the heart and attaching to the great vessels at the base. It anchors the heart and restricts excess motion during acceleration or repositioning of the body. (b) It prevents kinking of great vessels (c) Parietal fibrous portion is nondistensible (d) There is normally 30-50 mL of straw colored fluid within the pericardial sac that is secreted by the visceral pericardium and serves to provide lubrication, lymphatic drainage, and immunologic protection for the heart. (4) Pathogenesis of pericardial tamponade (a) Tamponade occurs when small penetrations of the pericardium seal from fatty tissues or the formation of clots. Once sealed, blood continues to collect within the pericardium. The most common site of cardiac penetration is over the right ventricle due to its anterior orientation. Increased fluid/blood in the pericardial sac creates an increase in intrapericardial pressure. (b) Clinical presentation depends on the interaction between pericardial compliance, rate of fluid accumulation, and the amount of fluid present in the pericardium. (i) There is a non-linear volume/pressure compliance curve in the pericardium. Cardiac output is maintained until compliance is overcome. Pericardial pressure rapidly escalates and stroke volume (SV) drops. (ii) In chronic disease, a slow, progressive accumulation of fluid may distend the sac from 100 to 1500 mL yet maintain adequate output. (iii) In traumatic injury, rapid accumulation of > 50-150 mL can cause significant alterations in cardiac output and hemodynamic compromise as there is no time for the tissues to stretch and accommodate for the excess fluid. (c) Initially, since the SV is decreased, an increased HR and increased myocardial contractility and ventricular filling pressure compensate for the decrease in CO. (d) Once the compensation limits are reached, further increases in pericardial volume cause severe impairment of cardiac functioning. (e) Pericardial pressure exceeds right atrial pressure and CVP, causing collapse of the atria and vena cavae running through the pericardium, decreasing venous return, ventricular filling, and stroke volume. Very similar to the end stage pathophysiology with a tension pneumothorax. (f) As a result, septal shifts occur and CO falls dramatically causing severe systemic hypotension. (g) Myocardial ischemia is exacerbated

Tension Pneumothorax

(1) Etiology: May result from the primary trauma, as an extension of a simple pneumothorax (damage to lung parenchyma, fractured ribs, and tracheobronchial tree injuries); be a delayed complication from an undetected injury; or may occur secondary to treatment such as positive pressure ventilations resulting in barotrauma or an inadvertently clamped chest tube. (2) Pathophysiology: Most common from blunt trauma (a) A closed pneumothorax progressively accumulates air within the pleural space on inspiration that cannot escape on expiration, creating a one-way valve. (b) This accumulation produces an increase in intrapleural pressure (tension) collapsing the lung on the affected side, depressing the diaphragm, and shifting the mediastinum to the opposite side also compromising the intact lung. (c) A mediastinal shift causes tracheal deviation within the thorax, but the extrathoracic trachea which is palpated in the anterior neck often remains in the midline. (d) High intrathoracic pressures exceeding CVP pressures compress the right atrium and vena cavae creating a mechanical obstruction of blood flow to right heart resulting in markedly decreased preload and cardiac output. (e) Hemodynamic dysfunction produces hypoxia and obstructive shock.

Open pneumothorax ("sucking chest wound")

(1) Etiology: Penetrating trauma from gunshot wound, stab wound or an impaled object. (2) Pathophysiology: Penetrating trauma creates a hole in the chest wall allowing air to enter the intrathoracic cavity which depends on negative pressures and intact pleural membranes to produce gas movement through the tracheobronchial tree. When chest wall and pleural integrity is lost, the involved lung paradoxically collapses on inspiration and expands minimally during expiration. This causes movement of air in and out of the defect, producing a "sucking" sound. (3) Critical diameter: When the size of the chest wound is approximately 2/3 the diameter of the trachea, air will move through the chest wall defect into and out of the pleural space instead of through the trachea to equalize intrathoracic and atmospheric pressures during ventilatory attempts (thus, no breath sounds on either side and patient will be unable to speak). (4) Life-threat: Patient dies from impaired gas exchange leading to profound hypoxia. (5) Assessment: Presentation and symptoms are dependent on the size of the defect (a) Inspect for visible chest wound bubbling with frothy blood, sucking noises near wound, pleuritic chest pain, restlessness, dyspnea, tachypnea, asymmetrical chest expansion, sub-q emphysema, cyanosis (late sign), and other signs of respiratory distress, (e.g., aphasia). (b) Palpate for sub-q emphysema in the neck and upper chest; tracheal deviation, and pulse irregularities/deficits. (c) Percuss: Hyperresonance on affected side (d) Auscultate for absent or decreased breath sounds on affected side (or both sides with significant injury) and for tachycardia (apical pulse). (6) Diagnostic indicators (a) Clinical diagnosis; don't wait for films to treat (b) Chest x-ray shows evidence of pneumothorax

"B": Assess breathing; ventilatory and gas exchange status- Inspection

(1) Visually inspect the thorax for appearance, contour, symmetry of excursion, and any gross abnormalities (such as deformity, contusions, abrasions, penetrating wounds, bruising, lacerations, subcutaneous or tissue edema, paradoxical movements, retractions, or impaled objects) (2) Also observe for: (a) General respiratory rate and depth (b) Use of accessory muscles (c) Cyanosis of the lips or nail beds (d) Type and amount of secretions (e) Neck veins: Abnormal distension of neck veins in the presence of chest trauma may indicate tension pneumothorax or cardiac tamponade. (3) Listen without a stethoscope for noisy ventilatory efforts, air being sucked into or out of an open chest wound.

Pericardial Tamponade Clinical Manifestations/ Diagnostic Indicators

(5) Clinical manifestations (a) Beck's triad - classic presentation (i) Hypotension (narrowed pulse pressure due to decreased SV and increased peripheral vascular resistance) (ii) JVD from impaired right heart filling that also causes a false positive elevation of CVP (iii) Muffled heart tones (b) Evidence of shock/hypoxemia (looks like cardiogenic shock) (i) Thready/absent peripheral pulses (PEA) (ii) Diaphoresis (iii) Pale/cyanotic, cold extremities (iv) Decreased level of consciousness or agitation (v) Tachycardia, tachypnea (c) Pulsus paradoxus: SBP decreases > 10 mmHg with inspiration. More easily seen if an arterial line is placed. (6) Diagnostic indicators (a) FAST (focused assessment with sonography in trauma) is ideally performed during the circulation phase of the primary survey to allow for the rapid detection of pathologic pericardial, intraperitoneal, or intrathoracic free fluid. The extended FAST (E-FAST) employs additional chest views to asses for pneumothorax. (b) Echocardiogram may be used to determine the presence of cardiac tamponade in stable patients. This may demonstrate right atrium or ventricle chamber collapse. (c) Pericardial window

Pericardial Tamponade Interventions/ Complications

(7) Interventions (a) Administer warm isotonic crystalloids to permissive hypotension levels while preparing for definitive interventions. (b) "Acute cardiac tamponade due to trauma is best managed by thoracotomy surgery. Pericardiocentesis may be used as a temporizing maneuver when thoracotomy is not an available option". (c) Emergency thoracotomy: Compensatory mechanisms fail as intrapericardial pressures approach the ventricular filling pressure and profound hypotension and coronary hypoperfusion occurs. Treatment is to immediately evacuate pericardial blood and clots and control cardiac bleeding. Surgical drainage, inspection and repair are the definitive treatment in patients with intrapericardial bleeding or clotted hemopericardium. (8) Complications (a) Cardiac arrest may occur secondary to unrecognized tamponade. Patients who survive arrest may sustain other complications such as sepsis, anoxic encephalopathy, or ischemic bowel if the arrest is prolonged. (b) Post-pericardiotomy syndrome may occur in the immediate postoperative period. Treatment includes use of nonsteroidal anti-inflammatory agents.

Resuscitative interventions for Massive Hemothorax

(a) An acute hemothorax that is large enough to appear on chest film should be treated with a 28-32 French chest tube. Larger blood collections may need a 36-40 F catheter to prevent clotting. (b) Monitor chest tube output (c) If massive hemothorax is suspected, prepare for autotransfusion (d) Accepted indications for urgent thoracotomy (i) ≥1500 mL of blood is evacuated after initial chest tube insertion (ii) >200 mL/hr blood evacuated for 2-4 hrs (iii) 150-200 mL/hr blood evacuated for 2-4 hrs (iv) Penetrating anterior chest wounds medial to the nipple line and posterior wounds medial to the scapula (v) Hemodynamic instability evidenced by SBP < 80 mmHg despite aggressive blood/volume resuscitation. (vi) Continued need for blood transfusions to maintain hemodynamic stability. (e) Anticipate further diagnostic workup (f) Monitor patient for worsening pulmonary status (g) Monitor patient for altered respiratory rate and pattern (h) If intubated, anticipate increased peak airway pressures (i) Eliminate excessive increases in metabolic demands: temperature regulation, pain control, reduction in anxiety (j) Prepare for transfer to the OR

Resuscitation - emergency interventions for a Tension Pneumothorax

(a) Apply oxygen 12-15 L/NRM (b) Immediately prepare for a needle thoracentesis (pleural needle decompression) as a temporizing measure. Prior to needle insertion, quickly clean the area with a substance approved by your facility. CDC recommends chlorhexidine. A practitioner approved to perform the procedure will insert a 10 -12 g (or 14 g); 3 inch long catheter (PneumoFix® is an excellent tool) into the 2nd-3rd intercostal space (ICS) in the midclavicular line on the injured side at a 90 degree angle to the chest wall. Once inserted, leave catheter in place, remove the needle. The catheter should not be allowed to kink. Due to the variable thickness of the chest wall, catheter that is too short, kinking of the catheter, or obstruction of the needle/catheter, needle decompression may not be successful. Finger thoracostomy is an alternative approach. (c) Release of pressure (tension) should relieve the patient's acute distress, improve ventilations, and re-establish venous return (and thus peripheral pulses) but it will not re- expand the lung (breath sounds will still be absent). Procedure may not always be successful. (d) An alternate site for needle decompression is the 4th-5th intercostal space slightly anterior to the midaxillary line but this approach may result in diaphragm and liver/spleen penetration by blind needle insertion in a supine patient. (e) Prepare for open tube thoracostomy (chest tube insertion) in the 4th-5th ICS in the triangle of safety between the midaxillary and anterior axillary lines. Chest tubes are inserted to drain pathologic pleural collections and to re- expand the lung. Most of these patients do not require surgical intervention.

Diagnostic indicators of Tension Pneumothorax

(a) Diagnosis should be based on history and clinical presentation, NOT discovered by x-ray. (b) If chest film is taken before recognition and decompression: it will show large pneumothorax with mediastinal shift.

Clinical Assessment of Tension Pneumothorax

(a) Inspect for complaint of severe pleuritic chest pain, restlessness, severe agitation, dyspnea, tachypnea, retractions and other signs of respiratory distress; asymmetric chest movement, jugular venous distention (JVD), and cyanosis (late sign). Hypovolemic patients will not have JVD. Patients who are spontaneously breathing often have extreme tachypnea and air hunger. Those who are mechanically ventilated have hemodynamic collapse (b) Palpate for SUBQ emphysema in the neck and upper chest; tracheal deviation (late sign and hard to detect); tachycardic carotid and absent radial pulses indicating hypotension. (c) Percuss for hyperresonance on the affected side (d) Auscultate for absent or decreased breath sounds on affected side, tachycardia (apical pulse), and distant heart sounds (if mediastinal shift to right). If a BP is obtained at this point (although not part of the primary survey), patient will have hypotension and a narrowed pulse pressure.

Flail Chest Assessment

(a) Inspect: Carefully inspect an unclothed patient. Chest must be viewed from anterior, posterior, and lateral angles to detect presence of a flail segment. Assess for severe pleuritic chest pain at fracture sites, labored ventilatory effort, splinting, dyspnea, decreased tidal volume, altered respiratory rate (>35 or < 8/min), decreased depth and cough, and other signs of respiratory distress/hypoxia; paradoxical chest movements, evidence of chest wall trauma to soft tissues (abrasion, laceration or ecchymosis), and cyanosis (late sign). (b) Palpate for sub-q emphysema in neck and upper chest, tenderness, crepitus, and pain at fracture sites. (c) Auscultate for absent or decreased breath sounds on affected side, stridor, and crepitus over fracture sites. (7) Diagnostic indicators (a) ABG; SpO2; EtCO2; remarkable hypoxia, hypercarbia (b) X-ray may show multiple rib/sternal fractures and developing pulmonary contusion.

Complications of Chest Tubes/needle decompression

(a) Lung laceration due to pleural decompression (b) Hemorrhage from pulmonary, internal mammary or intercostal vessels due to needle thoracentesis (c) If tension pneumothorax persists unrecognized and untreated, the patient's condition may deteriorate to pulseless electrical activity (PEA) and subsequent cardiorespiratory arrest.

Diagnostic clues based on mechanism of injury: Penetrating chest trauma

1. Anatomical location a. Parasternal wounds are associated with high risk for cardiac injury b. Any penetration below the nipples may have intraabdominal injury c. Subcutaneous emphysema that presents in the tissues of the neck may occur as a result of esophageal perforation 2. Decision tree a. The patient's clinical status needs to be quickly evaluated and treated. If unstable, the patient needs emergent interventions such as IV line placement, blood administration, etc. b. Co-morbid causes of instability need to be detected and resuscitated (1) Tension pneumothorax: pleural decompression/chest tube (2) Large hemothorax: chest tube placement; monitor tube for drainage type and amount. If drainage remains continuous or massive, a thoracotomy may be indicated. (3) Cardiac tamponade: thoracotomy. c. If the patient is stable, an initial chest x-ray is done (1) If negative, the patient is observed and reexamined (2) If positive for pneumothorax/hemothorax, a chest tube is placed. The patient is then monitored for resolution of the pleural collection and re-expansion of the lung. d. If the penetration is located in the posterior box (between the scapulae), and if the source of the penetration is a: (1) GSW: an arch angiography, esophagram, esophago- gastroduodenoscopy (EGD), and/or bronchoscopy may be done. (2) stab wound and the mediastinum is abnormal on chest x-ray: an angiogram, esophagram, EGD, and/or bronchoscopy may be done. 3. Parasternal wounds a. Anterior box: Sternal notch to costal margin between nipples b. Assess for signs & symptoms of cardiac tamponade and/or cardiac instability (1) Beck's triad (2) If unstable a thoracotomy/sternotomy may be performed c. If the patient is stable (1) Indirect measurements such as CVP, ECG, and echocardiogram may be done (2) A pericardiocentesis may be performed (3) If positive: thoracotomy 4. Mediastinal wounds a. Structures that may potentially be injured: heart, tracheobronchial tree, esophagus, and spinal cord b. Patient stability needs to be ascertained. If unstable, these patients should be considered to have exsanguinating hemorrhage, tension pneumothorax or cardiac tamponade and require emergent operative intervention. Mediastinal emphysema suggests airway or esophageal injury. c. Stable patients may need bilateral tube thoracostomy. Further diagnostic workup includes evaluation of the heart, airway, and esophagus. These tests include esophagogastroduodenoscopy (EGD), bronchoscopy, endoscopy, angiogram, and esophagram. Additional tests may include CT and ultrasound.

Diagnostic imaging for Zonal Neck Injuries

1. Angiography: Should be considered in Zone I and III injuries. a. Angiography is invasive, costly and does not always provide definitive data. Many injuries found with angiography spontaneously repair themselves. b. This supports the argument against expensive angiography to merely confirm the presence of injury. Emergency angiography requires extensive ancillary support staff to be available at all hours. c. Angiography in the stable patient can help to determine the best surgical approach for repair. 2. Color flow doppler: Less expensive than angiography and has been reported to be as sensitive. Does require extensively trained staff available 24/7. May be difficult to diagnose internal carotid injuries if patient has suspected or confirmed cervical spine injury due to inability to flex, extend or turn the neck. 3. Carotid duplex ultrasonography: Has been used instead of angiography and has been proven to be as sensitive. Test can be completed in half the time of angiography and is less expensive. 4. Esophagrams: When indicated by dysphagia, hematemesis, or clinical exam related to esophageal injury 5. Flexible bronchoscopy: Indicated by stridor, hoarseness, respiratory distress, crepitus, sub-q emphysema or clinical exam which correlates to trachea injury

Treatment plans for Zonal Neck Injuries

1. Based on physical assessment and patient stability the majority of the time. 2. Airway, breathing and circulation remain priorities. Resuscitate any patient presenting with profound shock with NS or LR and prep for OR. 3. Apply digital pressure and/or topical hemostatic dressings in Zone II injuries with active bleeding 4. Every patient with penetrating neck trauma should, at a minimum, be admitted for 24 hour observation and serial clinical exam. This is best managed in a well-staffed, Trauma Center with the availability of ancillary testing, operative access, and experienced surgeons promptly available. 5. Many of the vascular injuries can be observed and repair themselves. 6. Avoid manipulation, probing, or any actions that may result in choking, gagging, or coughing by the patient. These actions could result in dislodging a clot that would lead to hemorrhage. 7. Operative intervention currently is less frequent than in past years. Mandatory exploration of penetrating neck wounds is no longer a standard of care at most institutions. Surgical exploration often results in negative findings in as often as 33- 76% of the cases. Operative intervention is based on the patient hemodynamic and neurologic status. Emergency surgery is indicated primarily with Zone I injuries, which are often lethal.

Definitive management of thoracic trauma/zonal injuries of the neck: Knowledge deficit related to actual injury/hospitalization

1. Inform patient/family regarding plan of care 2. Assess patient's/family's baseline knowledge or comprehension of patient's injuries 3. Teach patient about current medical regime and implications of their care (i.e. anticipated outcomes, current medications, and prescribed therapies a. Assess patient's ability to understand and adhere to instructions b. Reinforce instructions; perform demonstrations/return demonstrations of all patient self-care procedures 4. Reinforce the importance of follow up and discharge instructions

Adjuncts to primary survey

1. Laboratory evaluation a. Arterial blood gases: essential in determining pH, acid/base, oxygen and ventilatory status b. Standard trauma labs - CBC, chem, PT/PTT (INR), Type & Screen, U/A or point of care testing. Other labs as determined by mechanism, clinical presentation. 2. Radiology a. Chest x-ray: Based on NEXUS criteria, patients <60 years old who have no chest pain or tenderness, no distracting injuries or intoxication, and whose mechanism did not involve rapid deceleration do not need routine chest x-ray .Physical exam alone does not have adequate diagnostic sensitivity for pneumothorax and penetrating trauma. All who suffer penetrating injury require a chest x-ray. Importance of serial chest x-rays is essential. An initial chest x-ray may not reveal pulmonary contusion because its onset may be delayed; serial exams will. b. Spiral computer tomography (CT): Compared to chest x-ray, chest CT has greater sensitivity for detecting a pneumothorax or hemothorax and allows for evaluation of the rib cage, mediastinum, lung parenchyma and the aorta 3. ECG: May reveal life-threatening dysrhythmias and/or potential cardiac injury. 4. Echocardiogram a. May be used to noninvasively evaluate precordial trauma. b. Sensitive test to determine penetration in proximity to the heart in hemodynamically stable patients who sustained penetrating precordial trauma. c. Transthoracic echocardiography (TTE) is a rapid and noninvasive test that provides information about the patient's cardiac structure and function and detects the presence or absence of pericardial fluid. d. Transesophageal echocardiography (TEE) is a valuable tool in helping to detect both cardiac and aortic injuries. 5. Emergency (resuscitative) ED thoracotomy a. "A patient sustaining a penetrating wound, who has required CPR in the pre- hospital setting, should be evaluated for any signs of life. If there are none and no cardiac electrical activity is present, no further resuscitative effort should be made. Patients sustaining blunt injuries who arrive pulseless but with myocardial electrical activity (PEA) are not candidates for resuscitative thoracotomy. Multiple reports confirm that ED thoracotomy for patients with blunt trauma and cardiac arrest is rarely effective". b. Defining limits (futility) for resuscitative thoracotomy include: prehospital CPR exceeds 10 min after blunt trauma without a response, prehospital CPR exceeds 15 min after penetrating trauma without a response, asystole is the presenting rhythm, and there is no pericardial tamponade.

Morbidity and mortality

1. Thoracic injuries are the second leading cause of trauma mortality occurring in up to 35% of all trauma-related deaths in the US. 2. Impairments in ventilatory efficiency related to: a. Pain restricting chest excursion b. Air or blood entering the pleural space c. Chest wall unable to move in unison d. Ineffective diaphragmatic contraction 3. Impairments in gas exchange: a. Pulmonary ventilation/perfusion mismatch: i.e.- contusion, hematoma, alveolar collapse b. Changes in intrathoracic pressure relationships: tension/open pneumothorax or severe hemothorax c. Atelectasis d. Contused lung tissue e. Respiratory acidosis, hypercarbia: most often results from inadequate ventilation caused by changes in intra-thoracic pressure relationships and depressed level of consciousness 4. Disruption of respiratory tract 5. Impairments in cardiac output related to: a. Blood loss b. Obstructive shock: Increased intrapleural pressures reduce venous return and RV preload or blood in pericardial sac reduces preload c. Myocardial valve damage d. Decreased stroke volume from blunt cardiac injury e. Vascular disruption 6. Metabolic acidosis: caused by hypoperfusion to tissues 7. Often associated with abdominal injuries and are a significant contributor to fatal outcomes. They are the leading cause of preventable trauma death. D. Prevention efforts have the potential to reduce the incidence of thoracic injuries: 1. Firearm safety 2. Sports training 3. Seatbelt use 4. Passive restraint systems 5. Decreased speed limits 6. Community/legal activity regarding drunk driving, etc. 7. Violence prevention education such as conflict resolution skills

"C": Assess perfusion/cardiac status

Detect/resuscitate injuries prone to compromised circulation (such as cardiac tamponade, massive hemothorax) 1. Inspect/palpate hemodynamics/perfusion a. Pulses: presence/absence, general rate (fast or slow), quality (full/ thready), rhythmicity (regular/irregular) and location (carotid, femoral, or radial) b. Skin color/temperature/moisture c. Mental status as an indicator of central perfusion 2. Auscultation: Heart sounds are best noted over the following areas: a. Mitral valve: 5th left intercostal space (ICS) in the midclavicular line b. Tricuspid valve: lower left sternal border at the 4th ICS c. Aortic valve: 2nd right ICS at the sternal border d. Pulmonic valve: 2nd left ICS at the sternal border e. Heart sounds are often difficult to assess while examining the multiple trauma patient. However, muffled or distant heart tones are noteworthy because this finding may indicate cardiac tamponade or a tension pneumothorax with significant mediastinal shift. 3. ECG monitor and evaluate rhythm

Blunt aortic injury (BAI)

a. Attributable to several mechanisms: (1) Shearing forces (2) Compression of aorta/great vessels (3) Intraluminal hypertension (4) Stress on fixation point of the descending aorta at the ligamentous arteriosum causes an intimal or transmural tear that results in false aneurysm formation. (5) BAI should be suspected in patients presenting with blunt chest trauma. (6) Presence or absence of restraints does not impact the incidence of BAl. Other MOI include pedestrian/vehicular incidents and falls. (7) Penetrating trauma: Gunshot wounds and stab wounds that transverse the mediastinum are highly suspicious for great vessel injury (8) Iatrogenic injuries can also account for great vessel injury (a) IV catheter placement and perforation of subclavian/innominate veins (b) Intercostal artery injury secondary to chest tube placement (c) Pulmonary artery rupture secondary to Swan Ganz overinflation (d) Aortic injury secondary to an intraaortic balloon pump (9) Morbidity and mortality (a) Blunt aortic injury is the second most common cause of death in blunt trauma patients. (b) Mortality estimated to be 80% within the first hour of injury. b. Physical exam: Many patients with thoracic vascular injury (secondary to blunt trauma) have no evidence of physical injury. (1) Chest pain that may radiate to back (2) Respiratory distress (3) Signs of pericardial tamponade (4) Physical evidence of major chest trauma e.g., steering wheel imprint on chest (5) Pulse differential between arms or between upper and lower extremities: decreased or absent femoral pulses (6) Upper extremity hypertension or BP differential between arms (7) Enlarging hematoma at the thoracic outlet (8) Interscapular murmur (9) Palpable fractures of sternum and/or thoracic spines (10) Trauma which may be suspicious for occult injuries (a) Scapula fracture (b) Multiple left rib fractures (c) Flail chest (d) Clavicle in the multisystem injured patient (e) First rib fracture c. History - MOI which may suggest great vessel trauma (1) Ejection from motor vehicle (2) Death of another passenger in same crash (3) Falls from height (4) Automobile deformity (5) Aircraft crashes

Rib Fractures

a. Common injury following blunt trauma b. Mechanism usually associated with age-related injuries: (1) Sports/recreational injuries in adolescents (2) MVC/assaults in adults (3) Falls in the geriatric population (4) Usually does not occur in children because of pliancy of chest wall c. Usually observed at the point of impact and the posterior angle d. 4th through 9th ribs are the more common site of fractures e. Site of injury may highlight other associated injuries: (1) 1st and 2nd rib fractures may signal neck and great vessel injury (subclavian artery/vein, aortic injury) (2) Fractures of the 9th through 11th ribs are associated with intraabdominal injury: lower left rib fractures: splenic injury; lower right rib fractures: liver injury. (3) Two or more rib fractures are associated with an increased incidence of internal injury. f. Clinical manifestations (1) Decrease in effective ventilations secondary to pain and guarding (2) Pulmonary shunting secondary to atelectasis and hypoxia (3) Point tenderness (4) Bony crepitus/subcutaneous emphysema (5) Shallow respiratory effort (6) Ecchymosis (7) Muscle spasm (8) Chest wall pain that increases with deep breathing (pleuritic chest pain), coughing, and movement (9) Decreased breath sounds if pneumothorax or hemothorax present g. Diagnostic indicators (1) Clinical exam and presentation (2) Upright posteroanterior (PA) chest x-ray usually provides a general visualization of rib fracture or intrathoracic injuries. (3) Selective use of rib series include: (a) Suspected rib fracture 1-2 (b) Suspected rib fracture 9-12 (c) Multiple rib fracture (d) Elderly patient (e) "Suspect" etiology of fracture (e.g. child abuse)

Small hemothorax

a. Etiology: Blunt or penetrating trauma. b. Clinical manifestations (1) Dyspnea, tachypnea (2) Decreased breath sounds over hemothorax (3) Dullness to percussion over hemothorax (4) With blood loss < 400 mL, there may be no observable alterations in the patient's presentation or vital signs c. Chest x-ray may not show a hemothorax of less than 300 mL. d. Management/interventions (1) Bleeding from parenchymal lacerations is often self-limited due to low pulmonary pressures and high concentrations of tissue thromboplastin in the lung. (2) Prepare for chest tube insertion (36-40 Fr to prevent clotting) 4th-5th ICS, just anterior to the midaxillary line on affected side (3) Monitor chest tube output and closed drainage device. (4) Anticipate further diagnostic workup; e.g. bronchoscopy (5) Monitor for worsening pulmonary status (altered respiratory rate, depth, work of breathing and ↓ SPO2) and shock. Infuse fluids/blood products as ordered to maintain perfusion. (6) If intubated, anticipate increased peak airway pressures (7) If worsening clinical presentation, check abg

Closed (simple) pneumothorax

a. Loss of pleural integrity allows air into the pleural space resulting in partial to total collapse of the lung on the affected side due to its natural elastic recoil. Collection of air, fluid or blood in the pleural space also cause the pleural pressures to become positive, causing inappropriate ventilation. b. Mechanisms of injury can be due to either blunt or penetrating trauma. The pleurae can be ruptured by the "paper-bag phenomenon" or "paper-bag syndrome" when blunt trauma is delivered at full inspiration with the glottis closed (breath holding), resulting in a dramatic spike in intra-alveolar pressure and alveolar rupture. It can also result from a fractured rib that penetrates the lung parenchyma. c. Classifications: Loss of negative intrapleural pressure results in partial to total collapse of the lung with accumulation of air in the pleural space. Pneumothorax size is determined by the degree of lung collapse: (1) Small: 15% or less occupation of the pleural cavity (2) Moderate: 15%-60% occupation of the pleural cavity (3) Large: 60% or greater occupation of the pleural cavity d. Clinical manifestations: Usually, a loss of more than 40% of lung volume presents with respiratory distress unless there is preexisting lung disease; in this case, a smaller loss of lung volume may cause distress. (1) Dyspnea (2) Chest pain; may not develop for hours (3) Tachypnea, tachycardia (4) Decreased or absent breath sounds on affected side (5) Hyperresonance over affected area if pneumothorax is large (6) Variability in presence/absence of cyanosis e. Diagnostic indicators (1) Clinical exam (2) Upright chest radiograph is an optimal film to diagnose air/fluid in pleural cavity

Sternal fracture and dislocation

a. Mechanism: Blunt anterior chest trauma. Classic mechanism: the chest hits the steering wheel in an MVC. Other injury mechanisms include direct blow to the sternum or compression of the sternum associated with hyperflexion sternal injury. b. Associated injuries (1) Blunt cardiac injury (2) Pulmonary insult (3) Pericardial tamponade (4) Cardiac rupture c. Mortality rates are high (25%-45%) secondary to associated injury. d. Clinical manifestations (1) Anterior chest pain (2) Tenderness (3) Palpable deformity (4) Unstable fractures may result in a flail chest (5) ECG changes e. Diagnostic indicators (1) Clinical exam (2) Confirmed best by lateral x-ray (3) Mediastinal widening may be noted on chest x-ray requiring further diagnostic workup (aortography/TEE) to r/o great vessel injury. f. Management (1) Goals of therapy (a) Identify and manage associated injuries (b) Treat pain (2) Interventions (a) Cardiac monitoring/ECGs to rule out myocardial insult (b) Echocardiogram may be ordered (c) Analgesics and limitation of motion when possible

Pulmonary contusion

a. Mechanisms: deceleration, direct impact, spallation and implosion, resulting from blunt or penetrating trauma. b. Pathophysiologic changes (1) Endothelial damage of the alveolar-capillary membrane, localized fluid shifts, and non-cardiogenic pulmonary edema (2) Interstitial and alveolar hemorrhage (3) Impaired gas exchange (PaO2 <80 mmHg) (4) Decreased surfactant levels (5) Atelectasis and ventilation/perfusion mismatch (6) Decreased blood flow and increased pulmonary vascular resistance in the injured lung (7) Overall, these changes create arteriovenous shunting with accompanying hypoxemia and respiratory failure c. Clinical manifestations (1) Hemoptysis (2) Dyspnea (3) Tachycardia (4) Tachypnea (5) Hypoxia, hypercarbia (6) Wheezing/crackles (7) Absent breath sounds (8) Cyanosis d. Diagnostic indicators (1) Mechanisms (deceleration forces/high velocity penetration) may forewarn the clinician of the possibility of pulmonary contusion (2) Certain clinical conditions such as flail chest, are usually associated with pulmonary contusion (3) ABGs; SpO2 will show marked hypoxia; EtCO2 shows hypercarbia (4) Chest x-ray: patchy, irregular infiltrates or obvious consolidation after several hours

Blunt chest trauma

a. Shearing, acceleration-deceleration (skeletal body starts or stops moving more quickly than the internal organs. This type of motion frequently causes more damage to relatively fixed structures, (aorta), than to non-fixed organs, such as the heart and lungs); compression (crush) b. MVCs are responsible for up to 80% of blunt thoracic trauma c. Falls: More than 1⁄2 in elderly d. Acts of violence; blast injuries

Tracheobronchial tree injury

a. Usually fatal due to associated airway obstruction. Majority of the patients die at the scene secondary to asphyxia. b. Mechanism of injury: Blunt or penetrating trauma (1) Tracheobronchial rupture/tear via blunt trauma occurs from crushing or compressive injury causing a sudden decrease in anterior/posterior diameter and increase in lateral diameter (such as a lap belt across the throat in MVC). Since the lungs may move laterally in response to the force, the trachea/bronchi may transect secondary to exceeded stretch. (2) The cricoid ring and carina serve as fixed points for the trachea. When there is an acute acceleration/deceleration force, a shearing force is produced at these points and creates a tracheal injury. (3) Direct insult to a hyperextended cervical trachea may cause rupture, e.g. striking the dashboard, steering wheel. (4) Rapid increase in intrathoracic pressures concomitant with a closed glottis may produce a "blowout" injury to the trachea with a linear rupture. (Similar to mechanism precipitating closed pneumothorax.) c. Site of injury: Transverse rupture is the most common type of tracheal injury and most occur within 2.5 cm of the carina. d. Associated injuries: Esophageal, great vessels, lung, cardiac, and cervical spine injuries are noted because of anatomical location and mechanism. Mechanism can also account for associated head injuries and facial injuries. e. Clinical manifestations (1) Variability in presentation: ranging from asymptomatic to severe dyspnea/cyanosis (2) Hoarseness (3) Tachypnea; hemoptysis (4) Subcutaneous emphysema (5) Pneumomediastinum (6) Incomplete transection causes stenosis accompanied by pulmonary infection and bronchiectasis (7) Decreased or absent breath sounds associated with pneumothorax (8) Hamman's sign may be present (crunching sound noted with heart auscultation)

"B": Assess breathing; ventilatory and gas exchange status- Palpation/Percussion/Auscultation

b. Palpation (1) Point tenderness (2) Loss of chest wall integrity; instability (3) Crepitus; subcutaneous emphysema (4) Edema (5) Tracheal position (deviation difficult to appreciate clinically as shifting first occurs in the chest, not neck) c. Percussion (1) Hyperresonance/tympany (pneumothorax) (2) Dull or flat tone (hemothorax) d. Auscultation (1) Breath sounds present, diminished, or absent; unilateral or bilateral (2) If decreased, attempt to discern etiology; treat appropriately (3) Adventitious sounds: treat during definitive care phase (4) Presence of bowel sounds in chest suggests a ruptured diaphragm

Tracheobronchial tree injury Diagnosis/ Intervention/ Complication

f. Diagnostic indicators (1) Clinical presentation and history (2) Chest x-ray: > 90% have an abnormal x-ray, such as evidence of pneumomediastinum, sub-q emphysema, and/or pleural effusion. Other abnormalities may include a large pneumothorax, fracture of the upper ribs (1-5), air surrounding the bronchus, and obstruction in the air filled bronchus. (3) Fiberoptic bronchoscopy diagnoses the presence of a tracheobronchial injury. It also helps to safely ensure the placement of an endotracheal tube. g. Management/interventions (1) Obtain/secure airway: O2 per appropriate device and FiO2, suction, etc. (2) Chest tube placement may reveal an ongoing air leak without expansion of the lung. (3) ETT placement needs to be advanced beyond the injury so repair can be done. (4) Maintain effective ventilations. (5) For mainstem bronchus injury, single lung ventilation or jet ventilation may be needed to repair the injury. (6) Nonoperative management: Used in small tracheal injuries with no loss of tissue. Tracheal intubation is usually maintained for 24-48 hours. (7) Operative management: Required for most diagnosed tracheal/bronchial injuries. Preparation of the patient and family is needed. h. Complication: Bronchopleural fistula: May occur from lung parenchymal injury. This injury may present with massive air leaks, decreased tidal volumes and altered gas exchange. Surgical intervention, including repair of pulmonary tissue and injured bronchioles, may be needed to achieve lung reexpansion.

Management and Complication of Rib Fractures

h. Management (1) Goals of therapy (a) Relieve pain (b) Maintain adequate pulmonary function (c) Avoid potential complications: atelectasis, pneumonia (2) Interventions (a) Administer analgesics as prescribed. Select patients benefit from epidural analgesia, intercostal nerve blocks or continuous analgesia. See pain management recommendations for flail chest. (b) Coughing/deep breathing; incentive spirometry (c) Postural drainage and inhalation therapy with bronchodilator/mucolytic treatments may benefit high risk patients such as the elderly or patients with pulmonary disease. (d) Avoid binders or taping of the chest wall to prevent further restriction of ventilation. (e) Reassess pain and response to pain medications. i. Complications (1) Pneumothorax/hemothorax (2) Pneumonia (3) Post traumatic neuroma (4) Costochondral separation (5) Atelectasis may occur from hypoventilation and pain. Because the patient does not breathe deeply, adequate tidal volumes may not be achieved. Additionally, there may be decreased production of surfactant, the substance that lowers surface tension and facilitates alveolar opening. This results in shunting of blood to nonventilated alveoli that can lead to arterial hypoxemia, plugging of proximal airways, segmental and lobar collapse, pneumonia, and bronchiectasis. (6) Pitfall: Do not underestimate the severe pathophysiology of rib fractures, especially in elderly patients.

Definitive management of thoracic trauma/zonal injuries of the neck: Potential for infection

related to invasive line placement, operative management, chest tube insertion, or pulmonary stasis 1. Assess patient for signs and symptoms of potential infection, i.e. increased WBC count, temperature, or pain, redness, inflammation, and abnormal drainage from invasive catheters, wounds, incisions 2. Maintain aseptic technique when placing lines, chest tubes, changing dressings 3. Instruct patient re: coughing and deep breathing 4. Mucolytics may be ordered to decrease tenacity of secretions. 5. There is sufficient evidence to recommend prophylactic antibiotic use in patients receiving tube thoracostomy following chest trauma. A first generation cephalosporin should be used for no longer than 24 hours. The data suggests there may be reduction in the incidence of pneumonia but not empyemia in trauma patients receiving prophylactic antibiotics when a tube thoracostomy is placed.

life-threatening injuries impairing ventilation or gas exchange

tension pneumothorax, open pneumothorax, flail chest