Thoracic Trauma

1. Thoracic Trauma Tintinalli Chapter 259

2. Introduction to Thoracic Trauma • 25% of civilian deaths • Hospital mortality <5% • Mechanism predicts mortality

3. Initial Resuscitation • Respiratory effort • Poor effort / poor movement • Good effort / poor movement • Listen to neck

4. Initial Resuscitation • Cardiac arrest during / after intubation • Inadequate preintubation oxygenation • Esophageal intubation • Mainstem intubation • Excess ventilation • Developed tension pneumothorax • Systemic air embolism • Vasovagal response • Sudden severe respiratory alkalosis

5. Initial Survey • Treat life threatening injuries • Airway obstruction • Tension pneumothorax • Cardiac tamponade • Massive hemothorax • Open pneumothorax • Flail chest

6. Initial Survey • Airway obstruction

7. Initial Survey • Tension Pneumothorax • Exam • Treatment

8. Initial Survey • Tension Pneumothorax • Exam • Treatment

9. Initial Survey • Cardiac Tamponade • Blunt or penetrating trauma • Presentation • Diagnosis • Treatment

10. Initial Survey • Cardiac Tamponade • Blunt or penetrating trauma • Presentation • Diagnosis • Treatment

11. Initial Survey • Cardiac Tamponade • Blunt or penetrating trauma • Presentation • Diagnosis • Treatment

12. Initial Survey • Massive Hemothorax • Mechanisms of lethality • Hypovolemia • Hypoxia • Vena cava compression • Treatment

13. Initial Survey • Open Pneumothorax • Pathophysiology • Treatment

14. Initial Survey • Open Pneumothorax • Pathophysiology • Treatment

15. Initial Survey • Flail Chest • Definition • Examination • Treatment

16. Ventilatory Support • Consider when: • Impaired ventilation that persists despite primary care treatment measures • Respiratory failure with flail chest • Shock • Multiple injuries • Comatose • Elderly

17. Shock • Goal: Maintain tissue perfusion • Splanchnic perfusion • Capnometry • PETCO2 <28 mm Hg • P(a – ET)CO2 >10 mmHg • Hypovolemic Hypoptension • Blunt • Penetrating

18. Treatment • Fluids • Correct hypotension ASAP • Access • Site choice • Stabilize intravascular volume

19. Treatment • Chest tube and thoracotomy

20. Cardiac Arrest • External massage (compressions) • Internal massage / thoracotomy • For all blunt injuries with thoracotomy • No SOL at scene: mortality 100% • Loose SOL on scene or enroute: mortality 97.5% • Lost SOL in ER: mortality 96% • For penetrating injuries with thoracotomy • Stab wounds: mortality 85% • GSW: mortality: 96%

21. Diagnosis of Thoracic Injuries • Symptoms • Physical • Inspection • Percussion • Auscultation • Imaging

22. Injuries to the Chest Wall • Bleeding • Open chest wounds • Tissue loss • Subcutaneous emphysema

23. Injuries to the Chest Wall • Bleeding • Open chest wounds • Tissue loss • Subcutaneous emphysema

24. Injuries to the Chest Wall • Bleeding • Open chest wounds • Tissue loss • Subcutaneous emphysema

25. Injuries to the Chest Wall • Bleeding • Open chest wounds • Tissue loss • Subcutaneous emphysema

26. Bony Injuries • Clavicular fractures • Rib fractures • First and second • Multiple • Flail Chest • Sternum fracture • Traumatic asphyxia

27. Bony Injuries • Clavicular fractures • Rib fractures • First and second • Multiple • Flail Chest • Sternum fracture • Traumatic asphyxia

28. Bony Injuries • Clavicular fractures • Rib fractures • First and second • Multiple • Flail Chest • Sternum fracture • Traumatic asphyxia

29. Bony Injuries • Clavicular fractures • Rib fractures • First and second • Multiple • Flail Chest • Sternum fracture • Traumatic asphyxia

30. Bony Injuries • Clavicular fractures • Rib fractures • First and second • Multiple • Flail Chest • Sternum fracture • Traumatic asphyxia

31. Injuries to the Lungs • Pulmonary contusion • Pathphysiology • Diagnosis • Treatment

32. Injuries to the Lungs • Hemothorax • Etiology • Pathophysiology • Diagnosis • Treatment

33. Injuries to the Lungs • Pneumothorax • Pathophysiology • Diagnosis • Treatment • Complications

34. Injuries to the Lungs • Pneumomediastinum • Pulmonary hematoma • Pulmonary laceration • Systemic air embolism • Intrabronchial bleeding • Aspiration

35. Injuries to the Lungs • Pneumomediastinum • Pulmonary hematoma • Pulmonary laceration • Systemic air embolism • Intrabronchial bleeding • Aspiration

36. Injuries to the Lungs • Pneumomediastinum • Pulmonary hematoma • Pulmonary laceration • Systemic air embolism • Intrabronchial bleeding • Aspiration

37. Injuries to the Lungs • Pneumomediastinum • Pulmonary hematoma • Pulmonary laceration • Systemic air embolism • Intrabronchial bleeding • Aspiration

38. Injuries to the Lungs • Pneumomediastinum • Pulmonary hematoma • Pulmonary laceration • Systemic air embolism • Intrabronchial bleeding • Aspiration

39. Injuries to the Lungs • Pneumomediastinum • Pulmonary hematoma • Pulmonary laceration • Systemic air embolism • Intrabronchial bleeding • Aspiration

40. Tracheobronchial Injury • Lower trachea and major bronchi • Deceleration • Forced expiration • Cervical tracheal injuries

41. Diaphragm Injury • Etiology • History • Diagnosis • Treatment

42. Penetrating Heart Injuries • Considerations • Diagnosis • Treatment

43. Blunt Heart Injuries • Etiology • Types • Diagnosis table 259-4

44. Blunt Heart Injuries • Blunt myocardial injury (BMI) • Patho • Diagnosis • Clinical • Radiological • EKG • Enzymes • Echo • Treatment

45. Pericardial Inflammation Syndrome • Etiology • Diagnosis • Treatment

46. Great Vessels of the Chest • Penetrating trauma • Stab > GSW • Diagnosis • History • Exam • Radiography • Treatment

47. Great Vessels of the Chest • Blunt trauma • Diagnosis • History – chart 259-5 • Exam • CXR • CT • Treatment

48. Special Considerations • Ascending aorta • Descending aorta • Innominate artery • Subclavian artery

49. Espohageal and Thoracic Duct Injuries • Esophageal laceration • Thoracic duct

50. Questions?