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DOCHERTY

DOCHERTY. CHEST TRAUMA. Purple Stars from Last Year. Clinical use of xrays in rib fractures Flail chest Treatment of pneumothorax (especially tension) Tamponade- beck’s triad, treatment. Chest Trauma. Blunt trauma: * mostly caused by MVA (40% of MVA injuries are blunt chest trauma)

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DOCHERTY

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  1. DOCHERTY CHEST TRAUMA

  2. Purple Stars from Last Year • Clinical use of xrays in rib fractures • Flail chest • Treatment of pneumothorax (especially tension) • Tamponade- beck’s triad, treatment

  3. Chest Trauma Blunt trauma: * mostly caused by MVA (40% of MVA injuries are blunt chest trauma) * spectrum of symptoms, may be asymtomatic, so reassess often * history of MVA should include: speed of car, position of patient in car, seatbelts, windshield smashed, pt ejected, steering wheel bent, dashboard damage, airbag deployed

  4. Rib Fractures: most common chest injury • 50% are not seen on initial xray (make Dx clinically—tender/ecchymosis/crepitus) • CXR is useful to r/o pneumothorax • Can lead to atelectasis and secondary PNA • 1st and 2nd rib fxrs = severe trauma • Tx goal: analgesia and pulmonary fxn • Most heal without complication 3-6 wks

  5. Sternal Fracture • Usu from striking chest on steering wheel • Concern is really about other structures (heart and lungs) being damaged because of the extreme force needed to fxr sternum

  6. Flail Chest • 3 or more ribs fxr’d at 2 points • Freely moving segment of chest wall (paradoxical motion- in with inspiration, out with expiration) • Compresses lung beneath it • Not always seen right away because muscle spasm “splints” the paradoxical motion

  7. Non penetrating Ballistic Injuries • Bullet proof vests • Kinetic energy is dissipated throughout body—can cause serious damage

  8. Pneumothorax • Air in pleural space, usu assoc with penetrating injuries (can occur spontaneously or in pts with pulmonary dz) • 3 types • Simple/noncommunicating • Communicating • Tension (the bad one)

  9. Simple Pneumothorax • Usu due to rib fxr that punctures pleura (or can be due to spontaneous bleb rupture) • Does NOT communicate with atmosphere • NO shift of mediastinum • Signs/Sxs: SOB, CP, cyanosis, tachypnea, or may have none • Definite Dx: PA CXR • Tx: if small can hospitalize with observation; if moderate to large or if pt deteriorates—chest tube

  10. Communicating Pneumothorax • Communicates with atmosphere • Can hear air going in and out • The oxygenated air which is expired from the normal lung reaches carina and then enters the injured side, only to return to the normal side with the next inspiration (this significantly impairs ventilation/oxygenation) • Tx: petroleum gauze over puncture wound until chest tube is placed

  11. Tension Pneumothorax • Shift of mediastinal structures compresses opposite lung • Air enters but cannot exit, ball valve mechanism • Sn/Sx: severe resp distress, dyspneic, agitated, confused, cyanotic, tracheal deviation and shift mediastinum to opposite side • Tx: rapidly fatal so may need to perform needle thoracentesis before obtain CXR, follow with chest tube placement

  12. Hemothorax • Blood in pleural space • Hemorrage from lung is usu self limited • Upright xray shows blunted costophrenic angles • Tx: restore blood volume to circulation, drain blood from lungs, chest tube allows monitoring of blood loss and re expansion of lung

  13. Myocardial Contusion • Due to sharp blow to sternum (ie steering wheel) • Sxs: CP, sternal/rib fxr, abnormal cardiac rhythms/elevated cardiac enzymes • Tx: same as acute MI

  14. Myocardial Rupture • Perforation of atria or (more likely) ventricle • Can be sudden (often instantaneously fatal) or delayed… few survivors • Tx: initial tx same as cardiac tamponade, emergent surgical intervention is only chance for survival

  15. Cardiac Tamponade • Fluid (usu blood) inside pericardium that compromises cardiac function • Increased intrapericardial pressure compresses the heart and limits ventricular filling…SV falls…arterial BP falls…blood backs up into vena cava… HR and TPR increase in an attempt to maintain CO and BP • Beck’s triad: distant heart sounds, hypotension, distended neck veins • Pulsus paradoxicus: SBP drops > 10mmHg during respiration • Electrical alternans: noted on EKG, changes in morphology/amplitude with every other beat • Tx: airway management, volume expansion with crystalloid, CVP line, pericardicentesis (needle drainage), immediate surgery, r/o assoc injuries

  16. That’s It For Docherty!

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