Thoracoabdominal Trauma

1. Thoracoabdominal Trauma Instructor Name: Title: Unit:

2. OBJECTIVES • ABDOMINAL TRAUMA • Anatomy & Physiology • MOI • Patient Assessment • General Treatment • Specific Injuries • Thoracic Trauma • Anatomy & Physiology • Patient Assessment • Specific Injuries

3. Abdominal Trauma: Facts • 7%-15% of all trauma deaths • Penetrating – Most Common; 5% mortality • Blunt – Most difficult to diagnose; 10%-30% mortality • 75% of blunt abd blunt trauma is caused by high speed motor vehicle crashes (MVC’s)

4. ABDOMINAL A&P • Abdominal cavity bounded by pelvis, diaphragm, anterior abdominal muscles, vertebral column and ribs, flank muscles • Peritoneum • Parietal • Visceral • Mesenteries • Peritoneal cavity • Potential space between visceral and parietal pleura • Abdominal Cavity – Divided into 2 spaces: • Retro peritoneal space – Kidneys, ureters, bladder, reproductive organs, inferior vena cava, aorta, pancreas, duodenum colon, & rectum • Peritoneal space – bowel, spleen, liver, stomach, & gall bladder

5. MECANISM OF INJURY (MOI) • Solid organs bleed • Hollow organs – discharge contents into the peritoneum which leads to peritonitis • Fx ribs/sternum – usually injures liver/spleen • Fx pelvis – injures bladder, reproductive organs, intestines

6. MOI (CONT’D.) • Steering wheel impacts may rupture abdominal cavity w/ herniation of left diaphragm • Stab wounds – possible to predict path of object, less able to predict injuries with GSW • Compression injuries – organs sheared at impact with other objects (ex: Liver)

7. PATIENT ASSESSMENT • Observe MOI and maintain index of suspicion • Suspect intrabdominal bleeding when: • Echymosis • Distention • Hematuria • Blood return in NG Tube • Pain • Abd. Tenderness • Abd. Rigidity • Unexplained shock • Testicular pain = retroperitoneal injury • L shoulder pain = Spleen • R Shoulder pain = Liver

8. PT. ASSESSMENT (CON’D) • Difficult to assess pain (abd. Vs. ribs) • Pain may be masked by drugs, head injury, ETOH • Observation • Distention • Contusions • Cullens sign – echymosis around umbilicus = spleenic injury • Grey Turners sign – Flank echymosis • Kehrs sign – referred pain to shoulders from abd. Injury, worse when lying flat = diaphragm and phrenic nerve)

9. PT. ASSESSMENT (CON’D) • Observation (con’d) • Penetration • Evisceration • Impaled object • Obvious bleeding • Scaphoid abdomen – Sn of herniated diaphragm • Encapsulating Injury – bleeding into itself without rupturing. (Ex. Spleen or Liver)

10. PT. ASSESSMENT (CON’D) • Palpation • Avoid deep palpation • Abdominal wall defects • Tenderness • Pelvic instability

11. GENERAL TREATMENT • Remember ABC’s!!! • Rapid assessment, packaging, and Transport • High flow O • IV Lines –Up to 3 L on way to ER (PHTLS) • MAST (no abd. Section) • Treat other injuries

12. THORACIC TRAUMA-FACTS • Second leading cause of trauma deaths • Accounts for 25% of all trauma deaths • 85% can be managed outside of the operating room • Major causes of Blunt Thoracic Trauma: • Steering wheel, bicycle handlebars, baseball • Major causes of Penetrating Trauma: • GSW and Stabbings

13. THORACIC A&P • Cavity is bounded by ribs, spine, and diaphragm • Pleura • Parietal • Visceral • Potential space can hold 3 liters on each side • Right lung – 3 lobes • Left lung – 2 lobes • Mediastinum - • trachea • Mainstem bronchi • Heart • Great vessels • Esophagus

14. PHYSIOLOGY • Respiration • Requires intercostal muscles and diaphragm • Operates on pressure gradient • During exhalation, diaphragm elevated to 4th intercostal space • Driven by PCO2 levels (chemoreceptors in brainstem) • COPD patients driven by PO2 receptors in aortic arch and carotid arteries

15. PATIENT ASSESSMENT • Signs & Symptoms • Dyspnea • Pleuritic chest pain • Splinting • Echymosis • Cyanosis • Lacerations • Asymmetrical chest • Crepitus • Flail segment • Puncture wounds • Neck vein distention • Tracheal deviation • SQ emphysema • Sucking chest wound • Deformity • Paradoxical chest • Tenderness • +/- lung sounds

16. RIB FRACTURES • Most commonly fx are 3-8 (thin) • 8-12 assoc. with spleen, kidney or liver injuries • 1&2 have high mortality because of the forces necessary to fx these ribs – produce serious injuries • Pain upon movement • Crepitus • Deformity • Local tenderness • Hypoventilation • Potential for: • Pneumo/hemothorax • Atelectasis/pneumonia

17. SIMPLE PNEUMOTHORAX • Air in the pleural space • Affected lung begins to collapse as pleural space expands • Caused by puncture wound, rib fx, or lung defect • Simple pneumo usually well tolerated in young, healthy adult • S&S: dyspnea, pleuritic chest pain, tachypnea, decreased lung sounds • Treatment: anticipate development of tension, semi-sitting position unless contraindicated, O2, assist ventilations PRN, IV, EKG, treat other injuries

18. OPEN PNEUMOTHORAX (Sucking Chest Wound) • Open chest wall injury • Stab wounds usually self-sealing • GSW more extensive damage • Air passes through opening into pleural space and remains outside of lung • S&S: gurgling sound during air movement, bubbling wound, dyspnea, tachypnea, diminished breath sounds. • Treatment: anticipate tension, cover wound w/ occlusive dressing to form flutter valve, O2, assist ventilations PRN, IV, EKG, treat other injuries

19. TENSION PNEUMOTHORAX • Air enters pleural space and becomes trapped – leads to pressure increase • Increased pressure further collapses lung and shifts mediastinum to unaffected side • Increased dyspnea and compressed heart and great vessels leads to decreased cardiac output and shock • S&S & Treatment: Con’d on next slide

20. TENSION PNEUMOTHORAX CON’D • Signs & Symptoms: • Dyspnea • Tachypnea • Anxiety • Cyanosis • Diminished lung sounds • Hypotension • SQ emphysema • Paradoxical pulse • Asymmetrical chest • JVD • Tachycardia • Narrow pulse pressure • Tracheal deviation • shock

21. TENSION PNEUMOTHORAX CON’D • Treatment • Remove dressing over open pneumo • If no improvement, open the wound then reseal • Needle decompression • Assist ventilations PRN • IV • EKG • Treat other injuries

22. DECOMPRESSING A TENSION PNEUMOTHORAX • Ensure tension exists and determine which side • 2nd or 3rd midclavicular ICS or 4th or 5th midaxillary ICS • Prep site • Insert 14 ga. Catheter on top of rib • Prepare valve • McSwain dart • Condom • Stopcock • Water valve • Latex glove – no longer recommended • Secure in place • Monitor patient closely

23. ABDOMINAL TRAUMA • Instructor Name: • Title: • Unit:

24. OVERVIEW • Review anatomy • Review types of injuries • Blunt • Penetrating • Evaluation of abdominal trauma • Management of abdominal trauma

25. ANATOMY • Three regions • Thoracic abdomen • True abdomen • Retroperitoneal abdomen • Bleeding into this area does not cause abdominal rigidity

26. ANATOMY Intrathoracic Abdomen True Abdomen

27. ANATOMYRETROPERITONEAL ABDOMEN

28. TYPES OF INJURIES • Blunt trauma • Penetrating trauma

29. BLUNT ABDOMINAL TRAUMA • Mortality 10-30% • Associated with injuries to other systems • Internal bleeding may be severe • Tenderness may not be present during early exam • Early onset of signs & symptoms suggests severe injury • Watch for development of shock

30. BLUNT FORCES CAUSE • Fracture of solid organs • Hemorrhage • Rupture of hollow organs • High risk of peritonitis • Tearing of organs, blood vessels, and mesentery (attachments) • Fractures of lower ribs associated with high incidence of liver or spleen injury

31. PENETRATING WOUNDS • Gunshot wounds • Have higher mortality (up to 15%) due to higher rates of damage to abdominal viscera • Stab wounds • Mortality 1-2% • All penetrating abdominal wounds should be evaluated in the hospital

32. PENETRATING WOUNDS • Causes of mortality • Hypovolemic shock • Injury to abdominal viscera • Sepsis and/or peritonitis are late causes of death • Internal path of penetrating object may not be apparent from external wound • Stab to the chest may penetrate the abdomen and vice versa • Stab to the buttocks has 50% chance of significant intra-abdominal injury

33. EVALUATION SCENE SIZE-UP • Extremely important • Provides clues to • Type of injury • Path followed • Forces involved • Important factors • Weapon or object involved • Distance • Force applied

34. EVALUATION BTLS PRIMARY SURVEY • Initial Assessment • ABCs • Rapid Trauma Survey • Head, Neck, Chest • Abdomen • Look for wounds, bruises, distention • Feel for guarding, tenderness, rigidity

35. EVALUATIONBTLS PRIMARY SURVEY • Signs of intra-abdominal injury usually develop late • After arrival at the hospital • Abdominal pain or tenderness present at the scene suggests severe injury • Patients are likely to develop shock • Penetrating wounds to the upper abdomen may cause chest injury

36. MANAGEMENT • Treat problems found in the BTLS Primary Survey • 100% oxygen • If abdominal tenderness Load & Go • Dress wounds • Two large bore IVs en route • NS or RL to maintain BP of 90-100 systolic

37. MANAGEMENT EVISCERATION • Cover protruding organs with moist sterile dressing and/or nonadherent material • Do not try to put organs back into the abdomen • Load & Go

38. SUMMARY • Second leading cause of preventable death from trauma • Most deaths from delayed treatment • Be alert to mechanisms of injury • Maintain high index of suspicion • Abdominal pain = impending shock • Penetrating wounds of the abdomen or tender abdomen mean Load & Go

39. QUESTIONS?