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Thoracic Trauma

Thoracic Trauma. Opening Case. Thoracic Trauma. Opening Case. You are dispatched at 1656 for a “car vs. train” accident in a rural area En route you are told by first responders that the patient was an unrestrained driver of a truck and was ejected

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Thoracic Trauma

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  1. Thoracic Trauma

  2. OpeningCase Thoracic Trauma

  3. Opening Case • You are dispatched at 1656 for a “car vs. train” accident in a rural area • En route you are told by first responders that the patient was an unrestrained driver of a truck and was ejected • They also tell you he is currently awake and alert; they already have him “boarded”

  4. SICK? Sick or Not-yet-sick? Why? or NOT YET SICK?

  5. Case (continued) • Upon arrival you find a 60-year-old male with the following physical examination findings: • SKIN: Pale, warm, dry • HEENT: Abrasions, contusions to face • CHEST: Crepitus to upper chest, lungs hard to auscultate (obese), denies SOB • BACK: c/o pain

  6. Assessment • What should be your course of treatment? • How should this patient be transported?

  7. Introduction

  8. Introduction • Trauma to thorax can cause a patient to deteriorate quickly

  9. The Deadly Dozen • The lethal six(identified in the primary survey) • The hidden six(identified in the secondary survey)

  10. The Lethal Six 1. Airway obstruction 2. Tension pneumothorax 3. Cardiac tamponade 4. Massive hemothorax 5. Open pneumothorax 6. Flail chest

  11. The Hidden Six 1. Thoracic aortic disruption 2. Tracheobronchial disruption 3. Myocardial contusion 4. Traumatic diaphragmatic tear 5. Esophageal disruption 6. Pulmonary contusion

  12. Epidemiology

  13. Epidemiology • Incidence • Major cause of chest trauma

  14. Applied Anatomy and Physiology

  15. Applied Anatomy and Physiology Review • 12 ribs • False ribs • Floating ribs • Neurovascular bundle • Hemithorax • Visceral and parietal pleura • Mediastinum • Ligamentum arteriosum

  16. Pathophysiology of Chest Injuries

  17. Blunt Trauma • Shearing forces • Compression injuries • Blast injuries

  18. Penetrating Trauma • Impaling Injuries • Projectile Injuries

  19. Scene Survey

  20. Scene Survey • Gather information • Severity of injury force • Incident-specific circumstances • Make use of bystanders and law enforcement officers for information

  21. Primary Survey

  22. The ABCs • Expose the chest • Look, listen, and feel • Rapidly determine status

  23. Initial Assessment of the Neck • Signs of distress • Inspection • Palpation

  24. Initial Assessment of the Chest • Look • Feel • Listen • Tachypnea • Bradypnea

  25. Secondary Survey

  26. You witness a car crashing into telephone pole at 65 mph. The driver is awake and disoriented, complaining of shortness of breath and chest pain. The steering wheel is bent and the dashboard is deformed. You cannot feel a radial pulse. You should suspect: A. Pericardial contusion B. Hemothorax C. Rib fractures D. Tension pneumothorax

  27. You witness a car crashing into telephone pole at 65 mph. The driver is awake and disoriented, complaining of shortness of breath and chest pain. The steering wheel is bent and the dashboard is deformed. You cannot feel a radial pulse. You should suspect: A. Pericardial contusion B. Hemothorax C. Rib fractures D. Tension pneumothorax

  28. Specific Thoracic Injuries • Lung and pleural injuries • Pneumothorax and hemothorax • Tension pneumothorax • Open chest wounds

  29. Hemothorax

  30. Tension Pneumothorax

  31. Tension Pneumothorax

  32. Difficulty breathing that worsens Hypotension Tachycardia Difficulty in performing BVM ventilations that worsens Asymmetrical breath sounds Drop in pulse oximetry Pulses paradoxus JVD Tracheal deviation Chest pain Signs and Symptoms of Tension Pneumothorax

  33. Street Secret • Endotracheal intubation and positive pressure ventilation have a higher potential of turning a simple pneumothorax into a tension pneumothorax • Current recommendations for assisting ventilations using a BVM for adults is to provide NO MORE than 12 breaths per minute

  34. Air Medicine • Monitor for tension pneumothorax carefully

  35. Specific Thoracic Injuries • Simple pneumothorax • Open pneumothorax • Hemothorax

  36. Signs and Symptoms of Massive Hemothorax • Hypotension and obvious shock • Pain • Tachypnea • Low pulse ox reading • Tachycardia • Possible decreased breath sounds • Tracheal deviation or JVD

  37. Specific Thoracic Injuries • Traumatic asphyxia • Pulmonary laceration • Pulmonary contusion

  38. Specific Thoracic Injuries • Tracheobronchial injuries • Causes • Signs and symptoms • Intubation risk?

  39. Pericardial Tamponade

  40. Specific Thoracic Injuries • Cardiac Injuries • Pericardial Tamponade • When pericardial sac fills with fluid • Hypotension, JVD, Beck’s triad • Prehospital treatment includes pericardiocentesis

  41. Signs and Symptoms of Pericardial Tamponade • Hypotension • Pulsus paradoxus tachycardia • Beck’s triad (JVD, narrow pulse pressure, muffled heart tones)

  42. Specific Thoracic Injuries • Cardiac injuries • Blunt cardiac injuries • Myocardial rupture • Myocardial infarction (traumatic) • Myocardial contusion • Myocardial concussion • Penetrating cardiac injuries

  43. Specific Thoracic Injuries • Great vessel injuries • Blunt trauma to the great vessels • Penetrating trauma to the great vessels

  44. Aortic arch Blood, with contrast, in aorta Blood clot in aorta

  45. Workman with accidental nail-gun injury to the chest Small wound to center of the chest

  46. Chest X-ray of workman with nail-gun injury to chest

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