Approach to Chest Trauma

1. Approach to Chest Trauma Mary Osinga Comprehensive Review Fleming College

2. Traumatic Injuries • Airway injuries • Chest and Breathing • Circulation – shock • Disability – neurological • E- expose and extremity

3. Airway Problems • Problem in trauma is that the airway may not look or behave as normal • Forces onto the head and/or neck may provide significant changes to the anatomy of the airway • Lets review normal airway anatomy

4. Normal airway

5. Edema Presence of fluid Loss of bony structure integrity Foreign objects Abnormal Airway

7. Airway management • Use a modified jaw thrust to avoid C spine displacement • Watch for nasal airway insertion in patients with….? • Oral airways in patients GCS<8 • Suction blood and secretions, remember patients supine on board • Watch for vomiting –beer and pizza

9. Chest Trauma

10. Introduction • Chest trauma is often sudden and dramatic • Accounts for 25% of all trauma deaths • 2/3 of deaths occur after reaching hospital • Serious pathological consequences: -hypoxia, hypovolemia, myocardial failure

11. Mechanism of Injury Penetrating injuries • E.g. stab wounds etc. • Primarily peripheral lung • Haemothorax • Pneumothorax • Cardiac, great vessel or oesophageal injury

12. Eating can be dangerous!

13. Blunt injuries • Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury • Rib fracture is the most common sign of blunt thoracic trauma • Fracture of scapula, sternum, or first rib suggests massive force of injury

14. Deadly Dozen from ITLS • Airway obstruction • Open Pneumo • Flail Chest • Tension Pneumo • Massive Hemothorax • Cardiac Tamponade Detected in the primary survey

15. Deadly Dozen from ITLS • Myocardial contusion • Traumatic aortic rupture • Tracheal bronchial tear • Diagphragmatic injury • Esophageal injury • Pulmonary contusion Detected in the secondary survey

16. Mechanism!

17. Chest wall injuries • Rib fractures • Flail chest • Open pneumothorax

18. Rib fractures • Most common thoracic injury • Localised pain, tenderness, crepitus • CXR to exclude other injuries • Analgesia..avoid taping • Underestimation of effect • Upper ribs, clavicle or scapula fracture: suspect vascular injury

19. Flail chest • Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration • 2 or more ribs in 2 or more places • Significant force required • Palpate carefully and laterally • Rx: ABC s and analgesia • +/- splint the flail segment

20. Flail chest

21. Flail Chest - detail

22. Lung injury • Pulmonary contusion • Pneumothorax • Haemothorax • Parenchymal injury • Trachea and bronchial injuries • Pneumomediastinum

23. Open pneumothorax • Defect in chest wall provides a direct communication between the pleural space and the environment • Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax • “Sucking chest wound” • Rx: ABCs…closure of wound…chest drain

25. Pneumothorax • Air in the pleural cavity • Blunt or penetrating injury that disrupts the parietal or visceral pleura • Unilateral signs: movement and breath sounds, resonant to percussion • Confirmed by CXR • Rx: chest drain

26. Pneumothorax

27. Tension pneumothorax • Air enters pleural space and cannot escape • P/C: chest pain, dyspnoea • Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension

28. Surgical emergency • Needle decompression required-ACP • In hospital-Either large bore cannula in 2nd ICS, MCL or insert chest tube • Reassess post needle

29. Hemothorax • Blunt or penetrating trauma • Requires rapid decompression and fluid resuscitation • May require surgical intervention • Clinically: hypovolemia absence of breath sounds dullness to percussion • Can lose entire blood volume in chest

30. Knife wound

32. Some problems with Hemothorax • Significant blood loss-how much? • Atelactasis • V/Q Mismatch • So what problems can your patients have?

33. Heart, Aorta & Diaphragm • Blunt cardiac injury - contusion - ventricular, septal or valvular rupture • Cardiac tamponade • Ruptured thoracic aorta • Diaphragmatic rupture

34. Cardiac Tamponade • Blood in the pericardial sac • Most frequently penetrating injuries • Shock, JVP, PEA, pulsus paradoxus • Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension • Rx: Volume resuscitation Pericardiocentesis

35. Cardiac tamponade

36. Aortic rupture • Usually blunt trauma involving deceleration forces; • ~90% die within minutes • Most common site near ligamentum arteriosum • Treat like an aneurysm if still alive, blunt trauma VSA if dead (?pronounce) • Rx: surgical…poor prognosis

37. Aortic rupture

39. Ruptured Hemi diaphragm • Etiology? • Side?? • Outcome • Diagnosis- how can you tell?? • Treatment?

41. Chest trauma: summary • Common • Serious • Primary goal is to provide oxygen to vital organs • Remember Airway Breathing Circulation • Be alert to change in clinical condition

42. Chest Trauma • Identify early • Rapid transport • Auscultate frequently • Consider tertiary care centre • Watch for shock and treat • IV fluids (bolus is…?) • Large bore IV’s • Trendelenberg