CHEST TRAUMA

1. CHEST TRAUMA Joe Lex, MD, FACEP, FAAEM Chestnut Hill Hospital Philadelphia, PA March 16, 1999

6. Where can adults “hide” blood and go into shock? Chest - listen, do chest x-ray Abdomen - do DPL or CT or US Retroperitoneum - do CT Thigh - physical examination Street - ask paramedic ...and in children, add Head

7. Incidence of Chest Trauma Cause 1 of 4 American trauma deaths Contributes to another 1 of 4 Many die after reaching hospital - could be prevented if recognized <10% of blunt chest trauma needs surgery 1/3 of penetrating trauma needs surgery Most life-saving procedures do NOT require a thoracic surgeon

8. Pathophysiology of Chest Trauma

9. Pathophysiology of Chest Trauma Tissue hypoxia Hypercarbia Respiratory acidosis - inadequate ventilation Metabolic acidosis - tissue hypoperfusion (e.g., shock)

10. Initial assessment and management Primary survey Resuscitation of vital functions Detailed secondary survey Definitive care

11. Initial assessment and management Hypoxia is most serious problem - early interventions aimed at reversing Immediate life-threatening injuries treated quickly and simply - usually with a tube or a needle Secondary survey guided by high suspicion for specific injuries

12. 6 Immediate Life Threats Airway obstruction Tension pneumothorax Open pneumothorax “sucking chest wound” Massive hemothorax Flail chest Cardiac tamponade

13. 6 Potential Life Threats Pulmonary contusion Myocardial contusion Traumatic aortic rupture Traumatic diaphragmatic rupture Tracheobronchial tree injury - larynx, trachea, bronchus Esophageal trauma

14. 6 Other Frequent Injuries Subcutaneous emphysema Traumatic asphyxia Simple pneumothorax Hemothorax Scapula fracture Rib fractures

15. Primary Survey Airway Breathing Circulation

16. A = Airway Assess for airway patency and air exchange - listen at nose & mouth Assess for intercostal and supraclavicular muscle retractions Assess oropharynx for foreign body obstruction

17. B = Breathing Assess respiratory movements and quality of respirations - look, listen, feel Shallow respirations are early indicator of distress - cyanosis is late

18. C = Circulation Assess pulses for quality, rate, regularity Assess blood pressure and pulse pressure Skin - look and feel for color, temperature, capillary refill Look at neck veins - flat vs. distended Cardiac monitor

19. Thoracotomy Closed heart massage is ineffective in a hypovolemic patient Left anterior thoracotomy with cross-clamping of descending thoracic aorta and open-chest massage may be useful in pulseless victim of penetrating trauma

20. Thoracotomy Emergency department thoracotomy for patients without cardiac activity who are victims of blunt thoracic injuries is ineffective

21. Thoracotomy

22. 6 Immediate Life Threats Airway obstruction Tension pneumothorax Open pneumothorax “sucking chest wound” Massive hemothorax Flail chest Cardiac tamponade

23. Airway Obstruction Airway obstruction at the alveolar level is assessed and managed during the secondary survey Upper airway obstruction is an immediate life threat and must be dealt with in the primary survey Most common cause: patient’s tongue

24. Airway Obstruction Chin-lift - fingers under mandible, lift forward so chin is anterior

25. Airway Obstruction

26. Airway Obstruction Jaw thrust - grasp angles of mandible and bring the jaw forward

27. Airway Obstruction Oropharyngeal airway inserted in mouth behind tongue. DO NOT push tongue further back.

28. Airway Obstruction Nasopharyngeal airway - well lubricated “trumpet” gently inserted through nostril

29. Airway Obstruction Definitive management - tube in trachea through vocal cords with balloon inflated.

30. Airway Obstruction Orotracheal intubation Nasotracheal intubation - in breathing patient without major facial trauma surgical airways jet insufflation cricothyrotomy tracheostomy

31. Airway Obstruction

32. Airway Obstruction

33. Tension pneumothorax Air leaks through lung or chest wall “One-way” valve with lung collapse Mediastinum shifts to opposite side Inferior vena cava “kinks” on diaphragm, leading to decreased venous return and cardiovascular collapse

35. Tension pneumothorax Tension pneumothorax is not an x-ray diagnosis - it MUST be recognized clinically Treatment is decompression - needle into 2nd intercostal space of mid-clavicular line - followed by thoracotomy tube

37. Open pneumothorax “Sucking Chest Wound” Normal ventilation requires negative intra-thoracic pressure Large open chest-wall defect leads to immediate equilibration of intra-thoracic and atmospheric pressures If hole is >2/3 tracheal diameter, air prefers chest defect

38. Open pneumothorax Initial treatment - seal defect and secure on three sides (total occlusion may lead to tension pneumothorax Definitive repair of defect in O.R.

39. Massive hemothorax Rapid accumulation of >1500 cc blood in chest cavity Hypovolemia & hypoxemia Neck veins may be: flat - from hypovolemia distended - intrathoracic blood Absent breath sounds, DULL to percussion

42. Massive hemothorax - treatment Large-bore (32 to 36 F) tube to drain blood If moderate sized - 500 to 1500 ml - and stops bleeding, closed drainage usually sufficient If initial drainage >1500 ml OR continuous bleeding >200 ml / hr, OPEN THORACOTOMY indicated

44. Flail chest “Free-floating” chest segment, usually from multiple ribs fractures Pain and restricted movement “Paradoxical movement” of chest wall with respiration

46. Flail chest - treatment Adequate ventilation Humidified oxygen Fluid resuscitation PAIN MANAGEMENT Stabilize the chest internal - ventilator external - sand bags

47. Cardiac tamponade Usually from penetrating injuries Classic “Beck’s triad” elevated venous pressure - neck veins decreased arterial pressure - BP muffled heart sounds Blood in sac prevents cardiac activity

48. Cardiac tamponade May find “pulsus paradoxus” - a decrease of 10 mm Hg or greater in systolic BP during inspiration Systolic to diastolic gradient of less than 30 mm Hg also suggestive

49. Cardiac tamponade Treatment is removal of small amount of blood - 15 to 20 ml may be sufficient - from pericardial sac

54. 6 Potential Life Threats Pulmonary contusion Myocardial contusion Traumatic aortic rupture Traumatic diaphragmatic rupture Tracheobronchial tree injury - larynx, trachea, bronchus Esophageal trauma

55. Pulmonary contusion Potentially life-threatening condition with insidious onset Parenchymal injury without laceration More than 50% will develop pneumonia, even with treatment Up to 50% have only hemoptysis as presenting symptom

56. Pulmonary contusion Patients with pre-existing conditions - emphysema, renal failure - need early intubation Treatment needs to occur over time as symptoms develop

58. Myocardial contusion Blunt precordial chest trauma Difficult to diagnose Risk for dysrhythmias sudden death, tamponade, pericarditis, ventricular aneurysm

59. Myocardial contusion

60. Myocardial contusion Also may see: myocardial concussion - “stunned” myocardium with no cell death coronary artery laceration Diagnosis by: trans-esophageal echocardiogram serial cardiac enzymes

61. Traumatic aortic rupture 90% or more dead at scene 90% mortality each undiagnosed day Must have high index of suspicion Disruption occurs at ligamentum arteriosum (ductus arteriosus) Contained hematoma of 500 to 1000 ml of blood

62. Traumatic aortic rupture Radiographic signs wide mediastinum 1st & 2nd rib fx obliteration of aortic knob tracheal deviation to right pleural cap depression left mainstem bronchus elevation and right shift mainstem bronchus obliteration “aortic window” deviation of esophagus to right

67. Traumatic aortic rupture Treatment - SURGICAL REPAIR

68. Traumatic diaphragmatic rupture Blunt trauma - tears leading to immediate herniation Penetrating trauma - small tears which may take years to develop herniation Usually on left side

71. Traumatic diaphragmatic rupture Treatment - surgical repair

72. Tracheobronchial tree injury Larynx - rare hoarseness subcutaneous emphysema palpable crepitus Intubation may be difficult tracheostomy (not cricothyroidotomy) is treatment of choice

73. Tracheobronchial tree injury Trachea blunt or penetrating esophagus, carotid artery and jugular vein may be involved noisy breathing ? partial airway obstruction

75. Tracheobronchial tree injury Bronchus rare and lethal usually BLUNT trauma within one inch of carina

76. Esophageal trauma Most commonly penetrating May be lethal if not recognized High suspicion if left pneumothorax and hemothorax without rib fracture shock out of proportion to apparent blunt chest trauma particulate matter in chest tube

77. Esophageal trauma If blunt trauma, linear tear in lower esophagus with leakage of stomach contents into mediastinum

78. 6 Other Frequent Injuries Subcutaneous emphysema Traumatic asphyxia Simple pneumothorax Hemothorax Scapula fracture Rib fractures

79. Subcutaneous emphysema “Rice Krispies” May result from airway injury lung injury blast injury No treatment required - address underlying problem

81. Traumatic asphyxia “Masque ecchymotique” - purple face from extravasation of blood Major damage is to underlying structures Purple face fades over time in survivors

83. Simple pneumothorax Air enters potential space between visceral and parietal pleura Breath sounds down on affected side Percussion shows hyper-resonance Treatment: chest tube in 4th or 5th intercostal space anterior to mid-axillary line

86. Hemothorax Lung laceration OR disruption of intercostal artery or internal mammary artery Most are self-limiting Surgical consultation for initial flow of >20 cc/kg (~1500 cc) continued flow of >200 cc/hr

88. Scapula fractures Fractures of scapula or 1st & 2nd ribs may indicate major mechanism of injury

89. Rib fractures Ribs - most frequently injured part of thoracic cage Most commonly injured - 4th ? 9th If 10th/11th/12th, be suspicious for liver or spleen injuries If 1st/2nd/3rd, worry about injury to head, neck, spinal cords, lungs, and great vessels

90. Rib fractures Treatment consists of… intercostal blocks epidural anesthesia systemic analgesics Contraindications include… taping rib belts external splints

91. Rib fractures Ribs x-rays… are expensive are inaccurate for diagnosis (~50% sensitivity) add nothing to treatment require painful positioning of the patient are, in general, not useful

92. How to place a chest tube

97. How to perform cricothyroidotomy

107. In conclusion... Chest trauma common in the multiply-injured patient Most conditions can be treated by the evaluating physician and do not require emergent thoracotomy Airway management and a judiciously placed needle can save many lives

108. Next week we’ll talk about... HYPERTENSION