CHEST TRAUMA

CHEST TRAUMA

• Second leading cause of trauma death

• 20 % of all trauma deaths

• 50% of trauma patients presenting to ER in respiratory distress will die

• If in respiratory distress and shock 75% will die

INITIAL SURVEY• Examine chest immediately after ABC’s

– Inspect: open wounds, tenderness, subcutaneous emphysema, unequal chest expansion

– Auscultation: decreased breath sounds– Palpation: pain– Respiratory rate

• History– From patients and witnesses

• Seat belts, steering wheel, speed, nature of collision, what fell on patient, how long was patient crushed

MECHANISM OF INJURY

BLUNT vs PENETRATING

• Blunt: common in all trauma patients– Injuries are principally a function of the magnitude of force and

the location/direction over which it is applied– Get a good history– Support patient while injuries heal

• Penetrating: Consider with suspicious chest wound and if patient remains hypotensive in spite of fluid therapy – Knife: Length of the instrument, velocity, angle of entry– Firearms: Type of gun, Range, – Limited range of problems

• Hemothorax, pneumothorax, hemopericardium

RIB FRACTURE

• Most common chest injury• Present in 10% of all traumatic injuries • More common in adults than childern• Especially common in elderly• Patients with 1 or 2 rib fractures had a 5%

mortality rate and patients with 7 or more fractures have a 29% mortality rate

• Ribs form rings– Consider possibility of break in two places

RIB FRACTURE

• Fractures of the 1st and 2nd ribs require high force– Frequently have injury to aorta or bronchi– 30% will die

• Most commonly 5th to 9th ribs– Poor protection

RIB FRACTURE

• Fractures of the 8th to 12th ribs can damage underlying abdominal solid organs– Liver– Spleen– Kidneys

RIB FRACTURE

• Signs and Symptoms– Dyspnea– Localized pain, tenderness

• Increases when patient:– Coughs– Moves– Breathes deeply

– Chest wall instability

– Deformity, bony crepitus, ecchymosis

– Associated pneumo or hemothorax

RIB FRACTURE

• Management– High concentration oxygen– Splint using pillow, swathes– Encourage patient to deep breath– Monitor elderly and COPD patients carefully

• Broken ribs can cause decompensation• Patients not breathing deeply will result in poor

clearance of secretions

FLAIL CHEST

• Two or more adjacent ribs broken in two or more places

• Produces free-floating chest wall segment– Chest wall becomes unstable

• Usually 2nd to blunt trauma• More common in older patients• The incidence of flail segments

is 10-15% in patients with major chest trauma

FLAIL CHEST

• Signs and Symptoms– Paradoxical movement

• May NOT be present initially due to intercostal muscle spasms that splint the segment

• Be suspicious in any patient with chest wall:– Tenderness– Crepitus of broken ribs

– Dyspnea– Hypoxia

• Usually not present unless underlying lung injury

FLAIL CHEST

• Ramification– Pain, leading to decreased ventilation– Increased work of breathing– Inefficient respirations– Lung contusion

FLAIL CHEST

• Management– Establish airway– Suspect spinal injuries– Assist ventilation with BVM and oxygen

• Intubate large (>4-6 inches) flail segment and for underlying acute or chronic lung disease

– Stabilize chest wall• Towel rolls, tape or sand bags

– Pain relief• Narcotics, thoracic epidurals

STERNUM FRACTURE

• Extremely painful

• Associated with a steering wheel injury

• Management– Monitor for cardiac arrhythmias and heart

failure (secondary to myocardial contusion)

PULMONARY CONTUSION

• Bruising of the lung– Injuries often involve high velocity rather than

slow crushing– Usually associated with rib fractures/ flail

chest. 20-40% of patients with rib fractures present with pulmonary contusions

– Always associated with hypoxia• If tension pneumothorax has been ruled out then

pulmonary contusion is the most likely cause of respiratory impairment

PULMONARY CONTUSION

• Signs and Symptoms– Chest pain– Rales– Dyspnea– Tachypnea– Ineffective cough– Hemoptysis– Chest wall contusions– X-ray will show opacity– ABG will worsen in time

due to edema

PULMONARY CONTUSION

• Management– Oxygen– Continual reassessment/ Observation

• Oxygenation and ventilation usually deteriorate over first 4 hours

– Be aggressive if patient has respiratory distress, severe abdominal injury or COPD.

• Intubate while lung recovers

PNEUMOTHORAX

• Air in pleural space– Interfers with expansion of lung

• Partial or complete lung collapse occurs– Respiratory distress is usually not seen until

the pneumo exceeds 40% of lung volume or pre-existing lung disease

• Patients with pulmonary disease tolerate pneumothoraces poorly

PNEUMOTHORAX

• Causes– Blunt trauma to the chest– Fractured rib lacerating

lung– Paper bag effect– Spontaneously

• Exertion• Coughing• Air travel

– Positive pressure ventilation

PNEUMOTHORAX

• Signs and Symptoms– Pain on inhalation– Difficulty breathing– Tachypnea– Decreased or

absent breath sounds

– Hyperresonance on percussion

– Pleuritic pain

PNEUMOTHORAX

• Management– Establish airway– Suspect spinal injury based on mechanism– High concentration oxygen with NRB– Assist decreased or rapid respirations with

BVM– Chest tube if > 20%– Monitor for tension pnemonthorax

OPEN PNEUMOTHORAX (SUCKING CHEST WOUND)

• Unusual motion during respiration– Retraction, shaking, burping

• Hole in chest wall

• Allows air to enter pleural space with inspiration

• Small wound can form a one way valve

• Larger wound, greater chance air will enter here than through the trachea

OPEN PNEUMOTHORAX (SUCKING CHEST WOUND)

• Management– Cover with occlusive dressing

• Vaseline gauze covered by 4x4’s• Tape dressing on three sides

– High concentration oxygen– Assist ventilations– Consider transport on injured side– Monitor for tension pneumothorax

• Form one way valve

– Chest tube • Placed at 2nd site

TENSION PNEUMOTHORAX

• One-way valve forms in lung or chest wall

• Air enters pleural space; cannot leave

• Air is trapped in the pleural space

• Pressure rises

• Pressure collapses lung

• Mediastinal shift

TENSION PNEUMOTHORAX

• Trapped air pushes heart and lungs away from injured side

• Vena cava becomes kinked

• Blood cannot return to heart

• Cardiac output falls

• Shock develops

Tension Pneumothorax clip

TENSION PNEUMOTHORAX

• Signs and Symptoms– Extreme dyspnea– Restlessness, anxiety, agitation– Decreased breath sounds, unilateral absence

of breath sounds– Hyperresonance to percussion– Cyanosis- late– Subcutaneous emphysema

TENSION PNEUMOTHORAX

• Signs and Symptoms– Rapid, weak pulse– Hypotension– Tracheal shift away from

injured side– Jugular vein distension– Respiratory distress– Shock

TENSION PNEUMOTHORAX

• Management – Secure airway– High concentration oxygen– Consider ALS for pleural decompression

• Severely compromised patient; insert a 12 g cannula into the 2nd intercostal space, mid clavicular line

HEMOTHORAX

• Most common result of major chest wall trauma

• The incidence of hemopneumothoraces in patients with rib fractures is 30%.

• Blood in pleura space– Massive hemothorax due to bleeding from the

major central chest vessels but occasionally an intercostal artery can bleed enough to cause a large amount of blood

HEMOTHORAX

• Signs and Symptoms– Rapid, weak pulse– Cool clammy skin– Restlessness, anxiety– Chills– Hypotension– Collapsed neck veins– Chest pain

HEMOTHORAX

• Signs and Symptoms– Decreased breath sounds on affected side– Dullness to percussion– Dyspnea– Ventilatory failure– Up to a liter of blood

may be present and not seen on portable supine x-ray

HEMOTHORAX

• Management– Secure airway– Assist breathing with high

concentration oxygen– Rapid transport– Place a large chest tube

(36-40) aimed posteriorly

TRAUMATIC ASPHYXIA

• Blunt force to chest causes– Increased intrathoracic pressure– Backward flow of blood out of the heart into

vessels of upper chest, neck, head

• Name given because patients look like they have been strangled or hanged

TRAUMATIC ASPHYXIA

• Signs and Symptoms– Possible sternal fracture or central flail chest– Shock– Purplish-red discoloration of head, neck,

shoulders– Sub-conjunctival haemorrhage (Blood shot)

protruding eyes– Swollen, cyanotic lips

TRAUMATIC ASPHYXIA

• Management– Airway with C-spine percautions– Assist ventilations with high concentration

oxygen– Spinal stabilization– Rapid transport

TRAUMATIC AIR EMBOLISM

• Suspect in penetrating chest wounds where there is sudden deterioration in cardiac output after intubation

• Immediately life-threatening

• Neurological signs in the absence of a head injury

• Hemoptysis

TRAUMATIC AIR EMBOLISM

• Management– 100% O2 – minimise ventilation volumes and pressures – emergency thoracotomy to clamp ascending

aorta, remove air source (by clamping pulmonary hilum) and aspirate air from LV and ascending

TRACHEOBRONCHIAL TREE RUPTURE

• Relatively rare• Signs and symptoms

– Dyspnea, Tachypnea– Hemoptysis– Subcutaneous emphysema in the neck, face, or suprasternal

area– Decreased or absent breath sounds– Persistant pneumothorax– Potential airway obstruction

• Management– Control of ventilation (ETT distal to the level of injury)– Bilateral needle decompression may be needed– Two chest tubes inserted on injured side– Bronchoscopy / surgery

CARDIOVASCULAR TRAUMA

• Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise

• All patients in shock with penetrating wound of chest have cardiac injury until proven otherwise. (Abdominal stab or gunshot wound may also reach the heart)

MYOCARDIAL CONTUSION

• Bruise of the heart muscle

• Most common cardiac injury

• Usually due to steering wheel impact

MYOCARDIAL CONTUSION

• Behaves like an acute myocardial infarction– May produce arrhythmias– May cause cardiogenic

shock, hypotension

MYOCARDIAL CONTUSION

• Signs and symptoms– Cardiac arrhythmias after blunt chest trauma– Angina-like pain unresponsive to nitroglycerin– Chest pain independent of respiratory movemen– Chest wall ecchymosist– Tachycardia out of proportion to other injuries– Friction rub may be present– ECG may be normal or ST elevation– Cardiac enzymes may be normal

MYOCARDIAL CONTUSION

• Management– High concentration oxygen– ECG– Transport– Consider ALS intercept– Hospitalized for cardiac monitoring and serial

enzymes

CARDIAC TAMPONADE

• Rapid accumulation of blood in space between heart and pericardium

• Heart is compressed

• Blood entering heart decreases

• Cardiac output falls

• Obstructive shock can occur

CARDIAC TAMPONADE

• Signs and symptoms– Classic Triad

• Hypotension unresponsive to treatment• Increased central venous pressure (distended

neck/arm veins in presence of decreased arterial blood pressure)

• Decreased/muffled heart sounds

– Less than ½ the patients present this way• Neck veins may not be distended if hypovolemic• Muffled heart sounds often not present

CARDIAC TAMPONADE

• Dyspnea

• Narrowing pulse pressure

• Pulsus paradoxicus– Radial pulse becomes weak

or disappears when patient inhales

• Drops >10 mm in SBP

CARDIAC TAMPONADE

• Management– Secure airway– High concentration oxygen– Rapid fluid administration– Rapid transport– Pericardiocentesis with

removal of 5 to 10 mL• Leave catheter in place until

the cardiac wound can be repaired

– Surgery

TRAUMATIC AORTIC ANEURYSM

• 90% die within minutes. Those who arrive to the hospital alive 90% will die

• Little external evidence of serious chest trauma

• Caused by sudden decelerations, massive blunt force:– Vehicle collisions, Falls from heights, crushing

chest trauma, blunt chest trauma, Animal kicks

TRAUMATIC AORTIC ANEURYSM

• Rupture usually occurs just beyond left subclavian, near the ligamentum arteriosum

• Attachment of aorta to pulmonary artery at this point produces shearing force on aortic arch

TRAUMATIC AORTIC ANEURYSM

• Signs and Symptoms – Increased BP in arms in absence of head injury– Decreased femoral pulses with full arm pulses– Respiratory distress– New murmur

• More likely in patients with 1st or 2nd rib fracture

– Ache in chest, shoulders (interscapular), back, abdomen

• Only 25 % of the patients

– X-ray shows a widened upper mediastinum, blurring of aortic knob, deviation of trachea to the right

TRAUMATIC AORTIC ANEURYSM

• Management– High concentration oxygen– Assist ventilation– Suspect spinal injury– Rapid fluid resuscitation– Rapid transport

ASSOCIATED ABDOMINAL TRAUMA

• Diaphragm forms dome that extends up into rib cage

• Trauma to chest below 4th rib = Abdominal injury until proven otherwise

DIAPHRAGMATIC RUPTURE

• Difficult to diagnose and often missed

• Mostly seen on left side

• Suspect when there is diminished air entry, bowel sounds in chest or mediastinal shift

DIAPHRAGMATIC RUPTURE

• Signs and symptoms– Dyspnea– Dysphagia– Abdominal pain– Sharp epigastric or chest pain radiating to the

left shoudler (Kehr’s Sign)– Bowel sounds in the lower to middle chest– Decreased breath sounds on the injuried side

CONCLUSION

• If you only remember one thing…

– NO MATTER WHAT THE INJURY THE TREATMENT IS ALWAYS… ABC’s