Majid Pourfahraji

CHEST TRAUMA

ANATOMY

Trauma, or injury, is defined as cellular disruption caused by an exchange with environmental energy that is beyond the body's resilience.

Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years and is the third most common cause of death regardless of age.

TRAUMA

The initial management of seriously injured patients consists of performing the primary survey (the "ABCs"—Airway with cervical spine protection, Breathing, and Circulation); the goals of the primary survey are to identify and treat conditions that constitute an immediate threat to life.

PRIMARY SURVEY

Blunt Trauma: Blunt force to chest.

Penetrating Trauma: Projectile that enters chest

causing small or large hole.

Compression Injury: Chest is caught between two

objects and chest is compressed.

MAIN CAUSES OF CHEST TRAUMA

Chest wall * Rib fracture * Flail chest

Airway obstruction Pneumothorax

* Simple/Closed * Open Pneumothorax * Tension Pneumothorax

Hemothorax Flail Chest and

Pulmonary Contusion Cardiac Tamponade Traumatic Aortic

Rupture Diaphragmatic

Rupture

TRAUMA TO THE CHEST

Blunt And Penetrating PAIN Shallow breathing Atelectasis Shunt: lack of ventilation respiratory and metabolic acidosis

RIB FRACTURE

ANATOMY

Intercostal nerve block

• Opening in lung tissue that leaks air into chest cavity• Blunt trauma is main cause• May be spontaneous : Cough• Usually self correcting

S/S• Chest Pain• Dyspnea• Tachycardia• Tachypnea• Decreased Breath Sounds on Affected Side

SIMPLE PNEUMOTHORAX

TREATMENT FOR SIMPLE/CLOSED

ABC’s with C-spine control Airway Assistance as needed If not contraindicated transport in semi-sitting position Provide supportive care Contact Hospital and/or ALS unit as soon as possible

Thoracocentesis

Chest Tube or throcostomy

TREATMENT FOR SIMPLE/CLOSED

CHEST TUBE!!

• An open pneumothorax or "sucking chest wound" occurs with full-thickness loss of the chest wall

• Causes the lung to collapse due to increased pressure in pleural cavity

• Can be life threatening and can deteriorate rapidly• Results in hypoxia and hypercarbia

• Complete occlusion of the chest wall defect without a tube thoracostomy may convert an

open pneumothorax to a tension pneumothorax

• Temporary management of this injury includes covering the wound with an occlusive dressing that is taped on three sides.

• Definitive treatment requires closure of the chest wall defect and tube thoracostomy remote from the wound.

OPEN PNEUMOTHORAX

OCCLUSIVE DRESSING

ASHERMAN CHEST SEAL

Dyspnea Sudden sharp pain Subcutaneous Emphysema Decreased lung sounds on affected side Red Bubbles on Exhalation from wound

…

S/S OF OPEN PNEUMOTHORAX

Respiratory distress Tachypnea Tachycardia Poor Color Anxiety/Restlessness Accessory Muscle Use *Hypotension* But JVP + Tracheal deviation away from the affected side Lack of or decreased breath sounds on the affected side Subcutaneous emphysema on the affected side Hypotension qualifies the pneumothorax Needle thoracostomy with a 14-gauge angiocatheter in the second intercostal space in the midclavicular line Tube thoracostomy should be performed immediately

TENSION PNEOMOTHORAX

The normally negative intrapleural pressure becomes positive, which depresses the ipsilateral hemidiaphragm and shifts the mediastinal structures into the contralateral chest

the contralateral lung is compressed and the heart rotates about the superior and inferior vena cava; this decreases venous return and ultimately cardiac output, which results in cardiovascular collapse

TENSION PNEOMOTHORAX

TENSION PNEOMOTHORAX

NEEDLE TORACOSTOMY

NEEDLE DECOMPRESSION

NEEDLE THORACOSTOMY

* Flail chest occurs when TWO or more contiguous ribs are fractured in at least two location

* additional work of breathing and chest wall pain caused by the flail segment is sufficient to compromise ventilation

* it is the decreased compliance and increased shunt fraction caused by the associated pulmonary contusion that is typically the source of post injury pulmonary dysfunction

* Treatment is intubation and mechanical ventilation (PEEP mode)• The patient's initial chest radiograph often underestimates the extent of the pulmonary parenchymal damage • Must chest tube if bleeding!

FLAIL CHEST

FLAIL CHEST

FLAIL CHEST

life-threatening injury number one

A massive hemothorax is defined as >1500 mL of blood or, in the pediatric population, one third of the patient's blood volume in the pleural space

tube thoracostomy is the only reliable means to quantify the amount of hemothorax

After blunt trauma, a hemothorax usually is due to multiple rib fractures

occasionally bleeding is from lacerated lung parenchyma

a massive hemothorax is an indication for operative intervention

Indication of emergency toracotomy

HEMOTHORAX

HEMOTHORAX

HEMOTHORAX PHYSICAL FINDINGS

RIB FRACTURE WITH HEMOTHORAX

RIB FRACTURE WITH HEMOTHORAX

life-threatening injury number two

Acutely, <100 mL of pericardial blood may cause pericardial tamponade

The classic diagnostic Beck's triad—dilated neck veins, muffled heart tones, and a decline in arterial pressure—often is not observed in the trauma

Increased intrapericardial pressure also impedes myocardial blood flow, which leads to subendocardial ischemia

Best way to diagnose is ultrasound of the pericardium

Early in the course of tamponade fluid administration

a pericardial drain is placed using ultrasound guidance

Pericardiocentesis is successful in decompressing tamponade in approximately 80% of cases : 15 to 20 cc

CARDIAC TAMPONADE

CARDIAC TAMPONADE

BECKS TRIAD

PERICARDIAL TAMPONADE PHYSICAL FINDINGS

PERICARDIOCENTESIS