CHEST TRAUMA HOWARD FRIEDLAND DO FACOEP NICOLE MAGUIRE DO
OBJECTIVES Anatomical
Review of Chest
Approach to Chest Trauma
Identifying and Treating Immediately Life Threatening Conditions.
Identifying and Treating Potentially Life Threatening Conditions.
Diagnostic Studies and Chest Trauma
OBJECTIVES Anatomical
Review of Chest
Approach to Chest Trauma
Identifying and Treating Immediately Life Threatening Conditions.
Identifying and Treating Potentially Life Threatening Conditions.
Diagnostic Studies and Chest Trauma
INCIDENCE OF CHEST TRAUMA Trauma is the # 1 cause of death in ages 1-
55. Chest trauma causes 1 in 4 deaths in America. Less than 10% of Blunt Chest Trauma requires surgery, where as 15-30% of Penetrating Chest Trauma requires an open thoracotomy.
CAUSES OF BLUNT TRAUMA VS CHEST TRAUMA
MVA = 70-80%
FALLS
Act of violence - IE.
• bat to chest etc.
Blast Injuries
Low Velocity impalements, knife wound. Medium Velocity bullets from most hand guns and air powered pellet guns. High Velocity - rifles and military weapons.
THORACIC CAVITY Superior Border of Thorax - Thoracic Inlet which holds the major blood supply to and venous drainage from the neck. Superior-lateral Border of Thorax - Thoracic Outlet, Brachial Plexus, Axillary Vein, Brachial Artery. Inferior Border - hemidiaphragm - holds the diaphragmatic hiatus = Aorta, Esophagus, Vagal Nerve, Thoracic Duct and Vena Cava.
ANATOMY REVIEW CONTINUED Within Chest Wall - Muscles, Ribs,
Sternum,Clavicle, Scapulae. Parietal Pleura - inner lining of chest wall. Visceral Pleura - invests major organs. Pleura Space - potential space between the
two with a small amount of fluid in it.
RESPIRATORY SYSEM IN 2 LINES OR LESS
Lungs - Right has 3 lobes, Left has 2 lobes.
Trachea splits into R and L mainstem
bronchi then divides into lobar bronchi.
Incase you forgot about the heart Heart is contained within pericardium.
Blood flow:
blood is received from the superior and inferior vena cava ~RA~RV via tricuspid valve ~ lungs via pulmonic valve ~ LA ~ LV via mitral valve ~ thoracic aorta via aortic valve.
Miscellaneous Organs Esophagus lies posterior to the trachea. To the right of it is the Aortic Arch. To
the left of it is the Descending Aorta.
Thoracic Duct runs posterior and is
proximal to the spinal column, it enters the Left Subclavian Vein in the neck.
Primary Survey (ATLS)
Physician must begin with ABC’s Trauma for any chest trauma patient:
A - airway
B - breathing
C circulation
T - thoracotomy
D - disability - neuro check
E - exposure - remove clothing, roll person.
AIRWAY Listen for airway movement at patient’s
nose and mouth. Access intercostal and supraclavicular
muscle retractions. Assess oropharynx for foreign body
obstruction, especially in an unconscious patient.
BREATHING Expose patient’s chest. Observe, palpate and listen for respiratory
movement. Rate of breathing. Breathing pattern - shallow breaths are
ominous. Cyanosis - late sign of hypoxia.
Circulation Check pulse for quality, rate and regularity. Blood Pressure Asses and palpate skin for color and
temperature. Check neck veins for distention - indication
of cardiac tamponade that may be absent if patient is hypovolemic. Cardiac Monitor - dysrythmia, PVC, PEA
Pulseless Electrical Activity
Hypovolemia Hypoxia H+ - Acidosis Hemothorax Hypothermia Hyperkalemia
Tension Pneumothorax Tamponade Toxins Beta Blockers Digitalis TCA Ca++ Channel Blockers Thrombus Pulmonary Embolus Myocardial Infarction
Thoracotomy Closed heart massage is ineffective in
patient’s in PEA with hypovolemia. Candidates for ED thoracotomy include
patient’s with exsanguinating, penetrating, precordial injuries who arrive in PEA and there is a . Thoracotomy is usually not effective in
patients with blunt thoracic injuries in PEA.
OPEN THORACOTOMY
THORACOTOMY Use of emergent resuscitative thoracotomy
has been reported to result in survival as follows: 9-57% patients with penetrating cardiac injury. 0-66% patients with non-cardiac thoracic injury. 8% overall survival rate.
SECONDARY SURVEY Head to foot exam, remember the back. If the patient is unstable a brief history is
applicable at this time = A - allergies M - medications P – past medical history L – last meal eaten E - events of trauma
SECONDARY SURVEY (con’t) If the patient is stabilized obtain a more in depth history including: Time of injury. Mechanism of Injury - velocity and deceleration for MVA. Complete Physical Exam - including evidence of injuries to other systems. Preliminary tests - CXR, EKG, ABG.
IMMEDIATELY LIFE THREATENING CHEST INJURIES
These conditions are evidenced in the primary survey:
Airway Obstruction and Traumatic Asphyxia
Tension Pneumothorax
Open Pneumothorax
Massive Hemothorax
Flail Chest
Cardiac Tamponade
POTENITALLY LIFE THREATENING CHEST INJURIES These conditions are evidenced in
secondary survey: Pulmonary Contusion Myocardial Contusion Aortic Disruption Traumatic Diaphragmatic Rupture Esophageal Rupture Blunt injuries to SVC and other major veins.
OTHER INJURIES EVIDENCED IN CHEST TRAUMA Rib Fractures
Clavicular Fractures
Scapular Fractures
Blunt injuries to Thoracic Duct.
AIRWAY OBSTRUCTION Evidenced in blunt trauma, especially MVA
and blast injuries. Will be seen in primary survey during airway step. Readjust head to sniffing position. • If C-spine has been cleared. Attempt direct visualization and removal. May need fiberoptics for visualization.
Traumatic Asphyxia Result of thoracic injury due to strong
crushing injury. Signs and Symptoms:
cyanosis of head and neck, subconjuctival hemorrhage, periorbital ecchymosis, petechiae, edematous moon-like face, epistaxis, hemotypmany, LOC, seizure.
TREATMENT OF TRAUMATIC ASHPYXIA Maintain adequate airway. Elevate head of bed to 30 degrees to
decrease pressure to the head. ICU admission with serial neuro checks. Associated injuries of head and torso seen
with this type of injury often need surgery. No specific surgery for this condition.
TENSION PNEUMOTHORAX A one war air leak that collapses the
affected lung with mediastinal and tracheal shift to the opposite side. Signs and Symptoms:
respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absent breath sounds, neck vein distension, cyanosis.
TREATMENT OF TENSION PNEUMOTHORAX Immediate Decompression with a 14”
gauge needle into the second intercostal space at midclavicular line of affected side. Definitive treatment - insertion of a chest
tube into the fifth intercostal space anterior to mid-axillary line.
Pneumothorax
S/P CHEST TUBE INSERTION
OPEN PNUEMOTHORAX “SUCKING CHEST WOUND” A large defect of the chest wall causing
equilibration between the interthoracic and atmospheric pressure. If the opening is 2/3 or more in diameter of
the trachea, air will prefer to pass through the open chest wound. Signs and Symptoms:
a large open wound of the chest, respiratory distress.
TREATMENT OF OPEN PNEUMOTHORAX Promptly close the defect with a sterile
dressing taped on 3 sides creating a flutter-type valve. Closure of all 4 sides of the dressing could
cause a tension pneumothorax if chest tube is not in place. Definitive surgical closure of
required.
the defect is
Massive Hemothorax Accumulation of more than 1500ml of
blood. Usually secondary to penetrating wound.
Signs and Symptoms:
shock, absent breath sounds, dullness to percussion on one side of the chest.
TREATMENT OF MASSIVE HEMOTHORAX Manage with simultaneous restoration of
blood volume and decompression of chest cavity. CHEST TUBE - 38 french or larger Prepare for auto-transfusion with massive
blood loss. Thoracotomy.
THORACOTOMY AND MASSIVE HEMOTHORAX Thoracotomy is indicated if there is
>1500ml blood loss or <1500 ml with continuous loss > 200ml/hr. Penetrating anterior wound medial to
nipple line or posterior wound medial to scapula may need thoracotomy due to damage to great vessels, hilar structures or heart. Surgeon must be present!
FLAIL CHEST Secondary to multiple rib fractures. A segment of the chest wall does not have
bony continuity with the rest of the thoracic cage. Major problem is from the injury to the
underlying lung. Paradoxical motion alone does not cause
hypoxia, it is the pain with restricted chest wall movement and lung injury .
SIGNS AND SYMPTOMS OF FLAIL CHEST Poor inspiratory effort.
Asymmetrical movement of thorax.
Crepitus of rib or cartilage fractures.
TREATMENT OF FLAIL CHEST Fluids - be careful not to overload patient. Adequate ventilation - some patients may
require intubation. Humidified oxygen. Analgesics. Re-expansion of lung via CT if necessary for
pneumothorax.
CARDIAC TAMPONADE Usually a result of penetrating injuries.
Only a small amount of blood in the
pericardial sac is needed to restrict cardiac activity.
SIGNS AND SYMPTOMS OF CARDIAC TAMPONADE
Becks Triad: Muffled Heart Tones Increased Venous Pressure – distended neck veins (absent with hypovolemia). Decreased Arterial Pressure – Hypotension
Pulsus Paradoxus – decreased pressure during inspiration in excess of 10mmHg.
Kussmaul’s Sign – rise in venous pressure with inspiration while breathing normal.
CARDIAC TAMPONADE SECONDARY TO HEMOPERICARDIUM
TREATMENT OF CARDIAC TAMPONADE Pericardiocentesis – use a plastic
sheathed needle if available and enter via subxyphoid route. All patients with a positive pericardiocentesis secondary to trauma will require an open thoracotomy. Open pericardiotomy may be required if blood in pericardial sac is clotted.
POTENTIALLY LETHAL CHEST INJURIES These injuries are not obvious on initial
exam and require a high index of suspicion to diagnose them. They are evaluated through the secondary
survey and are lethal if not detected and treated promptly.
PULMONARY CONTUSION
Most common potentially lethal chest injury
Sx – Respiratory failure that occurs over time.
Comorbidities – COPD, renal failure, CHF all predispose patients for early intubation.
Treatment – closely monitor, pulse oximetry, ABG, EKG, intubation if necessary.
Patient’s with significant hypoxia will need intubation within the first hour after dx.
MYOCARDIAL CONTUSION
Patient’s complain of chest discomfort that may be misinterpreted as pain secondary to chest wall injury.
Diagnosis is made via abnormalities on EKG without any other cause – acute MI, multiple PVC’s, unexplained sinus tachycardia, a-fib, Bundle branch block ST segment changes.
TREATMENT OF MYOCARDIAL CONTUSION Patient is at high risk for sudden
dysrythmias. ICU admission with cardiac monitor and
close observation. Treat dysrythmias as per ACLS protocols.
TRAUMATIC AORTIC RUPTURE Common cause of death after MVA or fall
from a great height. Usually fatal at scene. Viable patient’s usually have a tear near the ligamentum arteriosum and continuity of the adventitia layer prevents immediate death. Considered a contained hematoma.
SIGNS, SYMPTOMS, AND DIAGNOSTIC FINDINGS OF AORTIC RUPTURE Signs and Symptoms are usually absent. Pressure usually drops but responds to fluid resuscitation. Radiology Signs – widened widened mediastinum (most significant finding), fracture of first and second ribs, obliteration of the aortic knob, deviation of the trachea to the right, presence of pleural cap, elevation and R shift of R mainstem bronchus, depression of the L mainstem bronchus, deviation of the esophagus (seen via NGT placement).
TREATMENT OF TRAUMATIC AORTIC RUPTURE Angiography should be performed liberally
if high index of suspicion of injury.
Direct repair of the aorta or resection of the
injured area and grafting.
TRAUMATIC DIAPHRAGMATIC RUPTURE
More commonly dx on L secondary to liver obliterating defect on R.
Blunt Trauma – large radial tears that lead to herniation.
Penetrating Trauma – small perforations that take time even years to develop into hernias.
TRAUMATIC DIAPHRAGMATIC RUPTURE If a laceration of the Left diaphragm is
suspected, place a NGT. If this appears in the thoracic cavity on CXR need for contrast study is eliminated. Right diaphragmatic rupture is rarely diagnosed early – suspect if there is an elevated R. diaphragm on CXR. Treatment – Direct Repair.
ESOPHAGEAL TRAUMA Usually due to penetrating trauma. Blunt injury causes a forceful expulsion of
gastric contents into mediastinum – mediastinitis and may be lethal if not recognized. Delayed rupture into pleural space may
cause an empyema.
SIGNS AND SYMPTOMS OF ESOPHAGEAL TRAUMA L. pneumothorax or hemothorax without rib
fracture. Severe blow to the sternum or epigastrum with pain or shock out of proportion to injury. Particulate matter in the chest tube after blood clears. Presence of mediastinal air on CXR
TREATMENT OF ESOPHAGEAL TRAUMA Confirm with contrast study or
esophagoscopy. Wide drainage of the mediastinum and
pleural space. Direct Repair of injury.
DIAGNOSTIC STUDIES AND TRAUMA: LABS To aid in confirmation of diagnosis and
monitor patient. CBC – helps gauge blood loss. BMP – patient’s requiring massive fluid resuscitation should have electrolytes monitored. Aids with acid-base disorders. Coagulation Profile – for patient’s receiving massive transfusions (look for DIC).
LABS
Type and Cross
ABG – allows you to evaluate ventilation,
oxygenation and acid-base status.
Cardiac Enzymes – correlate with patient’s EKG, abnormalities in patients with blunt cardiac injury (Myocardial contusion).
Lactate Level – measure of tissue perfusion. Levels that clear quickly = better outcomes.
DIAGNOSTIC STUDIES AND TRAUMA: IMAGING STUDIES CXR – aids in confirmation of
pneumothorax, hemothorax, cardiac and great vessel injuries. (Should not wait for one to confirm clinical suspicion of tension pneumothorax). CT Scan – useful in more occult or
undetected injury. CT patient’s with possible aortic injuries
IMAGING STUDIES Aortogram – gold standard in diagnosis of aortic
and great vessel injury. If CT is positive for aortic injury, do aortogram to see exact location and extent of injury.
Thoracic US – usually done in ED during secondary survey. May visualize pericardium, heart, thoracic cavity. Pericardial effusions, tamponade, and hemothoraces are recognized with sensitivity and specificity of 90%.
DIAGNOSTIC STUDIES AND TRAUMA: EKG Aids in identification of new cardiac
abnormalities and underlying cardiac problems. Important in patients with clinically significant blunt cardiac injury. Most common EKG finding in patients with myocardial contusion – tachyarrhythmia, first degree blocks, bundle branch blocks.
