Advanced Trauma Life Support Thoracic Trauma

Objectives A-Identify and manage the following immediately life-threatening chest injuries evidenced in the primary survey: 1.Airway obstruction 2.Tension pneumothorax 3.Open pneumothorax (sucking chest wound) 4.Massive hemothorax 5.Flail chest 6.Cardiac tamponade

B-Identify and initiate treatment of the following potentially life-threatening injuries assessed during the secondary survey: 1.Pulmonarycontusion 2.Aortic disruption 3.Tracheobronchial disruption 4.Esophageal disruption 5.Traumatic diaphragmatic hernia 6.Myocardial contusion

Chest Trauma 1 out of 4 deaths Thoracic Injuries 85% Require : Correct hypoxia Improve circulation Alleviate ventilatory obstruction

Etiology of Hypoxia Hypovolemia tissue hypoxia Perfusion unventilated lung Ventilation of unperfused lung Abnormal pleural airway relationships

Primary Survey Life threatening chest trauma Airway Breathing Circulation

Tension Pneumothorax Air enters pleural space without exit Collapse of affected lung Impaired ventilation-unaffected lung Mechanical ventilation with PEEP Nonsealing Emphysematous bullae lung injury Tracheal deviation Respiratory distress Unilateral absence of breath sounds Distended neck veins Cyanosis - late

Treatment Immediate decompression Clinical diagnosis not radiologic Open Pneumothorax Management Immediate covering of defect Chest tube Definitive operation

Massive Hemothorax 1500 ml + blood loss Systemic of pulmonary vessel disruption Flat vs. distended neck veins Shock / no breath sounds or percussion dullness

Management Rapid volume restoration Chest decompression & X-ray Auto-transfusion Operative intervention Re-expand lung Oxygen Judicious fluid management Selective intubation Analgesia

Classic Findings Narrowed pulse pressure Elevated CVP Muffled heart sounds Distended neck veins Management Patient airway IV therapy Pericardiocentesis Open thoracotomy with repair

Secondary Survey In-depth physical exam Upright chest film ABGs ECG Pulmonary contusion Aortic disruption Tracheo-bronchial injury Myocardial contusion

Pulmonary Contusion Most common Selective intubation & ventilation Maintain adequate oxygenation

Major Intrathoracic Vascular Injury 90% fatal at scene 50% mortality each day treatment delayed Common site: ligamentum arteriosum

Widened Mediastinum On X-ray Management Direct repair Resection & graft Treatment by qualified surgeon

Tracheal Injuries Penetrating : ♦STAT surgical ♦repair ♦Associated Blunt : ♦Subtle ♦History ♦Important

Laryngeal Fractures Tracheal Injuries Bronchial Injury Hoarseness Subcutaneous emphysema Palpable fracture creptius Tracheal Injuries Partial vs. complete airway obstruction Endoscopy-diagnostic aid Bronchial Injury Frequently missed Blunt trauma 50% of deaths in 1 hour

Management Airway maintenance Surgical intervention Esophageal Trauma Blunt vs. penetrating Severe epigastric blow Pain/shock, injury Pneumo/hemothorax without fracture

Esophageal Trauma Chest tube-particulate matter Chest tube-bubbles continuously Mediastinal air/empyema Gastrografin swallow/esophagoscopy Management of Surgical Intervention

Traumatic Diaphragmatic Hernia Diagnosed left side Blunt: large tears Penetration: small perforation Misinterpreted X-ray Contrast radiography

Subcutaneous Emphysema Myocardial Contusion Blunt trauma History ECG changes Serial enzyme changes Treatment: observe/monitor Subcutaneous Emphysema Airway injury Pneumothorax Blast injury

Pneumothorax Blunt trauma Ventilation/perfusion defect Hyper-resonance Decreased breath sounds Treatment- tube thoracostomy

Hemothorax Etiology ♦Lung laceration ♦Vessel laceration Treatment ♦Tube Thoracostomy for continued bleeding

Rib Fractures Pain/splinting Impaired ventilation Increased secretions Atelectasis/pneumonia Ribs # 1-3 Severe force Associated injuries 50% mortality

Ribs # 5-9 Majority - blunt trauma Bowing effect Midshaft fracture Intrathoracic Management Obtain chest X-ray Avoid ♦Systemic analgesics ♦Constrictive devices

Indications for Chest Tube Insertion 1. Pneumothorax 2. Hemothorax 3. Selected cases, suspected severe lung injury 4. Prophylaxis

Summary Common in multiple injured patient Cognitive knowledge to diagnose Develop skills ECG monitoring

Pitfalls in Thoracic Injuries Failure to obtain a chest X-ray soon after admission and again within 4-8 hours may result in significant intrathoracic injuries being overlooked Excessive reliance on chest X-rays may lead to diagnostic errors Without careful inspection of the chest wall, contusions, flail chest, intrathoracic bleeding, and open or "sucking" chest wounds may be overlooked

A fractured sternum can be easily missed unless the sternum is palpated carefully or special X-ray views are obtained Cardiac arrest may occur suddenly and rapidly if there is any delay in relieving a suspected tension pneumothorax in a hypotensive patient. X-rays are not needed before treatment under such circumstances Inserting a chest tube while the patient is lying flat increases the chances for injury to the diaphragm

If an air leak and pneumothorax space are allowed to persist together, the patient is apt to develop an empyema or bronchopleural fistula If a patient with multiple injuries which include a flail chest is not given ventilatory assistance with a respirator soon after admission, he is apt to die of respiratory failure If a diaphragmatic injury is not suspected and looked for in all patients with chest trauma, the diagnosis will probably be missed

If it is assumed that bleeding from the chest wound in a hypotensive patient is superficial in origin, the diagnosis and treatment of severe intrathoracic bleeding may be delayed Repeated attempts to completely aspirate a small hemothorax with a needle or a syringe may cause a pneumothorax or empyema Use of high ventilatory pressures to inflate the lungs following penetrating chest wounds may result in systemic air emboli

Failure to obtain an aortogram when there is superior mediastinal widening following blunt chest trauma may result in an inaccurate diagnosis and an unnecessary thoracotomy Hypotension following blunt chest trauma is frequently due to intra-abdominal bleeding Delay in closure or drainage of esophageal injuries result in a high morbidity and mortality; hence, early diagnosis and treatment are vital

Any delay in providing adequate ventilatory support greatly increases the risk of irreversible respiratory failure Excessive administration of crystalloids greatly increases the risk of respiratory failure Failure to empty the stomach with a tube soon after chest trauma greatly increases the risk of aspiration and severe ileus