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 Second to brain and spinal cord injuries

INITIAL SURVEY Examine chest immediately after ABC’s History 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 If a life threatening injury is discovered during this examination treat it before going on. Initial survey is directed towards open pneumo, flail chest, tension pneumo, massive hemo, cadiac tamponade Following any intervention, reexamine the chest to determine the effects of treatment If in doubt about whether to intubate… intubate Severe internal injury may be present with external tenderness Chest injuries are often associated with other injuries so a high index of suspicion should be maintained

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 Blunt most common 70% of chest trauma get a good history – point to diagnostic alternatives Isolated blunt thoracic injury is uncommon. Head, extremity, and abdominal injuries frequently occur concurrently Penetrating: are frequently associated with abdominal trauma because of the anatomical proximity of the chest and abdomen. Knife: Tissue injury is related to the length of the instrument, the velocity at which the force was applied, and the angel of entry. Although the puncture site may apparently follow a straight path, this is not always true. Tissues may be disrupted and pushed aside by the penetrating instrument, thus causing damage to adjacent structures. Gun:Tissue damage inflicted by bullets is related to their velocity, shape, construction, and mass. The range, or distance between the barrel of the weapon and the victim, affects the velocity at which the bullet strikes the body tissues.

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 The injured arrea of lung underlying the fib fracture is usually of more clinical significance than the fracture.

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 Dyspnea Hypoxia 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 Mechanical ventilation reserved for patients who do not respond to conservative therapy.

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 wound allows air to be sucked into the chest with inspiration, if large enough it may interfere with air motion in the lungs by decreasing the amount of negative pressure that can be generated during inspiration. Small wounds can form one-way valves, leading to tension pneumothorax.

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 Tape on 3 sides so it can act as a one-way valve allowing air to exit with expiration but prevent sucking in during inspiration. If tension pneumo develops remove drsging Chest tube in 2nd location due to contamination of wound

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 Compresses the heart, great vessels, trachea, and the uninjuried lung Venous blood return to the heart slows and 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 Present in 70-80 % of penetrating, major non-penetrating chest trauma There are usually nine pairs of aortic intercostal arteries. They arise from the back of the aorta, and a redistributed to the lower nine intercostal spaces, the first two spaces being supplied by the highest intercostal artery, a branch of the costocervical trunk of the subclavian

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 sudden increase in venous pressure occurring as a result of sudden or severe compression of the thorax or upper abdomen, or both.

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 Patients with penetrating chest trauma are at high risk of traumatic air embolism and positive pressure ventilation of the affected lung will cause rapid death if the condition is not immediately recognized. Early aggressive treatment is therefore necessary for survival.

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 Blunt ruptures or tears of the lower trachea or mainstem bronchus may be caused by such mechanisms of injury as striking the dash board or steering wheel, karate-type blows, or “clothesline-type” injuries Tears or lacerations in the tracheobronchial tree interrupt the integrity of the lower airway because air dissects through the tear into the pleural space or the mediastinum. Patients with these injuries manifest dramatic symptoms early during resuscitaiton with massive air leaks into the subcutaneous tissue.

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 The sound that a pleural friction rub makes is a leather-on-leather type of sound. These sounds can be heard at the same points in the inhalatory and the exhalatory cycles Pleural Friction Rubs are created when the visceral and parietal pleurae become inflammed and roughened. The inflammed membranes will stick together

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 The mechanism of injury is associated with a combination of shearing forces, compression of the aorta on the vertebral column, and an increase in pressure inside the vessel during the episode of the trauma

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 If in doubt about airway: intubate If in doubt about chest movement: ventilate Resuscitate and assess simultaneously