Thoracic Trauma

Introduction Chest trauma is often sudden and dramatic Accounts for 25% of all trauma deaths 2/3 of deaths occur after reaching hospital Serious pathological consequences; hypoxia, hypovolaemia, myocardial failure The most common type of injuries is blunt.

Blunt injuries: can fracture ribs, sternum and costal cartilage, damage airways, lungs, great vessels and heart. Penetrating injuries: bullets, knives, … can damage internal organs. Compression: ribs and sternum fracture, internal organ injuries.

Anatomy and Physiology

Rib Fractures It is the most common thoracic injury Fracture of scapula, sternum, or first ribs suggests massive force of injury and suspect vascular injury. Lower ribs fracture are associated with spleen and liver injury S & S: chest pain, SOB, chest tenderness and crepitus. Rx.: pain relief, immobilization, obs. V/S, IV access, oxygen and ventilatory support

Flail Chest It is fracture of two or more adjacent ribs in two or more places that allows for free movement of fractures segment S & S: Paradoxical chest movements, dyspnea, chest pain, ↑ RR, and hypoxia. Rx.: ABC, ventilatory support, analgesics, monitoring, IV access

Flail Chest

Pulmonary Contusion It implies lung tissue laceration or tear by blunt or penetrating force, bleeding in alveolar space may be present. The chief abnormality is prevention of gas exchange. S & S: depends on severity of contusion Rx.: ventilatory support, monitoring, IVF.

Pneumothorax Air collection in the pleural space. Types: Simple Pneumothorax Open Pneumothorax (Sucking Chest Wounds) Tension Pneumothorax

Simple Pneumothorax Findings similar to those of rib fracture S & S: chest pain, ↓ breath sounds on side of injury, tympanic percussion. Rx.: monitoring (for possible tension pneumothorax development), decompression, oxygen administration, IV access.

Open Pneumothorax A defect in the chest wall results in communication between outside air and pleural space. Mainly caused by penetrating chest injuries. S & S: respiratory distress, anxious, tachypnea, ↑ HR, thready pulse, visible wound, audible sucking sounds during inspiration and bubbling during expiration.

Open Pneumothorax Rx.: closing the defect in the chest wall (occlusive dressing), administering oxygen, ventilatory support (PP), monitoring, decompression and IV access and fluids.

Tension Pneumothorax Air enter pleural space and does not vent, causing intrathoracic pressure build up. Consequences include respiratory distress and shock. S & S: apprehension, discomfort, chest pain, SOB, agitation, cyanosis, apnea, diminished breath sounds, tracheal deviation, distended neck veins, tympanic on percussion. Rx.: decompression (2nd or 3rd ICS MCL), oxygen supplement, ventilatory support.

Hemothorax Blood collection in the pleural space. It can accommodate 2500 to 3000 ml. S & S: chest pain, SOB, diminished breathing sound, dullness to percussion and signs of shock; pallor, confusion, tachycardia and hypotension. Rx.: high oxygen concentration, ventilatory support, care for shock (IVF, blood), monitoring

Cardiac Tamponade Blood collection within pericardial sac S & S: Beck’s triad: (distended neck veins, muffled heart sounds, low BP), very weak pulse, decreasing pulse pressure, PEA, Shock. Rx.: Volume resuscitation, Pericardiocentesis

Aortic Injury and Dissection Usually blunt trauma involving deceleration forces; especially RTAs ~90% die within minutes S & S: tearing chest pain radiating to the back, difference in BP between Rt & Lt arm, palpable pulsating mass, cardiac arrest. Rx: surgical…poor prognosis

Traumatic Asphyxia Caused by sudden compression of chest S & S: distended neck veins, dark blue upper body, bloodshot and bulging of eyes, swollen blue tongue and lips, chest deformity Rx: ABC, relieve pressure

Ruptured Diaphragm It is a potentially life-threatening injury that may result from forces that penetrate the body, such as gunshot wounds, or from acceleration or deceleration forces, such as MVC. Blunt injuries are more likely to injure the left leaf of the diaphragm since the right leaf is somewhat protected by the liver. A rupture or tear of the diaphragm may allow Herniation of abdominal contents into the thorax which may result in respiratory' compromise. Mediastinal structures may shift lo the opposite side of the injury.

S & S of Ruptured Diaphragm Dyspnea or orthopnea, dysphagia, abdominal pain, sharp epigastric or chest pain radiating to the left shoulder (Kehr's sign), bowel sounds in the lower to the middle chest, decreased breath sounds on the injured side Rx.: Surgical Reapir

Iatrogenic Trauma NG tubes: coiling, endobronchial placement, pneumothorax Chest tubes: subcutaneous, intraparenchymal, intrafissural Central lines: neck, coronary sinus, pneumothorax