1. CHEST TRAUMA

2. 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

4. 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

5. MECHANISM OF INJURY

6. 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.

8. 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.

9. RIB FRACTURE Fractures of the 1st and 2nd ribs require high force
Frequently have injury to aorta or bronchi
30% will die
Most commonly th to 9th ribs
Poor protection

10. RIB FRACTURE
Fractures of the 8th to 12th ribs can damage underlying abdominal solid organs
Liver
Spleen
Kidneys

11. 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

12. 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

14. 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

15. 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

16. FLAIL CHEST Ramification Pain, leading to decreased ventilation
Increased work of breathing
Inefficient respirations
Lung contusion

17. 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.

19. STERNUM FRACTURE Extremely painful
Associated with a steering wheel injury
Management
Monitor for cardiac arrhythmias and heart failure (secondary to myocardial contusion)

21. PULMONARY CONTUSION Bruising of the lung
Injuries often involve high velocity rather than slow crushing
Usually associated with rib fractures/ flail chest % 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

22. 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

23. 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

25. 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

26. PNEUMOTHORAX Causes Blunt trauma to the chest
Fractured rib lacerating lung
Paper bag effect
Spontaneously
Exertion
Coughing
Air travel
Positive pressure ventilation

27. PNEUMOTHORAX Signs and Symptoms Pain on inhalation
Difficulty breathing
Tachypnea
Decreased or absent breath sounds
Hyperresonance on percussion
Pleuritic pain

28. 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

30. 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.

31. 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

33. 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

34. 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

35. Tension Pneumothorax clip

36. 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

37. TENSION PNEUMOTHORAX Signs and Symptoms Rapid, weak pulse Hypotension
Tracheal shift away from injured side
Jugular vein distension
Respiratory distress
Shock

38. 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

40. 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 % 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

41. HEMOTHORAX Signs and Symptoms Rapid, weak pulse Cool clammy skin
Restlessness, anxiety
Chills
Hypotension
Collapsed neck veins
Chest pain

42. 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

43. HEMOTHORAX Management Secure airway
Assist breathing with high concentration oxygen
Rapid transport
Place a large chest tube (36-40) aimed posteriorly

45. 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.

46. 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

47. TRAUMATIC ASPHYXIA Management Airway with C-spine percautions
Assist ventilations with high concentration oxygen
Spinal stabilization
Rapid transport

49. 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.

50. 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

51. 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.

53. 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)

54. MYOCARDIAL CONTUSION Bruise of the heart muscle
Most common cardiac injury
Usually due to steering wheel impact

55. MYOCARDIAL CONTUSION Behaves like an acute myocardial infarction
May produce arrhythmias
May cause cardiogenic shock, hypotension

56. 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

57. MYOCARDIAL CONTUSION Management High concentration oxygen ECG
Transport
Consider ALS intercept
Hospitalized for cardiac monitoring and serial enzymes

59. 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

60. 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

61. CARDIAC TAMPONADE Dyspnea Narrowing pulse pressure Pulsus paradoxicus
Radial pulse becomes weak or disappears when patient inhales
Drops >10 mm in SBP

62. 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

64. 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

65. 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

66. 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

67. TRAUMATIC AORTIC ANEURYSM
Management
High concentration oxygen
Assist ventilation
Suspect spinal injury
Rapid fluid resuscitation
Rapid transport

69. ASSOCIATED ABDOMINAL TRAUMA
Diaphragm forms dome that extends up into rib cage
Trauma to chest below 4th rib = Abdominal injury until proven otherwise

70. 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

71. 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

73. 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