1. Approach to Chest Trauma Mary Osinga Comprehensive Review Fleming College

2. Traumatic Injuries n Airway injuries n Chest and Breathing n Circulation – shock n Disability – neurological n E- expose and extremity

3. Airway Problems n Problem in trauma is that the airway may not look or behave as normal n Forces onto the head and/or neck may provide significant changes to the anatomy of the airway n Lets review normal airway anatomy

4. Normal airway

5. Abnormal Airway n Edema n Presence of fluid n Loss of bony structure integrity n Foreign objects

7. Airway management n Use a modified jaw thrust to avoid C spine displacement n Watch for nasal airway insertion in patients with….? n Oral airways in patients GCS<8 n Suction blood and secretions, remember patients supine on board n Watch for vomiting –beer and pizza

9. Chest Trauma

10. Introduction n Chest trauma is often sudden and dramatic n Accounts for 25% of all trauma deaths n 2/3 of deaths occur after reaching hospital n Serious pathological consequences: -hypoxia, hypovolemia, myocardial failure

11. Mechanism of Injury Penetrating injuries n E.g. stab wounds etc. n Primarily peripheral lung n Haemothorax n Pneumothorax n Cardiac, great vessel or oesophageal injury

13. n Either: - direct blow (e.g. rib fracture) - deceleration injury or - compression injury n Rib fracture is the most common sign of blunt thoracic trauma n Fracture of scapula, sternum, or first rib suggests massive force of injury Blunt injuries

14. Deadly Dozen from ITLS n Airway obstruction n Open Pneumo n Flail Chest n Tension Pneumo n Massive Hemothorax n Cardiac Tamponade Detected in the primary survey

15. Deadly Dozen from ITLS n Myocardial contusion n Traumatic aortic rupture n Tracheal bronchial tear n Diagphragmatic injury n Esophageal injury n Pulmonary contusion Detected in the secondary survey

16. Mechanism!

17. Chest wall injuries n Rib fractures n Flail chest n Open pneumothorax

18. Rib fractures n Most common thoracic injury n Localised pain, tenderness, crepitus n CXR to exclude other injuries n Analgesia..avoid taping n Underestimation of effect n Upper ribs, clavicle or scapula fracture: suspect vascular injury

19. Flail chest n Multiple rib fractures produce a mobile fragment which moves paradoxically with respiration n 2 or more ribs in 2 or more places n Significant force required n Palpate carefully and laterally n Rx: ABCs and analgesia n +/- splint the flail segment

20. Flail chest

21. Flail Chest - detail

22. Lung injury n Pulmonary contusion n Pneumothorax n Haemothorax n Parenchymal injury n Trachea and bronchial injuries n Pneumomediastinum

23. Open pneumothorax n Defect in chest wall provides a direct communication between the pleural space and the environment n Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax n “Sucking chest wound” n Rx: ABCs…closure of wound…chest drain

25. Pneumothorax n Air in the pleural cavity n Blunt or penetrating injury that disrupts the parietal or visceral pleura n Unilateral signs:  movement and breath sounds, resonant to percussion n Confirmed by CXR n Rx: chest drain

26. Pneumothorax

27. Tension pneumothorax n Air enters pleural space and cannot escape n P/C: chest pain, dyspnoea n Dx: - respiratory distress - tracheal deviation (away) - absence of breath sounds - distended neck veins - hypotension

28. n Surgical emergency n Needle decompression required-ACP n In hospital-Either large bore cannula in 2nd ICS, MCL or insert chest tube n Reassess post needle

29. Hemothorax n Blunt or penetrating trauma n Requires rapid decompression and fluid resuscitation n May require surgical intervention n Clinically: hypovolemia absence of breath sounds dullness to percussion n Can lose entire blood volume in chest

30. Knife wound

32. Some problems with Hemothorax n Significant blood loss-how much? n Atelactasis n V/Q Mismatch n So what problems can your patients have?

33. Heart, Aorta & Diaphragm n Blunt cardiac injury - contusion - ventricular, septal or valvular rupture n Cardiac tamponade n Ruptured thoracic aorta n Diaphragmatic rupture

34. Cardiac Tamponade n Blood in the pericardial sac n Most frequently penetrating injuries n Shock,  JVP, PEA, pulsus paradoxus n Classically, Beck’s triad: - distended neck veins - muffled heart sounds - hypotension n Rx: Volume resuscitation Pericardiocentesis

35. Cardiac tamponade

36. Aortic rupture n Usually blunt trauma involving deceleration forces; n ~90% die within minutes n Most common site near ligamentum arteriosum n Treat like an aneurysm if still alive, blunt trauma VSA if dead (?pronounce) n Rx: surgical…poor prognosis

37. Aortic rupture

39. Ruptured Hemi diaphragm n Etiology? n Side?? n Outcome n Diagnosis- how can you tell?? n Treatment?

41. Chest trauma: summary n Common n Serious n Primary goal is to provide oxygen to vital organs n Remember Airway Breathing Circulation n Be alert to change in clinical condition

42. Chest Trauma n Identify early n Rapid transport n Auscultate frequently n Consider tertiary care centre n Watch for shock and treat –IV fluids (bolus is…?) –Large bore IV’s –Trendelenberg