Advanced Trauma Life Advanced Trauma Life SupportSupport

Thoracic Trauma Thoracic Trauma

ObjectivesObjectives A-Identify and manage the following A-Identify and manage the following

immediately life-threatening chest immediately life-threatening chest injuries evidenced in the primary survey: injuries evidenced in the primary survey:

1.Airway obstruction1.Airway obstruction 2.Tension pneumothorax2.Tension pneumothorax 3.Open pneumothorax (sucking chest 3.Open pneumothorax (sucking chest

wound)wound) 4.Massive hemothorax4.Massive hemothorax 5.Flail chest5.Flail chest 6.Cardiac tamponade6.Cardiac tamponade

B-Identify and initiate treatment B-Identify and initiate treatment of the following potentially life-of the following potentially life-threatening injuries assessed threatening injuries assessed during the secondary survey:during the secondary survey:

1.Pulmonarycontusion1.Pulmonarycontusion

2.Aortic disruption2.Aortic disruption

3.Tracheobronchial disruption3.Tracheobronchial disruption

4.Esophageal disruption4.Esophageal disruption

5.Traumatic diaphragmatic 5.Traumatic diaphragmatic herniahernia

6.Myocardial contusion6.Myocardial contusion

Chest TraumaChest Trauma1 out of 4 deaths1 out of 4 deaths

Thoracic Injuries 85% Thoracic Injuries 85% Require :Require :

Correct hypoxiaCorrect hypoxia Improve circulationImprove circulation Alleviate ventilatory Alleviate ventilatory

obstructionobstruction

Etiology of HypoxiaEtiology of Hypoxia

Hypovolemia tissue hypoxiaHypovolemia tissue hypoxia Perfusion unventilated lungPerfusion unventilated lung Ventilation of unperfused Ventilation of unperfused

lunglung Abnormal pleural airway Abnormal pleural airway

relationshipsrelationships

Primary SurveyPrimary Survey

Life threatening chest traumaLife threatening chest trauma

AirwayAirway

BreathingBreathing

CirculationCirculation

Tension PneumothoraxTension Pneumothorax Air enters pleural space without exitAir enters pleural space without exit Collapse of affected lungCollapse of affected lung Impaired ventilation-unaffected lungImpaired ventilation-unaffected lung Mechanical ventilation with PEEPMechanical ventilation with PEEP NonsealingNonsealing Emphysematous bullae lung injuryEmphysematous bullae lung injury Tracheal deviationTracheal deviation Respiratory distressRespiratory distress Unilateral absence of breath soundsUnilateral absence of breath sounds Distended neck veinsDistended neck veins Cyanosis - lateCyanosis - late

TreatmentTreatment Immediate decompressionImmediate decompression Clinical diagnosis not radiologicClinical diagnosis not radiologic

Open Pneumothorax Open Pneumothorax ManagementManagement

Immediate covering of defectImmediate covering of defect Chest tubeChest tube Definitive operationDefinitive operation

Massive HemothoraxMassive Hemothorax 1500 ml + blood loss1500 ml + blood loss Systemic of pulmonary vessel Systemic of pulmonary vessel

disruptiondisruption Flat vs. distended neck veinsFlat vs. distended neck veins Shock / no breath sounds or Shock / no breath sounds or

percussion dullnesspercussion dullness

ManagementManagement Rapid volume restorationRapid volume restoration Chest decompression & X-rayChest decompression & X-ray Auto-transfusionAuto-transfusion Operative interventionOperative intervention Re-expand lungRe-expand lung OxygenOxygen Judicious fluid managementJudicious fluid management Selective intubationSelective intubation AnalgesiaAnalgesia

Classic FindingsClassic Findings Narrowed pulse pressureNarrowed pulse pressure Elevated CVPElevated CVP Muffled heart soundsMuffled heart sounds Distended neck veinsDistended neck veins

ManagementManagement Patient airwayPatient airway IV therapyIV therapy PericardiocentesisPericardiocentesis Open thoracotomy with repairOpen thoracotomy with repair

Secondary SurveySecondary Survey In-depth physical examIn-depth physical exam Upright chest filmUpright chest film ABGsABGs ECGECG Pulmonary contusionPulmonary contusion Aortic disruptionAortic disruption Tracheo-bronchial injuryTracheo-bronchial injury Myocardial contusionMyocardial contusion

Pulmonary ContusionPulmonary Contusion

Most commonMost common Selective intubation & Selective intubation &

ventilationventilation Maintain adequate Maintain adequate

oxygenationoxygenation

Major Intrathoracic Vascular Major Intrathoracic Vascular InjuryInjury

90% fatal at scene90% fatal at scene 50% mortality each day 50% mortality each day

treatment delayedtreatment delayed Common site: ligamentum Common site: ligamentum

arteriosumarteriosum

Widened Mediastinum On X-Widened Mediastinum On X-rayray

ManagementManagement Direct repairDirect repair Resection & graftResection & graft Treatment by qualified Treatment by qualified

surgeonsurgeon

Tracheal InjuriesTracheal Injuries

Penetrating :Penetrating : ♦ ♦STAT surgicalSTAT surgical ♦ ♦repairrepair ♦ ♦AssociatedAssociated Blunt : Blunt : ♦ ♦SubtleSubtle ♦ ♦HistoryHistory ♦ ♦ImportantImportant

Laryngeal FracturesLaryngeal Fractures HoarsenessHoarseness Subcutaneous emphysemaSubcutaneous emphysema Palpable fracture creptiusPalpable fracture creptius

Tracheal InjuriesTracheal Injuries Partial vs. complete airway Partial vs. complete airway

obstructionobstruction Endoscopy-diagnostic aidEndoscopy-diagnostic aid

Bronchial InjuryBronchial Injury Frequently missedFrequently missed Blunt traumaBlunt trauma 50% of deaths in 1 hour50% of deaths in 1 hour

ManagementManagement Airway maintenanceAirway maintenance Surgical interventionSurgical intervention

Esophageal TraumaEsophageal Trauma Blunt vs. penetratingBlunt vs. penetrating Severe epigastric blowSevere epigastric blow Pain/shock, injuryPain/shock, injury Pneumo/hemothorax without Pneumo/hemothorax without

fracturefracture

Esophageal TraumaEsophageal Trauma

Chest tube-particulate matterChest tube-particulate matter Chest tube-bubbles continuouslyChest tube-bubbles continuously Mediastinal air/empyemaMediastinal air/empyema Gastrografin Gastrografin

swallow/esophagoscopyswallow/esophagoscopy

Management of Surgical Management of Surgical InterventionIntervention

Traumatic Diaphragmatic Traumatic Diaphragmatic HerniaHernia

Diagnosed left sideDiagnosed left side Blunt: large tearsBlunt: large tears Penetration: small perforationPenetration: small perforation Misinterpreted X-rayMisinterpreted X-ray Contrast radiographyContrast radiography

Myocardial ContusionMyocardial Contusion Blunt traumaBlunt trauma HistoryHistory ECG changesECG changes Serial enzyme changesSerial enzyme changes Treatment: observe/monitorTreatment: observe/monitor

Subcutaneous EmphysemaSubcutaneous Emphysema Airway injuryAirway injury PneumothoraxPneumothorax Blast injuryBlast injury

PneumothoraxPneumothorax

Blunt traumaBlunt trauma Ventilation/perfusion defectVentilation/perfusion defect Hyper-resonanceHyper-resonance Decreased breath soundsDecreased breath sounds Treatment- tube Treatment- tube

thoracostomythoracostomy

HemothoraxHemothorax

EtiologyEtiology

♦ ♦Lung lacerationLung laceration

♦ ♦Vessel lacerationVessel laceration TreatmentTreatment

♦ ♦Tube Thoracostomy for Tube Thoracostomy for continued bleedingcontinued bleeding

Rib FracturesRib Fractures Pain/splintingPain/splinting Impaired ventilationImpaired ventilation Increased secretionsIncreased secretions Atelectasis/pneumoniaAtelectasis/pneumonia

Ribs # 1-3Ribs # 1-3 Severe forceSevere force Associated injuriesAssociated injuries 50% mortality50% mortality

Ribs # 5-9Ribs # 5-9 Majority - blunt traumaMajority - blunt trauma Bowing effectBowing effect Midshaft fractureMidshaft fracture IntrathoracicIntrathoracic

ManagementManagement Obtain chest X-rayObtain chest X-ray AvoidAvoid

♦ ♦Systemic analgesicsSystemic analgesics

♦ ♦Constrictive devicesConstrictive devices

Indications for Chest Tube Indications for Chest Tube InsertionInsertion

1. Pneumothorax1. Pneumothorax

2. Hemothorax2. Hemothorax

3. Selected cases, suspected 3. Selected cases, suspected severe lung injurysevere lung injury

4. Prophylaxis4. Prophylaxis

SummarySummary

Common in multiple injured Common in multiple injured patientpatient

Cognitive knowledge to Cognitive knowledge to diagnosediagnose

Develop skillsDevelop skills ECG monitoringECG monitoring

Pitfalls in Thoracic InjuriesPitfalls in Thoracic Injuries Failure to obtain a chest X-ray soon Failure to obtain a chest X-ray soon

after admission and again within 4-8 after admission and again within 4-8 hours may result in significant hours may result in significant intrathoracic injuries being overlookedintrathoracic injuries being overlooked

Excessive reliance on chest X-rays Excessive reliance on chest X-rays may lead to diagnostic errorsmay lead to diagnostic errors

Without careful inspection of the Without careful inspection of the chest wall, contusions, flail chest, chest wall, contusions, flail chest, intrathoracic bleeding, and open or intrathoracic bleeding, and open or "sucking" chest wounds may be "sucking" chest wounds may be overlookedoverlooked

A fractured sternum can be easily A fractured sternum can be easily missed unless the sternum is missed unless the sternum is palpated carefully or special X-ray palpated carefully or special X-ray views are obtainedviews are obtained

Cardiac arrest may occur suddenly Cardiac arrest may occur suddenly and rapidly if there is any delay in and rapidly if there is any delay in relieving a suspected tension relieving a suspected tension pneumothorax in a hypotensive pneumothorax in a hypotensive patient. X-rays are not needed before patient. X-rays are not needed before treatment under such circumstancestreatment under such circumstances

Inserting a chest tube while the Inserting a chest tube while the patient is lying flat increases the patient is lying flat increases the chances for injury to the diaphragmchances for injury to the diaphragm

If an air leak and pneumothorax If an air leak and pneumothorax space are allowed to persist together, space are allowed to persist together, the patient is apt to develop an the patient is apt to develop an empyema or bronchopleural fistulaempyema or bronchopleural fistula

If a patient with multiple injuries If a patient with multiple injuries which include a flail chest is not given which include a flail chest is not given ventilatory assistance with a ventilatory assistance with a respirator soon after admission, he is respirator soon after admission, he is apt to die of respiratory failureapt to die of respiratory failure

If a diaphragmatic injury is not If a diaphragmatic injury is not suspected and looked for in all suspected and looked for in all patients with chest trauma, the patients with chest trauma, the diagnosis will probably be misseddiagnosis will probably be missed

If it is assumed that bleeding from the If it is assumed that bleeding from the chest wound in a hypotensive patient chest wound in a hypotensive patient is superficial in origin, the diagnosis is superficial in origin, the diagnosis and treatment of severe intrathoracic and treatment of severe intrathoracic bleeding may be delayedbleeding may be delayed

Repeated attempts to completely Repeated attempts to completely aspirate a small hemothorax with a aspirate a small hemothorax with a needle or a syringe may cause a needle or a syringe may cause a pneumothorax or empyemapneumothorax or empyema

Use of high ventilatory pressures to Use of high ventilatory pressures to inflate the lungs following penetrating inflate the lungs following penetrating chest wounds may result in systemic chest wounds may result in systemic air emboliair emboli

Failure to obtain an aortogram when Failure to obtain an aortogram when there is superior mediastinal widening there is superior mediastinal widening following blunt chest trauma may following blunt chest trauma may result in an inaccurate diagnosis and result in an inaccurate diagnosis and an unnecessary thoracotomyan unnecessary thoracotomy

Hypotension following blunt chest Hypotension following blunt chest trauma is frequently due to intra-trauma is frequently due to intra-abdominal bleedingabdominal bleeding

Delay in closure or drainage of Delay in closure or drainage of esophageal injuries result in a high esophageal injuries result in a high morbidity and mortality; hence, early morbidity and mortality; hence, early diagnosis and treatment are vitaldiagnosis and treatment are vital

Any delay in providing adequate Any delay in providing adequate ventilatory support greatly ventilatory support greatly increases the risk of irreversible increases the risk of irreversible respiratory failurerespiratory failure

Excessive administration of Excessive administration of crystalloids greatly increases the crystalloids greatly increases the risk of respiratory failurerisk of respiratory failure

Failure to empty the stomach Failure to empty the stomach with a tube soon after chest with a tube soon after chest trauma greatly increases the risk trauma greatly increases the risk of aspiration and severe ileusof aspiration and severe ileus