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Thoracic Trauma

Down and Dirty Chest CheckoutDown and Dirty Chest Checkout

The Basics of Thoracic Trauma

Steven “Kelly” Grayson, CCEMT-P

Thoracic Trauma

Thoracic Trauma

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Thoracic Trauma

ObjectivesObjectivesReview the epidemiology of thoracic trauma.Review thoracoabdominal anatomy andphysiology.Discuss pathophysiology of thoracic traumaresulting from:

Injuries to the chest wallPulmonary injuryCardiac injuryVascular injury

Discuss and describe clinical syndromes invarious types of thoracic trauma.

Thoracic Trauma

EpidemiologyEpidemiologySecond leading cause of trauma deaths25% of all trauma deaths45 – 50% of unrestrained drivers have thoracicinjuries50% of all trauma patients have associatedthoracic injuries2/3 reach the Emergency Department aliveOnly 15% require surgery

Thoracic Trauma

Anatomy and PhysiologyAnatomy and Physiology

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Thoracic Trauma

Anatomy and PhysiologyAnatomy and Physiology

Thoracic Trauma

Anatomy and PhysiologyAnatomy and Physiology

Thoracic Trauma

Anatomy and PhysiologyAnatomy and Physiology

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Thoracic Trauma

The Dirty DozenThe Dirty DozenLung contusionMyocardial contusionAortic ruptureDiaphragmatic ruptureTracheobronchialruptureEsophageal injury

Airway obstructionTensionpneumothoraxOpen pneumothoraxFlail chestMassivehemothoraxCardiac tamponade

Thoracic Trauma

AssessmentAssessmentInspection

BruisingAbrasionsParadoxical motionTracheal deviation

PalpationCrepitusSubcutaneous emphysemaDeformityBilateral expansionTactile vocal fremitus

Thoracic Trauma

AssessmentAssessmentAuscultation

Breath soundsHeart tonesAsymmetrical BP

PercussionDullness/fullnessHyperresonance

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Thoracic Trauma

The BLS SixThe BLS Six

Airway obstructionPneumothoraxOpen pneumothoraxRib fractures and flail chestPulmonary contusionAortic dissection

Thoracic Trauma

Airway ObstructionAirway ObstructionFollow the Airway Continuum

SuctionBLS adjunctsSupraglottic airwaysEndotracheal intubationCricothyroidotomy

Remember, supraglottic airways onlymanage a supraglottic obstruction!

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Thoracic Trauma

Thoracic Trauma

ManagementManagement

The Gold Standard ofairway management isnot a tool, it’s anoutcome.The goal is effectiveoxygenation andventilation.BLS airwaymanagement issufficient in most cases

Thoracic Trauma

Simple Pneumothorax vsTension Pneumothorax

Simple Pneumothorax vsTension Pneumothorax

SimpleDegree of hypoxia directlyrelated to size of lung areaaffectedResponds well tosupplemental oxygenLittle or no hemodynamiccompromiseRequires no EMSintervention other thanoxygenation

TensionSevere hypoxiaWorsens despitesupplemental oxygenPoor ventilatorycomplianceSevere hemodynamiccompromiseLife-threatening if nottreated immediately

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Thoracic Trauma

Progression ofTension Pneumothorax

Progression ofTension Pneumothorax

EarlyUnilaterally decreased breath soundsWorsening dyspnea despite treatment

Middle:Increased respirationsSubcutaneous emphysemaPoor ventilatory compliance

Late:Jugular venous distentionTracheal deviationAcute hypoxiaNarrowing pulse pressureDecompensated shock

Thoracic Trauma

Tension PneumothoraxTension PneumothoraxBlunt or penetrating traumaHypoventilation

HypoxiaHypercapnea

Cardiovascular compromiseShockCardiovascular collapse

Life-threatening if not treated early

Thoracic Trauma

Tension PneumothoraxTension Pneumothorax

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Thoracic Trauma

PathophysiologyPathophysiologyAir trapped in pleural spacefrom damaged lung or chestwallPressure collapses ipsilaterallungContralateral mediastinal shiftReduction in cardiac output

Increased intrathoracicpressureVena cava kinks, reducingblood return to the heart

Thoracic Trauma

Likely Assessment FindingsLikely Assessment FindingsSevere respiratory distressRestlessness, anxiety, agitationDecreased or absent breath soundsShockSubcutaneous emphysema

AxillaeNeck

Cardiovascular collapseTachycardiaWeak pulseHypotensionNarrow pulse pressure

Thoracic Trauma

Unlikely Assessment FindingsUnlikely Assessment Findings

Jugular venous distensionabsent if also hypovolemic

Hyper-resonance to percussionContralateral tracheal deviation

Late signSubtle finding

Cyanosis (late)

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Thoracic Trauma

Thoracic Trauma

ManagementManagementMaintain airway

Consider ETIHigh flow O2Ventilate PRNNeedle thoracentesis

2nd or 3rd ICSAngle of LouisNo flutter valve necessaryCatheter length < 2 inches resulted infailure to reach pleural cavity in 65% ofcases

Treat shock

Thoracic Trauma

Open PneumothoraxOpen Pneumothorax

Penetrating traumaSucking chest wounds

Air enters pleural spacevia hole in chest wallHole has to be large tosuck air

Impaled objectsAvulsed wounds and openrib fractures due to bluntor crushing trauma.

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Thoracic Trauma

AssessmentAssessment

Opening in the chest wallSucking sound oninhalationTachycardiaTachypneaRespiratory distressSQ emphysemaDecreased lung sounds onaffected side

Thoracic Trauma

PathophysiologyPathophysiologyAllows communication between pleural space andatmospherePrevents development of negative intrathoracicpressure

Profound hypoventilationHypoxiaPressure may build within pleural spaceReturn from vena cava may be impaired

Results in ipsilateral lung collapse due to ineffectiveventilation

Thoracic Trauma

Open PneumothoraxOpen Pneumothorax

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Thoracic Trauma

ManagementManagementOcclusive dressingHigh flow O2Assisted ventilations PRNBe alert for tension pneumothorax

Burp dressingNeedle decompression

Thoracic Trauma

ManagementManagement

Thoracic Trauma

Flail ChestFlail Chest

3 or more ribs broken in2 or more placesFree floating segment ofchest wallParadoxical motionPulmonary contusionMortality rate 20-40% dueto associated injuries

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Thoracic Trauma

Assessment FindingsAssessment FindingsChest wall contusionRespiratory distressPleuritic chest painSplinting of affectedsideCrepitusTachypnea, tachycardiaParadoxical movement(possible)

Thoracic Trauma

PathophysiologyPathophysiology

Impairment of bellows systemInadequate diaphragmaticmovementPain and increased work ofbreathingIntra-alveolar bleedingHypoventilation:

HypoxiaHypercapnea

Thoracic Trauma

Flail ChestFlail Chest

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Thoracic Trauma

ManagementManagementSuspect spinal injuriesEstablish airwayHigh flow O2Assisted ventilations

Treat hypoxiaPromote full lungexpansion

Mechanical stabilizationdoes not work

Thoracic Trauma

Pulmonary ContusionPulmonary ContusionBlunt trauma to the chestfrom:

Rapid deceleration forcesHigh energy shock waveshigh velocity projectilesLow velocity projectileMost common injury fromblunt thoracic trauma30-75% of blunt traumaMortality 14-20%

Thoracic Trauma

Assessment FindingsAssessment Findings

Tachypnea or respiratory distressTachycardiaEvidence of blunt chest traumaCough and / or hemoptysisApprehensionCyanosis

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Thoracic Trauma

PathophysiologyPathophysiology

Rib fractures in many but not all casesRib fractures less common in children

Alveolar rupture with hemorrhage and edemaincreased capillary membrane permeability

Large vascular shunts developGas exchange disturbancesHypoxemiaHypercapnea

Thoracic Trauma

ManagementManagement

Supportive therapyEarly use of positive pressure ventilationreduces ventilator therapy durationAvoid aggressive crystalloid infusionSevere cases may require ventilator therapyEmergent transport

Thoracic Trauma

PEEP/CPAPPEEP/CPAP

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Aortic DissectionAortic Dissection

15% of all blunt traumadeaths1 of 6 MVC fatalities hadaortic rupture

85% die on scene10-15% survive to hospital

1/3 die within 6 hours1/3 die within 24 hours1/3 survive 3 days orlonger

Thoracic Trauma

Assessment FindingsAssessment FindingsRetrosternal or interscapular painPain in lower back or one legRespiratory distressAsymmetrical perfusion

BP difference between armsIpsilateral pulse deficit

Upper extremity hypertension withDecreased femoral pulses, ORAbsent femoral pulses

Dysphagia

Thoracic Trauma

PathophysiologyPathophysiology

Separation of the tunica intima and mediaTears due to high-speed decelerationDescending aorta at the isthmus distal to left subclavianartery is most common site

Fixation point – ligamentum arteriosumBlood enters tunica media through a small intimal tear

Forms a false lumen between layersLumen expands and lengthens with each beat

Rupture results in circulatory collapse within seconds

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Thoracic Trauma

ManagementManagementEstablish airwayHigh flow O2

Vascular access, but…… NS at TKO rate only!… the only fluid you shouldbolus is diesel!Transport to trauma centerwith vascular surgery

Thoracic Trauma

Tactile Vocal FremitusTactile Vocal FremitusVibration of sound inchestUse diphthong sounds(“blue balloon”)Most concentrated inintrascapular regionShould be equalbilaterally

Unilaterally decreased inpneumothoraxUnilaterally increased overconsolidation

Thoracic Trauma

SummarySummary

Thoracic trauma results in significant morbidityand mortality.With the exception of endotracheal intubationand needle decompression, most treatment isBLS.Airway management and ventilation are thekeys to proper care.

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Thoracic Trauma

Questions?

Thoracic Trauma

www.kellygrayson.com

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Thoracic Trauma

ReferencesReferencesInadequate needle thoracostomy rate in the prehospital settingfor presumed pneumothorax: an ultrasound study. Blaivas M.J Ultrasound Med. 2010 Sep;29(9):1285-9.Thoracic needle decompression for tension pneumothorax:clinical correlation with catheter length. Ball CG, et al. Can JSurg. 2010 June; 53(3): 184–188.Needle thoracostomy in the prehospital setting. Eckstein M,Suyehara D. Prehosp Emerg Care. 1998 Apr-Jun;2(2):132-5.http://en.wikipedia.org/wiki/Fremitus