Thoracictrauma

Thoracic TraumaThoracic TraumaDave Lloyd, MDDave Lloyd, MD

Introduction to Thoracic InjuryIntroduction to Thoracic Injury Vital StructuresVital Structures

– Heart, Great Vessels, Esophagus, Heart, Great Vessels, Esophagus, Tracheobronchial Tree, & LungsTracheobronchial Tree, & Lungs

25% of MVC deaths are due to thoracic trauma25% of MVC deaths are due to thoracic trauma– 12,000 annually in US12,000 annually in US

Abdominal injuries are common with chest Abdominal injuries are common with chest trauma.trauma.

Prevention FocusPrevention Focus– Gun Control LegislationGun Control Legislation– Improved motor vehicle restraint systemsImproved motor vehicle restraint systems

Passive Restraint SystemsPassive Restraint Systems AirbagsAirbags

Anatomy and Physiology of the Anatomy and Physiology of the ThoraxThorax

Thoracic SkeletonThoracic Skeleton– 12 Pair of C-shaped ribs12 Pair of C-shaped ribs

Ribs 1-7: Join at sternum with cartilage end-pointsRibs 1-7: Join at sternum with cartilage end-points Ribs 8-10: Join sternum with combined cartilage at 7Ribs 8-10: Join sternum with combined cartilage at 7thth rib rib Ribs 11-12: No anterior attachmentRibs 11-12: No anterior attachment

– SternumSternum ManubriumManubrium

– Joins to clavicle and 1Joins to clavicle and 1stst rib rib– Jugular NotchJugular Notch

BodyBody– Sternal angle (Angle of Louis)Sternal angle (Angle of Louis)

Junction of the manubrium with the sternal bodyJunction of the manubrium with the sternal body Attachment of 2Attachment of 2ndnd rib rib

Xiphoid processXiphoid process– Distal portion of sternumDistal portion of sternum


Thoracic SkeletonThoracic Skeleton– Topographical Thoracic Reference LinesTopographical Thoracic Reference Lines

Midclavicular lineMidclavicular line Anterior axillary lineAnterior axillary line Mid-axillary lineMid-axillary line Posterior axillary linePosterior axillary line

– Intercostal spaceIntercostal space Artery, Vein and Nerve on inferior margin of each ribArtery, Vein and Nerve on inferior margin of each rib

– Thoracic InletThoracic Inlet Superior opening of the thoraxSuperior opening of the thorax Curvature of 1Curvature of 1stst rib with associated structures rib with associated structures

– Thoracic OutletThoracic Outlet Inferior opening of the thoraxInferior opening of the thorax 1212thth rib and associated structures & Xiphisternal joint rib and associated structures & Xiphisternal joint


DiaphragmDiaphragm– Muscular, dome-like structureMuscular, dome-like structure– Separates abdomen from the thoracic cavitySeparates abdomen from the thoracic cavity– Affixed to the lower border of the rib cageAffixed to the lower border of the rib cage– Central and superior margin extends to the Central and superior margin extends to the

level of the 4level of the 4thth rib anteriorly and 6 rib anteriorly and 6thth rib rib posteriorlyposteriorly

– Major muscle of respirationMajor muscle of respiration Draws downward during inspirationDraws downward during inspiration Moves upward during exhalationMoves upward during exhalation


Associated MusculatureAssociated Musculature– Shoulder girdleShoulder girdle– Muscles of respirationMuscles of respiration

DiaphragmDiaphragmIntercostal musclesIntercostal muscles

– Contract to elevate the ribs and increase thoracic Contract to elevate the ribs and increase thoracic diameterdiameter

– Increase depth of respirationIncrease depth of respiration

SternocleidomastoidSternocleidomastoid– Raise upper rib and sternumRaise upper rib and sternum


Physiology of RespirationPhysiology of Respiration– Changing pressure assists:Changing pressure assists:

Venous return to heartVenous return to heart Pumping blood to systemic circulationPumping blood to systemic circulation

– InhalationInhalation Diaphragm contracts and flattensDiaphragm contracts and flattens Intercostals contract expanding ribcageIntercostals contract expanding ribcage Thorax volume increasesThorax volume increases

– Less internal pressure than atmosphericLess internal pressure than atmospheric– Air enters lungsAir enters lungs

– ExhalationExhalation Musculature relaxesMusculature relaxes Diaphragm & intercostals return to normalDiaphragm & intercostals return to normal

– Greater internal pressure than atmosphericGreater internal pressure than atmospheric– Air exits lungsAir exits lungs


Trachea, Bronchi & LungsTrachea, Bronchi & Lungs– TracheaTrachea

Hollow & cartilage supported structureHollow & cartilage supported structure

– BronchiBronchi Right & left extend for 3 centimetersRight & left extend for 3 centimeters Enters lungs at Pulmonary HilumEnters lungs at Pulmonary Hilum

– Also where pulmonary arteries & veins enterAlso where pulmonary arteries & veins enter Further subdivide and terminate as alveoliFurther subdivide and terminate as alveoli

– Basic unit of structure & function in the lungsBasic unit of structure & function in the lungs– Single cell membraneSingle cell membrane– External versus Internal RespirationExternal versus Internal Respiration

– LungsLungs Right = 3 lobesRight = 3 lobes Left = 2 lobesLeft = 2 lobes


Trachea, Bronchi & LungsTrachea, Bronchi & Lungs– PleuraPleura

Visceral PleuraVisceral Pleura– Cover lungsCover lungs

Parietal PleuraParietal Pleura– Lines inside of thoracic cavityLines inside of thoracic cavity

Pleural SpacePleural Space– POTENTIAL SPACEPOTENTIAL SPACE

Air in Space = PNEUMOTHORAXAir in Space = PNEUMOTHORAX Blood in Space = HEMOTHORAXBlood in Space = HEMOTHORAX

– Serous (pleural) fluid withinSerous (pleural) fluid within Lubricates & permits ease of expansionLubricates & permits ease of expansion


MediastinumMediastinum– Central space within thoracic cavityCentral space within thoracic cavity– BoundariesBoundaries

Lateral: LungsLateral: Lungs Inferior: DiaphragmInferior: Diaphragm Superior: Thoracic outletSuperior: Thoracic outlet

– StructuresStructures HeartHeart Great VesselsGreat Vessels EsophagusEsophagus TracheaTrachea NervesNerves

– VagusVagus– PhrenicPhrenic

Thoracic DuctThoracic Duct


HeartHeart– ChambersChambers– ValvesValves– VesselsVessels– External VesselsExternal Vessels

Coronary ArteriesCoronary Arteries

Contraction CycleContraction Cycle– SystoleSystole– DiastoleDiastole

Filling of the coronary arteries occurFilling of the coronary arteries occur


HeartHeart– General StructureGeneral Structure

PericardiumPericardium– Surrounds heartSurrounds heart– VisceralVisceral– ParietalParietal– SerousSerous

35-50 ml fluid35-50 ml fluid EpicardiumEpicardium

– Outer LayerOuter Layer MyocardiumMyocardium

– Muscular layerMuscular layer EndocardiumEndocardium

– Innermost layerInnermost layer

– Nervous StructureNervous Structure SA NodeSA Node

– Right AtriumRight Atrium Intra-atrial PathwaysIntra-atrial Pathways AV NodeAV Node

– AV JunctionAV Junction Bundle of HisBundle of His Left & Right Bundle Left & Right Bundle

BranchesBranches Purkinje FibersPurkinje Fibers


Great VesselsGreat Vessels– AortaAorta

Fixed at three sitesFixed at three sites– AnnulusAnnulus

Attaches to heartAttaches to heart– Ligamentum Ligamentum

ArteriosumArteriosum Near bifurcation Near bifurcation

of pulmonary of pulmonary arteryartery

– Aortic hiatusAortic hiatus Passes through Passes through

diaphragmdiaphragm

– Superior Vena CavaSuperior Vena Cava– Inferior Vena CavaInferior Vena Cava– Pulmonary ArteriesPulmonary Arteries– Pulmonary VeinsPulmonary Veins

EsophagusEsophagus– Enters at thoracic inletEnters at thoracic inlet– Posterior to tracheaPosterior to trachea– Exits at esophageal hiatusExits at esophageal hiatus

Pathophysiology of Thoracic Pathophysiology of Thoracic TraumaTrauma

Blunt TraumaBlunt Trauma– Results from kinetic energy forcesResults from kinetic energy forces– Subdivision MechanismsSubdivision Mechanisms

BlastBlast– Pressure wave causes tissue disruptionPressure wave causes tissue disruption– Tear blood vessels & disrupt alveolar tissueTear blood vessels & disrupt alveolar tissue– Disruption of tracheobronchial treeDisruption of tracheobronchial tree– Traumatic diaphragm ruptureTraumatic diaphragm rupture

Crush (Compression)Crush (Compression)– Body is compressed between an object and a hard surfaceBody is compressed between an object and a hard surface– Direct injury of chest wall and internal structuresDirect injury of chest wall and internal structures

DecelerationDeceleration– Body in motion strikes a fixed objectBody in motion strikes a fixed object– Blunt trauma to chest wallBlunt trauma to chest wall– Internal structures continue in motionInternal structures continue in motion

Ligamentum ArteriosumLigamentum Arteriosum shears aorta shears aorta

– Age FactorsAge Factors Pediatric Thorax: More cartilage = Absorbs forcesPediatric Thorax: More cartilage = Absorbs forces Geriatric Thorax: Calcification & osteoporosis = More Geriatric Thorax: Calcification & osteoporosis = More

fracturesfractures


Penetrating TraumaPenetrating Trauma– Low EnergyLow Energy

Arrows, knives, handgunsArrows, knives, handguns Injury caused by direct Injury caused by direct

contact and cavitationcontact and cavitation

– High EnergyHigh Energy Military, hunting rifles & Military, hunting rifles &

high powered hand gunshigh powered hand guns Extensive injury due to Extensive injury due to

high pressure cavitationhigh pressure cavitation

Trauma.org


Penetrating Injuries (cont.)Penetrating Injuries (cont.)– ShotgunShotgun

Injury severity based upon the distance between the Injury severity based upon the distance between the victim and shotgun & caliber of shotvictim and shotgun & caliber of shot

Type I: >7 meters from the weaponType I: >7 meters from the weapon– Soft tissue injurySoft tissue injury

Type II: 3-7 meters from weaponType II: 3-7 meters from weapon– Penetration into deep fascia and some internal Penetration into deep fascia and some internal

organsorgans Type III: <3 meters from weaponType III: <3 meters from weapon

– Massive tissue destructionMassive tissue destruction

Trauma.org

Injuries Associated with Injuries Associated with Penetrating Thoracic TraumaPenetrating Thoracic Trauma

Closed pneumothoraxClosed pneumothorax Open pneumothorax Open pneumothorax

(including sucking (including sucking chest wound)chest wound)

Tension Tension pneumothoraxpneumothorax

PneumomediastinumPneumomediastinum HemothoraxHemothorax HemopneumothoraxHemopneumothorax Laceration of vascular Laceration of vascular

structuresstructures

Tracheobronchial tree Tracheobronchial tree lacerationslacerations

Esophageal lacerationsEsophageal lacerations Penetrating cardiac Penetrating cardiac

injuriesinjuries Pericardial tamponadePericardial tamponade Spinal cord injuriesSpinal cord injuries Diaphragm traumaDiaphragm trauma Intra-abdominal Intra-abdominal

penetration with penetration with associated organ injuryassociated organ injury

Pathophysiology of Thoracic Pathophysiology of Thoracic Trauma Trauma Chest Wall InjuriesChest Wall Injuries

ContusionContusion– Most Common result of blunt injuryMost Common result of blunt injury– Signs & SymptomsSigns & Symptoms

ErythemaErythema EcchymosisEcchymosis DYSPNEADYSPNEA PAIN on breathingPAIN on breathing Limited breath soundsLimited breath sounds HYPOVENTILATIONHYPOVENTILATION

– BIGGEST CONCERN = “HURTS TO BREATHE”BIGGEST CONCERN = “HURTS TO BREATHE” CrepitusCrepitus Paradoxical chest wall motionParadoxical chest wall motion


Rib FracturesRib Fractures– >50% of significant chest trauma cases due to >50% of significant chest trauma cases due to

blunt traumablunt trauma– Compressional forces flex and fracture ribs at Compressional forces flex and fracture ribs at

weakest pointsweakest points– Ribs 1-3 requires great force to fractureRibs 1-3 requires great force to fracture

Possible underlying lung injuryPossible underlying lung injury– Ribs 4-9 are most commonly fracturedRibs 4-9 are most commonly fractured– Ribs 9-12 less likely to be fracturedRibs 9-12 less likely to be fractured

Transmit energy of trauma to internal organsTransmit energy of trauma to internal organs If fractured, suspect liver and spleen injuryIf fractured, suspect liver and spleen injury

– Hypoventilation is COMMON due to PAINHypoventilation is COMMON due to PAIN


Sternal Fracture & DislocationSternal Fracture & Dislocation– Associated with severe blunt anterior traumaAssociated with severe blunt anterior trauma– Typical MOITypical MOI

Direct Blow (i.e. Steering wheel)Direct Blow (i.e. Steering wheel)– Incidence: 5-8%Incidence: 5-8%– Mortality: 25-45%Mortality: 25-45%

Myocardial contusionMyocardial contusion Pericardial tamponadePericardial tamponade Cardiac ruptureCardiac rupture Pulmonary contusionPulmonary contusion

– Dislocation uncommon but same MOI as Dislocation uncommon but same MOI as fracturefracture

Tracheal depression if posteriorTracheal depression if posterior


Flail ChestFlail Chest– Segment of the chest that becomes free to Segment of the chest that becomes free to

move with the pressure changes of respirationmove with the pressure changes of respiration– Three or more adjacent rib fracture in two or Three or more adjacent rib fracture in two or

more placesmore places– Serious chest wall injury with underlying Serious chest wall injury with underlying

pulmonary injurypulmonary injury Reduces volume of respirationReduces volume of respiration Adds to increased mortalityAdds to increased mortality

– Paradoxical flail segment movementParadoxical flail segment movement– Positive pressure ventilation can restore tidal Positive pressure ventilation can restore tidal

volumevolume

Pathophysiology of Thoracic Pathophysiology of Thoracic Trauma Trauma Pulmonary InjuriesPulmonary Injuries

Simple PneumothoraxSimple Pneumothorax– AKA: Closed PneumothoraxAKA: Closed Pneumothorax

Progresses into Tension PneumothoraxProgresses into Tension Pneumothorax– Occurs when lung tissue is disrupted and air leaks into Occurs when lung tissue is disrupted and air leaks into

the pleural spacethe pleural space

– Progressive PathologyProgressive Pathology Air accumulates in pleural spaceAir accumulates in pleural space Lung collapsesLung collapses Alveoli collapse (atelectasis)Alveoli collapse (atelectasis) Reduced oxygen and carbon dioxide exchangeReduced oxygen and carbon dioxide exchange Ventilation/Perfusion MismatchVentilation/Perfusion Mismatch

– Increased ventilation but no alveolar perfusionIncreased ventilation but no alveolar perfusion– Reduced respiratory efficiency results in HYPOXIAReduced respiratory efficiency results in HYPOXIA

– Typical MOI: “Paper Bag Syndrome”Typical MOI: “Paper Bag Syndrome”


Open PneumothoraxOpen Pneumothorax– Free passage of air between atmosphere and Free passage of air between atmosphere and

pleural spacepleural space– Air replaces lung tissueAir replaces lung tissue– Mediastinum shifts to uninjured sideMediastinum shifts to uninjured side– Air will be drawn through wound if wound is 2/3 Air will be drawn through wound if wound is 2/3

diameter of the trachea or largerdiameter of the trachea or larger– Signs & SymptomsSigns & Symptoms

Penetrating chest traumaPenetrating chest trauma Sucking chest woundSucking chest wound Frothy blood at wound siteFrothy blood at wound site Severe DyspneaSevere Dyspnea HypovolemiaHypovolemia


Tension PneumothoraxTension Pneumothorax– Buildup of air under pressure in the Buildup of air under pressure in the

thorax.thorax.– Excessive pressure reduces Excessive pressure reduces

effectiveness of respirationeffectiveness of respiration– Air is unable to escape from inside the Air is unable to escape from inside the

pleural spacepleural space– Progression of Simple or Open Progression of Simple or Open

PneumothoraxPneumothorax

Pathophysiology of Thoracic Pathophysiology of Thoracic Trauma Trauma Pulmonary InjuriesPulmonary InjuriesTension Pneumothorax Signs & SymptomsTension Pneumothorax Signs & Symptoms

DyspneaDyspnea– Tachypnea at firstTachypnea at first

Progressive Progressive ventilation/perfusion ventilation/perfusion mismatchmismatch– Atelectasis on Atelectasis on

uninjured sideuninjured side HypoxemiaHypoxemia Hyperinflation of Hyperinflation of

injured side of chestinjured side of chest Hyperresonance of Hyperresonance of

injured side of chestinjured side of chest

Diminished then Diminished then absent breath sounds absent breath sounds on injured sideon injured side

CyanosisCyanosis DiaphoresisDiaphoresis AMSAMS JVDJVD HypotensionHypotension HypovolemiaHypovolemia Tracheal ShiftingTracheal Shifting

– LATE SIGNLATE SIGN


HemothoraxHemothorax– Accumulation of blood in the pleural spaceAccumulation of blood in the pleural space– Serious hemorrhage may accumulate 1,500 mL Serious hemorrhage may accumulate 1,500 mL

of bloodof blood Mortality rate of 75%Mortality rate of 75% Each side of thorax may hold up to 3,000 mLEach side of thorax may hold up to 3,000 mL

– Blood loss in thorax causes a decrease in tidal Blood loss in thorax causes a decrease in tidal volumevolume

Ventilation/Perfusion Mismatch & ShockVentilation/Perfusion Mismatch & Shock

– Typically accompanies pneumothoraxTypically accompanies pneumothorax HemopneumothoraxHemopneumothorax

Trauma.org


Hemothorax Signs & SymptomsHemothorax Signs & Symptoms Blunt or penetrating chest traumaBlunt or penetrating chest trauma ShockShock

– DyspneaDyspnea– TachycardiaTachycardia– TachypneaTachypnea– DiaphoresisDiaphoresis– HypotensionHypotension

Dull to percussion over injured sideDull to percussion over injured side


Pulmonary ContusionPulmonary Contusion– Soft tissue contusion of the lungSoft tissue contusion of the lung– 30-75% of patients with significant blunt chest trauma30-75% of patients with significant blunt chest trauma– Frequently associated with rib fractureFrequently associated with rib fracture– Typical MOITypical MOI

DecelerationDeceleration– Chest impact on steering wheelChest impact on steering wheel

Bullet CavitationBullet Cavitation– High velocity ammunitionHigh velocity ammunition

– Microhemorrhage may account for 1- 1 ½ L of blood loss Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar tissuein alveolar tissue

Progressive deterioration of ventilatory statusProgressive deterioration of ventilatory status– Hemoptysis typically presentHemoptysis typically present

Pathophysiology of Thoracic Pathophysiology of Thoracic Trauma Trauma Cardiovascular InjuriesCardiovascular Injuries

Myocardial ContusionMyocardial Contusion– Occurs in 76% of patients with severe blunt chest traumaOccurs in 76% of patients with severe blunt chest trauma

– Right Atrium and Ventricle is commonly injuredRight Atrium and Ventricle is commonly injured

– Injury may reduce strength of cardiac contractionsInjury may reduce strength of cardiac contractions Reduced cardiac outputReduced cardiac output

– Electrical Disturbances due to irritability of damaged Electrical Disturbances due to irritability of damaged myocardial cellsmyocardial cells

– Progressive ProblemsProgressive Problems HematomaHematoma HemoperitoneumHemoperitoneum Myocardial necrosisMyocardial necrosis DysrhythmiasDysrhythmias CHF & or Cardiogenic shockCHF & or Cardiogenic shock


Myocardial Contusion Signs & SymptomsMyocardial Contusion Signs & Symptoms

Bruising of chest wallBruising of chest wall Tachycardia and/or irregular rhythmTachycardia and/or irregular rhythm Retrosternal pain similar to MIRetrosternal pain similar to MI Associated injuriesAssociated injuries

– Rib/Sternal fracturesRib/Sternal fractures Chest pain unrelieved by oxygenChest pain unrelieved by oxygen

– May be relieved with restMay be relieved with rest– THIS IS TRAUMA-RELATED PAINTHIS IS TRAUMA-RELATED PAIN

Similar signs and symptoms of medical Similar signs and symptoms of medical chest painchest pain

Pathophysiology of Thoracic Trauma Pathophysiology of Thoracic Trauma Cardiovascular InjuriesCardiovascular Injuries

Pericardial TamponadePericardial Tamponade– Restriction to cardiac filling caused by blood or Restriction to cardiac filling caused by blood or

other fluid within the pericardiumother fluid within the pericardium– Occurs in <2% of all serious chest traumaOccurs in <2% of all serious chest trauma

However, very high mortalityHowever, very high mortality

– Results from tear in the coronary artery or Results from tear in the coronary artery or penetration of myocardiumpenetration of myocardium

Blood seeps into pericardium and is unable to escapeBlood seeps into pericardium and is unable to escape 200-300 ml of blood can restrict effectiveness of 200-300 ml of blood can restrict effectiveness of

cardiac contractionscardiac contractions– Removing as little as 20 ml can provide reliefRemoving as little as 20 ml can provide relief


Pericardial Tamponade Signs & SymptomsPericardial Tamponade Signs & Symptoms

DyspneaDyspnea Possible cyanosisPossible cyanosis Beck’s TriadBeck’s Triad

– JVDJVD– Distant heart tonesDistant heart tones– Hypotension or Hypotension or

narrowing pulse narrowing pulse pressurepressure

Weak, thready pulseWeak, thready pulse ShockShock

Kussmaul’s signKussmaul’s sign– Decrease or absence of Decrease or absence of

JVD during inspirationJVD during inspiration Pulsus ParadoxusPulsus Paradoxus

– Drop in SBP >10 during Drop in SBP >10 during inspirationinspiration

– Due to increase in CO2 Due to increase in CO2 during inspirationduring inspiration

Electrical AlteransElectrical Alterans– P, QRS, & T amplitude P, QRS, & T amplitude

changes in every other changes in every other cardiac cyclecardiac cycle

PEAPEA


Myocardial Aneurysm or RuptureMyocardial Aneurysm or Rupture– Occurs almost exclusively with extreme blunt Occurs almost exclusively with extreme blunt

thoracic traumathoracic trauma– Secondary due to necrosis resulting from MISecondary due to necrosis resulting from MI– Signs & SymptomsSigns & Symptoms

Severe rib or sternal fractureSevere rib or sternal fracture Possible signs and symptoms of cardiac tamponadePossible signs and symptoms of cardiac tamponade If affects valves onlyIf affects valves only

– Signs & symptoms of right or left heart failureSigns & symptoms of right or left heart failure Absence of vital signsAbsence of vital signs


Traumatic Aneurysm or Aortic RuptureTraumatic Aneurysm or Aortic Rupture– Aorta most commonly injured in severe blunt or Aorta most commonly injured in severe blunt or

penetrating traumapenetrating trauma 85-95% mortality85-95% mortality

– Typically patients will survive the initial injury insultTypically patients will survive the initial injury insult 30% mortality in 6 hrs30% mortality in 6 hrs 50% mortality in 24 hrs50% mortality in 24 hrs 70% mortality in 1 week70% mortality in 1 week

– Injury may be confined to areas of aorta attachmentInjury may be confined to areas of aorta attachment

– Signs & SymptomsSigns & Symptoms Rapid and deterioration of vitalsRapid and deterioration of vitals Pulse deficit between right and left upper or lower Pulse deficit between right and left upper or lower

extremitiesextremities


Other Vascular InjuriesOther Vascular Injuries– Rupture or lacerationRupture or laceration

Superior Vena CavaSuperior Vena Cava Inferior Vena CavaInferior Vena Cava General Thoracic VasculatureGeneral Thoracic Vasculature

– Blood Localizing in MediastinumBlood Localizing in Mediastinum– Compression of:Compression of:

Great vesselsGreat vessels MyocardiumMyocardium EsophagusEsophagus

– General Signs & SymptomsGeneral Signs & Symptoms Penetrating TraumaPenetrating Trauma Hypovolemia & ShockHypovolemia & Shock Hemothorax or hemomediastinumHemothorax or hemomediastinum

Pathophysiology of Thoracic Trauma Pathophysiology of Thoracic Trauma Other Thoracic InjuriesOther Thoracic Injuries

Traumatic Esophageal RuptureTraumatic Esophageal Rupture– Rare complication of blunt thoracic traumaRare complication of blunt thoracic trauma– 30% mortality30% mortality– Contents in esophagus/stomach may move into Contents in esophagus/stomach may move into

mediastinummediastinum Serious Infection occursSerious Infection occurs Chemical irritationChemical irritation Damage to mediastinal structuresDamage to mediastinal structures Air enters mediastinumAir enters mediastinum

– Subcutaneous emphysema and penetrating Subcutaneous emphysema and penetrating trauma presenttrauma present


Tracheobronchial InjuryTracheobronchial Injury– MOIMOI

Blunt traumaBlunt trauma Penetrating traumaPenetrating trauma

– 50% of patients with injury die within 1 hr of injury50% of patients with injury die within 1 hr of injury– Disruption can occur anywhere in tracheobronchial treeDisruption can occur anywhere in tracheobronchial tree– Signs & SymptomsSigns & Symptoms

DyspneaDyspnea CyanosisCyanosis HemoptysisHemoptysis Massive subcutaneous emphysemaMassive subcutaneous emphysema Suspect/Evaluate for other closed chest traumaSuspect/Evaluate for other closed chest trauma


Traumatic AsphyxiaTraumatic Asphyxia– Results from severe compressive forces Results from severe compressive forces

applied to the thoraxapplied to the thorax– Causes backwards flow of blood from right side Causes backwards flow of blood from right side

of heart into superior vena cava and the upper of heart into superior vena cava and the upper extremitiesextremities

– Signs & SymptomsSigns & Symptoms Head & Neck become engorged with bloodHead & Neck become engorged with blood

– Skin becomes deep red, purple, or blueSkin becomes deep red, purple, or blue– NOT RESPIRATORY RELATEDNOT RESPIRATORY RELATED

JVDJVD Hypotension, Hypoxemia, ShockHypotension, Hypoxemia, Shock Face and tongue swollenFace and tongue swollen Bulging eyes with conjunctival hemorrhageBulging eyes with conjunctival hemorrhage

Assessment of the Thoracic Assessment of the Thoracic Trauma PatientTrauma Patient

Scene Size-upScene Size-up Initial AssessmentInitial Assessment Rapid Trauma AssessmentRapid Trauma Assessment

– ObserveObserve JVD, SQ Emphysema, Expansion of chestJVD, SQ Emphysema, Expansion of chest

– QuestionQuestion– PalpatePalpate– AuscultateAuscultate– PercussPercuss– Blunt Trauma AssessmentBlunt Trauma Assessment– Penetrating Trauma AssessmentPenetrating Trauma Assessment

Ongoing AssessmentOngoing Assessment

Management of the Chest Injury PatientManagement of the Chest Injury PatientGeneral ManagementGeneral Management

Ensure ABC’sEnsure ABC’s– High flow OHigh flow O22 via NRB via NRB– Intubate if indicatedIntubate if indicated– Consider RSIConsider RSI– Consider overdrive ventilationConsider overdrive ventilation

If tidal volume less than 6,000 mLIf tidal volume less than 6,000 mL BVM at a rate of 12-16BVM at a rate of 12-16

– May be beneficial for chest contusion and rib fracturesMay be beneficial for chest contusion and rib fractures– Promotes oxygen perfusion of alveoli and prevents atelectasisPromotes oxygen perfusion of alveoli and prevents atelectasis

Anticipate Myocardial CompromiseAnticipate Myocardial Compromise Shock ManagementShock Management

– Consider PASGConsider PASG Only in blunt chest trauma with SP <60 mm HgOnly in blunt chest trauma with SP <60 mm Hg

– Fluid Bolus: 20 mL/kgFluid Bolus: 20 mL/kg– AUSCULTATE! AUSCULATE! AUSCULATE!AUSCULTATE! AUSCULATE! AUSCULATE!

Management of the Chest Injury Management of the Chest Injury PatientPatient

Rib FracturesRib Fractures– Consider analgesics for pain and to Consider analgesics for pain and to

improve chest excursionimprove chest excursionVersedVersedMorphine SulfateMorphine Sulfate

– CONTRAINDICATIONCONTRAINDICATIONNitrous OxideNitrous Oxide

– May migrate into pleural or mediastinal space and May migrate into pleural or mediastinal space and worsen conditionworsen condition


Sternoclavicular DislocationSternoclavicular Dislocation– Supportive OSupportive O22 therapy therapy– Evaluate for concomitant injuryEvaluate for concomitant injury

Flail ChestFlail Chest– Place patient on side of injuryPlace patient on side of injury

ONLY if spinal injury is NOT suspectedONLY if spinal injury is NOT suspected– Expose injury siteExpose injury site– Dress with bulky bandage against flail segmentDress with bulky bandage against flail segment

Stabilizes fracture siteStabilizes fracture site– High flow OHigh flow O22

Consider PPV or ET if decreasing respiratory statusConsider PPV or ET if decreasing respiratory status– DO NOT USE SANDBAGS TO STABILIZE FXDO NOT USE SANDBAGS TO STABILIZE FX

Trauma.org


Open Open PneumothoraxPneumothorax– High flow OHigh flow O22

– Cover site with Cover site with sterile occlusive sterile occlusive dressing taped on dressing taped on three sidesthree sides

– Progressive airway Progressive airway management if management if indicatedindicated


Tension PneumothoraxTension Pneumothorax– ConfirmationConfirmation

Auscultaton & Auscultaton & PercussionPercussion

– Pleural DecompressionPleural Decompression 22ndnd intercostal space in intercostal space in

mid-clavicular linemid-clavicular line– TOP OF RIBTOP OF RIB

Consider multiple Consider multiple decompression sites if decompression sites if patient remains patient remains symptomaticsymptomatic

Large over the needle Large over the needle catheter: 14gacatheter: 14ga

Create a one-way-Create a one-way-valve: Glove tip or valve: Glove tip or Heimlich valveHeimlich valve


HemothoraxHemothorax– High flow OHigh flow O22

– 2 large bore IV’s2 large bore IV’sMaintain SBP of 90-100Maintain SBP of 90-100EVALUATE BREATH SOUNDS for fluid EVALUATE BREATH SOUNDS for fluid

overloadoverload Myocardial ContusionMyocardial Contusion

– Monitor ECGMonitor ECGAlert for dysrhythmiasAlert for dysrhythmias

– IV if antidysrhythmics are neededIV if antidysrhythmics are needed


Pericardial TamponadePericardial Tamponade– High flow OHigh flow O22

– IV therapyIV therapy– Consider pericardiocentesis; rapidly Consider pericardiocentesis; rapidly

deteriorating patientdeteriorating patient Aortic AneurysmAortic Aneurysm

– AVOID jarring or rough handlingAVOID jarring or rough handling– Initiate IV therapy enrouteInitiate IV therapy enroute

Mild hypotension may be protectiveMild hypotension may be protective Rapid fluid bolus if aneurysm rupturesRapid fluid bolus if aneurysm ruptures

– Keep patient calmKeep patient calm


Tracheobronchial InjuryTracheobronchial Injury– Support therapySupport therapy

Keep airway clearKeep airway clear Administer high flow OAdminister high flow O22

– Consider intubation if unable to maintain patient airwayConsider intubation if unable to maintain patient airway Observe for development of tension pneumothorax and SQ Observe for development of tension pneumothorax and SQ

emphysemaemphysema Traumatic AsphyxiaTraumatic Asphyxia

– Support airwaySupport airway Provide OProvide O22

PPV with BVM to assure adequate ventilationPPV with BVM to assure adequate ventilation– 2 large bore IV’s2 large bore IV’s– Evaluate and treat for concomitant injuriesEvaluate and treat for concomitant injuries– If entrapment > 20 min with chest compressionIf entrapment > 20 min with chest compression

Consider 1mEq/kg of Sodium BicarbonateConsider 1mEq/kg of Sodium Bicarbonate

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Thoracictrauma