28.- 31 chest trauma Flashcards
Rib fracture
cause and clinical features. assoc condition
etiology: mostly blunt trauma, pathologic fractures, nonaccidental trauma (child abuse
- Clinical features
- Pain on inspiration
- Focal chest wall tenderness
- Crepitus
- Chest wall deformity
- assoc w/ flail chest
dg of rib fracture
Chest x-ray = gold standard (AP and lateral view): fracture lines , displaced fractures
Possible CT if complications are suspecte
rib fracture complications
Pneumothorax
Hemothorax
Especially in the elderly: pain → splinting and hypoventilation → atelectasis and/or pneumonia
Pulmonary contusion
Respiratory failure
Fracture of the lower ribs → abdominal organ injury
why is rib fracture rx an eneasthetists job
Usually no surgery necessary
Analgesia
- NSAIDs
- Opiates
- Local Intercostal nerve block, usually performed under the affected rib
Intubation with positive pressure ventilation in severe flail chest (bridge to surgery)
indications for surgery in rib fracture
Significant chest wall deformity
Severe flail chest
Nonunion aka Pseudarthrosis
- Failure of bone healing caused by nonunion of long bone fragments (e.g., due to insufficient immobilization). Results in the creation of a false joint (pseudarthrosis) due to the nonunion.
flail chest definition
severe disruption of normal chest wall movement from trauma associated with multiple rib fractures-3 ribs broken in 2 or more places
occurs when a segment of the chest wall does not have bony continuity with the rest or the thoracic cage.
dg of flail chest
clinical anatomic diagnosis
noted in blunt trauma patients with paradoxical or motion of a chest wall segment while spontaneously breathing.
Arterial blood gas (ABG) measurements
show the severity of the hypoventilation created by both
the pulmonary contusion and the pain of the rib fractures, to assess the need for mechanical ventilation and to follow the patient during management.
posteroanterior (PA) chest radiography to note number of fractured ribs
2 types of rxx for FLAIL CHEST
Internal/ external pneumatic stabilization
Surgical Stabilization
Traumatic hemothorax DEFinition
thoracic sources of blood
A hemothorax is defined as the presence of blood in the pleural space.
Thoracic sources of blood
- lung parenchyma,
- chest wall including the intercostal* or *internal mammary arteries,
- the heart and great vessels.
def and etio of massive heamothotax
The rapid accumulation of more than 1500 ml of blood or one-third or more of the patient’s blood volume in the chest cavity
- etio: mc by a penetrating wound that disrupts the systemic or hilar vessels;
sx dg of massive hemothroax
shock! associated with the
absence of breath sounds or dullnes to percussion on one side of the chest;
similar findings of
MASSIVE hemothorax and TENSION pneumothorax
decreased breath sounds on auscultation;
DX betw /tension pneum and massive hemothroax
on PHYSICAL EXAM (percussion)
hyperresonance confirms a pneumothorax,
whereas dullness confirms a massive hemothorax.
general treatment of hemothroax (ttd)
Tube Thoracostomy drainage
-
hemopneumothorax, placement of two chest tubes preferred,
- with the tube draining the pneumothorax placed in a more superior and anterior position.
- if over 1500ml evac = massive hemothorax
complication so hemothorax
- Empyema usually develops from superimposed infection in a retained collection of blood
- Fibrothorax is a late uncommon complication that can result from retained hemothorax.
Thoracotomy and decortication are required for treatment.
what is the deathly dozen in surgery
definition and etiology of traumatic PNEUMOthorax
collection of air in the pleural space 2ndary to trauma
etio= blunt/ penetrating trauma
what is the classification/ types of PNEUMOthorax
There are three subtypes of pneumothoraces:
- simple/closed pneumothorax,
- open pneumothorax,
- tension pneumothorax.
define simple pneumothroax
collection of air trapped in pleural space.
define open Pneumothorax
list it’s characteristics
- Full thickness defects of the chest wall that remain open;
- enables free comm bet/ chest wall and atmosphere leading to equilibrium:
- intrathoracic pressure = atmospheric pressure
- Effective ventilation is thereby impaired as air enters the pleaura with each breath
- leading to hypoventilation, hypoxia and hypercarbia.
treatment of pneumothorax
promptly closing the defect with a sterile occlusive 3 sided dressing for a flutter-type valve effect
inspiration= the dressing occludes the wound,preventing air from entering.
exhalation= the open end of the dressing allows air to escape from the pleural space
define the cahracteristics of tension Pneumothorax
- A tension pneumothorax develops when a tear in the lung/ chest wall causes a “one-way valve“ air leak
- inhaled Air is forced into the pleural space without any means of escape, making the oringially negative space to become positive
- positive presure causes complete collapse of the affected lung which displaces the mediastinum to the opposite side
- this compresses the opposite lung decreasing it’s venous return
Iatrogenic cause of Tension Pneumothorax
Mechanical Positive Pressure ventilation
(PEEP? Positive End Expiratory Pressure)
how is Tension Pneumothorax diagnosed
clinical diagnosis based on characteristic sx, do not wait for radio confirmation!!
characteristic sx and signs of tension pneumothorax
Cyanosis & Chest pain
respiratory distress
Tachycardia & Tracheal deviation
hypotension (1/3 of becks triad)
unilateral absence of breath sound (1/3 of beck’s triad)
neck vein distention (1/3 of becks triad)
what are the 2 DX of Tensino Pneumothorax
-
cardiac tamponade !!!
- TENSION pneumothorax has a hyperresonant note on percussion (CT is dull on percussion d/2 blood accum) and absent breath sounds over the affected hemithorax!!!
-
hemothorax
- TENSION pneumothorax has a hyperresonant note on percussion (HEMOthorax is dull on percussion d/2 blood accum)
imaging dg to confirm tension pneum
what is the gold standard imaging for tension pneumothorax
- U.S. - BARCODE SIGN: aka ‘stratosphere’ shows lack of lung sliding w/ insp/exp
- C.T. - GOLD STANDARD - Collapsed lung visualised
treatment of tension pneumothorax
Initial rx: immediate decompression
- to create an OPEN pneumothroax
- rapidly inserting a large-caliber needle into the second intercostal space in the midcavicular line of the affected hemithorax for
Definitive rx: Thoracostomy
- insert a chest tube into the fifth intercostal space (usually the nipple level), just anterior to the midaxillary line.
