37. Thoracic Trauma Flashcards
Key thoracic trauma emergencies – list five
Cardiac tamponade, tension, pneumothorax, airway obstruction, uncontrolled haemorrhage
Define flail chest
Three or more adjacent ribs are fractured at two points, allowing a free segment of chest wall to move in a paradoxical motion
What ribs are most common to break?
4–9
What ribs have specific concern for associated intra-abdominal injury, liver injury, or splenic injury?
9 to 11
Right sided, left sided
What is a paradoxical movement in flail chest?
Chest wall moves in on inspiration and out on expiration, product of negative intrathoracic pressure and is secured if the patient has been intubated or is receiving positive pressure ventilation
In your differential diagnosis for rib factors, what are particularly concerning differential?
Trachea bronchial injury, Umax, hemothorax, diaphragmatic injury, cardiovascular injury, like a contusion or aortic injury, oesophageal injury
Nexus CT criteria for chest CT after Blunt, trauma, list criteria
Abnormal chest, x-ray, rapid deceleration mechanism as a fall greater than 20 feet or motor vehicle collision greater than 40 mph, distracting, painful injury, chest wall, tenderness, sternal, tenderness, thoracic, spine, tenderness, scapular tenderness
Single rib fracture management
Opioid and non-opioid analgesia
Multiple rib fracture treatment
Opioid a non-opioid medication, intercostal nerve blocks, patient controlled, algesia, thoracic epidural
Flail segment management
Management as per multiple rib, fractures, consultation with trauma or thoracic surgeon for query surgical intervention
Indications for open fixation of flail chest
Patients who cannot be weaned from the ventilator secondary to mechanics of flail chest, persistent pain, severe chest, while instability or progressive decline and pulmonary function
How long does it take most rib fractures to heal?
3 to 6 weeks
How long should patients be observed for after thoracic trauma and rib fractures?
If not to be admitted, 12 to 24 hours to ensure that occult vascular or intrapulmonary injuries are not present and then consider for discharge
What is a common mechanism of sternal fractures and dislocations?
Enter Blunt chest trauma by MVC or bicycle accident when the chest strikes the steering wheel or handlebars
Risk factors for sternal fracture from blunt trauma
Vehicular passenger restraint system, and patient age as restrained passengers are more likely to sustain a fracture
Treatment for sternal fractures
Adequate analgesia like for rib, fractures, isolated, sternal, fractures with adequate pain control on oral medication’s can go home. They cannot go home if they have severe pain and develop respiratory compromise or nonunion.
Treatment for sternal fractures
Adequate analgesia like for rib, fractures, isolated, sternal, fractures with adequate pain control on oral medication’s can go home. They cannot go home if they have severe pain and develop respiratory compromise or nonunion.
Examples of non-penetrating ballistic injury
Rubber bullets by police, beanbag shotgun shells
What organs are particularly vulnerable to non-penetrating ballistic injury?
Kinetic energy can still be high: heart, liver, spleen, lung, spinal cord
When my patients with a non-penetrating ballistic injury need further imaging?
Meet CT Nexus rules or concern for retained foreign body, symptoms of rib fracture, pneumothorax, hemothorax, intrapleural, or peritoneal penetration
How long should a patient with superficial non-penetrating ballistic injury to the chest be observed for?
4 to 6 hours
What are common mechanisms of pulmonary contusions?
MVC with rapid deceleration, high velocity missile, high energy, shockwaves of an explosion in air water
What are common mechanisms of pulmonary contusions?
MVC with rapid deceleration, high velocity missile, high energy, shockwaves of an explosion in air water
Why are some of the worst pulmonary contusions in patients without rib fractures?
Example: children as more elastic chest wall transmits increased force to the thorax
On chest x-ray or imaging when do you typically see pulmonary contusion present?
Begin to appear within minutes and range from Apache, irregular alveolar, infiltrate to Frank consolidation, or almost always present within six hours
Pulmonary contusion needs to be differentiated from ARDS. What indicates a more likely contusion?
Localized to a segment or a lobe, often apparent on the initial chest study intends to last 48 to 72 hours
Pulmonary contusion needs to be differentiated from ARDS. What indicates a more likely contusion?
Localized to a segment or a lobe, often apparent on the initial chest study intends to last 48 to 72 hours
What scan is very helpful for a pulmonary contusion?
Ct
What scan is very helpful for a pulmonary contusion?
Ct
How to manage pulmonary contusion
Primarily supportive
How to manage pulmonary contusion
Primarily supportive
What is the pneumothorax and what are the three types?
Accumulation of air in the plural space, one simple, two communicating, three tension
Simple PTX defn
no communication with atmosphere or any shift in mediastinum or hemidiaphragm
Communicating ptx defn
assoc defect in chest wall, typically combat injuries like GSW
How can a communicating pneumothorax be described as a sucking chest wound?
loss of chest wall integrity causes involved lung to paradoxically collapse on inspiration and expand on expiration to force air out of the wound
this causes large functional dead space for normal lung with loss of ventilation of involved lung
Tension ptx defn
progressive accumulation of air under pressure within pleural cavity, shift of mediastinum to opp hemithorax and compression of contralateral lungand great vessels
Why does a tension ptx cause so much issue?
one way valve - air in, can’t get out with expiration
can lead to compression of SVC, distorting cavoatrial junction so heart can’t fill
Cardinal signs of a tension ptx
tachycardia, hypotensin, oxyhbg desat, JVD, absent breath sounds on ipsilatearl side
Initial test for ptx - CXR needs to be done in what pos?
upright full inspiratory film as air tends to collect at apex of the lung
List 9 indications for a tube thoracostomy
- traumatic cause of ptx (unless asymptomatic, apical)
- moderate to large ptx
- resp sx regardless of size
- increasing side of ptx after conservative therapy
- Pt requiring ventilator support
- assoc hemothorax
- Pt RQ general anesthesia
- bilat pneumothorax regardless of size
- tension ptx
How to insert a CT for a pneumothorax:
- Landmark 4-5th IC site at mid axillary line, top of rib
- Clean and prep
- Scalpel
- Kelly’s to dissect
- finger sweep to ensure in lung, no adhesion
- 36-40F tube in adults, kids 16-32 all holes in
- Connect to machine, turn on suction if large hemothorax or air leak
Name 8 complications of tube thoracostomy
- hemothorax
- pulmonary edema
- bronchopleural fistula
- pleural leaks
- empyema
- subcutaneous emphysema
- infection
- intercostal a laceration
- contralateral pneumothorax
- parenchymal lung injury
Rosen’s traumatic/hemothorax with chest tube insertion recommendation of what abx?
cefazolin 1-2g prior or within 1h Ct insertion
if allergy vanco 1g of clinda 500mg
How to deal immediately with a communicating ptx
occlusive dressing
?tube in
ppv
Tension ptx: how to immediatley relieve:
- needle thoracostomy in 4-5th midaxillary line (14g or larger, at least 5cm) - can also just finger if no ime
Earliest sign of a tension PTX on patient getting CPR on ventilator?
increase R to ventilation
BP falls, CVP rises
Hemothorax: defn
accumulation of blood in the pleural space
Hemothorax: bleeding from what vessels may be brisk as come right off of aorta?
intercostal!
How much blood needs to be there in an upright cxr of a hemothorax to see in costophrenic angles?
200-300ml
Management of a hemothorax
- Airway
- Relieve blood (CT) - suction to 20-30
- Restore volume
Name 5 indications for an urgent thoracotomy
- initial tube drains more than 20ml/kg blood
- Persistent bleed at rate > 7ml/kg/h
- Incr hemothorax on CXR
- Pt remains hypotensive despite adq blood replacement and other sites of blood loss ruled out
- Pt decompensates after initial resus
Urgent thoracotomy: if hemothorax CT drains more than ? L from pleural cavity immediately or at least __ml/h for _ hours
1500ml
200ml/h x3h (cont)
What is the mc cause of tracheobronchial injury?
MVC
How does a tracheobronchial injury occur?
risk if knife wound in cervical trachea, gunshot at any point: decel of thoracic cage pulling lungs away from mediastinum produces traction on trachea at the carina - elasticity of tracheobronchial tree exceeded and ruptures
Where do most tracheobronchial injuries occur?
within 2cm of carina
Name 4 features of a tracheobronchial injury
massive air leak through chest tube
hemoptysis
dramatic incr in subcutaneous emphysema
Ausculation of heart = Hamman’s crunch if air track’s to mediastinum
What are the two main groups of patients where tracheobronchial injury is seen?
- wound opens to pleural space producing large ptx, cont bubbling/air leak
- complete transection of tracheobronchial tree but little or no communication with pleural space - weeks later little known atelectasis or pneumonia
Radiographic signs of patients with tracheobronchial fistula from complete transection (list 4)
- pneumomediastinum
- ext subcut emphysema
- ptx
- Fracture of ribs 1-5
- air surrounding bronchus
- obstruction in air filled bronchus
Diagnostic testing for a tracheobronchial injury
bronchoscopy or ct - see bronchopleural fistula or mediastinal fluid collection
Management of bronchotracheal injury: intubation?
under direct so you don’t do something funny
Management of bronchotracheal injury: standard tx
thoracotomy with intraop trac hand surgical repair of disrupted airway
Management of bronchotracheal injury: which pt can have conservative tx?
- <2cm in size (tracheal tear)
and - no esophageal prolapse
- mediastinitis
- massive air leak
Why can diaphragmatic hernia be particularly bad?
herniation into thoracic cavity, strangulation of abdo viscera (esp small bowel)
Which side are 3/4 of diaphragmatic rupture on?
left (liver presumably protects on the R)
Why does a diaphragmatic hernia injury occur in blunt injury?
incr pressure in abdo cavity causing diaphragmatic tear and pressure difference 5-10mmhg forcing abdo contents through
Can diaphragmatic hernia present late?
YES - so keep it in your differential
clinical feat diaphragmatic hernia: list 5
asx
emesis
sob
abdo, thoracic or referred shoulder pain
multiorgan failure - visceral obs, strangulation or perforation
Management of diaphragmatic rupture
surg
blunt cardiac trauma: life threatening complications list 5
dysrh
conduction abn
hf
cardiogenic shock
hemopericardium with tamponade
cardiac rupture
valve rupture
IV thrombi
TE phenomena
CA occlusion vent aneurysm
constr pericarditis
Myocardial concussion/commotio cordis defn
acute blow to mid ant chest stunning myocardium resultin in brief dysh, hypot, loc
Myocardial concussion/commotio cordis: when does this occur in the cardiac cycle
vent repol
Myocardial concussion/commotio cordis: clinical feat
mechanism characteristic and sudden collapse
ASAP AED, ACLS
Myocardial consution: mechanisms postulated for this
- direct blow E through rib to spine, displacing sternum posteriorly to heart is displaced
- can also displace abdo viscera up
Myocardial contusion: sx - most sn vs sp?
sinus tach
sp - no diagnostic standard: ECG: dys, conduction disturbance, ischemia, trop
Treatment of suspected myocardial contusion:
augment preload 200-250ml bolus q15 min to max 1-2L
What chambers are most effected in myocardial rupture?
ventricles - sp R
What is the pathophysiology of myocardial rupture in blunt trauma pt?
during closure of outflow tract when vent compression of blood filled chambers is outdone by pressure more sufficient to tear chamber wall/septum/valve
mech: shearing forces or fixed attachments, upward displ blood and abdo viscera, direct compressi of heart between sternum and rib
complications of myocardial contusion, necrosis leading to rupture
Features of myocardial rupture from blunt trauma
tamponade
severe hemorrhage
Features of characteristic auscultation/heart murmur in myocardial rupture from blunt trauma
bruit de moulin - splashing mill wheel caused by pneumopericardium
Management of myocardial rupture from blunt trauma
thoracotomy and pericardiotomy
Penetrating cardiac injury: which ventricle most effected?
RV
How does pericardial tamponade cause negative effect?
stops atria and ventricles from filling adequately so decreases CO
rosen’s indications for an ED thoracotomy in PENETRATING trauma - 3
- Cardiac arrest at any point with initial signs of life in field
- SBP <50 after fluid resus
- Sev shock with clinical signs of tamponade
rosen’s indications for an ED thoracotomy in BLUNT trauma -
Cardiac arrest in the ED
Beck’s triad
pericardial tamponade: hypotension, distended neck veins, distant or muffled heart sounds
ED thoracotomy: why is a left lateral incision more favorable than R?
best exposure of great vessels vs R:
risk f internal mammary artery bleed (need to ligate), pericardium vertically incised anterior to phrenic n
Blunt aortic injury: what is the physiology of why this occurs?
desc thoracic aorta is relatively fixed and immobile as tethered to intercostal and ligamentum arteriosum - sudden decel allows more mobile aorta at isthmus to whiplash/shear
Blunt aortic injury: where do most aortic tears occur?
descending aorta at isthmus just distal to L subclavian a
Blunt aortic injury: where can injuries occur?
descending aorta at isthmus distal to L subclavian a
ascending aorta
distal desc at level diaphragm
midthoracic descending oarta
origin of L subclavian a
MC sx of blunt aortic injury?
interscapular or retrosternal pain
Sx of blunt aortic injury
interscapular or retrosternal pain
dyspnea
stridor
hoarseness
dusphagia
extremity pain
Best imaging for aortic blunt injury?
ct -abnormal contour
Management strategies for blunt aortic injury:
- BP - SBP 100-120 to stop shearing
- Esmolol for HR - 0.5mg/kg over 1 min then infusion 0.05mg/kg/min; nicardipine as second line
Surgery - endovascular repair
Esophageal perforation: three areas of anatomic narrowing at BL?
cricopharyngeal m near esophageal introitus
level at which esphagus crosses L mainstem bronchus
GE junction
Common sx of esophageal perforation
pleuritic cp along course of esophagus - worse by swallowing or neck flexion
Hamman’s crunch sign in esophageal perforation
mediastinal air surrounding heart, produce systolic crunching sound
6 causes of esophageal perforation
iatrogenic
fb
caustic burn
blunt or penetrating injury
spontaneous rupture from emesis/boerhaave
postop breakdown of anastomoes
What type of chem burn is most likely to cause esophageal perforation? Why?
liquefaction necrosis from strong alkali pH >12 than coagulation necrossi from acid ph <2
Caustic burn causing esophageal perforation - recommends to do what to manage?
if stable esophagram with water soluble agent
endoscopy first 6-18 hours
Classic signs of Boerhaave syndrome
emesis –> sev CP, subcut emphysema, CP collapse
Name 5 classic findings of esophageal perforation on CXR
mediastinal air with or without subcut emphysema
L pleural effusion
ptx
wide mediastinum
lat view c spine area
Why is gastrograffin recommended for esophageal peforation study?
does not obscure visualization during endoscopy post and less mediastinal contamination than barium
if no leak can do barium after fo etter delineation
Management of esophageal perforation
broad spec abx
vol replacement
airway
asap surgery
NPO at least 72h
