4 - Chest Trauma

Question 1

Chest trauma BLUF:

Answer 1

Most are treated non-operatively

Question 2

Things to look out for on visual examination on the traumatic chest:

Answer 2

Cyanosis

SubQ emphysema

Flail chest

Lac / hematoma

JVD

Tracheal deviation

Question 3

On your chest exam, don’’t forget to:

Answer 3

Roll em over to look at the back

Check the axillae

Question 4

Palpation of the chest

Answer 4

Expansion

Tenderness , crepitus

SubQ emphysema

Question 5

Percussion of the chest

Answer 5

Compare sides

Dullness = fluid

Hypertympany = PTX

Question 6

Auscultation

Answer 6

Diminished. /absent breath sounds may indicate fluid or PTX

Muffled, displaced crunching heart sounds may indicate myocardial injury / pericardial effusion

Question 7

Which are treated surgically?

Answer 7

Penetrating with > 1L blood loss

Diaphragmatic rupture

Aortic transection

Cardiac tamponade

Question 8

Non-operative chest injuries include:

Answer 8

Rib fx’s

PTX

Hemothorax

Question 9

Rib fx’s

Answer 9

Normally self limiting

Flail chest - low threshold for intubation

Ensure adequate pain control - consult anesthesia for epidural block

Aggressive pulm toilet - incentives spirometer, cough, albuterol and mucolytic

Question 10

Slide 11

Answer 10

Algorithm

Question 11

How to do needle decomp

Answer 11

14G 3.25 inch (8cm) IV Angiocatheter inserted just above the 3rd rib at the MCL

If you have to miss, miss laterally (avoid those critical structures located more medial)

Question 12

Definitive txt for hemo/pneumo

Answer 12

Thoracostomy

Question 13

Monitor the blood output through the chest tube with a hemothorax - if more than 1L:

Answer 13

Take to OR

Question 14

Pulmonary contusion

Answer 14

Bruised lung

Alveoli fill with blood

Txt with O2

Closely monitor fluid intake and avoid pulmonary edema

Question 15

Diaphragmatic hernia

Answer 15

Decompress the stomach

Take to OR

Repair diaphragmatic rent

Question 16

Aortic transection

Answer 16

Most don’t survive

If adventitia holds, may survive to trauma bay

Control HR and BP, emergent surgery

Question 17

Initial treatment of penetrating chest wound (i.e. open)

Answer 17

3-way valve

If large enough, then taken to OR

Question 18

Beck’s triad

Answer 18

Pericardial effusion / tamponade

HOTN
Muffled heart sounds
JVD

Question 19

Txt for pericardial effusion / tamponade

Answer 19

Pericardiocentesis

Insert needle under negative pressure

Evacuate blood

Definitive - send to OR

Question 20

Resuscitative thoracotomy

Answer 20

Emergent, life-saving procedure done in the ED

Indications - penetrating trauma - loss of pulses within 15 mins of presentation to trauma bay; blunt - loss of pulses; must have organized rhythm to consider (even PEA)

Common procedures - pericardial window, hilar twist, cross-clamp aorta

Survival - stabs > GSW, blunt appx 1%, penetrating appx 14%

Question 21

Urgent exploration

Answer 21

Hemorrhage - >1500ml initially or >300ml/hr x 3 hrs

Major airway disruption - pulmonary lac - hilar twist

Cardiac / vascular injuries

Esophageal disruption

Diaphragmatic disruption

Question 22

Delayed exploration

Answer 22

Retained hemothorax

Post-traumatic empyema

Smaller missed hemorrhages

Question 23

Approaches to delayed exploration

Answer 23

Medial sternotomy

Posterolateral thoracotomy - 4th-5th ICS - can be converted to bilateral

VATS (laproscopic, video)

Question 24

Why cant you hear a pterodactyl go to the bathroom?

Answer 24

Because the P is silent