4 - Chest Trauma Flashcards
Chest trauma BLUF:
Most are treated non-operatively
Things to look out for on visual examination on the traumatic chest:
Cyanosis
SubQ emphysema
Flail chest
Lac / hematoma
JVD
Tracheal deviation
On your chest exam, don’’t forget to:
Roll em over to look at the back
Check the axillae
Palpation of the chest
Expansion
Tenderness , crepitus
SubQ emphysema
Percussion of the chest
Compare sides
Dullness = fluid
Hypertympany = PTX
Auscultation
Diminished. /absent breath sounds may indicate fluid or PTX
Muffled, displaced crunching heart sounds may indicate myocardial injury / pericardial effusion
Which are treated surgically?
Penetrating with > 1L blood loss
Diaphragmatic rupture
Aortic transection
Cardiac tamponade
Non-operative chest injuries include:
Rib fx’s
PTX
Hemothorax
Rib fx’s
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
Slide 11
Algorithm
How to do needle decomp
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)
Definitive txt for hemo/pneumo
Thoracostomy
Monitor the blood output through the chest tube with a hemothorax - if more than 1L:
Take to OR
Pulmonary contusion
Bruised lung
Alveoli fill with blood
Txt with O2
Closely monitor fluid intake and avoid pulmonary edema
Diaphragmatic hernia
Decompress the stomach
Take to OR
Repair diaphragmatic rent
Aortic transection
Most don’t survive
If adventitia holds, may survive to trauma bay
Control HR and BP, emergent surgery
Initial treatment of penetrating chest wound (i.e. open)
3-way valve
If large enough, then taken to OR
Beck’s triad
Pericardial effusion / tamponade
HOTN
Muffled heart sounds
JVD
Txt for pericardial effusion / tamponade
Pericardiocentesis
Insert needle under negative pressure
Evacuate blood
Definitive - send to OR
Resuscitative thoracotomy
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%
Urgent exploration
Hemorrhage - >1500ml initially or >300ml/hr x 3 hrs
Major airway disruption - pulmonary lac - hilar twist
Cardiac / vascular injuries
Esophageal disruption
Diaphragmatic disruption
Delayed exploration
Retained hemothorax
Post-traumatic empyema
Smaller missed hemorrhages
Approaches to delayed exploration
Medial sternotomy
Posterolateral thoracotomy - 4th-5th ICS - can be converted to bilateral
VATS (laproscopic, video)
Why cant you hear a pterodactyl go to the bathroom?
Because the P is silent
