abdomen and thoracic trauma Flashcards
blunt injury
-MC injured in blunt abdominal trauma
-2nd MC injured in blunt abdominal trauma
-we are most worried about solid organs for blunt trauma
-ribs cant protect you from this
A 21 year old male sustains a single gunshot wound to the abdomen. There is an entrance wound 5 cm lateral to the umbilicus on the right side. BP is 80/40, P 130/min, R: 22, T: 99. What is the stepwise management of this patient?
-monitor
-supplemental O2
-2 large bores IV access`
-trauma panel sent- CBC, BMP, coagulation studies, tox screen, cross match
A 33 yo male is brought into the ED after been extricated from a head on collision with a van. His Glascow is 11. BP: 80/60, P: 134, R: 18/min. Please discuss the stepwise management of this patient up until definitive care can be rendered.
-potential for bleed from abdomen but also hypotension
-head injury may be significant
-worry about brain injury with hypotension -> ischemia
-hypocarbia -> vasodilation -> ICP
-scan the brain
approach to trauma pt
-Initial survey - blood or spillage of bowel contents
-Blood vs peritoneal contamination
-Primary goal is to evaluate the need for emergent surgery
-No abdominal problem takes precedence over primary survey responsibilities
-its all about the 1st hr
-trauma is the leading cause of death in the 1st 4 decades of life in developed countries
-rule of rights
-diagnosis is not important
-ABCDE = same for adult/peds/pregnant
-primary survey should be repeated often
-primary and resuscitation should happen at the same time
abdominal eval
-unconscious pt
-development of peritoneal signs
-tender abdomen or unconscious pt
-assume significant injury
-hypotensive!! pt or those who will undergo non-abdominal surgery-> FAST
-pelvis- free blood around bladder or uterus
-heart- pericardial effusion
-spleen- blood under diaphragm - morrisons pouch
-lung sliding- hemo/pneumo thorax
-stable -> CT
dx
-FAST
-CT scan
-organ specific dx is foolish - dont know about injury type -> just want to know where
-GSW vs stab wounds
-GSW all need to be explored
-stab wounds depend if peritoneal cavity was penetrated
morrisons pouch
-anechoic - blood
stablization
-ABCs
-NGT
-oral GT if head trauma- worry about cribriform plate
-foley catheter
-thoracoabdominal wounds- combined abdominal and thoracic wounds
hepatic injury
-Blunt or penetrating trauma
-Biliary tract injury is harder to dx
-Look for overlying rib fractures
-CT scan -> Approach to repair
-DPL- dx peritoneal lavage- bile
classification of hepatic injury
-Grade 1 - Subcapsular hematoma less than 1 cm in maximal thickness, capsular avulsion, superficial parenchymal laceration less than 1 cm deep, and isolated periportal blood tracking
-Grade 2 - Parenchymal laceration 1-3 cm deep and parenchymal/subcapsular hematomas 1-3 cm thick
-Grade 3 - Parenchymal laceration more than 3 cm deep and parenchymal or subcapsular hematoma more than 3 cm in diameter
-Grade 4 - Parenchymal/subcapsular hematoma more than 10 cm in diameter, lobar destruction, or devascularization
-Grade 5 - Global destruction or devascularization of the liver
-Grade 6 - Hepatic avulsion
-devascularization, evulsion -> OR for embolization
-porta hepatis - exsanguination
-IR is always your friend
spleen
-2nd most injured solid viscera
-hypotension from hemorrhage is MC presenting sign
-8,9,10 left sided rib fractures
-Trendelenburg position -> khers sign
-FAST vs CT scan
-splenorrhaphy (dont do) vs splenectomy
-splenectomy is now recommended
-calcifications
-splenic artery aneurysms
radiographic splenic triad
-elevated hemidiaphragm
-left lower lobe atelectasis
-pleural effusion - not really often
-spleen that has been shattered
-transection through the spleen
-surgery
-subcapsular contained hematoma
-splenectomy
Grading Splenic Injuries
-Grade I
-Subcapsular non-expanding < 10%
-Non-bleeding noncapsular tear < 1cm
-Grade II
-Subcapsular, non-expanding, 10-50% surface area; intra-parenchymal non-expanding < 2 cm in diameter
-Capsular tear, active bleeding, 1-3 cm parenchymal depth that does not involve a trabecular vessel
Grade III
Subcapsular, > 50% surface area or expanding; ruptured subcapsular hematoma with active bleeding, intra-parenchymal hematoma > 2 cm or expanding
> 3 cm parenchymal depth or involving trabecular vessels
Grade IV
Ruptured intra-parenchymal hematoma with active bleeding
Laceration involving segmental or hilar vessels producing major devascularization (> 25% of spleen)
Grade V
Laceration: Completely shattered spleen
Vascular: Hilar vascular injury that devascularizes spleen
-shattered spleen -> surgery
-3-4 surgery
kidney injury
-Proximity of injury
-Hematuria of any type must be investigated
-Flank pain
-Fractures of 11th - 12th ribs
-Don’t look for flank discoloration - no grey turners sign like in pancreas
-CT with contrast
-Contused vs lacerated kidney
-trauma surgery- nephrectomy
-urologist called in- heminephrectomy or repair
bowel injuries
-free air
-penetrating vs blunt
-symptoms depend upon location of injury
-retroperitoneal air
-incorrect use of seatbelt
-tears
-duodenum - fixation at pyloric sphincter
-ileocecal valve
pancreatic injuries
-overlies vertebral bodies
-rapid deceleration -> transection
-delayed presentation
-retroperitoneal injury
-lipase levels
-ERCP with cannulation of pancreatic duct with dye
order of intervention
-primary survey- airway (c-spine stabilization), breathing, circulation
-resuscitation
-secondary survey
-diagnostic evaluation
-definitive care
airway
-listen to the voice
-protect the c-spine
-nasotracheal
-orotrachael
-cricothyroidotomy- not under age 12
-operative intervention
breathing
-tension pneumothorax
-open pneumothorax
-flail chest
shock
-hypovolemic
-neurogenic (spinal shock)
-septic
-cardiogenic
-FES
-PE
shock classification
-Class 1- 750cc
-class 2- 750-1500cc
-class 3- 1500-2000cc
-class 4- >2000cc
a transient response to resuscitation in an acute trauma is most likely due to
Pulmonary embolism
Myocardial infarction
Continued hemorrhage
Dehydration
circulation
-60mmHg - Carotid
-70mmHg - Femoral
-80mmHg - Radial
-Control
-IV access
-Hypotension is not an early sign of hypovolemia
fluids
-ringers lactate
-isotonic crystalloid
-role of collodis - O+ or O- for women of childbearing age
-monitoring response
-urine output- .5cc/kg/h(adult), 1cc/kg/h(child), 2cc/kg/h(infant)
fluid response categories
-responders
-transient responders
-non-responders
nonresponders
-nonsurvivable injuries
-tension pneumothorax
-pericardial tamponade
-myocardial contusion or infarction
-air embolism
-emergency bay thoracotomy
myocardial contusion
-1/3 of significant blunt chest trauma
-ventricular dysrhythmias
-atrial fibrillation
-sinus bradycardia
-bundle branch blocks
-NOT transient sinus tachycardia
transient responders
-ACTIVE HEMORRHAGE
Pt with myocardial contusions should be?
-Discharged if with a normal EKG
-Admitted to the hospital for observation
-Discharged after normal enzymes
-24 hours telemetry admission
secondary survey
-identification of occult injuries
-digit in every orifice, tube in every opening
-look everywhere!!!!!
-at site hx
-time of transport
-selective radiography
energy transfer rules
-20 miles/hour
-20 feet/distance
-20 minutes trapped
-Low velocity GSW <2000ft/s
-High velocity GSW >2000ft/s
-Shotgun wounds > or < 7 meters
penetrating injuries
-stab
-gunshot
-shotgun
head
-GCS < 14 get CT scan
-Epidural, subdural, diffuse axonal injury
-Subdurals have a worse prognosis
-Penetrating - plain films
-Entry wounds can be hidden
what is MC injured structure in blunt chest trauma
Heart
Lung
Ribs
Diaphragm
thoracic trauma
-Chest trauma is often sudden and dramatic
-Accounts for 25% of all trauma deaths
-2/3 of deaths occur after reaching hospital
-Serious pathological consequences: -hypoxia, hypovolemia, myocardial failure
mechanism of injury: penetrating injuries
-stab wounds etc.
-Primarily peripheral lung
-Hemothorax
-Pneumothorax
-Cardiac, great vessel or esophageal injury
blunt injuries
-Either: -direct blow (e.g. rib fracture)
-deceleration injury or
-compression injury
-Rib fracture is the most common sign of blunt thoracic trauma
-Fracture of scapula, sternum, or first rib suggests massive force of injury
chest wall injuries
-rib fractures
-flail chest
-open pneumothorax
rib fractures
-MC thoracic injury
-Localised pain, tenderness, crepitus
-CXR to exclude other injuries
-Analgesia..avoid taping
-Underestimation of effect
-Upper ribs, clavicle or scapula fracture: suspect vascular injury
A 23-year-old man is brought to the ED after having fallen onto a construction barrier from a height of 15 feet. In the ED he has right chest ecchymosis, marked tenderness and paradoxical respirations are noted. The most likely diagnosis is?
Flail chest
Pnemothorax
Pulmonary contusion
Hemothorax
Cardiac tamponade
in flail chest the most likely assoc injury is
Hemothorax
Pneumothorax
Cardiac tamponade
Pulmonary contusion
flail chest
-multiple rib fractures produce a mobile fragment which moves paradoxically with respiration
-significant force required
-usually dx clinically
-rx- ABC
-analgesia
flail chest
flail chest
open pneumothorax
-Defect in chest wall provides a direct communication between the pleural space and the environment
-Lung collapse and paroxysmal shifting of mediastinum with each respiratory effort ± tension pneumothorax
-“Sucking chest wound”
-Rx: ABCs…closure of wound…chest drain
what is your dx based on the previous slide
Cardiomegaly
Cardiac tamponade
Pnemothorax
Hemothorax
Ruptured diaphragm
lung injury
-Pulmonary contusion
-Pneumothorax
-Hemothorax
-Parenchymal injury
-Trachea and bronchial injuries
-Pneumomediastinum
pneumothorax
-Air in the pleural cavity
-Blunt or penetrating injury that disrupts the parietal or visceral pleura
-Unilateral signs: movement and breath sounds, resonant to percussion
-Confirmed by CXR
-Rx: chest drain
pneumothorax
A 45-year-old male is in the ICU on a ventilator when he suddenly develops desaturation, increasing airway pressures, and difficulty ventilating with an Ambu bag off of the ventilator. Exam reveals absent breath sounds on the left with shift of the trachea to the right and hypotension. The next most appropriate step in his management would be?
Chest tube insertion on the right
Pericardiocentesis
Needle decompression of the left thorax
Increase PEEP and tidal volume
tension pneumothorax
-Air enters pleural space and cannot escape
-P/C: chest pain, dyspnoea
-Dx: - respiratory distress -tracheal deviation (away)
-absence of breath sounds
-distended neck veins
-hypotension
-Surgical emergency
-Rx: emergency decompression before CXR
-Either large bore cannula in 2nd ICS, MCL or insert chest tube
-CXR to confirm site of insertion
hemothorax
-Blunt or penetrating trauma
-Requires rapid decompression and fluid resuscitation
-May require surgical intervention
-Clinically: hypovolemia absence of breath sounds dullness to percussion
-CXR may be confused with collapse
heart, aorta, and diaphragm
-Blunt cardiac injury
-contusion
-ventricular, septal or valvular rupture
-Cardiac tamponade
-Ruptured thoracic aorta
-Diaphragmatic rupture
cardiac tamponade
-Blood in the pericardial sac
-Most frequently penetrating injuries
-Shock, increase JVP, PEA, pulsus paradoxus
-Classically, Beck’s triad: -distended neck veins -
-muffled heart sounds
-hypotension
-Rx: Volume resuscitation Pericardiocentesis
cardiac tamponade
aortic rupture
-Usually blunt trauma involving deceleration forces
-~90% die within minutes
-MC site near ligamentum arteriosum
-Dx: clinical suspicion, CXR, aortography, contrast CT or TOE
-Rx: surgical…poor prognosis
aortic rupture
iatrogenic trauma
-NG tubes:
-coiling -
-endobronchial placement -
-pneumothorax
-Chest tubes:
-subcutaneous
-intraparenchymal
-intrafissural
-Central lines:
-neck
-coronary sinus -
-pneumothorax
line in jugular vein
misplaced NG tube
thoracic trauma summary
-Common
-Serious
-Primary goal is to provide oxygen to vital organs
-Remember -Airway -
-Breathing -Circulation
-Be alert to change in clinical condition
