Ch. 45 Stab Wound to the Chest

Question 1

What is the most likely dx in this pt?

And how can the dx be made?

Answer 1

Cardiac tamponade (Beck’s triad)

In addition, he has absent breath sounds on the left, in association with hypotension; thus he may have a concurrent tension pneumothorax

Cardiac tamponade can be supported with FAST scan –> demonstrates fluid in pericardiac sac… pts may also exhibit pulsus paradoxus (decrease in systolic pressure > 10 mmHg with inspiration)

Question 2

Deadly dozen of Airway obstruction​

• Lethal six:
• “Hidden” six:

Answer 2

Lethal six:

1. Airway obstruction
2. Tension pneumo
3. Open pneumo
4. Massive hemo
5. Flail chest
6. Cardiac tamponade

Question 3

What is the differential dx of absent breath sounds on the left?

Answer 3

• Pneumothorax
• Massive hemothorax

Question 4

What is the significance of air bubbling from penetrating chest wound?

Answer 4

Sucking chest wound, a type of open pneumothorax

Indicates injury to lung or bronchial tree that connects directly to the atmosphere

WIth a sucking chest wound, chest wall defect is so large (at least 2/3 diameter of trachea) that inspired air enters chest cavity through wound instead of through trachea

Question 5

What to WATCH OUT! for with tension pneumothorax treatment

Answer 5

Rapidly exacerbated by (+) pressure ventilation

Thus, decompress with chest tube (needle/tube thoracostomy) ASAP and then –> positive pressure ventilation

Note* Tube thoracostomy used to treat pneumothorax, while thoracotomy often performed by surgeon in an emergency setting to perform invasive resuscitation maneuevers to decompress hemothorax and/or pneumothorax

Question 6

In a trauma patient with distended jugular veins, what are your concerns?

Answer 6

1. Cardiac tamponade
2. Tension pneumothorax due to compression of SVC, IVC (decreased preload, severe reduction in CO)

Question 7

Are vasopressors recommended in the mgmt of traumatic cardiac tamponade?

Answer 7

No. Most pressors will increase systemic vascular resistance (afterload) which will exacerbate myocardial dysfunction in the setting of traumatic pericardial tamponade.

Question 8

• How is a sucking chest wound managed?
• How is a flail chest managed?

Answer 8

• How is a sucking chest wound managed?
  
  • Cover chest wall defect with an occlusive dressing that is taped on three sides
    
    • Prevents air from entering pleural space on inspiration while allowing air to escape during expiration
    • Result: re-expansion of lung while minimizing risk of developing tension pneumothorax
• How is a flail chest managed?
  
  • Analgesics
  • If oxygenation or ventilation is compromised, pts will require intubation with PEEP

Question 9

What nerve is at risk when opening the pericardium?

Answer 9

L phrenic nerve

It passes longitudinally over the posterior aspect of the pericardium of the L ventricle