Chapter 4 Thoracic Trauma Flashcards
Possible Causes of Airway Problem in the presence of Thoracic Trauma
Airway Obstruction
Tracheobronchial Tree Injury
Etiologies of Airway Obstruction
Laryngeal Injury
Posterior Dislocation of Clavicular Head
Penetrating Trauma
Exam sg/sx of Airway Obstruction
- Inspection
- Accessory Muscle Use
- Obvious obstruction in oropharynx
- Auscultation
- Noisy Air Movement
- Stridor
- Change in Voice
- Palpation:
- Crepitus over anterior neck
- step off
Treatment of Airway Obstruction
- Suction to clear obstruction from airway (temporizing)
- Palpation for defect and reduction of posterior clav. dislocation
Possible causes of tracheobronchial tree injury
- Rapic deceleration after blunt trauma
- Blast injury
- Penetrating injury
Presentation of Tracheobronchial Tree injury
- Hemoptysis
- cervical subcutaneous emphysema
- Tension PTX
- sometimes cyanosis
- ***Incomplete expansion of the lung after placement of chest tube suggests TBTI***
Exam to confirm tracheobronchial tree injury
Bronchoscopy confirms
Tx of tracheobronchial tree injury
Placement of defintive airway past tear site
surgical repair
Possible Etiologies of Breathing Problems in the presence of Thoracic Trauma
- Tension PTX
- Open PTX
- Massive Hemothorax
What is the most common cause of tension pneumothorax
Mechanical Positive-pressure ventilation in pts w/ visceral pleural injury
Sg/Sx of T-PTX
Deviated trachea
absent BS unilaterally
Hyperresonance
**These are important and exclusive to T-PTX**
Tx for T-PTX
Rapid decompression w/ cath over needle
Finger thoracostomy
Exam for open PTX
Usually found by pre-hospital personelle
- Tachypnea
- pain
- difficult breathing
Tx for O-PTX
Close defect w/ sterile dressing
chest tube placement remote to wound
How many sides of the dressing for an O-PTX should be taped down? Why is this important?
3
If taping all 4 sides down air could become trapped in the pleural space causing a T-PTX
What are the possible cauess of Circulation problems in presence of thoracic trauma?
Massive Hemothorax
Cardiac Tamponade
Traumatic Circulatory Arrest
Exam sg/sx for massive hemothorax
Decreased breath sounds
Dull percussion
Collapsed Neck veins
Mobile chest movement
In What ways do the Exam sx/sg of Massive hemothorax differ from those of Tension PTX
- T-PTX:
- Percussion is hyperresonant
- Neck Veins are Distended
- Tracheal Deviation
- unilateral lack of Chest movement
- unilateral absent BS
- Massive HTX:
- Percussion is Dull
- Neck veins more commonly collapsed
- Treachea is midline
- bilateral chest movement
- Breath sounds are decreased
Presentation of Shock w/ dullness to percussion on one side of the chest and decreased Breath sounds should make you think of
Massive Hemothorax
Tx of Massive Hemothorax
Restore blood loss!!
Place Chest tube
If > 1500mL return of blood from chest tube –> immediate thoracotomy by trauma surgeon
Classic Triad of Cardiac Tamponade
Muffled Heart Sounds
Hypotension
Distended neck veins
What are more relaible indicators of cardiac tamponade?
PEA (although it can mean other things)
Kussmauls sign- Inc venous pressure w/ inspiration
How useful is the classic triad of cardiac tamponade? Why?
Not very
muffled heart sounds can be hard to distinguish in a noisy trauma room
JVD may not be present in a pt w/ hypovolemia
Most efficient way to determine Cardiac Tamponade
FAST
90-95% accurate
Echo can also be done or pericardial window (although only if FAST isn’t available)
TX for cardiac tamponade
Emergent thoracotomy/sternotomy by surgeon
-if not available needle decompression or seldinger technique is temporizing maneuver
Causes of Traumatic Circulatory Arrest
Hypoxia
T-PTX
Profound hypovolemia
Cardiac Tamponade
Cardiac herniation
Severe myocardial contusion
What defines Traumatic Circulatory arrest
Thoracic trauma pt who is unconcious and without pulse
(includes pt’s in PEA, Asystole, and Vfib)
Tx for Traumatic Circulatory arrest
Immediate CPR w/ ABC’s
Mech vent 100%O2
Rapid fluid resusc through large bore IV
Amin epinephrine
Tx according to ACLS
What potential life threatening injuries should be addressed during the secondary survey in the presence of Thoracic Injury?
Simple PTX
Hemothorax
Flail Chest
Pulm contusion
Blunt Cardiac Injury
Traumatic Aortic Disruption
Traumatic diaphragmatic Injury
Blunt Esophageal Rupture
MOI of Simple PTX
Penetrating or Blunt Trauma
Exam of Simple PTX
BS decreased and hyperresonance on affected side
What imaging is best for dx of a simple PTX?
Upright Expiratory CXR
although this may not be available in pt w/ polytrauma
Tx for simple PTX
Chest tube 5th ICS anterior to mid axillary line
Confirm appropriate placement of tube w/ CXR also observe reinflation of the lung
What defines simple hemothorax
<1500mL of blood in pleural space
What sutdy is best for dx hemothorax?
Supine CXR
If blood is seen on CXR d/t hemothorax what is tx?
Placement of 28-32 Fr tube
What is true of children and pulmonary contusion?
Often times pulm contusion is not preceeded by rib fx. Children have more compliant chest walls.
What is MC life potentially life threatening injury in adults w/ chest trauma?
Pulmonary contusion w/ multiple rib fx
Tx of pulm contusion
Humidified O2
Ventilation
Judicious use of IV fluid
Analgesics (consider local to prevent resp dep)
ABG’s checked to corelate
Possible intubation
MC cause of blunt cardiac injury
MVC
What diagnosis that should be noted in the primary survey typically preceeds blunt cardiac injury?
tamponade
MC cause of traumatic aortic disruption
MVC or fall from great height
What is common between all survivors of traumatic aortic disruption
all have contained hematoma
Sg on CXR of potential traumatic aortic disruption
- Wide mediastinum
- obliteration of aortic knob
- tracheal dev to the R
- Esophageal dev to the R
- Depression of L mainstem bronchus
- L hemothorax
- Elevation of R mainstem bronchos
- Wide paratracheal space
- FX of 1st or 2nd rib and scapula
Why is CXR not ideal in traumatic aortic disruption? What follow up study should be done?
It’s not very specific and can miss the dx
CT scan should be done if pt is hemodynamically stable
Tx for traumatic aortic disruption
Manage HR < 80bpm
Manage MAP 60-70mmHg
Mc location of diaphragmatic inury? Why does this occur?
L side
Liver both obscurs and protects the R sie
Diaphragmatic Injry d/t blunt trauma appears as
Large radial tear
Diaphragmatic injury d/t penetrating trauma appears as
sm perforations
What might a Elevated R diaphgragm on X-ray suggest?
R sided traumatic diaphragmatic injury
** and may be the only sign of one
MC MOI of blunt esophageal rupture
Penetrating Injury
Presence of L pneumothorax or hemothorax in the absence of rib fx might suggest what dx?
Blunt esophageal rupture
