Usually found by pre-hospital personelle Tachypnea pain difficult breathing

Chapter 4 Thoracic Trauma Flashcards by Marialaina Tomolonis

Possible Causes of Airway Problem in the presence of Thoracic Trauma

Airway Obstruction

Tracheobronchial Tree Injury

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Etiologies of Airway Obstruction

Laryngeal Injury

Posterior Dislocation of Clavicular Head

Penetrating Trauma

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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

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Treatment of Airway Obstruction

Suction to clear obstruction from airway (temporizing)
Palpation for defect and reduction of posterior clav. dislocation

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Possible causes of tracheobronchial tree injury

Rapic deceleration after blunt trauma
Blast injury
Penetrating injury

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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***

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Exam to confirm tracheobronchial tree injury

Bronchoscopy confirms

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Tx of tracheobronchial tree injury

Placement of defintive airway past tear site

surgical repair

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Possible Etiologies of Breathing Problems in the presence of Thoracic Trauma

Tension PTX
Open PTX
Massive Hemothorax

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What is the most common cause of tension pneumothorax

Mechanical Positive-pressure ventilation in pts w/ visceral pleural injury

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Sg/Sx of T-PTX

Deviated trachea

absent BS unilaterally

Hyperresonance

**These are important and exclusive to T-PTX**

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Tx for T-PTX

Rapid decompression w/ cath over needle

Finger thoracostomy

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Exam for open PTX

Usually found by pre-hospital personelle

Tachypnea
pain
difficult breathing

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Tx for O-PTX

Close defect w/ sterile dressing

chest tube placement remote to wound

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How many sides of the dressing for an O-PTX should be taped down? Why is this important?

If taping all 4 sides down air could become trapped in the pleural space causing a T-PTX

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What are the possible cauess of Circulation problems in presence of thoracic trauma?

Massive Hemothorax

Cardiac Tamponade

Traumatic Circulatory Arrest

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Exam sg/sx for massive hemothorax

Decreased breath sounds

Dull percussion

Collapsed Neck veins

Mobile chest movement

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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

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Presentation of Shock w/ dullness to percussion on one side of the chest and decreased Breath sounds should make you think of

Massive Hemothorax

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Tx of Massive Hemothorax

Restore blood loss!!

Place Chest tube

If > 1500mL return of blood from chest tube –> immediate thoracotomy by trauma surgeon

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Classic Triad of Cardiac Tamponade

Muffled Heart Sounds

Hypotension

Distended neck veins

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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