chapter 7 - throatic and neck trauma Flashcards
Where is the apex of the heart?
bottom left corner
Preload
The volume of blood in the left ventricle at the end of diastole
- it directly relates to the amount of blood that is returned to the heart
- if there is less volume returned the verticles with not have as much stretch, decreasing preload
- the TRAUMA pt. may have decreased preload as the total blood volume decreases
Afterload
The resistance of the system (either systemic or pulmonary) that the ventricles must overcome to eject blood.
- intrathoracic pressure affects right ventricular pressure as it contacts the pulmonary system
- the patient’s blood pressure and elasticity of the peripheral vascular affect left ventricular pressure
- hypotensive trauma patients may have reduced afterload as the pressure within the vacultautr system is lower than in the ventricles
Contactibility
the heart’s contractile strength
- factors affecting myocardial contractility include preload and sympathetic nerve system stimulation
Anatamony of the neck - ZONES
ZONE 1 - sternal notch to circoid cartilage (majority of injury to here)
ZONE 2 - cricoid cartilage to the angle of the mandible
ZONE 3 - the angle of the mandible to the base of the skull
Vascular supply - spine
basilar artery to vertebral artery down to subclavian
Vascular supply - brain
circle of wills to internal and then external carotid then to common carotid then to subclavian
SPINE
- Cerebral
C1-C7
(also controls arms) - imagine putting arms up - Thoratic
T1-T12
(one tiny section of the inner arm) - Lumber
L1-L5
- front of legs - Sacral
S1-S4
- back of legs
Thoracic fractures
Sternal fractures; blunt cardiac injury + pneumothorax
First and second rib fractures; great vessles injuries, brachial plexua injuries, head and spinal cord injuries
Multiple rib fracture and fail chest ; pulmonary contuson, pnenmothrox, hemothroax.
lower rib fracture; liver (right sided fractures) and spleen (left sided fractures
Respiration vs Vetilation
Resp
the exchange of oxygen and c02 across the membranes
Vent
- active, mechanical movements of air into and out of the lungs during the resp cycle which consist of both inspiaory and expiratory vent
3 signs of the becks traid
CARDIAC TAMPONADE
- low arterial BP
- muffled heart sounds
- Distended neck veins
FAST Sonography
- parasternal long cardiac view
- apical four chamber cardiac view
- inferior vena cava view
8 + 9. R) + L) pulmonary view
Tracheobroncial injury
Tracheobronchial injury is damage to the tracheobronchial tree. It can result from blunt or penetrating trauma to the neck or chest, inhalation of harmful fumes or smoke, or aspiration of liquids or objects.
ASSESSMENT:
dyspnea
hoarseness
sub. emphysena
pneumoc
hemoptysis
deceased breathe sounds
INTERVENTIONS:
Small ETT or cric
Types to consider
blunt oesophageal trauma
rib & sternal fractures
neck trauma
Flail chest
Injury where three of more sequential ribs in two or more locations that results in a flail section.
> unstable chest wall that moves paradoxically, drawing in with chest expansion and pushing out with exhalation
> normally inspiration is generated by negative intrapleural pressure that draws air in from the outside
> this CAN NOT be generated with a flail chest
ASSESSMENT:
Pain ++
shallow breathing
dyspnea
diminished breathe sounds
chest wall pain
paradoxical movements
INTERVENTIONS
support oxygen and ventilation
admin, analgesic
intubate and vent.
SIMPLE (closed) pneumothorax
Caused by a blunt or penetrating trauma. With such injury, air escapes from the injured lung into the plural space and negative intaplural pressure is lost causing a partial or complete lung collapse.
ASSESSMENT:
> dyspnea
> tachy
> decreased or absent breath sounds
> chest pain
INTERVENTIONS
STABLE = observe w or without oxygen
UNSTABLE = chest drain
OPEN penumo
result of penetrating wound through the chest wall that causes air to become trapped in the intraplural space. during inspiraryion, air enters the pleural soace through the wound as well as through the trachea.
Assessment - subcutaneous emphysema
sucking sounding chest wound
INTERVENTIONS
> cover with a nonporous dressing (3 sided)
> monitor for risk of tension pneumo
Pnenmo - throax w Positive Pressure V
Mechanically ventilated pt. with even a slight pneumothorax are at a high risk for expansion or development of a tension due to PP ventilation.
Tension pneumothorax
This occurs when air enters the pleural space but can not scape on expiration. The increasing intrathroatic pressure causes the lungs on the inured side to collapse the mediastinum can shift toward the uninjured side. compressing the heart and opposite lung
ASSESSMENT
> anxiety
> Resp distress
> dimished breath sounds
> distended neck, head
> hypotension
> trachy deviation
TREATMENT
> chest tube
> 14G to 2nd intercostal space at the mid line
Hemothorax
Caused by blood accumulating in the plural space. It results from injury to multiple structures e.g. blood vessels and lung.
> can also result from trauma to the liver or sleepn combined with an injury to the diaphragm.
**Massive hemothroax = > 1500 ml of blood.
ASSESSMENT
- Anxiety
- Dyspnea / tachyponsea
- shock
- decreased breath sounds on that side
TREATMENT
- chest tube (make sure it is the largest size as blood can clot and block off)
- replace lost blood
Pulmonary contusion
A pulmonary contusion is a bruise of a lung, which causes bleeding and swelling. Usually occurs after an MVA. Progression @ 4-6 hours
Assessment
- ineffective cough
- WOB
- hypoxia
- chest pain
INTERVENTIONS
Oxygen and pain management + be judious w IVF
Blunt cardiac trauma
BCI includes myocardial contusion. Occurs from direct impact to the thoracic cavity. Most commonly causing with motorbike collisions
ASSESSMENT
ECG changes; a - fib, tachy, premature ventricular contractions, ST segment changes, ischemia or AV block.
INTERVENTIONS
CCM
treat dysrhythmias
ECG
Monitor biomarkers; creatine, trop).
Cardiac tampondae
Collection of blood in the pericardial sac. even as little as 50 ml can compress the heart - this decreases the ability of the ventricle to fill and subsequently causes decreased stroke volume and cardiac output.
ASSESSMENT
Becks triad
Cyanosis
Pulsus paradoxes
INTERVENTIONS
surgical pericardectomy
or
needle pericardectomy
Aortic diruption
trauma - 80% die at scene and the remaining 50% will die in hospital. prep for angio.
Ruptured diaphragm
When the bowel is pushed into the lungs (up from the bottom) occurs from high-speed MVAs.
More common on the left side as the right side is protected from the liver.
** Left shoulder pain is a classic sign of a splenic injury (kehr’s sign)
Pulsus paradoxus
A decrease of more than 10 mmHg in the systolic blood pressure occurs during inhalation (inspiration)
> caused by a fall in cardiac output as a result of increasing negative intrathoracic pressure during inhalation.
Assessing + troubleshooting chest drains
Assessing: FOCA
Fluctuations in the water seak chamber Output
Colour
An air leak present?
Troubleshooting: DOPE
Displaced tube
Obstruction
Pneumothorax
Equipment failure
*** if there is a continuing blood loss of more then 200 ml per hour for 2-4 hours tell DR
