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Trauma and Trauma Systems > chest injury > Flashcards

chest injury Flashcards

1
Q

chest trauma introduction

A
  • Vital Structures
  • Heart, Great Vessels, Esophagus, Tracheobronchial Tree, & Lungs
  • 25% of MVC deaths are due to thoracic trauma
  • 12,000 annually in US
  • Abdominal injuries are common with chest trauma.
  • Prevention:
  • Improved motor vehicle restraint systems
  • Passive Restraint Systems
  • Airbags
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2
Q

muscles of respiration

A
  • diaphragm
  • intercostal muscles
  • Sternocleidomastoid
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3
Q

diaphragm

A

– Primary muscle of respiration
– Inhalation: Contracts downward
– Exhalation: Relaxes upward

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4
Q

intercostal muscles

A

– Contract to elevate the ribs and increase thoracic diameter
– Increase depth of respiration

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5
Q

sternocleidomastoid

A

– Raise upper rib and sternum

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6
Q

pleura

A
  • Visceral Pleura- Cover lungs
  • Parietal Pleura- Lines inside of thoracic cavity
  • Pleural Space
  • POTENTIAL SPACE
  • Air in Space = PNEUMOTHORAX
  • Blood in Space = HEMOTHORAX
  • serous (pleural) fluid within- Lubricates & permits ease of expansion
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7
Q

blunt trauma

A

-Results from kinetic energy forces

– Subdivision Mechanisms

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8
Q

blast trauma

A

– Pressure wave causes tissue disruption
– Tear blood vessels & disrupt alveolar tissue
– Disruption of tracheobronchial tree
– Traumatic diaphragm rupture

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9
Q

crush (compression) trauma

A

– Body is compressed between an object and a hard surface

– Direct injury of chest wall and internal structures

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10
Q

deceleration trauma

A

-Body in motion strikes a fixed object
– Blunt trauma to chest wall
– Internal structures continue in motion- Ligamentum Arteriosum shears aorta

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11
Q

age factors

A
  • Pediatric Thorax: More cartilage = Absorbs forces

- Geriatric Thorax: Calcification & osteoporosis = More fractures

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12
Q

penetrating trauma: low energy

A

-Low Energy
• Arrows, knives, handguns
• Injury caused by direct contact and cavitation
-low energy- determined by the path it decides to take

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13
Q

penetrating trauma: high energy

A
  • Military, hunting rifles & high powered hand guns

- Extensive injury due to high pressure cavitation

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14
Q

shotgun

A

-Injury severity based upon the distance between the victim and shotgun
& caliber of shot
-Type I: > 7 meters from the weapon-> Soft tissue injury
-Type II: 3-7 meters from weapon- Penetration into deep fascia and some internal organs
-Type III: < 3 meters from weapon-> Massive tissue destruction

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15
Q

Injuries Associated with Penetrating Chest Trauma

A
  • Closed pneumothorax
  • Open pneumothorax (including sucking chest wound)
  • Tension pneumothorax
  • Pneumomediastinum
  • Hemothorax
  • Hemopneumothorax
  • Laceration of vascular structures
  • Tracheobronchial tree
  • lacerations
  • Esophageal lacerations
  • Penetrating cardiac injuries
  • Pericardial tamponade
  • Spinal cord injuries
  • Diaphragm trauma
  • Intra-abdominal
  • penetration with associated organ injury
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16
Q

contusion

A

-Most Common result of blunt injury
-Signs & Symptoms:
• Erythema
• Ecchymosis
• Difficulty Breathing
• Limited breath sounds
• Hypoventilation
– BIGGEST CONCERN = “HURTS TO BREATHE”

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17
Q

rib fractures

A
  • more than 50% of significant chest trauma cases due to blunt trauma
  • Compressional forces flex and fracture ribs at weakest points
  • Ribs 1-3 requires great force to fracture
  • Possible underlying lung injury
  • Ribs 4-9 are most commonly fractured
  • Ribs 9-12 less likely to be fractured ->Transmit energy of trauma to internal organs
  • If 9-12 fractured, suspect liver and spleen injury
  • Hypoventilation from pain
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18
Q

sternal fracture and dislocation

A
  • Associated with severe blunt anterior trauma
  • Typical Mechanism of Injury
  • Direct Blow
  • Incidence: 5-8%
  • Mortality: 25-45%
  • Myocardial contusion
  • Pericardial tamponade
  • Cardiac rupture
  • Pulmonary contusion
  • Dislocation uncommon but same MOI as fracture- tracheal depression if posterior
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19
Q

flail chest

A
  • Segment of the chest that becomes free to move with the pressure changes of respiration
  • 3 or more adjacent rib fracture in two or more places
  • Serious chest wall injury with underlying pulmonary injury
  • Reduces volume of respiration
  • Adds to increased mortality
  • Paradoxical flail segment movement
  • Positive pressure ventilation can restore tidal volume
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20
Q

simple pneumothorax

A

-AKA: Closed Pneumothorax
-Progresses into Tension Pneumothorax
-Occurs when lung tissue is disrupted and air leaks into the
pleural space
-Progressive Pathology:
-Air accumulates in pleural space
-Lung collapses
-Alveoli collapse (atelectasis)
-Reduced oxygen and carbon dioxide exchange
-ventilation/Perfusion Mismatch -> Increased ventilation but no alveolar perfusion
– Reduced respiratory efficiency results in HYPOXIA
– Typical Mechanism: “Paper Bag Syndrome”

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21
Q

open pneumothorax

A

-Free passage of air between atmosphere and pleural space
-Air replaces lung tissue -> shift
-Mediastinum shifts to uninjured side
-Air will be drawn through wound if wound is 2/3
diameter of the trachea or larger
-Signs & Symptoms:
• Penetrating chest trauma
• Sucking chest wound
• Frothy blood at wound site
• Severe Dyspnea
• Hypovolemia

22
Q

tension pneumothorax

A

– Buildup of air under pressure in the thorax.
– Excessive pressure reduces effectiveness of respiration
– Air is unable to escape from inside the pleural space
– Progression of Simple/Open Pneumothorax

23
Q

Tension Pneumothorax Signs/Symptoms

A
  • Dyspnea- Tachypnea at first
  • Hypoxemia
  • Hyperinflation of injured side of chest
  • Hyperresonance of injured side of chest
  • Diminished then absent breath sounds on injured side
  • Cyanosis
  • Diaphoresis
  • AMS
  • JVD
  • Hypotension, Hypovolemia
  • Tracheal Shifting (late sign)
24
Q

hemothorax

A
  • Accumulation of blood in the pleural space
  • Serious hemorrhage may accumulate 1,500 mL of blood
  • Mortality rate of 75%
  • Each side of thorax may hold up to 3,000 mL
  • Blood loss in thorax causes a decrease in tidal volume
  • Ventilation/Perfusion Mismatch & Shock
  • Typically accompanies pneumothorax- Hemopneumothorax
25
Q

signs and symptoms of hemothorax

A 
– Dyspnea
– Tachycardia
– Tachypnea
– Diaphoresis
– Hypotension
• Percussion: Dull over injured side
26
Q

pulmonary contusion

A
  • Soft tissue contusion of the lung
  • 30-75% of patients with significant blunt chest trauma
  • Frequently associated with rib fracture
  • Deceleration- Chest impact on steering wheel
  • Bullet Cavitation- High velocity ammunition
  • Microhemorrhage may account for 1- 1.5 L of blood loss in alveolar tissue
  • Progressive deterioration of ventilatory status
  • Hemoptysis typically present
27
Q

myocardial contusion

A

-Occurs in 76% of patients with severe blunt chest trauma
-Right Atrium and Ventricle is commonly injured
-injury may reduce strength of cardiac contractions- > Reduced cardiac output
-Electrical Disturbances due to irritability of damaged myocardial
cells
-Progressive Problems:
• Hematoma
• Myocardial necrosis
• Dysrhythmias
• CHF & or Cardiogenic shock

28
Q

myocardial contusion signs and symptoms

A

– Bruising of chest wall
– Tachycardia and/or irregular rhythm
– Retrosternal pain similar to MI

29
Q

associated injuries with myocardial contusion

A

– Rib/Sternal fracture

30
Q

myocardial contusion treatment

A

-pain is not relieved by oxygenation
-May be relieved with rest
– Pain is Trauma Related

31
Q

pericardial tamponade

A
  • Restriction to cardiac filling caused by blood or other fluid within the pericardium
  • Occurs in <2% of all serious chest trauma -> Very high mortality
  • Results from tear in the coronary artery or penetration of myocardium
  • Blood seeps into pericardium and is unable to escape
  • 200-300 ml of blood can restrict effectiveness of cardiac contractions
  • Removing as little as 20 ml can provide relief
32
Q

pericardial tamponade signs and symptoms

A
  • Dyspnea
  • Possible cyanosis
  • *Beck’s Triad:
    1. JVD
    1. Distant heart tones
    1. Hypotension or narrowing pulse pressure* (numbers getting closer together)
  • Weak, thready pulse
  • Shock
  • Kussmaul’s sign- Decrease or absence of JVD during inspiration
  • Pulsus Paradoxus- Drop in SBP > 10 during inspiration due to increase in CO2 during inspiration
  • Electrical Alterans- P, QRS, & T amplitude changes in every other cardiac cycle**
  • PEA
33
Q

myocardial rupture

A

-Occurs almost exclusively with extreme blunt thoracic
trauma
-Secondary due to necrosis resulting from MI
-Signs & Symptoms:
-Severe rib or sternal fracture
-Possible signs and symptoms of cardiac tamponade
-If affects valves only- Signs & symptoms of right or left heart failure
-Absence of vital signs

34
Q

traumatic aneurysm/aortic rupture

A

-Aorta most commonly injured in severe blunt or penetrating trauma
-85-95% mortality
-Typically patients will survive the initial injury insult
-30% mortality in 6 hrs
-50% mortality in 24 hrs
-70% mortality in 1 week
-Injury may be confined to areas of aorta attachment
-Signs & Symptoms:
• Rapid and deterioration of vitals
• Pulse deficit between right and left upper or lower extremities

35
Q

Assorted Vascular Injuries

A

-rupture or laceration of Superior Vena Cava, Inferior Vena Cava, General Thoracic Vasculature
-Blood Localizing in Mediastinum
-compression of: Great vessels, Myocardium, Esophagus
-General Signs & Symptoms:
• Penetrating Trauma
• Hypovolemia & Shock
• Hemothorax or hemomediastinum

36
Q

Traumatic Rupture/Perforation of Diaphragm

A
  • High pressure blunt chest trauma
  • Penetrating trauma
  • Most common in patients with lower chest injury
  • Most often occurs on left side
  • Signs & Symptoms:
  • Herniation of abdominal organs into thorax
  • Compression of lung
  • Displacement of mediastinum
  • Abdomen may appear hollow
  • Bowel sounds may be noted in thorax
  • Similar to tension pneumothorax
  • Dyspnea, Hypotension & JVD
  • Evaluate for other injuries
37
Q

Traumatic Esophageal Rupture

A
  • Rare complication of blunt thoracic trauma
  • 30% mortality
  • Contents in esophagus/stomach may move into mediastinum
  • Serious Infection occurs
  • Chemical irritation
  • Damage to mediastinal structures
  • Pneumomediastinum
  • Subcutaneous emphysema and penetrating trauma present
38
Q

tracheobronchial injury

A

-Blunt or Penetrating Trauma
-50% of patients with injury die within 1 hr of injury due to lack of ventilation
-Disruption can occur anywhere in tracheobronchial tree
-Signs & Symptoms:
• Dyspnea
• Cyanosis
• Hemoptysis
• Massive subcutaneous emphysema
• Suspect/Evaluate for other closed chest trauma

39
Q

traumatic asphyxia

A

-Results from severe compressive forces applied to the thorax
-Causes backwards flow of blood from right side of
heart into superior vena cava and the upper extremities
-Signs & Symptoms:
-Head & Neck become engorged with blood ->Skin becomes deep red, purple, or blue
-JVD
-Hypotension, Hypoxemia, Shock
-Face and tongue swollen
-Bulging eyes with conjunctival hemorrhage

40
Q

assessment of the chest trauma patient

A

-Scene Size-up
-initial Assessment
-Rapid Trauma Assessment
-Observe
-look for JVD, SQ Emphysema, Expansion of chest
– Question
– Palpate
– Auscultate
– Percuss
– Blunt Trauma Assessment
– Penetrating Trauma Assessment
-Ongoing Assessment

41
Q

Management of the Chest Injury Patient

A
  • Ensure ABC’s
  • High flow O2 via NRB
  • Intubate if indicated
  • Consider RSI
  • Consider overdrive ventilation
  • If tidal volume less than 6,000 mL
  • BVM at a rate of 12-16
  • May be beneficial for chest contusion and rib fractures
  • Promotes oxygen perfusion of alveoli and prevents atelectasis
  • Anticipate Myocardial Compromise
  • Shock Management
42
Q

rib fractures management

A
  • Consider analgesics for pain and to improve chest excursion
  • Valium
  • Morphine Sulfate
  • Meperidine
  • No Nitrous Oxide- > May migrate into pleural or mediastinal space and worsen condition
  • if you give too much pain management -> pt looses the drive to breathe
43
Q

Sternoclavicular Dislocation management

A
  • Supportive O2 therapy

– Evaluate for associated injuries

44
Q

flail chest management

A
  • Place patient on side of injury
  • If spinal injury is not suspected
  • expose injury site
  • Dress with bulky bandage against flail segment
  • Stabilizes fracture site
  • High flow O2
  • Consider PPV or ET if decreasing respiratory status
  • No Sandbags/IV Fluid Bag
45
Q

open pneumothorax management

A
  • high flow O2
  • Cover site with sterile occlusive dressing taped on three sides
  • Progressive airway management if indicated
46
Q

tension pneumothorax management

A

-Confirmation
-Auscultaton & Percussion
-Pleural Decompression
-2nd intercostal space in mid-clavicular line
–TOP OF RIB
-Consider multiple decompression sites if patient remains symptomatic
-Large over the needle catheter: 14ga
-Create a one-wayvalve: Glove tip or Heimlich valve

47
Q

hemothorax management

A

– High flow O2
– 2 large bore IV’s
• Maintain SBP of 90
• Monitor Breath Sounds to Prevent Fluid Overload

48
Q

myocardial Contusion management

A

– Monitor ECG
-Alert for dysrhythmias
– IV if antidysrhythmics needed

49
Q

pericardial tamponade management

A
  • High flow O2
    – IV therapy
    – Consider pericardiocentesis
50
Q

aortic aneurysm management

A 
– AVOID jarring or rough handling
– Initiate IV therapy enroute
• Mild hypotension may be protective
• Rapid fluid bolus if aneurysm ruptures
– Keep patient calm
51
Q

tracheobronchial injury management

A

-Support therapy
• Keep airway clear
• Administer high flow O2
– Consider intubation if unable to maintain patient airway
• Watch for development of tension pneumothorax and SQ
emphysema

52
Q

traumatic asphyxia management

A

– Support airway
• Provide O2
• BVM Ventilation PRN
– 2 large bore IV’s
– Evaluate and treat for concomitant injuries
– If entrapment > 20 min with chest compression
• Consider 1mEq/kg of Sodium Bicarbonate

Trauma and Trauma Systems (18 decks)

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