chest injury Flashcards
chest trauma introduction
- 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
muscles of respiration
- diaphragm
- intercostal muscles
- Sternocleidomastoid
diaphragm
– Primary muscle of respiration
– Inhalation: Contracts downward
– Exhalation: Relaxes upward
intercostal muscles
– Contract to elevate the ribs and increase thoracic diameter
– Increase depth of respiration
sternocleidomastoid
– Raise upper rib and sternum
pleura
- 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
blunt trauma
-Results from kinetic energy forces
– Subdivision Mechanisms
blast trauma
– Pressure wave causes tissue disruption
– Tear blood vessels & disrupt alveolar tissue
– Disruption of tracheobronchial tree
– Traumatic diaphragm rupture
crush (compression) trauma
– Body is compressed between an object and a hard surface
– Direct injury of chest wall and internal structures
deceleration trauma
-Body in motion strikes a fixed object
– Blunt trauma to chest wall
– Internal structures continue in motion- Ligamentum Arteriosum shears aorta
age factors
- Pediatric Thorax: More cartilage = Absorbs forces
- Geriatric Thorax: Calcification & osteoporosis = More fractures
penetrating trauma: low energy
-Low Energy
• Arrows, knives, handguns
• Injury caused by direct contact and cavitation
-low energy- determined by the path it decides to take
penetrating trauma: high energy
- Military, hunting rifles & high powered hand guns
- Extensive injury due to high pressure cavitation
shotgun
-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
Injuries Associated with Penetrating Chest Trauma
- 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
contusion
-Most Common result of blunt injury
-Signs & Symptoms:
• Erythema
• Ecchymosis
• Difficulty Breathing
• Limited breath sounds
• Hypoventilation
– BIGGEST CONCERN = “HURTS TO BREATHE”
rib fractures
- 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
sternal fracture and dislocation
- 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
flail chest
- 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
simple pneumothorax
-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”
open pneumothorax
-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
tension pneumothorax
– 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
Tension Pneumothorax Signs/Symptoms
- 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)
hemothorax
- 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
signs and symptoms of hemothorax
– Dyspnea – Tachycardia – Tachypnea – Diaphoresis – Hypotension • Percussion: Dull over injured side
pulmonary contusion
- 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
myocardial contusion
-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
myocardial contusion signs and symptoms
– Bruising of chest wall
– Tachycardia and/or irregular rhythm
– Retrosternal pain similar to MI
associated injuries with myocardial contusion
– Rib/Sternal fracture
myocardial contusion treatment
-pain is not relieved by oxygenation
-May be relieved with rest
– Pain is Trauma Related
pericardial tamponade
- 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
pericardial tamponade signs and symptoms
- Dyspnea
- Possible cyanosis
- *Beck’s Triad:
- JVD
- Distant heart tones
- 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
myocardial rupture
-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
traumatic aneurysm/aortic rupture
-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
Assorted Vascular Injuries
-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
Traumatic Rupture/Perforation of Diaphragm
- 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
Traumatic Esophageal Rupture
- 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
tracheobronchial injury
-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
traumatic asphyxia
-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
assessment of the chest trauma patient
-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
Management of the Chest Injury Patient
- 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
rib fractures management
- 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
Sternoclavicular Dislocation management
- Supportive O2 therapy
– Evaluate for associated injuries
flail chest management
- 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
open pneumothorax management
- high flow O2
- Cover site with sterile occlusive dressing taped on three sides
- Progressive airway management if indicated
tension pneumothorax management
-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
hemothorax management
– High flow O2
– 2 large bore IV’s
• Maintain SBP of 90
• Monitor Breath Sounds to Prevent Fluid Overload
myocardial Contusion management
– Monitor ECG
-Alert for dysrhythmias
– IV if antidysrhythmics needed
pericardial tamponade management
- High flow O2
– IV therapy
– Consider pericardiocentesis
aortic aneurysm management
– AVOID jarring or rough handling – Initiate IV therapy enroute • Mild hypotension may be protective • Rapid fluid bolus if aneurysm ruptures – Keep patient calm
tracheobronchial injury management
-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
traumatic asphyxia management
– 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
