Chest Trauma Flashcards
What is most common causes of chest trauma
Rtc’s Falls Crush injuries Assault Blunt force Gunshot/s Knife wounds Blast injuries
How much fluid can accommodate the pleural space?
3000mls
What is the most common problem associated with thoracic trauma and why is this?
Hypoxia
Impaired ventilation or secondary to hypovolaemia due to massive bleeding into the chest (haemothorax) or major vessel disruption
Blunt trauma to the sternum may also cause myocardial contusion
Q. How might we detect this?
ECG disturbances
Penetrating trauma may damage the heart, lungs and great vessels.
Q. What conditions may this result in?
Haemothorax, pneumothorax, cardiac tamponade
What are the 5 major thoracic injuries encountered in the pre hospital setting
Open chest wounds Tension pneumothorax Massive haemothorax / haemopneumothorax Cardiac tamponade Flail chest
Signs & Symptoms of Chest Trauma
- Dyspnoea , tachypnoea, reduced SaO²
- Pain, panic & anxiety, diaphoresis
- Pallor, cyanosis
- Tachycardia, muffled heart sounds.
- Reduced C.R.T., Hypotension, Jugular Vein Distension.
- Haemoptysis (coughing up blood) tracheal & apex beat deviation
- Reduced/absent chest sounds
- Hypo/hyper-resonance
- Asymmetry of chest wall
What’s the thing to remember with children and chest trauma
Children can have severe internal chest injuries with minimal or no external evidence of chest injury
What to do in a time critical situation
Correct C, A and B problems (as per guidelines), and transport to Trauma Centre/ Unit/ A&E
A.T.M.I.S.T. to receiving hospital
If non-time critical perform a thorough respiratory assessment with a brief secondary survey
Consider positioning of patient!
When would you consider assisting the patient’s breathing at a rate of 12 – 20 rpm?
SaO² is <90% on high concentration oxygen
Respiratory rate is below 10 or above 30 breaths per minute
Inadequate chest expansion is evident
N.B. Remember that any positive pressure ventilation may exacerbate a pneumothorax.
What pain relief would you consider for chest trauma
Avoid Entonox in a patient with a chest injury as there is a significant risk of enlarging a pneumothorax
Morphine analgesia may improve ventilation by allowing better chest wall movement but high doses may also induce respiratory depression. Careful titration of doses is therefore required
What fluids would you give for the penetrating trauma to the trunk
fluid therapy to maintain a palpable central pulse (carotid or femoral)
or systolic BP of 60mmHg
What fluid would you give to a Blunt trauma to the trunk
fluid therapy to maintain a palpable peripheral pulse (radial)
or systolic BP of 90mmHg
What’s important to remember about fluid therapy
DO NOT delay time on scene to administer fluid
Wherever possible cannulate and give fluid en route to hospital
What is a Spontaneous Pneumothorax and who is it more likely to affect
Presence of air in the pleural cavity
Rupture of air sac leads to leakage into thoracic cavity
Often occurs in young adults
What is an Open Pneumothorax
Defect in the chest wall - penetrative injury
Air sucked into open wound
Some air may bubble out during expiration.
How do you manage an open Pneumothorax
C, A & B assessment (C – E ?) with diagnostics
Patient position / consider spinal immobilisation!
Oxygen 100%, Intermittent positive pressure ventilation if necessary
Cover open chest wounds (Asherman’s/ Russell)
Rapid evacuation
cannulate en route
Consider pain relief
What is Subcutaneous Emphysema
Leakage of air into the subcutaneous tissues - may result from either penetrating chest injury or blunt trauma
the presence of surgical emphysema should be assumed to be a sign of significant chest pathology until proven otherwise
What is a Tension Pneumothorax
LIFE THREATENING CONDITION
Flap of tissue acts as one-way valve
Damaged area of lung leaks air out into the pleural space on each inspiration but does not permit the air to exit from the chest on expiration
Intra-thoracic pressure continues to rise on the affected side, collapsing the lung and putting increased pressure on the heart and great vessels and opposite lung
Signs and symptoms of a Tension Pneumothorax
- Respiratory distress, cyanosis may present
- pain
- Air entry will be reduced or absent
- Chest on the affected side will appear to have reduced movement or none at all
- May appear hyper-inflated on affected side
- Hyper-resonance on percussion
- Tachycardia, hypotensive, may appear shocked
- Neck veins may become distended
- Tracheal deviation may displace away from affected side (late sign)
- Apex beat also displaces.
Management or tension pneumothorax
Asses vital signs & chest wall
Manage airway & breathing
Oxygen 100%, I.P.P.V. if required
Needle decompression
Rapid evacuation
Re-assessments en- route (consider cannulation, pain relief etc).
First Anatomical location of needle decompression and why this site
Mid-clavicular line, 2nd inter-costal space, superior to the 3rd rib
Immobilisation of arms, less chance of catheter becoming displaced.
2nd Attempt anatomical space needle decompression
5th intercostal space just anterior to mid auxiliary line
What is the complications with the second anatomical site of needle decompression
Injuries to heart, great vessels and intercostal vessel with resultant haemorrhage
The intercostal artery and vein run around the inferior margin of each rib. Poor needle placement can lacerate one of the vessels
Creation of a pneumothorax may occur if not already present.
If your assessment was incorrect, you may give the patient a pneumothorax when you insert the needle into the chest.
Laceration of the lung is possible. Poor technique or inappropriate insertion can cause laceration of the lung causing bleeding and more air leak.
Risk of infection is a complication. Adequate skin preparation with antiseptic may prevent this.
What is a flail chest
Several adjacent ribs broken in several places
Segment can detach from main thoracic cage
Causes paradoxical movement of chest
Management of flail chest
A & B assessment (C – E ?) with diagnostics
Allow the patient to sit supported at 30-45° rather than lay on a scoop stretcher
Oxygen 100%, I.P.P.V. if necessary
Rapid evacuation
Paramedic may cannulate en route
Consider pain relief & or TXA
Remember the potential for massive hypovolaemia
What is a Haemothorax
Damage to lungs causing bleeding into pleural cavity
Can cause massive hypovolaemia
Look for signs and symptoms of shock
If blood enters the lungs and pools at the bottom when the patient takes a breath in of warm air it will cause blood to clot, preventing diffusion to take place in alveoli sac
Signs and symptoms of a haemothorax
Cyanosis
Neck veins distended
Signs of shock, skin cold and clammy
Breath sounds absent, percussion is dull and flat
Management of haemothorax
Manage A & B
Oxygen 100%, I.P.P.V. if required
Rapid evacuation
Manage circulation and fluids en route
Maintain blood pressure as per JRCALC
Consider pain relief & or TXA
Monitor D& E (if appropriate) and vital signs regularly.
What is a cardiac tamponade
Blood enters pericardial sac
Compression of ventricles increases
Cardiac output reduced
What is a Pulsus paradoxus
an abnormally large decrease in systolic blood pressure and pulse wave amplitude during inspiration, usually a decrease of 10mmHg or more
What are signs and symptoms of flail chest
Cyanosis Respiratory difficulty Shock Severe pain at site of injury Paradoxical chest wall movements Obvious deformity
What are signs and symptoms of cardiac tamponade
Muffled heart sounds
Narrowed pulse pressure
Elevated venous pressure/JVD
Becks triad
Signs and symptoms of tension pneumothorax
Agitation, apprehension Air hunger, cyanosis, severely impaired ventilations Possible subcutaneous emphysema Shock, cold skin, clammy Distended neck veins Tracheal displacement toward normal side Hyper resonant percussion Reduced breath sounds or absent
Complications of needle decompression
Injuries to heart, heart vessels
Poor needle placement can lacerate one of the vessels
Could miss the area
Infection
Cannula might not reach
Laceration of lung possible
Could cause a pneumothorax if diagnoses is wrong
What is commotio cordis
Chest receives a direct blow during repolarisation period and may cause immediate VF arrest. A result of blunt, non penetrating impact to the pre cordial region, often caused by ball, bat or projectile.
What is myocardial contusion
Heart lies in an oblique position behind the sternum
At speeds of 25-35mph sudden deceleration of chest wall may cause the heart to move forward until it collides with the posterior aspect of the sternum.
Injury is characterised by local tissue contusion, haemorrhage, oedema and cellar damage to the myocardium
Direct damage to coronary arteries and veins, compromising blood flow to heart
Damage at cellular level may result in ectopic electrical activity and arrythmias
What is a tension pneumothorax and its pathophysiology
When there is an open flap from the lung or from a wound
Air enters into the pleural space when inhaling but cannot escape during exhaling
Compressing the lung, heart, blood vessels and other structures in chest
Can cause lung to collapse or the lung to get pushed over to the other side
Pathophysiology of a flail chest
Flail segment of chest wall will negatively affect respiration in 3 ways - ineffective ventilation, pulmonary contusion, and hyperventilation with atelectasis.
- Ineffective ventilation present due to increased dead space, decreased intrathoracic pressure and increased oxygen demand from injured tissue
- pulmonary contusion in adjacent lung tissue. Leads to edema, haemorrhage, may have some element of necrosis
- hyperventilation and atelectasis may result from pain of injury
- pain causes splinting which decreases tidal volume and predisposes to the formation of atelectasis
