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Medicine II: Emergency Medicine > Chest Trauma > Flashcards

Chest Trauma Flashcards

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1
Q

What is the leading cause of trauma deaths?

A

TBI is leading cause of Trauma Deaths. Chest trauma responsible for 25% of trauma deaths BUT appropriate early management of chest trauma can save lives.

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2
Q

T/F: Majority of chest trauma in the ER requires operation.

A

False, Less than 10% of blunt and only 15-30 % of penetrating trauma requires open thoracotomy. This means most chest trauma is managed non-operatively

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3
Q

What important structures are in the chest?

A

Heart, lungs, Thoracic Aorta, SVC Potential Spaces for in the pleura and the pericardium

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4
Q

Identify Life Threatening Injuries:

A 
–	AW Obstruction
–	Tension Ptx
–	Sucking Chest Wound
–	Flail Chest 
–	Cardiac Tamponade
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5
Q

What do we do with life threatening emergencies in the ER?

A

TREAT! Do NOT pass Go, Do NOT collect $200

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6
Q

Airway Obstruction/Laryngeotracheal Injury Presentation:

A

Secure the Airway, check for Teeth and other foreign bodies

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7
Q

Airway Obstruction/Laryngeotracheal Injury Special Cases:

A
  • Tracheal injuries/Tears Intubate, not surgical
  • Posterior Dislocation of Sternoclavicular joint must be reduced
  • Intubation or surgical airway will not help
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8
Q

Airway Obstruction/Laryngeotracheal Injury

A

Treatment is generally intubation, but may involve surgical airway.

  • S Suction
  • O Oxygen
  • A AW Device
  • P Pharmacology
  • M Mechanical Ventillating Device (e.g. BVM
  • E Escape ( More than 1, especially if use RSI)

May require Tracheostomy in OR

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9
Q

Tension Pneumothorax

A

Should never be diagnosed by X-ray–Diagnose and treat clinically. You are never wrong if the first X-ray is after the Chest tube!

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10
Q

Tension Pneumothorax Pathophys:

A

One way valve allows air into the trachea, trachea deviates away from the affected side, affected side is tympanic to percussion.

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11
Q

Presentation of a Tension Pneumothorax:

A 
o	Respiratory distress
o	Shock
o	Distended neck veins
o	Unilateral decrease in breath sounds
o	Hyperresonance
o	Cyanosis (late sign)
•	KUSSMAUL’S VEINS: abnormal dilation of neck veins on inspiration?
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12
Q

Tension Pneumothorax Treatment:

A

Needle decompression followed by a chest tube. Leave the Needle In.

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13
Q

What is a Open Pneumothorax (Aka Sucking Chest Wound)?

A

An opening in the chest wall 2/3 the size of the trachea will suck air into and out of the pleural space. This volume of air is lost to effective ventilation.

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14
Q

How big is your trachea? How big is 2/3 the size of the trachea?

A

the size of your thumb; the size of your little finger

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15
Q

Treatment for an Open Pneumothorax:

A

Treat Immediately with an occlusive dressing, taped 3/4 of way around the wound, followed by a chest tube remote from the site.

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16
Q

What is Flail Chest?

A

2 or more ribs fractured in 2 or more places, producing a “free-floating” segment

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17
Q

What is the Pathophysiolgy of Flail Chest?

A

loss of mechanical advantage of breathing frequently associated with underlying pulmonary contusion, further compromising respiration

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18
Q

Flail Chest Treatment:

A

Supplemental oxygen. Reexpand the lung.

Limit fluids unless hypotensive (prevents worsening of pulmonary contusion). Analgesia (improves spontaneous ventilation).

If severe: intubate and ventilate

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19
Q

Define a Massive Hemothorax.

A

Loss of > 1500 cc by chest tube when placed

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20
Q

Massive Hemothorax Pathophys:

A

Loss of > 1500 cc to chest.

o Usually represents a great vessel.

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21
Q

What are the Symptoms of a Massive Hemothorax?

A

Unlike Tension TX, dull to percussion. Neck veins may be distended from obstruction or flat due to volume loss in the chest.

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22
Q

Massive Hemothorax Treatment:

A

First, restore volume/blood (3:1 crystalloid, 1:1 colloid).

Second, decompress chest with chest tube, using an autotransfuser if available. Operative Repair: if 1500 cc immediately drained, or if <1500cc immediately and continues at 200 cc/hr for 2-4 hours.

Per ACOS: Thoractomy not indicated unless a surgeon is present.

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23
Q

What is the primary etiology of Cardiac Tamponade?

A

Primarily caused by penetrating injury. The Pericardium is a fixed, fibrous structure which does not extend well with acute volume increase (bleeding)

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24
Q

What are the diagnostic criteria of Cardiac Tamponade?

A

Beck’s Triad
o Decreased BP.
o Increased CVP (sign: Kussmaul’s veins).
o Muffled heart sounds.
• Note: Echocardiogram has 5% false negative rate

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25
Q

What is treatment for Cardiac Tamponade?

A

Volume Resuscitation

Definitive repair in OR. If OR/Surgeon not availaable, then pericardiocentesis can temporize until definitive therapy

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26
Q

T/F: The primary survey is a more detailed head to toe exam to identify problems not immediately life-threatening requiring definitive treatment.

A

False, The secondary survey is a more detailed head to toe exam to identify problems not immediately life-threatening requiring definitive treatment.

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27
Q

Closed Ptx Diagnosis:

A

CXR, accentuated on expiratory CXR decreased breath sounds on affected side

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28
Q

Why is there No tracheal deviation in a closed pneumothorax?

A

if deviated, tension ptx

29
Q

Treatment for Closed Ptx:

A

100% O2 for ventilation and denitrification.

Chest tube before surgery (NO2 will enlarge ptx, PPV will enlarge ptx) or air transport (altitude will enlarge ptx)

30
Q

What is the definition of a Hemothorax (Non-massive)?

A

Less than Massive Hemothorax- Less than 1500 cc

31
Q

How do we diagnose a hemothorax?

A

Dull to percussion. May be dx on CXR as “traumatic effusion”

32
Q

Treatment for a hemothorax:

A

Chest tube only-Non operative management , but set up autotransfuser incase worsens to massive hemothorax.

33
Q

What is the Most Common Potentially Lethal Injury in a patient with chest trauma?

A

Pulmonary Contusion

34
Q

Pulmonary Contusion Diagnosis:

A

“Traumatic Infiltrate” underlying chest wall injury. Leads to respiratory failure overtime

35
Q

What is the Treatment for a Pulmonary Contusion?

A

Limit fluids, unless the need for resuscitation of hypotension.

Intubate if PaO2 < 65 or SaO2<90% on Room Air

36
Q

What are possible types of Blunt Cardiac Injury?

A

Includes myocardial contusion, cardiac chamber rupture, valvular disruption

37
Q

Diagnosis of Blunt Cardiac Injury:

A

Hypotension

EKG changes: ST/PVCs/New Afib/New RBBB/ST changes (Why RBBB?-which venticle is most anterior?)

A New murmur

2D Echocardiogram
Increased CVP without other cause ( due to pump failure)

38
Q

Treatment Blunt Cardiac Injury:

A

Rx: Monitor EKG x 24°, cardiac enzymes

39
Q

What is a complication with Thoracic Aortic Dissections?

A

Most individuals with this injury exsanguinate immediately. Those who survive to the ED have only a partial tear with a contained hematoma. While few in number, they are potentially salvageable if able to be identified early

40
Q

How do we Diagnosis a Thoracic Aortic Dissections?

A

Keep a high Index of suspicion. High deceleration forces. Widened mediasteinum on CXR (Be aware an AP film makes the mediasteinum appear falsely enlarged.
– Obliteration of Aortic knob
– Tracheal deviation to R
– NG tube (esophagus deviated) to R
– Fx 1st or 2nd rib or scapula
– Note: Typically are not repeatedly hypotensive
– If suspected: Aortogram

41
Q

Treatment for a Thoracic Aortic Dissections:

A

Operative repair

42
Q

A Traumatic Diaphragmatic Injury is almost always diagnosed on the Left side, Why?

A

Rarely seen on R side, due to liver covering the tear

43
Q

How do we diagnose a Traumatic Diaphragmatic Injury?

A

NG tube, stomach, small bowel in chest on CXR
– If in doubt, get Upper GI study
– If present, must be repaired in the OR

44
Q

What is the treatment for a Traumatic Diaphragmatic Injury?

A

Operative

45
Q

Mediasteinal Transversing Wound

A

Where is the entrance wound?
– If Left, then MTW
– If Right, then May be MTW

Penetrating Injury to great vessels, tracheobronchial tree, and the esophagus

46
Q

Mediasteinal Transversing Wound Diagnosis in a Stable patient:

A 
Entrance wound on one hemithorax with exit opposite thorax
In a Stable patient:
•	Aortography
•	Esophagoscopy
•	Bronchoscopy
•	CT/US
47
Q

Mediasteinal Transversing Wound Diagnosis in a UnStable patient:

A

In a Unstable patient: exsanguination, hemeoptysis, tension ptx, pericardial tamponade

48
Q

Mediasteinal Transversing Wound Treatment

A

Bilateral chest tubes. Operative thoracostomy

49
Q

What do we see with SQ Emphesema?

A

Subcutaneous Emphesema- “Rice Krispies” under the skin represents airway or lung injury

May be seen on CXR as air in muscle tissues

50
Q

What is Traumatic Asphyxia? Is it serious?

A

Eccymosis and petechiae to head, neck, and upper extremities due to backflow of venous blood due to heavy weight compression of the chest.

While impressive looking, it is not serious in itself, however, must look for underlying disease as in the Deadly Dozen Plus(?the Fatal Fourteen?)

51
Q

Fractures to the Scapula, Ribs 1-3 are markers of ___________.

A

Severe MOI/force. Associated with head, neck, pulmonary, cardiac, and great vessel injuries.

52
Q

Rib and Scapular Fractures: With Ribs 4-9:

A

Beware of underlying pulmonary contusion

53
Q

Rib and Scapular Fractures: With Ribs 10-12: May be associated with abdominal injury

A

May be associated with abdominal injury

54
Q

Posterior Sternoclavicular fracture or dislocation:

A

Can cause lifethreatening airway obstruction not treated by usual means. Must reduce compression on airway, not intubate or other airway maneuvers.

55
Q

Esophageal Tears are __________ if unrecognized due to secondary infection.

A

Lethal

56
Q

Consider a diagnosis of an esophageal tear if:

A

L sided ptx without rib fracture. Pain and shock out of proportion to obvious injuries in the setting of a blow to the low sternum. Food material exiting chest tube.

57
Q

Treatment for an esophageal tear:

A

Surgery

58
Q

Traceobrachial injury etiology:

A

These patients often have smoke inhalation damage.

59
Q

How do we diagnosis and treatment a Traceobrachial injury?

A

Order and ABG and don’t rely on the pulse ox. In children think aspiration of some sharp or jagged object. Flex. Endoscopy might be indicated to assess the damage OR remove the object

60
Q

Penetration chest wounds treatment:

A

Open thoracotomy may be indicated to stop bleeding

*anyone of these situations could lead to rapid sequence intubation.

61
Q

Recognize the indications for an emergency thoracotomy

A

(1) penetrating thoracic wound with agonal state or recent loss of vital signs, deterioration or cardiac arrest after care has been initiated, or uncontrolled hemorrhage from thoracic inlet or out of chest tube;
(2) need for open cardiac massage or occlusion of descending thoracic aorta before laparotomy; and
(3) suspected subclavian vessel injury with intrapleural exsanguination.

62
Q

Diaphragmatic hernia

A

They result either by direct violation of diaphragm or significant intra-abdominal or intrathoracic pressure applied to the diaphragm resulting in its rupture.

The right side is affected up to three times less than the left because it is relatively well protected by the liver.

Up to 50% of these injuries are missed on the initial trauma evaluation, and their delayed presentation may not be clinically significant until herniation of abdominal contents through the diaphragm results in obstruction, incarceration, strangulation, perforation, or even death.

63
Q

Diaphragmatic hernia Diagnosis:

A

Patients with diaphragmatic hernias may be asymptomatic, particularly in the acute phase, or may present with symptoms of bowel obstruction. Delayed presentation is common with nonspecific respiratory or bowel complaints since early diagnosis is difficult to establish and often missed.

64
Q

Diaphragmatic hernia CXR

A

The CXR is a valuable screening tool in detecting blunt diaphragmatic rupture. The initial X-ray is interpreted as normal in up to 50% of acute cases but will be abnormal in almost 100% of those with delayed presentations. Findings on an upright CXR suggestive of diaphragmatic rupture include elevation or irregularity of the diaphragmatic border, unilateral pleural thickening, obvious herniation of abdominal contents into the chest cavity, and the presence of a nasogastric tube in the chest cavity.

65
Q

Diaphragmatic hernia Treatment

A

Surgical reduction of the hernia and repair of the diaphragm is mandatory in all patients with diaphragmatic rupture. Care should be taken to avoid abdominal injury when placing a chest tube in patients with concomitant hemothorax or pneumothorax.

66
Q

Role of Emergency Department Thoracotomy in Penetrating Injuries:

A

Emergency department thoracotomy is best used in patients sustaining penetrating thoracic injuries who have witnessed a cardiopulmonary arrest in the emergency department or lose signs of life during a short transport to the emergency department. Survival rates for cardiac injuries and stab wounds are typically better than noncardiac injuries and gunshot wounds. Thoracotomy for penetrating injuries yields an overall survival rate of approximately 11%.

67
Q

What is Commotio Cordis?

A

Commotio cordis is condition of sudden cardiac death or near sudden cardiac death after blunt, low-impact chest wall trauma in absence of structural cardiac abnormality.

Ventricular fibrillation is the most commonly reported induced arrhythmia in commotio cordis. Young male athletes aged 5–18 years are particularly at risk for this catastrophe. It has been described after blows to the chest from baseballs, softballs, hockey pucks, and other objects. Death is usually instantaneous, and successful resuscitation is uncommon.

68
Q

Contraindications to thoracotomy include:

A

penetrating trauma with no signs of life in the field or blunt trauma with no signs of life on arrival in the ED. Thoracotomy should be performed only if immediate surgical backup is available.

69
Q

What happens if there is a tear in the diaphragm?

A

Once a tear in the diaphragm occurs, it will not heal spontaneously, allowing for the herniation of abdominal contents into the chest cavity. Delayed presentations of blunt diaphragmatic rupture have been reported up to 50 years after the primary traumatic event.

Medicine II: Emergency Medicine (11 decks)

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