Chest Trauma Flashcards
What should be identified during the primary survey?
Airway obstruction Tension pneumothorax Open pneumothorax Flail chest and pulmonary contusion Massive hemothorax Cardiac tamponade
ATLS algorithm for monitoring trauma patients
A (Airway with c-spine protection): Is the patient speaking in full sentences?
B (Breathing and Ventilation): Is the breathing labored? Bilateral symmetric breath sounds?
C (Circulation with hemorrhage control): Pulses present and symmetric? Skin appearance (cold clammy, warm well perfused)
D (Disability): GCS scale? Moving all extremities?
E (Exposure/Environmental Control): Completely expose the patient. Rectal tone? Gross blood per rectum?
IV – 2 large bore (minimum 18 Gauge) Antecubital IV
O2 – Nasal cannula, Face Mask
Monitor: Place patient on monitor.
Tension Pneumothorax findings
- Shortness of breath chest pain in the setting of trauma and in certain cases traumatic arrest.
- Absent breath sounds ipsilateral to the PTX, tracheal deviation opposite to the PTX, crepitus and jugular venous distension
Tension Pneumothorax treatment
needle decompression followed by tube thoracostomy
Pneumothorax findings
chest pain and shortness of breath, tachycardia, tachypnea, hypoxia. On physical exam they often have bilateral breath sounds, although typically asymmetric with decreased noted on the site of the PTX
What is an open pneumothorax?
Open pneumothorax is a sucking chest wall wound from penetrating injury, usually with a big defect in the chest wall.
How does an open pneumothorax present?
chest pain shortness of breath with sonorous breath sounds on physical exam, sucking air from wound and shallow respirations.
How do you treat an open pneumothorax?
- square dressing tape on three sides to create an escape valve
- Ultimately a chest tube is placed ipsilateral to the side of the wound but at a different anatomic location than the wound.
Hemothorax presentation
Patients present with shortness of breath, chest pain or occasionally asymptomatic. Typically presents with decreased breath sounds, dullness to percussion on exam. Although vital signs typically indicate tachycardia, tachypnea or hypoxia, occasionally they can present as completely normal.
Hemothorax treatment
treatment is placement of a chest tube. If the hemothorax is retained despite the chest tube then a video assisted thorascopic surgery is recommended.
What are indications for emergent treatment of a hemothorax?
Indications for emergent surgery are greater than 1500 ml of blood on initial chest tube placement and if there is greater than 200 ml/hour of blood for 2-4 hours.
What is a flail chest?
multiple rib fractures (3 or more ribs in 2 places)
Flail chest findings
chest pain, dyspnea, painful respirations and are tachycardic, tachypneic and hypoxic. Clinical findings are pertinent for a visible or palpable deformity, bruising or crepitus, paradoxical movement and splinting with secondary hypoventilation.
Treatment of a flail chest
re-expand the lung with CPAP (positive pressure) or physiotherapy, and to avoid atelectasis. For patients with less severe injuries pain control and incentive spirometry can be attempted. All patients need admission for observation.
What is a pulmonary contusion?
Severe blunt chest trauma causes leakage of blood and proteins into alveoli causing atelectasis and that can lead to ARDS
Pulmonary contusion findings
shortness of breath, chest pain, hemoptysis and cough. On exam tachypnea, tachycardia, hypoxia is common. In severe cases ecchymosis can be evident over chest wall and decreased breath sounds on auscultation.
What is the best imaging for a pulmonary contusion?
CT
Treatment of pulmonary contusion
For large pulmonary contusions patients need to be intubated. Smaller contusions can be managed with conservative management that includes incentive spirometry, pulmonary toilet, pain control and careful fluid administration.
What are cardiac contusions associated with?
associated with sternal fractures.
Cardiac contusion findings
chest pain. Physical exam may be completely normal. Some patients can have chest wall contusions. Those with sternal fractures will have obvious sternal pain. 40% of patients with cardiac contusions can develop signs of decreased cardiac output.
Diagnosis of cardiac contusion
requires high clinical suspicion. echocardiograms (2D-ECHOs) for evaluation of EF. If the 2D-ECHO shows a reduced EF (new from prior) patients should undergo a dobutamine stress test.
What is Becks triad?
On exam Beck’s triad (hypotension JVD and distant heart sounds) is sometimes present. Cardiac tamponade.
Cardiac tamponade findings
- Chest pain, shortness of breath, with air hunger, frequently altered mental status.
- hypotensive in shock, with pulsus parodoxus and narrowing of pulse pressure.
Imaging in cardiac tamponade
Diagnosis is clinical however can be made with bedside sonogram while performing the eFAST exam (figure 4). Although EKG can show electrical alternans, it is not frequently seen in traumatic tamponade. CXR can show an enlarged cardiac silhouette.
