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Chp 4 Thoracic Trauma Flashcards

1
Q

% of blunt trauma and % of penetrating trauma that requires operative intervention

A

10% BLUNT, 15-30% PENETRATING

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2
Q

Physiologic consequences of thoracic trauma are due to?

A

Hypoxia, hypercarbia and acidosis

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3
Q

What causes in thoracic trauma hypoxia and later metabolic acidosis?

A

Hematoma, Contusion, Alveolar collapse and changes in the intrathoracic pressure relationships

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4
Q

What causes hypercarbia and what is the following physiologic mechanism?

A

Causes respiratory acidosis, the INADEQUATE VENTILATION causes by changes in the intrathoracic pressure relationships and depressed level of consciousness`

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5
Q

Goal of early intervention in thoracic trauma?

A

Prevent hypoxia

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6
Q

Most serious consequence of chest injury?

A

Hypoxia

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7
Q

How thoracic trauma can cause laryngeal injury?

A
  • Direct blow to the neck or a shoulder restraint the is missplaced across the neck
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8
Q

Tx of posterior dislocation of the clavicular head

A

Reduction by extending patient’s shoulder or grasping the clavicle with a penetrating towel clamp.

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9
Q

Tracheobronchial tree injury can be potentially fatal but it’s unusual. T or F?

A

True

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10
Q

Tracheobronchial tree injury occurs 2 inches of the canula? T o F>

A

False. It is 1 inch

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11
Q

Majority of patients w/ tracheobronchial tree injury die at scene and has a very high mortality when they reach to the hospital

A

True

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12
Q

Tracheobronchial injury signs and symptoms

A

Hemoptysis, cervical subcutaneous emphysema, tension pneumothorax and/or cyanosis

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13
Q

T or F? Placement of more than one chest tube is necessary to overcome a significant air leak - tracheobronchial tree injury?

A

True

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14
Q

What confirms the dx of tracheobronchial tree injury?

A

Bronchoscopy

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15
Q

Inmediate tx of tracheobronchial tree injury?

A

Placement of a definitive airway

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16
Q

Why is difficult to intubate a patient w/ tracheobronchial tree injury?

A

Due to anatomic distorsion from paratracheal hemaoma

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17
Q

What can be needed in intubation of tracheobronchial tree injury patient?

A

Fiber-optically assisted endotracheal tube placement past the tear site of selective intubation of the unaffected bronchus

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18
Q

Cyanosis is a late sign of hypoxia in a trauma patient? Its abscence indicate adequate tissue oxygenation?

A

False

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19
Q

Pathophysiology of Tension pneumothorax?

A

The mediastinum get displaced and this compressed the opposite lung. This decrease the Venous return and the cardiac output.

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20
Q

MCC of TPTX?

A

mECHANICAL POSITIVE pressure ventilation in patients with visceral pelural injury

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21
Q

Usually, Tension TPTX occurs from markedly displaced thoracic spine fx?

A

False, is rare

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22
Q

Inmediate mangement of TPTX?

A

Inmediate decompression by inserting a large over the needle catheter into the pleural space. If it’s not successful finger thoracostomy is indicated

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23
Q

for TPTX we used a 5 cm or 8 cm needle?

A

5 cm has only 50% probability to reach the pleural space. 8 cm has more than 90% probability to reach the pleural space.

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24
Q

Tube thoracostomy is mandatory after needle or finger decompression of the chest?

A

Yes

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25
Place of the needle in TPTX?
5TH INTERSPACE, SLIGHTLY anterior to the midaxillary line.
26
What is a sucking chest wound?
An open pneumothorax
27
Pathophysiology of Opent PTX?
tHERE is a equilibration between atmospheric pressure and intrathoracic pressure inmediately. Air tends to follow the path of LEAST RESISTANCE, when the opening in the chest wall is approx 2/3 the diameter of the trachea or greater, air passes preferentially through the chest wall defect w/ each inspiration
28
What happen to ventilation w/ open PTX
Effective ventilation is impaired, leading to hypoxia and hypercarbia
29
Management of Open PTX
Close the defect w/ sterile dressing large enough to overlap the wound's edge. ONLY 3 SIDES
30
Definition of Massive Hemothorax
> 1500 mL of blood in one side of the chest
31
PEA on ECG can be present in which pathologies>
Cardiac tamponade, Tension PTX, Profound HYPOVOLEMIA, Blunt rupture of atria or ventricle, 5Hs, 5Ts.
32
Breath sounds: TPTX and Massive Hemothorax
TPTX: Absent or decreased MH: Decreased
33
Percussion: TPTX and MH
TPTX: Hyperresonant MH: Dull
34
Tracheal position: TPTX and MH
TPTX: Deviated away MH: Midline
35
Neck veins: TPTX and MH
TPTX: Distended MH: Collapsed
36
Chest movement: TPTX and MH
TPTX: Expanded immobile MH: Mobile
37
Usually massive hemothorax is MIDLINE?
Yes
38
Management of MH
Decompression and transfusion of UNCROSSED or TYPE SPECIFIC ASAP
39
Chest tube needed in MH?
Yes
40
Indications for the OR in hemothorax
Inmediate return of 1500 mL or more and 200 mL/2h-4h
41
T or F. Color of the blood is a GOOD indicator of the necessity of thoracotomy
False is a poor indicator
42
Cardiac tamponade is caused mostly for penetrating injuries
Yes
43
Beck's triad
Muffled heart sounds, hypotension, distended veins
44
Muffled heart sounds are difficult to hear in the ER?
yES
45
In CT. Distended veins may be absent. WHy
Due to hypovolemia
46
Explain the kussmaul signs
Arise in venous pressure w/ inspiration when breathing spontaneously
47
How can pT be dx?
FAST (90-95%), Pericardial window and ECHO
48
Is the administration of IVF necessary for PT?
tRUE
49
Management of PT
Emergency thoracotomy or sternotomy ASAP
50
Place of pericardiocentesis
subxiphoid
51
When is considered a patient is in circulatory arrest?
PEA, Vfib and asystole
52
Causes of circulatory arrest?
Severe hypoxia, TPTX, profound hypovolemia, cardiac tamponade, cardiac herniation, severe Myocardial contusion.
53
%CPR survival rate w/ cirulatory arrest
1.9%
54
%Resucitative thoracotomy w/ circulatory arrest
10%
55
Circulatory arrest IN THORACIC TRAUMAafter ABC and CPR w/ no ROSC. Next step?
Bilateral chest decompression
56
Circulatory arrest IN THORACIC TRAUMAafter ABC and CPR w/ no ROSC after BL chest decompression? Next step?
Anterolateral or clamshell thoracotomy and vertical pericardiotomy
57
Circulatory arrest IN THORACIC TRAUMA after thoractomoy the shows CARDIAC INJURY? Next step?
Control of cardiac lesion and repair of heart wound
58
Circulatory arrest IN THORACIC TRAUMA after thoractomy and severe hypovolemia.. What to do with the thorax?
Hemostatis of pulmonary pedicle and mediastinal vessels
59
Circulatory arrest IN THORACIC TRAUMA after thoractomy and severe hypovolemia.. What to do with the abdomen?
Clamp on descending aorta
60
What to do if a patient fell in cardiac arrest during thoractomy?
Internal cardiac massage and/or internal electric shock.
61
8 potentially lethal injuries of THORACIC TRAUMA that can be managed during secondary survey
Simple PTX, Hemothorax, Flail chest, Pulmonary contusion, Blunt cardiac injury, Traumatic aortic disruption, Traumatic diaphragmatic injury, Blunt esophageal rupture
62
WHat defines PTX
aIR ENTERing the potential space between the visceral and parietal pleura
63
Primary cause of hemothorax
Laceration of the lung, great vessels, an intercostal vessel or an internal mammary artery
64
When hemothorax is associated w/ thoracic spine fxs, bleeding is usually self limiting?
Yes
65
Chest tube needed for hemothorax
28-32 F
66
How can a retained hemothorax can be prevented
Ensure appropriate placement of chest tube and obtain surgical consultation
67
Definition of flail chest
Two or more adjacent ribs fx in two or more places OR | COSTOCHONDRAL separation of a single rib from the thorax
68
Pulmonary contusion def
Bruis of the lung caused by thoracic trauma. Blood and other fluids accumulate in the LUNG TISSUE, interfering w/ ventilation and potentially leading to hypoxia
69
Children can present lung contusion w/o rib fractures? Why?
Yes, becuase they hay more compliant chest walls
70
Adults usually present pulmonary contusions w/o rib fxs?
No, usually they have. They are lethal
71
Restricted chest wall movement associated w/ pain and underlying lung contusion can lead to respiratory failure?
Yes
72
Tx of flail chest AND pulmonary contusion?
Adequate oxygenation Administer fluids Provide analgesia
73
WHich anesthesia is better for flail chest
Local anesthetic w/ intercostal nerve block
74
Condition that increased the likelihood of requiaring early intubation and mechanical ventilation
copd and Renal failure
75
BCI trauma cases
MVC followed by pedestrian struck by vehicles, motorcycle crashes and falls from heights greater than 20 feets (6 m)
76
BCI can result to the heart
Myocardial muscle contusion, cardiac chamber rupture, coronary artery dissection and/or thrombosis, and valvular disruption.
77
Cardiac rupture usually presents as
Cardiac tamponade
78
Common ECG findings w/ Blunt cardiac injury
Frank MI, multiple premature ventricular contractions, unexplained sinus tachycardia, afib, bundle branch block (usually right), and ST segment changes.
79
Traumatic aortic rupture is a common cause of sudden death?
Yes, after a vehicle collision or fall from a great height
80
Contained hematoma of aortic rupture prevent patient from death?
Yes
81
Best dx approach for aortic rupture
CT Scan >> X ray. Def dx aortography
82
Radiographic signs of Blunt aortic injury?
- Widened medistinum, - Obliteration of the aortic knob, - deviation of the trachea to the right - Depression of the L mainstem bronchus - Elevation of the R mainstem bronchus - Obliteration of the space between pulmoary artery and the aorta (obscuration of the aortopulmonary window). - Deviation of the esophagus (NG tube) to the R. - Widened paratracheal stripe - Widened paraspinal interfaces - Presence of a pleural or apical cap - L hemothorax - Fx of the first and second rib or scapula
83
Management of abLUNT aORTIC iNJURY
Analgesics, Short acting B blocker or CCB - Esmolol or Nicardipine. NG or Nitroprusside 2nd line. (HR goal < 80 bpm AND MAP 60-70 mmhg). SURGERY
84
BAi IN A LOW resource capabilities hospital
Transfer because a rupture of hematoma can lead to death from exanguination
85
Radiographic signs of diaphragmatic injuries
- Elevated diaphragm - Acute gastric dilation - Loculated hemoPtx - Subpulmonic hematoma
86
How NG tube is used to diaphragmatic injury and what typoe of diaphragmatic injury?
gASTRIC TUBE IN THE THORACIC cavity
87
How to confirma a diaphragmatic injury
UGI studies
88
Type of trauma tha most likely affect esophageal rupture?
Penetrating
89
What mediastinintis causes?
Empiema
90
How to confirme esophageal rupture?
Contrast studies and/or esophagoscopy
91
Tx of esophageal repair
Wide drainage of pleural space and mediastinum w/ direct repair of the injury
92
Subcutaneous emphysema is caused by?
Crushing injury (traumatic asphyxia). rib, sternum and scapular fxs.
93
Tx of subcutaneous emphysema
DOes not require tx but id of underlying cause is necessary
94
Ribs that are more affected for blunt trauma
Middle ribs (4 to 9).

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