S21C258 - Pulmonary Trauma

Question 1

Causes of cardiac arrest after intubatioN:

Answer 1

• inadequate preoxygenation
• esophageal intubation
• intubation of the R or L mainstem bronchus
• tension pneumo
• systemic air embolism
• decreased venous return due to excessive ventialtory rate or pressures
• vasovagal response

Question 2

Tension pneumo signs

Answer 2

• distended neck veins
• hypotension
• tracheal deviation
• decreased breath sounds

Question 3

Hemothorax

Answer 3

-each hemithorax can hold 40% of a pts blood volume
-massive hemothorax = immediate drainage of 1500cc (2/3 of space in hemithorax)
OR 200cc /h for 4h
–> indictations for operative management ^^
-massive hemothorax compromises: blood volume, venous return, oxygenation
-if a chest tube is placed and the pt suddenly becomes more unstable clamp the tube as this indicates there is an exsanguinating injury and drainage of the blood resulted in loss of the protective vascular tamponade effect

Question 4

Sucking chest woudn

Answer 4

-cover with an occlusive dressing, a 3 way dressing that allows air to escape is best, completely occluding the wound may convert it to a tension pneumo

Question 5

Flail chest

Answer 5

• free-floating segment of ribs

- at least two fractures per rib (producing a free segment), in at least two ribs

Question 6

Chest tube placement

Answer 6

• anterior axillary line
• nipple level or inframmamry crease in women
• 5th intercostal space
• incise and insert above the rib
• simple pneumo = 24 or 28F
• hemo = 32-40F

-continue chest tube until 24h after all air leaks have stopped or until drainage is erious and

Question 7

Pulmonary Contusion: pathophys

Answer 7

• direct injury to the lung
• hemorrhage and edema w/o pulmonary laceration
• 2 stages to contusion
• first, direct parenchymal damage from initial injury
• 2nd: IV fluids causes extravasation into uninjured lung, incr blood flow through both lungs, hydrostatic prssure causes leakage of blood and fluid into interstitium and avleoli, segments of lung become progressively congested and contused continuing on to the next uninjured segment leading to intrapulmonary shunting, resistance to airflow, decreased lung elasticity, increased WOB, hypoxia, hypercarbia, respiratory acidosis and cardiopulmonary collapse

-areas of opacification w/in 6h on CXR in setting of blunt trauma are considered pulm contusion

Question 8

Pulmonary Contusion: treatment

Answer 8

• pain control, nerve blocks, epidural analgesia

- 1/4 lung, may requireventilatory assistance

Question 9

Pneumothorax

Answer 9

-usually doesn’t cause symptoms unless >40% of lung volume lost

Question 10

Causes of failure of chest tubes to evacuate a pneumothorax

Answer 10

• improper connections or leaks in the external tubing or water-seal collection apparatus
• improper positioning of the chest tube
• occlusion of bronchi or bronchioles by secretions or foreign body
• tear of one of the large bronchi
• large tear of the lung parenchyma

-indicate bronchoscopy or thoracotomy is needed

Question 11

Pneumomediastinum

Answer 11

• 10% of cases may have a tracheobronchial injury

- assess larynx, trachea, major bronchi, pharynx, esophagus

Question 12

Systemic Air embolism

Answer 12

• pts with penetrating chest wounds who require positive pressure ventilation are at risk for developing air embolus
• high vent pressures may force air from an injured bronchus into an adjacent injured vessel
• may cause dysrhythmia, or CNS deficits
• mgmt: place in supine position, 100% O2 to decrease air bubble size by dipslacing nitrogen and promoting resorption, hyperbaric O2 therapy
• if pt arrests: CPR, thoracotomy to clamp injured lung and air aspiration from heart and ascending aorta, and bypass

Question 13

Intrabronchial bleeding

Answer 13

• keep good lung free of blood if possible
• can use a double-lumen ETT to temporize and confine the bleeding to the affected lung
• can also place a normal ETT over a bronchoscope into the unaffected lung

Question 14

Tracheobronchial injury

Answer 14

• usually from rapid deceleration injury or from forced expiration against a closed glottis
• Sx: dyspnea, hemoptysis, subcu emph, Hamman sign, sternal tenderness
• if bronchopleural fistula present the chest tube will have a continuous and massive air leak, dx with bronchoscopy and use high-frequency oscillation for ventilation
• lacerations >1/3 circumference of bronchi need surgical repair

Question 15

Diaphragmatic Injury

Answer 15

• can either be acute or a small tear can become significant years later when some bowel herniates through and torse
• CXR positive in only 25% of cases
• requires surgical repair - laparotomy

Question 16

Esophageal injury

Answer 16

• can perform an esophagogram –> use water soluble contrast then repeat with barium if negative
• complications: mediastinitis
• or do a flex esophagoscopy

Question 17

Thoracic duct injury

Answer 17

• usually discovered during surgery

- may result in a chylothorax

Question 18

Subcutaneous Emphysema

Answer 18

• represents an injury to either: lung, pharynx, larynx, esophagus
• if severe subcu emph, suspect a major bronchial injury

Question 19

Rib #

Answer 19

• first three ribs if fractured indicate high-energy trauma and risk of other injuries: myocardial injury, bronchial tear, vascular injury
• lower rib # suggest intra-abdominal injury

Question 20

Flail chest

Answer 20

• usually means contusion underneath, lung compliance fails, decreased ventilatory efficiency, increased WOB and sudden respiratory arrest can occur
• if mild/moderate flail and little to no contusion, ventilator may not be necessary
• if PO2 8 rib #, >65yo

Question 21

Sternal #

Answer 21

• 1.5% assoc with cardiac dysrhythmias

- do an ECG at presentation and then repeat in 6h, if both normal the no further w/u required