Thoracic Trauma Flashcards
What is the goal of the chest wall?
to prevent hypoxia through effective oxygenation/ventilation
The chest creates ____________ intrathoracic pressure during inspiration and _____________ pressure during expiration. This is disrupted with a ______________.
negative, positive, PTX
What are two examples of violation of the pleura?
PTX +/- HTX
If a patient has little or no effort to breath consider
1
2
3
head trauma, intoxicantion, spinal cord injury
Effort present > no air movement > consider ____________________
upper airway obstruction
Decreased/poor or absent breath sounds, you want to consider thoracic trauma:
1.
2.
3.
4
5
6
PTX, HTX, rib fx, fail chest, diaphragm, lung parenchymal damage
Apply _________ and _____________ when doing initial resuscitation
02, secure airway
- Are examples of what will kill your patient first.
- hemorrhagic shock (acute blood loss)
- obstructive shock (tension ptx, cardiac tamponade)
- respiratory failure
hypoxia > low SPO2 or PO2
Hypercabia > pH 7.20 pCO2 55 PO2: 90 HCO3 24
For which patients do you want to consider early ventilatory support?
shock state
poly trauma
comatose
massive transfusion
elderly
underlying pulmonary disease
If a patient is intubuted/put on ventilator, they need a baseline then serial _______________
ABG
When inspecting the chest, ensure to look in the ___________
axilla
When inspecting the abdomen, you want to ensure to look for:
1.
2.
scaphoid abdomen- More of an inward cave to the abdomen, can see this with a diaphragm injury
2. abd movement during breathing may indicate chest wall damage
_____________ is the first study to consider STAT in a patient with thoracic trauma.
CXR
__________ is used to evaluate for intrabdominal trauma and can be used to evaluate for a PTX
FAST exam
What is a normal finding for a fast exam?
a comet tail- will see white strands coming down inferior to the pleura
Closed pneumothroax
Open pneumothroax
Tension pneumothorax
When doing a needle decompression, you want to place the needle at the _________________
2nd intercostal space at the midclavicular line
What is the first line treatment for a pneumothroax?
needle decompression followed by a chest tube
What are the s/s of a tension pneumothroax?
Anxiety
Respiratory distress/arrest
Hypoxia
Decreased/Absent Breath Sounds
Distended neck veins
Crepitus
Tracheal Deviation
Tachypnea
Tachycardia
Chest pain
Hypotension
Ventilated patients– High airway pressures
When placing a chest tube for a patient with a pneumothorax, you always want to reassess with ______________.
Always reassess with CXR after placement +/- daily CXR and CXR following transition to water seal
What is the ideal placement for a chest tube?
4th 5th intercostal space at the midaxillary line.
Males- nipple line
Females- inframammary fold
Pharmacotherapy considerations
local anesthesia, IV/PO narcotic analgesia
Indications for a chest tube:
1.
2.
3.
4.
5.
- PTX
- HTX
- H/PTX
- PTX requiring intubation (PPV)
- Air transport at risk for PTX
Complications of a chest tube
1.
2.
3.
4.
5.
- placement issues
- bleeding
- dislodgement
- abdominal organ penetration
- retained PTX/HTX
What are the signs of someone with a simple traumatic pneumothorax? This patient will get serial CXRs, supplemental O2, and a pulse ox.
decreased breath sounds
-hyperresonance
-SOB
-CP
Occult ptx is only apparent on a ___________. You want to treat these patients supportively in cases of ______________. If symptomatic of PTX worsens on repeat CXR, place ___________.
CT scan. bunt trauma. chest tube
What are the symptoms of an open ptx?
Many of same symptoms as closed ptx plus:
“Sucking wound”
Penny size wound
Coughing up blood
Frothy bleeding from wound
Dyspnea
Anxiety
Cyanosis
What is the initial treatment for an open pneumothorax? What is the definitive management?
Occlusive dressing on 3 sides
definitive: Chest Tube ASAP
Never through the wound
Pain control
Antibiotics
Large defects may require closure/vac
What is the presentation of a patient with a hemothroax? You want to be cautious with a ____________ HTX.
Present very similar to PTX
Look at VS!!
Dyspnea
Hypoxia
Decreased Breath Sounds
Anxiety
Chest pain
Tachypnea
Hypotension
Respiratory compromise
delayed, particularly those with rib fractures.
How is a large hemothroax treated?
with a chest tube
If a patient with a hemothorax has drained > _____________ or _______________ for 2-3 hours = _____________. Always confirm improvement with _____________ after chest tube placement.
> 1500cc or >200cc/hr for 2-3 hour = Thoracotomy
CXR
Flail chest is _______ or more adjacent rib fractures in _________ or more places > creates _______________. This is an unstable chest that has a paradoxical motion. This causes significant morbidity usually from underlying contusion.
3, 2, floating segment.
One of the most important things for pt education for anyone with a chest wall injury is _______________. It is done _______ an hour while awake. This can prevent them from getting pneumonia and oxygen.
incentive spirometry
10x
In the management of flail chest, ____________ is key. This includes:
pain control
PCA, IV narcotics, consider TOradol (if no other bleeding issues/Cr ok)
rib blocks
throacic epidural
____________ is the most common thoracic injury
> 2 rib fractures
1-3rd rib fractures, increased risk of________________ injury/ _____________injury.
intrathoracic, vascular
If ribs 10-12 are fractured, you want to consider an _____________ injury
intra abdominal
In the treatment of a rib fracture, you want ____________ pain control. This includes:
1.
2.
3.
4.
5.
multimodal.
1. PCA, narcotics, nerve block
2. NSAIDs
3. Tylenol
4. topical lido
5. Gabapentin
What is the imaging of choice for a sternal fracture?
CT scan
Pulmonary contusion CXR will show: ________________
Diagnosis
1.
2.
Management
CXR-irregular opacifications of the parenchyma
Diagnosis
CXR
CT (not needed)
Management:
Pain Control
Pulmonary toilet/Ambulation
Maintain euvolemia
Increased risk for ARDS/Pneumonia
02 prn watch for resp failure requiring Intubation
Cardiac Tamponade= Becks Triad:
1.
2.
3.
- neck vein distension
- hypotension
- muffled heart sound
Cardiac tamponade is most common with ___________ trauma.
penetrating (cardiac box)
What is the presentation of someone with a cardiac tamponade
Pale/Grey Skin
Palpitations
Tachypnea
Weak pulse
What is the gold standrd for what you want to do for initial tx for a cardiac tamponade
pericardiaocentesis
_________________ is one of the main findings for a patient with a tracheobronchial injury. These types of patients will have continuous ___________. There’s going to be reaccumulating ___________ or __________ despite the CT. The definitive dx is _____________.
Subcutaneous Emphysema
air leak.
pneumomediastinum or PTX
bronchoscopy
What are the s/s for esophageal perforation? What is the gold standard to dx it?
Blood in NG aspirate, Subq cervical air, neck hematoma, severe neck/back pain.
barium swallow
Diaphragm injury (L more common than R) can be hard to diagnose because it is not seen on __________ scan.
CT.
What is the presentation of a patient with myocardial contusion?
Unexplained Tachycardia, New BBB, ST-T abnormal
