THORACIC TRAUMA Flashcards
MANAGEMENT
DDx: CRITICAL INJURIES
AIRWAY:
Laryngeal Injury
Tracheobronchial Tree Injury
BREATHING:
Tension Pneumothorax
Open Pneumothorax
CIRCULATION:
Massive Hemothorax
Cardiac Tamponade
POCUS
Subxiphoid
Lung Resus
Pleural Effusion
SHOCK:
HEMORRHAGIC
CODE TRANSFUSION
Indication: Anticipate the need for at least 4 U pRBC, & component therapy plt, Plasma, Fibrinogen
Criteria:
Blood loss greater than 1500 mL or greater than 6 PC
Uncontrolled hemorrhage and hemodynamic instability
Ongoing bleeding after 4 PC
Trauma patients with ABC score greater or equal to 2
Resuscitation intensity of greater or equal to 4 units of fluid in first 30 min (fluid = 1 unit RBC, 1 unit plasma, 500 mL colloid, 1 L crystalloid)
TXA: 2 g in 100 mL IV over 20 min via pump
Testing:
Baseline and q hourly:
CBC, INR, PTT, Fibrinogen, iCa, Lactate, Lytes, ABG
Ensure blood bank has group and screen
Transfusion Protocol:
Pack 1: 4 pRBC
Pack 2: 4 pRBC and 4 Plasma
All subsequent packs: 4 pRBC and 2 plasma
Platelets and fibrinogen PRN based on lab results
Prepare 4 g of fibrinogen concentrate for all code obstetrics
Transfusion Targets:
Hgb > 80
Plt > 50
INR < 1.8
Fibrinogen > 1.5 (2 for obstetrics)
iCa >< 1.15
Base deficit < 3
SBP 70-90 mmHg unless TBI
No role for octaplex
TENSION PNEUMOTHORAX
Needle Decompression
Peds – 2nd intercostal space midclavicular line
Adults – 5th intercostal space anterior to midaxillary line
5 cm or 8 cm over-the-needle catheter with Luer-Lok 10 cc syringe
Aspirate the syringe while advancing
Puncture Pleura
Remove Syringe
Listen to air escape
Advance catheter into the pleural space
Stabilize and prepare for chest tube insertion
HEMOTHORAX
Finger and Tube Thoracostomy
Tube thoracostomy tray, antiseptic, sterile drape, underwater seal, tubing
28-32 F Chest Tube for Hemothorax
OR
14 F Pig Tail Catheter for pneumothorax
Ipsilateral arm extended overhead and flexed at elbow
Prep and Drape lateral chest wall, include nipple in the intraoperative field
Identify 4th or 5th intercostal space anterior midaxillary line
Inject site with local anesthetic
Incision just above the rib
Puncture pleura with Kelly clamp
Advance tube, look for fogging
Wrap with xeroform
Precut gauze
TAMPONADE
Blind Approach
18-gauge spinal needle
* 20-mL syringe
* Position the patient supine.
* Use the subxiphoid approach.
* Clean the area and inject 2.5-5 mL of lidocaine 1% with epinephrine to create a wheal over the needle insertion area, if patient is not in cardiac arrest.
* Place an 18-gauge spinal needle on the 20-mL syringe.
* Insert the needle 1 cm inferior to the junction between the left costal arch and xiphoid process.
* Angle the needle between 15° and 30°, aiming toward the left shoulder.
o A medial or steep entry carries a risk of right atrial or intra-abdominal puncture.
* Slowly advance the needle with continual aspiration until fluid is obtained.
o Redirection, using an anterior-to-posterior motion, may be required if no fluid is aspirated.
IMAGING
Portable CXR
CT Scan of Chest with IV Contrast
ECG
DOCUMENTATION
HISTORY
Restraint
Speed of Vehicle
Ejection from Vehicle
Abrupt Deceleration
PHYSICAL EXAM
Respiratory distress / Increased work of breathing
Tenderness of chest wall (MOST SENSITIVE SIGN)
Palpable subcutaneous air (crepitus) or bony abnormalities of chest wall
Seatbelt sign
