Thoracic Trauma Flashcards
What Methods of Assessment is needed for Thoracic Trauma?
Dr cA(c)BCDE (the use) then IPPA
What things are you looking for When Inspecting the Chest?
- Cut off clothes
- Symmetry/deformity
- Bleeding, wounds, bruising
- Hyperinflation
- Rate
- Pattern of bresthing
- Axillary, post, lat
- Effort, depth, muscle use
- Paradoxical movement
Proccess of Palpation and What feeling for
- Palate all parts of chest; clavicle, sternum, ribs
- Crepitus
- Pain/tenderness
- Surgical emphysema
- Symmetry
- Respiratory excursion/unilateral hyp
Percussion Assessment and Sounds
- Hyperesonance - excess air
- Hyporesonance - consolidation
- Assess laterally and posteriorly
What we’re Listening for in Auscultation
- normal sounds
- Abscent sounds
- Decreased breath sounds
- Adventitious sounds
List of Potential Chest Injuries (9)
- Rib Fractures
- Pulmonary Contusion
- Flail Chest
- Tension Pneumothorax
- Open Pnuemothorax
- Haemothorax
- Blunt Cardiac Injury
- Ruptures
- Cardiac Tamponade
Rib Fractures
- Most common 4-8 laterally
- Can be assc with liver or spleen injuries
- Most common complaint of simple rib fracture is SOB due to pain
- Adequate pain releif wil releive SOB and any potential hypoxia as pt can now increase tidal volume
What is a Pulmonary Contusion?
- An injury to the lungs associated with blunt trauma which leads to blood and oedema accumulating in the alveoli
- This will mean there is a loss of normal structures, an impairment of gas exchange, increased vascular resistance and decreased lung compliance
- Can be potentially lethal complication of thoracic injury
- Severe inflammatory reaction leads to acute respiratory distress syndrome (ARDS) in 50-60% of cases
Fl
What is Flail Chest?
- 2 or more rib fractures in 2 or more places
- It then becomes difficult to ventilate
- Can also lead to blood loss
Spontaneous Pneumothorax (what is it? pt group? Treatment)
- (stereotypically) tall, skinny males spontaneously having their lung collapse
- Air is in the pleural cavity
- Non-expanding air
- Lungs collapse to variable extent
- Don’t decompress just go to hospital
- No midiastinal shift
What are the Pneumothorax Types?
- Spontaneous
- Open
- Haemothorax
- Tension
What is a Tension Pneumothorax?
- A progressive build up of air, trapped in pleural space
- Air enters the pleural space on inspiration but cannot escape in expiration due to the formation of a one way valve
- Will lead to compromise/collapse of cardiovascular function
Presentation of Tension Pneumothorax
- Tachycardic
- Tachypnora
- Increased WOB (muscle use)
- Wheeze/reduced breath sounds on affected side
- Cardiovascular collapse
- Hypoxia
- Hyper-inflated chest (hard to BVM)
- Hyper-resonant on affected side
TWELVE pneumonic (Assessment for Tension Pneumothorax)
T racheal deviation
W ounds, bruising, swelling around neck
E mphysema (surgical)
L aryngeal crepitus
V enous engorgment (jugular)
What is an Open Pneumothorax?
- A hole in the chest wall causing air to enter the pleural space, hole creates a one way valve meaning air can only come in
- When the person inhales, air enters the lungs increasing the pressure
- Can eventually casue the lung to collapse due to pressure
What is a Haemothorax?
An accumulation of blood in the plural space following blunt or penetrating trauma eg rib fractures
What is a Blunt Cardiac Injury?
The most commonly undiagnosed fatal thoracic injury. It occurs when there is direct compression of the heart due to blunt trauma or rapid deceleration
What is a Cardiac Tamponade?
- Fluid/blood ect goes into the pericardial sac, compressing the heart until its too restricted to move
- Usually from penetrating injury into the heart or great vessels
- The heart has a fixed volume it can allow bleeding into which will decrease cardiac output
Injuries Associated with Penetrating Injuries
- Laceration of heart and great vessels
- Laceration of intercostal vessels
- Damage to airway, oesophagus, diagram and alveoli
Injuries Associated with Blunt Mechanism
- Cardiac tamponade
- Pulmonary contusion
- Rub fractures with maybe flail segment
- Thoracic spine fractures
Injuries Associated with Crush Mechanism
- Ruptured bronchus, oesophagus
- Cardiac contusion
- Pulmonary contusion
- Bilateral rib fractures with or without flail segments
Injuries Associated with Blast Mechanism
- Disruption of any organ
- Pulmonary contusion
- Alveoli rupture
- Pneumothorax
- Spinal fracture
- Fragmentation injuries
Injuries Associated with Deceleration Mechanism
- Aortic disruption
- Major airway injury
- Diagrammatic rupture
What are the Two Types of Penetrating Injuries (exampes of both)
- Two types ; high velocity and low velocity
- High velocity - bullets (high speed)
- Low Velocity - crush, knife
Mechanism of Penetrating Injury
- The force applied to the chest wall will be transferred to the thoracic organs, diffusing injury to all the organs
- Can cause underlying contusions
Diagnosis of Pulmonary Contusion
- Tends to develop over 24-48 hours
- Usually seen in the presence of blunt chest wall trauma eg bruises or underlying rib fractures
- Rib fractures are less likely presentation in children
- MOI based
- Increasing respiratory distress
- Hypoxia
Treatment of Pulmonary Contusion
- Treatment such as tubing or ventilating is uncommon and only done when necessary
- Oxygen therapy on monitoring for 24-48hours
- Look out for complications of ARDS and pneumonia
Diagnosis of Flail Chest
- Hard to breath deeply due to pain
- Paradoxical movement when breathing
- Crepitus on palpation
- Segment of chest that sucks in paradoxically to the rest of the lungs
- Usually only seen in large MOI trauma
Treatment of Flail Chest
- Go to MTC with O2
- Pain decreases tidal volume, inhibits coughing (allowing secretions to build up) so pain management is important
Important things to Note with Tensions (Positive vs Negative Pressure Breathing)
- If alive and spontaneously breathing let them keep doing negative pressure breathing to counteract the positive pressure pneumothorax
- As soon as tired/dead start provide BVM - this is positive pressure which will increase the pressure further (NEEDS decompression)
Late Signs of a Tension Pneumothorax
- Deviated trachea
- PEA arrest
- Increased JVP
- Cardiovascular collapse
Treatment of a Tension Pneumothorax
- Needle thoracentesis (decompression) on affected side
- Be careful of giving them a tension
- Can and probably will retention naturally or due to cannula blocking
- Use largest bore cannula (orange) in second intercostal space, just above the third rib. Mid-clavicular line
Diagnosis of an Open Pneumothorax
- Look for visible wounds
- Think about MOI
- Can have similar presentation to tension pneumothorax
Treatment of an Open Pneumothorax
- Needs Russel chest seal
- Makeshift chest seal - dry gauze with three sided tape
Diagnosis of a Haemothorax
- Percussion will be more dull/hypo resonance
- Percussion sort of only way of differentiating pre-hospitally
- Massive haemothorax diagnosed as 1500ml/third of blood vol into pleural space/intercostal drain
Treatment of a Haemothorax
- We cannot di anything but suspect diagnosis
- CCP/HEMS can do drainage
- Follow hypotensive protocols
Diagnosis of Blunt Cardiac Injury
- May lead to valve rupture, ventricular damage, MIs (missed as MSK pain)
- 20% of patients have arrythmias eg sinus tachy, SVT, AF, ectopic’s, ventricular tachycardia, ventricular fibrillation
- Conduction problems like bundle branch blocks to complete heart block may develop
- Increased JVP could be due to right ventricular dysfunction
- Troponin lvls more conclusive
Treatment of Blunt Cardiac Injury
Varies on what injury heart has sustained eg MI would be treated accordingly, valve repair if ruptured, balloon pump if needed
Diagnosis of a Cardiac Tamponade
- Will present similarly to a tension
- Becks Triad - hypotension, increased JVP, muffled heart sounds
- Kussmaul’s breathing pattern
- MOI based diagnosis
- Doesn’t respond to fluid therapy
- Note; if there is significant hypovolaemia there will be no increased JVP and heart sounds will not be heard in a busy environment aka difficult to diagnose pre-hospitally
Treatment of Cardiac Tamponade (Plus the differences between the Thora-omy’s
- Pericardiocentesis - a needle is used to drain away blood from the pericardial sac (actual treatment)
- Thoracostomy - putting a tube into the axilla to drain away fluid or air from between the pleural space and chest wall
- Thoracotomy - opening up the chest, 2 min procedure
What are Tracheobronchial Injuries?
- Injuries to the trachea or main bronchus caused by either blunt or penetrating trauma
- May be fatal if not recognised, there is a very high mortality rate in these patients
Diagnosis of Tracheolbronchial Injuries
- Any dmg to neck, mediastinum and chest wall should always raise suspicion
- Laryngeal fractures are rare but would produce hoarseness, emphysema, palpable crepitus over fracture
- Pneumothorax may be present
- Emphysema
- Diagnosis is confirmed with a bronchoscopy
Treatment of Tracheobronchial Injuries
- Intubation indicated though probably difficult due to anatomy changes
- Surgical repair needed through thoracostomy
What is a Diaphragmatic Injury?
- A tear in the muscle between the that separates the abdominal cavity and the chest wall
- Blunt trauma produces large, radical tears of the diaphragm and herniation of abdominal viscera into the chest (abdo organs move to thorax when shouldn’t)
- Penetrating trauma can also cause injury to the diaphragm
Diagnosis of Diaphragmatic Injury
- Left sided tearing is more likely, bilateral rupture is rare
- Abdo pain
- Chest pain, especially to left side
- Mediastinal shift may be present
- May hear bowel sounds higher up in chest due to herniation of abdominal contents
- DIB and decreased lung sounds
- MOI based
- A chest radiograph will tell you organ positioning
Complications of a Diaphragmatic Injury
- Can cause pneumothorax due to increased pressures from the abdominal herniation
- Increased pressure could eventually tamponade the heart
- Bowel herniation, incarceration, strangulation
What are Ruptures?
Tears are usually associated with blunt or deceleration injuries such as RTCs or falls from height
What is an Aortic Rupture?
- The aorta may be completely or partially transected or may have a spiral tear
- Anatomically, the aorta has three fixed points so that decelerating, the mobile parts create shearing forces
Diagnosis and Treatment of Aortic Rupture
- In 90% of cases this is immediately fatal and accounts for around 15% of immediate trauma deaths in RTCs
- Survival is only possible by early recognition with early surgical intervention
- Permissive hypotension needed
What is Oesophageal Injury?
- Damage to the oesophagus is usually caused by penetrating trauma
- The proximity to the major vessels and other mediastinal structures means that the consequences of the damage to these are more important and the oesophagus damage will be overlooked
- Blunt trauma is rare
Diagnosis of Oesophageal Injury
- If there is any blunt trauma it would be from the upper abdomen forcing the stomachs contents into the oesophagus causing a tear, this will then mean there is a leaking of contents into the pleural space
- The diagnosis should be considered in any blunt trauma to the abdomen
- Can only be confirmed with draining tube or endoscopy
Treatment of Oesophageal Injury
- Be careful of diagnosis of haemothorax, be aware it could be stomach contents in upper part of abdomen
- Suction
- Treatment is surgical repair after diagnosis
Indication of Thoracotomy in Penetrating Injuries
- TCA with previously witness cardiac activity
- Unresponsive hypotension to fluids (<70)
- Rapid exsanguination from intercostal drainage or into airways
Indication of Thoractomoy in Blunt Injuries
- Unresponsive hypotension to fluids (<70)
- Rapid exsanguination from intercostal drainage or into airways
