Thoracic Trauma Flashcards
Tissue hypoxia result from:
Inadequate O2 delivery to tissues 2ndary to airway obstruction
Hypovolemia from blood loss
Ventilation/perfusion mismatch from lung parenchymal injury
Compromise of ventilation and/or circulation from tension pneumothorax
Pump failure from severe myocardial injury / pericardial tamponade
Major symptoms of chest injury
SOB
Chest pain
Major signs of chest injury
Chest wall contusion Open wounds Subcutaneous emphysema Hemoptysis Distended neck veins Tracheal deviation Asymmetrical chest movement Cyanosis Shock Tenderness Instability Crepitation
Deadly dozen of major thoracic injuries:
ITLS 1' survey: Airway obstruction Flail chest Open pneumothorax Massive haemothorax Tension pneumothorax Cardiac tamponade
ITLS 2' survey: Myocardial contusion Traumatic aortic rupture Tracheal/bronchial tree injury Diaphragmatic tears Pulmonary contusions Blast injuries
Airway obstruction
FB
Tongue
Aspiration of vomitus/blood
Flail chest:
of 2/more adjacent ribs in 2/more places causing instability of chest wall and paradoxical movement of flail segment. The unstable segment will suck in with inhalation and push out with exhalation.
Always pulmonary contusion.
Risk for haemothorax/pneumothorax.
Algorithm flail chest:
- Scene size-up: T-bone/intrusion of door?
- Initial assessment:
LOC - often unconscious
Airway - snoring / gurgling
Breathing - apneic/ shallow+guarded/often NO tidal volume
Pulses - rapid/thready, skin cool/clammy, cyanotic - Rapid trauma survey:
Neck veins - flat
Trachea - midline
Chest - asymmetrical + paradoxical motion on affected side
Breath sounds - usually decreased on affected side
Abdomen - pain of # ribs may mask abdominal tenderness
Mx of flail chest:
- Open airway.
- Assist ventilation
- Administer high-flow O2
- Stabilize segment with manual pressure, then bulky dressings taped to chest.
- Load and go.
- Rapid transport.
- Notify ahead.
- Large: ET intubation + assisted ventilation with PEEP
Smaller flails: O2 + CPAP - Adequate pain relief.
- In shock - prevent fluid overload
Open pneumothorax
Accumulation of air in potential space between visceral and parietal pleura 2ndary to penetrating injury presenting as open or sucking chest wound >3cm in diameter.
Algorithm open pneumothorax
- Scene size-up: Safe?
- Initial assessment:
LOC - possibly decreased
Airway - possibly gurgling
Breathing - rapid + shallow/possibly labored/poor or NO tidal
volume
Pulses - rapid, thready/skin cool, clammy/cyanotic - Rapid trauma survey:
Neck veins - flat
Trachea - midline
Chest - asymmetrical with penetrations
Breath sounds - decreased on affected side
Heart tones - note for comparison later
Abdomen - where did object go
Back - where did object go
Mx open pneumothorax:
- Open airway
- High-flow O2. Assist ventilation prn
- Seal wound with gloved hand. Chest seal/flutter-type valve
- Load and go
- Large bore IV
- Monitor HR and heart tones for comparison
- Monitor O2 saturation with pulse oximeter and capnography
- Rapid transport
- Notify
Massive haemothorax:
Presence of at least 1500cc blood loss into pleural space.
Algorithm massive haemothorax
- Scene size-up:
- safe? Penetrating vs. blunt
- Initial assessment:
- LOC: decreased
- Breathing: rapid/shallow/labored
- pulses: weak/thready/absent radials
- skin: cool/clammy/diaphoretic/pale
- Rapid trauma survey
- neck: veins flat/trachea midline
- breath sounds: decreased/absent on affected side
- percussion: dull on affected side
Mx massive haemothorax
- Open airway
- High-flow O2
- Load and go
- Notify
- Rx shock:
- IV
- sBP 80-90mmHg
- Observe for developing tension heamopneumothorax:
- require acute chest decompression
Tension pneumothorax:
Air continuously leaks out of lung into pleural space.
Tension pneumothorax clinical signs:
Dyspnoea Anxiety Tachypnoea Distended neck veins Tracheal deviation Diminished breath sounds on affected side Hyperresonance Shock with hypotension
Algorithm tension pneumothorax:
- Scene size-up: seat belt/steering wheel?
- Initial assessment:
- LOC: decreased
- airway: open/movement of air?
- breathing: rapid/shallow, labored
- pulses: weak/thready, absent radials
- skin: cool/clammy/cyanotic
- Rapid trauma survey:
- head/neck: neck vein distention/possible tracheal deviation
- chest: absent/decreased breath sounds on affected side,
hyperresonant on affected side
Mx tension pneumothorax:
- Open airway
- High-flow O2
- Decompress affected side if indicated (more than 1):
- respiratory distress and cyanosis
- loss of radial pulse (late shock)
- decreasing LOC
- Load and go
- Rapid transport
- Notify
Cardiac tamponade:
Rapid collection of blood between heart and pericardium from cardiac injury. The accumulating blood compresses the ventricles preventing the ventricles from filling between contractions and causes cardiac output to fall.
Algorithm cardiac tamponade:
- Scene size-up: trauma to anterior chest?
- Initial assessment:
- LOC: decreased
- breathing: rapid/shallow
- pulses: weak/thready/absent radials/possible paradoxical pulse
- skin: cool/clammy/diaphoretic
- Rapid trauma survey:
- head/neck: neck vein distention/trachea midline
- chest: sternal contusion/#? Penetrating wound? Breath sounds
equal + present - heart sounds: muffled
Dx of cardiac tamponade rely on Beck’s triad + hypotension with narrow pulse pressure:
Distended neck veins
Muffled heart sounds
Pulsus paradoxus
Pulsus paradoxus:
Palpated radial pulse disappears during inspiration.
Mx cardiac tamponade:
- Open airway
- High-flow O2
- Load and go
- Rapid transport
- Notify
- Monitor heart
- 12-lead ECG (including V4R)
- Rx shock: IV for sBP 80-90mmHg
- Rx dysrhythmias
- Watch for other complications
Myocardial contusion:
Potentially lethal lesion due to blunt chest injury. Most frequently right atrium and ventricle. Resulting in chest pain, dysrhythmias, cardiogenic shock.
Algorithm myocardial contusion:
- Scene size-up: blunt trauma to anterior chest?
- Initial assessment:
- LOC: decreased
- breathing: rapid/shallow
- pulses: weak/thready/irregular pulse
- skin: cool/clammy/diaphoretic
- Rapid trauma survey:
- head/neck: neck vein distention/trachea midline
- chest: sternal contusion/#? / Breath sounds equal + present
Mx myocardial contusion:
- Open airway
- High-flow O2
- Load and go
- Rapid transport
- Notify
- Monitor heart
- 12-lead ECG (including V4R)
- Rx shock: IV for sBP 80-90mmHg
- Rx dysrhythmias
- Watch for other complications
Traumatic aortic rupture:
Tear in wall of aorta.
Suspect traumatic aortic rupture in:
- Blunt mechanism with rapid deceleration.
- May be no symptoms
- Chest / scapular pain
- Asymmetric BP measurements in upper extremities/upper extremity HTN, widened pulse pressure, diminished lower extremity pulses.
Mx traumatic aortic rupture:
- Open airway
- High-flow O2
- Rapid transport
- IV, but limit fluid administration.
- Monitor heart
- 12-lead ECG (including V4R)
- Notify.
Tracheal/bronchial tree injury:
Partial or complete disruption of airway. Localized within 2cm of carina in 80%. Present with dyspnoea and pneumothorax, subcutaneous emphysema, deformed chest.
Diaphragmatic tears:
Sudden increase in intra-abdominal pressure may tear diaphragm and allow herniation of abdominal organs into thoracic cavity. May cause marked respiratory distress. Breath sounds diminished, bowel sounds may be heard. Abdomen appear scaphoid.
Mx Diaphragmatic rupture:
- Open airway
- Assist ventilation
- High-flow O2
- Transport
- Rx shock: IV - hypovolaemia may occur.
- Notify.
Pulmonary contusion:
Haemorrhage into lung parenchyma 2ndary to blunt force trauma/penetrating injury such as missile. Common with flail chest/multiple rib #. Takes hours to develop. May cause marked hypoxia.
Mx pulmonary contusion:
- Intubation and/or assisted ventilation.
- O2
- Transport.
- IV
Blast injuries MOI:
1’: initial air blast. Affect air-filled structures like lungs, ears, GIT.
Pulmonary contusion, pneumothorax, tension pneumothorax.
2’: shrapnel propelled by blast force.
3’: body thrown by pressure wave and impact another object.
Crush injuries, as soon with structural collapse.
4’: thermal burns, radiation, respiratory injuries from toxins.
5’: hyperinfammatory state caused by chemicals in manufacturing
of bomb.
Mx blast injury:
- Open airway
- High-flow O2 (beware PPV)
- Load and go
- Mx other injuries
- IV
- Notify
