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ER 2 > Thoracic Trauma > Flashcards

Thoracic Trauma Flashcards

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1
Q

Overview

A
  • Sig source of morbidity and mortality: Blunt chest trauma → 7-17% mortality and 33% morbidity (pneumonia, empyema, atelectasis)
  • Occurs in up to 20% trauma admissions
  • Blunt: <10% require sx intervention
  • Penetrating: 15-30% require intervention
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2
Q

Rib Fx

- overview

A
  • Extremely painful: Splinting secondary to pain might prevent adequate ventilation
  • Affects lung and chest wall mechanics
  • May damage underlying lung: hemorrhage, lung laceration, contusions
  • May produce prolonged morbidity: chronic pain, respiratory insufficiency
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3
Q

Rib Fx

- mortality related to what

A
  • Intrathoracic injury
  • Extrathoracic injury
  • Advanced age
  • 5+ rib fractures, mortality increases 1.8-3.2% per rib
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4
Q

Flail chest

A
  • Three sequential ribs fx in two or more places
    • Difficult to break this way, indicates significant amount of trauma
    • Harder to break ribs 1-4
  • Hypoventilation dt pain and paradoxical chest wall movement → inefficient mechanical ventilation
  • Associated with contusion of underlying lung which can lead to hypoxia and increased shunt fraction
  • PE: can feel crepitus, subcutaneous emphysema on CXR
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5
Q

Rib Fx

- Tx

A
  • Respiratory support: basic or advanced ventilation
  • Resuscitation as needed
  • Pain management: spinal blocks and epidurals vs. opiates
  • Early mobilization: fixate ribs to reduce movement reduces pain
  • Treat underlying conditions/injuries
  • Operative fixation if needed
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6
Q

Rib Fx

- Operative fixation

A
  • Decreased incidence of pneumonia and mortality
  • Not for every pt, select operative pts carefully
  • Avoid in polytrauma patients: TBI and multi-orthopedic injuries
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7
Q

Rib Fx

- Non-ventilator guidelines

A
  • Optimize analgesia (ideally epidural, also paravertebral analgesia if epidural CI)
  • Chest physiotherapy? Not common in real world
  • Diuretics if hydrostatic fluid overload, crystalloid to keep pressure up
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8
Q

Rib Fx

- Ventilator guidelines

A
  • CPAP/BIPAP if awake, helps prevent intubation
  • PEEP
  • High-frequency oscillatory ventilation (HFOV) via pulmonologist
  • Independent lung ventilation: if severe unilateral issue, ventilation mis-match situation
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9
Q

Pulmonary Contusion

- Overview

A
  • MC source of pulm dysfunction in chest trauma
  • Ventilation: perfusion mismatch → hypoxia
  • Immunologic response can lead to SIRS, may directly involve the alveolar-capillary membrane
  • Can lead to ARDS
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10
Q

Pulmonary Contusion

- tx

A
  • Pulmonary PT and hygiene to prevent infection/pneumonia
  • PEEP/CPAP to maintain alveolar expansion
  • IVF: hydration and pressure support
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11
Q

Pneumothorax

- overview

A
  • Collection of air in pleural space

- One of the MC injuries sustained in major trauma (>20%)

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12
Q

Pneumothorax

- Three types

A
  • Simple
  • Tension
  • Open
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13
Q

Simple Pneumothorax

A
  • Air in pleural space
  • Not associated with hemodynamic instability
  • Usually dt lung injury
  • Might not need tx, does not require emergent intervention (absence of breath sounds IS NOT indication for emergent chest decompression)
  • Can progress to tension pneumo
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14
Q

Occult Pneumothorax

A
  • Not seen on CXR
  • Was it really occult or just missed…
  • Concern for occult in setting of severe trauma IS valid indication for thoracic CT
  • If pt is stable, may be observed
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15
Q

Tension pneumothorax

A
  • Air collecting in pleural space is under more pressure than atmospheric pressure – transmitted onto mediastinum which causes a shift in the heart and great vessels away from the pneumothorax
  • Leads to decreased venous return and possibly total circulatory collapse
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16
Q

Tension pneumothorax

- dx

A 
Clinical:
• Respiratory distress
• Shock
• Unilateral decreased breath sounds
• Distended neck veins
• Hyperresonance
17
Q

Tension pneumothorax

- tx

A
  • Needle decompression
  • Tube thoracostomy
  • Between 2nd and 3rd at mid-clavicular line (above 3rd rib)
18
Q

Open pneumothorax

A
  • Chest wall allows air to enter pleural space from outside the chest
  • Always need chest tube, commonly associated with hemothorax
  • 3-sided occlusive dressing over wound + chest tube, possible sx
19
Q

Pneumothorax management

- small

A
  • Often no intervention needed
    • Pulmonary PT
    • Repeat films to show stability/resolution
    • O2?
20
Q

Pneumothorax management

- Chest tube required

A
  • Suction and water seal
  • Chest tube removal once PTX resolved (no more bubbles in water seal)
  • Persistent leak: 3 days post injury → VATS evaluation. VATS is video assisted thoracotomy
21
Q

Pneumothorax management

- pt education

A

Ok to fly >14 days after resolution of PTX

22
Q

Hemothorax

- define

A

Blood in pleural space, can be from any source

23
Q

Massive hemothorax

A
  • > 1.5 L, associated signs of shock and hypoperfusion
  • Can cause tension physiology
  • Decreased breath sounds
  • Dullness to percussion (vs. hyperresonant like tension pneumo)
  • Neck veins NOT a good indicator
24
Q

Hemothorax

- tx

A
  • Restoration of volume, rapid
  • Chest decompression + chest tube
  • Possible operative intervention
  • All should be considered for drainage, initial attempt via tube thoracostomy: if pull out a lot of blood, need to find source!!
25
Q

Hemothorax

- problem with blood

A

causes lots of long term problems including inflammation and fibrosis. Can also delay healing and cause infection and empyema

26
Q

Hemothorax

- indications for operative intervention

A
  • Based on patient physiology
  • 1500 mL of output / 24 hr regardless of mechanism
  • 200 mL / hour output for several hours after tube placement
27
Q

Risks associated with retained hemothorax

A
  • Empyema
  • Pneumonia
  • Fibrothorax (can’t re-expand the lungs)
28
Q

Retained hemothorax tx

A
  • VATS has high rates of success for tx but ¼ require thoracotomy
  • If retained HTX occurs after chest tube, don’t’ place another tube, do VATS
  • VATS should be done between hospital days 3-7
  • Intrapleural thombolytics may also be used to remove clots
29
Q

Penetrating trauma of the precordium

A
  • aka the box, where the important stuff is :)

- Sternum and spine protect this area well, requires sig trauma to get injury here

30
Q

Penetrating trauma of the precordium

- Dx tests for diaphragm injury

A
  • CXR, DPL, CT, FAST US

* Laparotomy is risky

31
Q

Complications of missed diaphragm injury

A

strangulated abd viscera (bowel MC), 36% mortality

32
Q

Thoracotomy

- Indications

A

Not clear

33
Q

Thoractomy

- Questions to ask prior to performing

A
  • Are there signs of life? Respiratory or motor effort, cardiac electrical activity, pupillary activity??
  • How long was arrest vs. presentation to ER
  • Blunt trauma? No indication if blunt
34
Q

Thoractomy

- Indications

A
  • Witnessed penetrating trauma and < 15 min pre-hospital CPR
  • Witnessed penetrating non-thoracic trauma with <5 min pre-hospital CPR
  • Witnessed blunt trauma with <5 min pre-hospital CPR
  • Persistent severe post injury hypotension (SBP <60) dt cardiac tamponade, hemorrhage, air embolism
35
Q

Thoracotomy

- Primary objectives

A
  • Release pericardial tamponade
  • Control cardiac hemorrhage
  • Control intrathoracic bleeding
  • Evacuate massive air embolism
  • Perform open cardiac massage
  • Temp. occlude descending thoracic aorta

ER 2 (10 decks)

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