- 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

- 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

- 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

- 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

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

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

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

Thoracic Trauma Flashcards by Kathleen McKenzie

Overview

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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Rib Fx

- overview

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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Rib Fx

- mortality related to what

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

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Flail chest

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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Rib Fx

- Tx

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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Rib Fx

- Operative fixation

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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Rib Fx

- Non-ventilator guidelines

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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Rib Fx

- Ventilator guidelines

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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Pulmonary Contusion

- Overview

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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Pulmonary Contusion

- tx

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

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Pneumothorax

- overview

Collection of air in pleural space

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

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Pneumothorax

- Three types

Simple
Tension
Open

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Simple Pneumothorax

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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Occult Pneumothorax

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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Tension pneumothorax

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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Tension pneumothorax

- dx

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

Tension pneumothorax

- tx

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

Open pneumothorax

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

Pneumothorax management

- small

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

Pneumothorax management

- Chest tube required

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

Pneumothorax management

- pt education

Ok to fly >14 days after resolution of PTX

Hemothorax

- define

Blood in pleural space, can be from any source

Massive hemothorax

> 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

Hemothorax

- tx

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!!

Hemothorax | - problem with blood

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

Hemothorax | - indications for operative intervention

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

Risks associated with retained hemothorax

- Empyema - Pneumonia - Fibrothorax (can’t re-expand the lungs)

Retained hemothorax tx

* 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

Penetrating trauma of the precordium

- aka the box, where the important stuff is :) | - Sternum and spine protect this area well, requires sig trauma to get injury here

Penetrating trauma of the precordium | - Dx tests for diaphragm injury

* CXR, DPL, CT, FAST US | * Laparotomy is risky

Complications of missed diaphragm injury

strangulated abd viscera (bowel MC), 36% mortality

Thoracotomy | - Indications

Not clear

Thoractomy | - Questions to ask prior to performing

- 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

Thoractomy | - Indications

- 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

Thoracotomy | - Primary objectives

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