Traumatic Lung Disorders Flashcards
penetrating chest trauma
*foreign object that:
-pierces the skin
-enters the chest cavity with underlying organ injury
-leaves an open wound
*most common etiologies: gunshot wound, stabbing
penetrating chest trauma - associated injuries
*variable associated injuries, including:
-cardiac tamponade → cardiac arrest
-hemothorax
-pneumothorax
-tension pneumothorax
-tracheobronchial injury
-diaphragmatic injury
-rib fractures
-vascular injuries
-spinal cord injuries
penetrating chest trauma - clinical features
*hemorrhagic shock
*respiratory distress or failure
*absent or decreased breath sounds
*penetrating chest wound, “sucking chest wound”
*impaled foreign object
*tracheal deviation
*PNEUMOTHORAX or TENSION PNEUMO
tension pneumothorax
*accumulation of air in pleural space
*increasing trapped air → tension pneumo
*trachea deviates away from affected lung
*may lead to increased intrathoracic pressure → mediastinal displacement → kinking of IVC → decreased venous return → decreased cardiac output, obstructive shock (hypotension, tachycardia), jugular vein distention
*needs immediate needle decompression and chest tube placement
penetrating chest trauma - diagnosis
*history
*CXR
*eFAST (bedside ultrasound)
*CT chest (CTA if concerns for vascular injury)
*bronchoscopy if tracheoesophageal injury suspected
*echocardiogram for tamponade
penetrating chest trauma - treatment
*treat underlying injuries
*3-way occlusive dressing treats the open wound:
-on inspiration, dressing seals wound, preventing air entry
-expiration allows trapped air to escape through untaped section of dressing
*if tension pneumo → needle decompression and chest tube placement
*emergent thoracotomy if patient is unstable
chest blunt force trauma
*non-penetrating chest wounds
*common etiologies:
-motor vehicle crash (airbags, steering wheel, seat belt)
-vehicle-pedestrian crash
-struck by an object
-fall from height
-bike injuries
-assault
chest blunt force trauma - associated injuries
*chest wall injury/rib fractures and “flail chest”
*aortic rupture
*esophageal tear
*pulmonary contusion
*hemothorax
*pneumothorax
*cardiac injury
chest blunt force trauma - pulmonary contusion
*injury associated with localized ISCHEMIA/EDEMA to lung tissue
*if vascular structures of the chest wall are involved, there can be a mass effect (tension pneumo)
*PFTs would show decreased DLCO, decreased TLC, decreased lung compliance
chest blunt force trauma - diagnosis
*history
*chest imaging (CXR or CT)
*EKG
*echocardiogram
*bronchoscopy
chest blunt force trauma - management
*close monitor of vital signs, esp respiratory status
*risk of progressive repsiratory failure, esp with pulmonary contusion
*treat any underlying complications
*emergent thoracotomy if patient is unstable
drowning - defined
*respiratory impairment from submersion or immersion in a liquid
-submersion: victim’s airway goes below the surface of the liquid
-immersion: liquid splashes into the airway of the victim
drowning - risk factors
*male sex
*age < 14 years
*alcohol use
*rural residency
*exposure to aquatic activities
*lack of appropriate supervision
*epilepsy
drowning - mechanisms
*upon submersion/immersion: water voluntarily spit or swallowed; breath hold, quiet process
*water is aspirated after about 1 min of breath-holding
*cough reflex/laryngospasm until the onset of brain hypoxia and loss of consciousness
*time to cardiac arrest can be seconds to minutes, leading to anoxic brain injury (can be longer in hypothermic environment)
drowning - pathophysiology
*aspirated water (both salt water and fresh water) leads to SURFACTANT DYSFUNCTION AND WASHOUT → decreased compliance
*water disrupts the alveolar-capillary membrane → increased permeability & alveolar filling
*results in:
-low lung compliance
-V/Q mismatch
-atelectasis
-bronchospasm
drowning - signs and symptoms
*hypoxemia, hypotension, hypothermia, dysrhythmia
*cough, shortness of breath, altered mental status
drowning - treatment of a conscious victim
*if the pulmonary exam is abnormal to an isolated lobe, → ED for evaluation
*if shock, hypotension, or abnormal sounds in ALL lung fields → admit to ICU
drowning - treatment of an unconscious victim
*bring to land
*start CPR if no pulse
*call EMS
*ICU admission
drowning - treatment of a hypothermic victim
*continue resuscitation efforts until the core temperature is 32-35 C (90-95 F)
*cannot pronounce patient dead until they are warm and dead
barotrauma
*damage to tissue due to pressure difference in an enclosed cavity
pulmonary barotrauma
*damage to alveoli due to excessive positive pressure
*can have the presence of extra-alveolar air due to alveolar rupture
*seen in:
-scuba divers
-free divers
-MECHANICAL VENTILATION
pulmonary barotrauma - breathing mechanics
*in non-ventilated patients, due to: negative intrathoracic pressure
*in ventilated patients: due to positive pressure (mechanical ventilation)
pulmonary barotrauma - pathophysiology
*overdistention from positive pressure and increased alveolar pressure cause ALVEOLAR INFLAMMATION → INCREASED PERMEABILITY and ALVEOLAR EDEMA → worsening non-uniformity and lung compliance
*non-uniformity: not every alveolus experiences the same pressure → normal alveoli receive more tidal volume (and pressure) → rupture
pulmonary barotrauma - risk factors
*mechanical ventilation in patients with underlying pulmonary pathology are at increased risk:
-COPD
-interstitial lung disease
-pneumocystis jirovecii pneumonia
-ARDS
pulmonary barotrauma - management & complications
*treatment = prevention (low tidal volume ventilation & monitor plateau pressure)
*treat complications: pneumothorax & tension pneumothorax
tracheal stenosis
*narrowing of the subglottic region and trachea
*various etiologies:
-iatrogenic (endotracheal intubation, tracheostomy)
-autoimmune (granulomatosis with polyangiitis)
-infectious
-neoplasm
-traumatic
-idiopathic
tracheal stenosis - PFTs
*obstruction on flow-loop
- variable extrathoracic: Inspiratory loop flattened → EXTRAthoracic obstruction (I→E)
- variable intrathoracic: Expiratory loop flattened → INTRAthoracic obstruction (E→I)
- fixed: inspiratory and expiratory flattening
tracheal stenosis - diagnosis
*bronchoscopy / largyngoscopy
*CT neck/chest (rule out extra-tracheal stenosis)
tracheal stenosis - pathophysiology in prolonged intubation
*damage due to endotracheal tube cuff pressure
*tissue ischemia → ulceration → fibrotic strictures
tracheal stenosis - treatment
*bronchoscopy: mechanical dilation, laser therapy, stenting
*open surgery
*tracheostomy
tracheoesophageal fistula
*abnormal connection between the trachea and esophagus
*can be congenital or ACQUIRED (acquired due to malignancy, trauma, or intubation)
tracheoesophageal fistula - symptoms
*cough
*cyanosis
*malnutrition
*recurrent pneumonitis or pneumonia
tracheoesophageal fistula - diagnosis
*esophagogram with barium
*CT chest
*endoscopy: bronchoscopy or upper endoscopy
tracheoesophageal fistula - treatment
*no oral intake until resolved
*treat underlying etiology
*endoscopic stents: airway and/or esophagus
*surgical repair
atelectasis
*decreased expansion or loss of lung volume
*risk factors: age, surgery, malignancy, smoking
atelectasis - pathogenesis
*several different causes:
1. DEFLATION OF THE ALVEOLI
2. obstruction of proximal airway (plugging, tumor, foreign bodies)
3. COMPRESSION: loss of contact between visceral and parietal pleura (effusion, pneumothorax)
atelectasis - symptoms
*usually asymptomatic but can have shortness of breath, chest pain, cough
*hypoxemia, tachypnea, cyanosis
*decreased breath sounds
*dullness to percussion
*decreased fremitus
*tracheal deviation due to volume loss (TOWARD affected lung)
note - contrast this to tension pneumothorax, where the trachea deviates away from the affected side
atelectasis - diagnosis
*CXR
*CT chest
*broncoscopy
atelectasis - treatment
*treat underlying condition
*focus on mucus clearance, similar to CF and bronchiectasis
what happens to the pleural pressure in a pneumothorax
*pleural pressure equalizes with atmospheric pressure
what happens to pleural pressure in a TENSION pneumothorax
*pleural pressure becomes SUPRA-ATMOSPHERIC (above atmospheric pressure)
*leads to mediastinal displacement → kinking of the IVC → decreased venous return → decreased cardiac output, obstructive shock (hypotension, tachycardia), and jugular vein distention
