Thoracic Trauma. Athens Technical College EMS Programs

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1 Thoracic Trauma Athens Technical College EMS Programs 1

2 Chest Trauma Second leading cause of trauma deaths after head injury About 20% of all trauma deaths 25% of MVC deaths are due to thoracic trauma 12,000 annually in US Abdominal injuries are common with chest trauma. 2

3 Anatomy of the chest Heart Lungs Aorta Vena Cavas Great blood vessels Trachea Esophagus 3

4 Pathophysiology of Thoracic Trauma Penetrating Trauma Low Energy Arrows, knives, handguns Injury caused by direct contact and cavitation High Energy Military, hunting rifles & high powered hand guns Extensive injury due to high pressure cavitation Trauma.org

5 Pathophysiology of Thoracic Trauma Blunt Trauma Results from kinetic energy forces Subdivision Mechanisms Blast Pressure wave causes tissue disruption Tear blood vessels & disrupt alveolar tissue Disruption of tracheobronchial tree Traumatic diaphragm rupture Crush (Compression) Body is compressed between an object and a hard surface Direct injury of chest wall and internal structures Deceleration Body in motion strikes a fixed object Blunt trauma to chest wall Internal structures continue in motion Ligamentum Arteriosum shears aorta 5

6 Chest Trauma Initial exam directed toward: Open pneumothorax Flail chest Tension pneumothorax Massive hemothorax Cardiac tamponade 6

7 Rib Fracture Most common chest injury More common in adults than children Especially common in elderly Ribs form rings Consider possibility of break in two places 7

8 Rib Fracture Most commonly 5th to 9th ribs Poor protection 8

9 Rib Fracture Fractures of 1st, 2 nd, 3rd ribs require high force Frequently have injury to aorta or bronchi 30% will die 9

10 Rib Fracture Fractures of 8th to 12th ribs can damage underlying abdominal solid organs: Liver Spleen Kidneys 10

11 Rib Fracture Signs and Symptoms Localized pain, tenderness Increases when patient: Coughs Moves Breathes deeply Chest wall instability Deformity, discoloration Associated pneumo or hemothorax 11

12 Rib Fracture Management High concentration O 2 Splint using pillow, swathes Encourage patient to breath deeply 12

13 Flail Chest Two or more adjacent ribs broken in two or more places Produces free-floating chest wall segment Usually secondary to blunt trauma More common in older patients 13

14 Flail Chest Signs and Symptoms Paradoxical movement May NOT be present initially due to intercostal muscle spasms Be suspicious in any patient with chest wall: Tenderness Crepitus 14

15 Flail Chest Consequences Pain, leading to decreased ventilation Increased work of breathing Contusion of lung 15

16 Flail Chest Management Establish airway Suspect spinal injuries Assist ventilation with BVM and oxygen Stabilize chest wall 16

17 Simple Pneumothorax Air in pleural space Partial or complete lung collapse occurs 17

18 Simple Pneumothorax Causes Chest wall penetration Fractured rib lacerating lung Paper bag effect May occur spontaneously following: Exertion Coughing Air Travel 18

19 Simple Pneumothorax Signs and Symptoms Pain on inhalation Difficulty breathing Tachypnea Decreased or absent breath sounds Severity of symptoms depends on size of pneumothorax, speed of lung collapse, and patient s health status 19

20 Simple Pneumothorax Management Establish airway Suspect spinal injury based on mechanism High concentration O 2 with NRB Assist decreased or rapid respirations with BVM Monitor for tension pneumothorax 20

21 Open Pneumothorax Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance air will enter there than through trachea Sucking Chest Wound 21

22 Open Pneumothorax Management Close hole with occlusive dressing High concentration O 2 Assist ventilations Consider transport on injured side Monitor for tension pneumothorax 22

23 Tension Pneumothorax One-way valve forms in lung or chest wall Air enters pleural space; cannot leave Air is trapped in pleural space Pressure rises Pressure collapses lung 23

24 Tension Pneumothorax Trapped air pushes heart, lungs away from injured side Vena cavae become kinked Blood cannot return to heart Cardiac output falls 24

25 Tension Pneumothorax Signs and Symptoms Extreme dyspnea Restlessness, anxiety, agitation Decreased breath sounds Hyperresonance to percussion Cyanosis Subcutaneous emphysema 25

26 Tension Pneumothorax Signs and Symptoms Rapid, weak pulse Decreased BP Tracheal shift away from injured side Jugular vein distension Early dyspnea/hypoxia - Late shock 26

27 Tension Pneumothorax Management Secure airway High concentration O 2 with NRB If available, request ALS intercept for pleural decompression 27

28 Hemothorax Blood in pleura space Most common result of major chest wall trauma Present in 70 to 80% of penetrating, major non-penetrating chest trauma 28

29 Hemothorax Signs and Symptoms Rapid, weak pulse Cool, clammy skin Restlessness, anxiety Thirst Chills Hypotension Collapsed neck veins 29

30 Hemothorax Signs and Symptoms Decreased breath sounds Dullness to percussion Dyspnea Ventilatory failure Shock precedes ventilatory failure 30

31 Hemothorax Management Secure airway Assist breathing with high concentration O 2 Rapid transport 31

32 Traumatic Asphyxia Blunt force to chest causes Increased intrathoracic pressure Backward flow of blood out of heart into vessels of upper chest, neck, head 32

33 Traumatic Asphyxia Signs and Symptoms Possible sternal fracture or central flail chest Shock Purplish-red discoloration of: Head Neck Shoulders Blood shot, protruding eyes Swollen, cyanotic lips 33

34 Traumatic Asphyxia Name given because patients looked like they had been strangled or hanged 34

35 Traumatic Asphyxia Management Airway with C-spine control Assist ventilations with high concentration O 2 Spinal stabilization Rapid transport 35

36 Cardiovascular Trauma Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise 36

37 Myocardial Contusion Bruise of heart muscle Most common blunt cardiac injury Usually due to steering wheel impact 37

38 Myocardial Contusion Behaves like acute MI May produce arrhythmias May cause cardiogenic shock, hypotension 38

39 Myocardial Contusion Signs and Symptoms Cardiac arrhythmias after blunt chest trauma Angina-like pain unresponsive to nitroglycerin Chest pain independent of respiratory movement Suspect in all blunt chest trauma 39

40 Myocardial Contusion Management High concentration O 2 Transport Consider ALS intercept 40

41 Cardiac Tamponade Rapid accumulation of blood in space between heart, pericardium Heart compressed Blood entering heart decreases Cardiac output falls 41

42 Cardiac Tamponade Signs and Symptoms Hypotension unresponsive to treatment Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP) Small quiet heart (decreased heart sounds) Beck s Triad 42

43 Cardiac Tamponade Signs and Symptoms Narrowing pulse pressure Pulsus paradoxicus Radial pulse becomes weak or disappears when patient inhales 43

44 Cardiac Tamponade Management Secure airway High concentration O 2 Rapid transport Definitive treatment is pericardiocentesis followed by surgery 44

45 Aortic rupture Usually blunt trauma involving deceleration forces; especially RTAs ~90% die within minutes Most common site near ligamentum arteriosum Dx: clinical suspicion, CXR, aortography, contrast CT or TOE Rx: surgical poor prognosis

46 Management of the Chest Injury Patient General Management Ensure ABC s High flow O2 via NRB Intubate if indicated Consider RSI Consider overdrive ventilation If tidal volume less than 6,000 ml BVM at a rate of May be beneficial for chest contusion and rib fractures Promotes oxygen perfusion of alveoli and prevents atelectasis Anticipate Myocardial Compromise Shock Management Fluid Bolus: 20 ml/kg AUSCULTATE! AUSCULATE! AUSCULATE!

47 Questions? 47

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