56154976 Chest Trauma

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Thoracic Trauma Thoracic Trauma

Bisatyo MardjikoenBisatyo MardjikoenUniversitas Islam Negeri Syarif HidayatullahUniversitas Islam Negeri Syarif Hidayatullah

Fakultas Kedokteran & Ilmu KesehatanFakultas Kedokteran & Ilmu KesehatanProgram Studi Ilmu KedokteranProgram Studi Ilmu Kedokteran

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Chest TraumaChest Trauma

Second leading cause of trauma deaths afterSecond leading cause of trauma deaths afterhead injury head injury

About 20% of all trauma deaths About 20% of all trauma deaths

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Anatomy Anatomy

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Type of Chest I njuries Type of Chest I njuries

Penetrating Penetrating the forces are distributed over a small area

BluntBluntthe forces are distributed over a larger area

occur from compression or shearing forceoccur from compression or shearing force

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A ssessme n t A ssessme n t

Signs and symptoms of chest trauma:Shortness of breath

Tachypnea

Chest pain

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Chest TraumaChest Trauma

Initial exam directed toward:Initial exam directed toward:O pen pneumothoraxO pen pneumothorax

Flail chestFlail chest Tension pneumothorax Tension pneumothoraxMassive hemothoraxMassive hemothorax

Cardiac tamponadeCardiac tamponade

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R ib FractureR ib Fracture

Most common chest injury Most common chest injury

More common in adults than childrenMore common in adults than childrenEspecially common in elderly Especially common in elderly Ribs form ringsRibs form rings

Consider possibility of break in two placesConsider possibility of break in two places

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Most commonly 5th to 9th ribsMost commonly 5th to 9th ribsPoor protectionPoor protection

Associated injuries:pulmonary contusion

laceration of the intercostals artery an/or vein withresulting hemothorax & pneumothorax

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Fractures of 1st, 2nd ribs require high forceFractures of 1st, 2nd ribs require high forceFrequently have injury to aorta or bronchiFrequently have injury to aorta or bronchi30% will die30% will die

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Fractures of 8th to 12th ribs can damage underlying Fractures of 8th to 12th ribs can damage underlying abdominal solid organs:abdominal solid organs:

L iverL iverSpleenSpleenKidneysKidneys

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Signs and SymptomsSigns and SymptomsL ocalized pain, tendernessL ocalized pain, tenderness

Increases when patient:Increases when patient:CoughsCoughsMovesMovesBreathes deeply Breathes deeply

Chest wall instability Chest wall instability Associated pneumo or hemothorax Associated pneumo or hemothorax

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ManagementManagementO xygenation, if necessary O xygenation, if necessary

Encourage patient to breath deeply Encourage patient to breath deeply

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Flail ChestFlail Chest

Two or more adjacent ribs broken in two or Two or more adjacent ribs broken in two ormore placesmore places

Produces freeProduces free--floating chest wall segmentfloating chest wall segmentUsually secondary to blunt traumaUsually secondary to blunt traumaMore common in older patientsMore common in older patients

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Signs and SymptomsSigns and SymptomsParadoxical movementParadoxical movement

May May NO TNO T be present initially due to intercostalbe present initially due to intercostalmuscle spasmsmuscle spasmsBe suspicious in any patient with chest wall:Be suspicious in any patient with chest wall:

Tenderness TendernessCrepitusCrepitus

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ConsequencesConsequencesPain, leading to decreased ventilationPain, leading to decreased ventilation

Increased work of breathing Increased work of breathing Contusion of lung Contusion of lung

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ManagementManagementEstablish airway Establish airway

Suspect spinal injuriesSuspect spinal injuriesO xygenationO xygenation

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S imple P neumothoraxS imple P neumothorax

Air in pleural space Air in pleural spacePartial or complete lung collapse occursPartial or complete lung collapse occurs

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CausesCausesChest wall penetrationChest wall penetration

Fractured rib lacerating lung Fractured rib lacerating lung Paper bag effectPaper bag effectMay occur spontaneously following:May occur spontaneously following:

ExertionExertionCoughing Coughing Air Travel Air Travel

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Signs and SymptomsSigns and SymptomsPain on inhalationPain on inhalation

Difficulty breathing Difficulty breathing Tachypnea TachypneaDecreased or absent breath soundsDecreased or absent breath sounds

Severity of symptoms depends on size of pneumothorax, speed of lung collapse,

and patients health status

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O pe n PneumothoraxO pe n Pneumothorax

Hole in chest wallHole in chest wall Allows air to enter pleural space Allows air to enter pleural space

L arger hole = Greater chance air will enter thereL arger hole = Greater chance air will enter therethan through tracheathan through trachea

Sucking Chest Wound

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S ucki ng Chest Wou nd : First A id

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O pe n PneumothoraxO pe n Pneumothorax

ManagementManagementClose hole with occlusive dressing Close hole with occlusive dressing

High concentration OHigh concentration O 22 Assist ventilations Assist ventilationsConsider transport on injured sideConsider transport on injured side

Monitor for tension pneumothoraxMonitor for tension pneumothorax

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Te nsio n Pneumothorax Te nsio n Pneumothorax

O neO ne--way valve forms in lung or chest wall way valve forms in lung or chest wall Air enters pleural space; cannot leave Air enters pleural space; cannot leave Air is trapped in pleural space Air is trapped in pleural spacePressure risesPressure rises

Pressure collapses lung Pressure collapses lung

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Trapped air pushes heart, lungs Trapped air pushes heart, lungs away away fromfrominjured sideinjured side

Vena cavae become kinked Vena cavae become kinkedBlood cannot return to heartBlood cannot return to heartCardiac output fallsCardiac output falls

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Signs and SymptomsSigns and SymptomsExtreme dyspneaExtreme dyspneaRestlessness, anxiety,Restlessness, anxiety,

agitationagitationDecreased breath soundsDecreased breath soundsHyperresonance toHyperresonance topercussionpercussion

CyanosisCyanosisSubcutaneous emphysemaSubcutaneous emphysema

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Signs and SymptomsSigns and SymptomsRapid, weak pulseRapid, weak pulse

Decreased BPDecreased BP Tracheal shift Tracheal shift away away from injured sidefrom injured side Jugular vein distension Jugular vein distension

E arly dyspnea/hypoxia - Late shock

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ManagementManagementSecure airway Secure airway

High concentrationO

High concentrationO

22If available, request AL S intercept for pleuralIf available, request AL S intercept for pleuraldecompressiondecompression

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H emothoraxH emothorax

Blood in pleural spaceBlood in pleural spaceMost common result of major chest wall traumaMost common result of major chest wall trauma

Present in 70 to 80% of penetrating, major nonPresent in 70 to 80% of penetrating, major non--penetrating chest traumapenetrating chest trauma

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Signs and SymptomsSigns and SymptomsRapid, weak pulseRapid, weak pulseCool, clammy skinCool, clammy skin

Restlessness, anxiety Restlessness, anxiety Thirst ThirstChillsChillsHypotensionHypotensionCollapsed neck veinsCollapsed neck veins

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Signs and SymptomsSigns and SymptomsDecreased breath soundsDecreased breath sounds

Dullness to percussionDullness to percussionDyspneaDyspnea

Ventilatory failure Ventilatory failure

Shock precedes ventilatory failure

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Assist breathing with high concentrationO

Assist breathing with high concentrationO

22Rapid transportRapid transport

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Traumatic A sphyxia Traumatic A sphyxia

Blunt force to chest causesBlunt force to chest causesIncreased intrathoracic pressureIncreased intrathoracic pressureBackward flow of blood out of heart into vessels of Backward flow of blood out of heart into vessels of upper chest, neck, headupper chest, neck, head

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Signs and SymptomsSigns and SymptomsPossible sternal fracture or central flail chestPossible sternal fracture or central flail chest

Shock Shock PurplishPurplish--red discoloration of:red discoloration of:HeadHeadNeck Neck

ShouldersShouldersBlood shot, protruding eyesBlood shot, protruding eyesSwollen, cyanotic lipsSwollen, cyanotic lips

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Name given because patients lookedName given because patients lookedlike they had been strangled or hangedlike they had been strangled or hanged

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ManagementManagement Airway with C Airway with C--spine controlspine control

Assist ventilations with high concentration O Assist ventilations with high concentration O 22Spinal stabilizationSpinal stabilizationRapid transportRapid transport

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Card iovascular TraumaCard iovascular Trauma Any patient with significant blunt or Any patient with significant blunt or

penetrating trauma to chest haspenetrating trauma to chest hasheart/great vessel injury until provenheart/great vessel injury until proven

otherwiseotherwise

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M yocar d ial Con tusio nM yocar d ial Con tusio n

Bruise of heart muscleBruise of heart muscleMost common blunt cardiac injury Most common blunt cardiac injury Usually due to steering wheel impactUsually due to steering wheel impact

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Behaves like acute MIBehaves like acute MIMay produce arrhythmiasMay produce arrhythmiasMay cause cardiogenic shock, hypotensionMay cause cardiogenic shock, hypotension

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Signs and SymptomsSigns and SymptomsCardiac arrhythmias after blunt chest traumaCardiac arrhythmias after blunt chest trauma

Angina Angina--like pain unresponsive to nitroglycerinlike pain unresponsive to nitroglycerinChest pain independent of respiratory movementChest pain independent of respiratory movement

Suspect in all blunt chest trauma

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ManagementManagementHigh concentration OHigh concentration O 22

Transport TransportConsider AL S interceptConsider AL S intercept

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Card iac Tampo nadeCard iac Tampo nade

Rapid accumulation of blood in space betweenRapid accumulation of blood in space betweenheart, pericardiumheart, pericardium

Heart compressedHeart compressedBlood entering heart decreasesBlood entering heart decreasesCardiac output fallsCardiac output falls

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Signs and SymptomsSigns and SymptomsHypotension unresponsive to treatmentHypotension unresponsive to treatmentIncreased central venous pressure (distendedIncreased central venous pressure (distendedneck/arm veins in presence of decreased arterialneck/arm veins in presence of decreased arterialBP)BP)Small quiet heart (decreased heart sounds)Small quiet heart (decreased heart sounds)

B ecks Triad

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Signs and SymptomsSigns and SymptomsNarrowing pulse pressureNarrowing pulse pressurePulsus paradoxicusPulsus paradoxicus

Radial pulse becomes weak or disappears when patientRadial pulse becomes weak or disappears when patientinhalesinhales

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High concentrationO

High concentrationO

22Rapid transportRapid transportDefinitive treatment is pericardiocentesisDefinitive treatment is pericardiocentesisfollowed by surgery followed by surgery

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Traumatic A ortic Aneurysm Traumatic A ortic Aneurysm

Caused by sudden decelerations, massive bluntCaused by sudden decelerations, massive bluntforce:force:

Vehicle collisions Vehicle collisionsFalls from heightsFalls from heightsCrushing chest traumaCrushing chest traumaBlunt chest traumaBlunt chest trauma

Animal kicks Animal kicks

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Rupture usually occurs just beyond leftRupture usually occurs just beyond leftsubclavian artery subclavian artery

Attachment of aorta to pulmonary artery at this Attachment of aorta to pulmonary artery at thispoint produces shearing force on aortic archpoint produces shearing force on aortic arch

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Signs and SymptomsSigns and SymptomsIncreased BP in arms in absence of head injury Increased BP in arms in absence of head injury

Decreased femoral pulses with full arm pulsesDecreased femoral pulses with full arm pulsesRespiratory distressRespiratory distress

Ache in chest, shoulders, lower back, abdomen. Ache in chest, shoulders, lower back, abdomen.( O nly 25% of patients)( O nly 25% of patients)

D etection requires high index of suspicion

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ManagementManagementHigh concentrationHigh concentrationoxygenoxygen

Assist ventilation Assist ventilationSuspect spinal injury Suspect spinal injury Rapid transportRapid transport

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A ssociate d A bdomi nal Trauma A ssociate d A bdomi nal Trauma

Diaphragm forms dome that extends up into ribDiaphragm forms dome that extends up into ribcagecage

Trauma to chest below 4th rib = Abdominal Trauma to chest below 4th rib = Abdominalinjury until proven otherwiseinjury until proven otherwise

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56154976 Chest Trauma