Chest Trauma Basics

7/29/2019 Chest Trauma Basics

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CHEST TRAUMAHEST TRAUMAHEST TRAUMAHEST TRAUMAJoe Lex, MD, FAAEMoe Lex, MD, FAAEMTemple University Hospitalemple University Hospital

Philadelphia, PAhiladelphia, PAJuly 20uly 20 thh, 20062006

Joe Lex, MD, FAAEMoe Lex, MD, FAAEMTemple University Hospitalemple University HospitalPhiladelphia, PAhiladelphia, PAJuly 20uly 20 thh, 20062006


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Incidence of Chest TraumaIncidence of Chest Trauma

Incidence of Chest TraumaIncidence of Chest Trauma

1/4 American trauma deaths

Contributes to another 1 of 4

Many die after reaching hospital -preventable if recognized


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Pathophysiology of Chest TraumaPathophysiology of Chest Trauma


hypovolemia

ventilation-

perfusionmismatch

changes inintrathoracic

pressure

relationships

TISSUEHYPOXIA

Inadequate oxygendelivery to tissues


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Tissue hypoxia

Hypercarbia

Respiratory acidosis: inadequate ventilation

Metabolic acidosis: tissue hypoperfusion(e.g., shock)

Tissue hypoxia

Hypercarbia

Respiratory acidosis: inadequate ventilation

Metabolic acidosis: tissue hypoperfusion(e.g., shock)


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Blunt traumaBlunt trauma

Blunt traumaBlunt trauma


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Blunt traumaBlunt traumaBlunt traumaBlunt trauma


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Penetrating traumaPenetrating traumaPenetrating traumaPenetrating trauma


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Splinter



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6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats

Airway obstruction

Tension pneumothorax

Open pneumothorax

sucking chest wound

Massive hemothorax Flail chest

Cardiac tamponade

Airway obstruction


Open pneumothorax

sucking chest wound


Cardiac tamponade


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6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats

Lung contusion

Heart contusion

Aorta rupture

Diaphragm rupture

Tracheobronchial tree injury -larynx, trachea, bronchus

Esophagus trauma

Lung contusion

Heart contusion

Aorta rupture

Diaphragm rupture

Tracheobronchial tree injury -larynx, trachea, bronchus

Esophagus trauma


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6 Other Frequent Injuries6 Other Frequent Injuries6 Other Frequent Injuries6 Other Frequent Injuries

Subcutaneousemphysema

Traumatic asphyxia

Simple pneumothorax

Hemothorax

Scapula fracture

Rib fractures

Subcutaneousemphysema

Traumatic asphyxia

Simple pneumothorax

Hemothorax

Scapula fracture

Rib fractures


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Primary SurveyPrimary SurveyPrimary SurveyPrimary Survey

Airway

Breathing

Circulation

Airway

Breathing

Circulation


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A = AirwayA = AirwayA = AirwayA = Airway

Assess for airway patency and airexchange - listen at nose & mouth

Assess for intercostal and supraclavicularmuscle retractions

Assess oropharynx for foreign body

obstruction

Assess for airway patency and airexchange - listen at nose & mouth

Assess for intercostal and supraclavicularmuscle retractions

Assess oropharynx for foreign body

obstruction


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B = BreathingB = BreathingB = BreathingB = Breathing

Assess respiratory movements and qualityof respirations look, listen, feel

Shallow respirations are early indicator ofdistress cyanosis is late

Assess respiratory movements and qualityof respirations look, listen, feel

Shallow respirations are early indicator ofdistress cyanosis is late


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C = CirculationC = CirculationC = CirculationC = Circulation

Assess pulses for quality, rate, regularity

Assess blood pressure and pulse pressure

Skin - look and feel for color,temperature, capillary refill

Look at neck veins - flat vs. distended

Cardiac monitor

Assess pulses for quality, rate, regularity

Assess blood pressure and pulse pressure

Skin - look and feel for color,temperature, capillary refill

Look at neck veins - flat vs. distended

Cardiac monitor


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Where can adults hide blood and goWhere can adults hide blood and go

into shock?into shock?Where can adults hide blood and goWhere can adults hide blood and go

into shock?into shock?

Chest: listen, do chest x-ray

Abdomen: do DPL or CT or US

Retroperitoneum: do CT

Thigh: physical examination

Street: ask paramedic...and in children, add

Head

Chest: listen, do chest x-ray

Abdomen: do DPL or CT or US

Retroperitoneum: do CT

Thigh: physical examination

Street: ask paramedic...and in children, add

Head


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Initial assessment and managementInitial assessment and managementInitial assessment and managementInitial assessment and management

Primary survey

Resuscitation of vital functions Detailed secondary survey

Definitive care

Primary survey

Resuscitation of vital functions Detailed secondary survey

Definitive care


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Initial assessment and managementInitial assessment and managementInitial assessment and managementInitial assessment and management

Hypoxia most serious problem: earlyinterventions aimed at reversing

Immediate life-threatening injuriestreated quickly and simply, usually withtube or a needle

Secondary survey guided by highsuspicion for specific injuries

Hypoxia most serious problem: earlyinterventions aimed at reversing

Immediate life-threatening injuriestreated quickly and simply, usually withtube or a needle

Secondary survey guided by highsuspicion for specific injuries


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ThoracotomyThoracotomyThoracotomyThoracotomy

Closed heart massage is ineffective in ahypovolemic patient

Left anterior thoracotomy with cross-clamping of descending thoracic aorta andopen-chest massage may be useful in

pulseless victim of penetrating trauma

Closed heart massage is ineffective in ahypovolemic patient

Left anterior thoracotomy with cross-clamping of descending thoracic aorta andopen-chest massage may be useful in

pulseless victim of penetrating trauma


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Emergency departmentthoracotomy for patientswithout cardiac activity who

are victims of blunt thoracicinjuries is ineffective

Emergency departmentthoracotomy for patientswithout cardiac activity who

are victims of blunt thoracicinjuries is ineffective


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6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats6 Immediate Life Threats

Airway obstruction


Open pneumothorax

sucking chest wound


Cardiac tamponade

Airway obstruction


Open pneumothorax

sucking chest wound


Cardiac tamponade


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Airway ObstructionAirway ObstructionAirway ObstructionAirway Obstruction

Airway obstruction at alveolar level:assessed and managed during 2o survey

Upper airway obstruction immediatelife threat which must be dealt with inprimary survey

Most common cause: patients tongue

Airway obstruction at alveolar level:assessed and managed during 2o survey

Upper airway obstruction immediatelife threat which must be dealt with inprimary survey

Most common cause: patients tongue


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Chin-lift: fingersunder mandible,

lift forward sochin is anterior

Chin-lift: fingersunder mandible,

lift forward sochin is anterior


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Jaw thrust: grasp angles of mandible andbring jaw forward

Jaw thrust: grasp angles of mandible andbring jaw forward


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Oropharyngealairway: insert into

mouth behind tongue DO NOT push tongue

further back

Oropharyngealairway: insert into

mouth behind tongue DO NOT push tongue

further back


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Nasopharyngealairway: gently

insert well-lubricated

trumpet

through nostril

Nasopharyngealairway: gently

insert well-lubricated

trumpet

through nostril


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Definitive Airway

Management: tubein trachea throughvocal cords with

balloon inflated

Definitive Airway

Management: tubein trachea throughvocal cords with

balloon inflated


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Orotracheal intubation

Nasotracheal intubation: in breathing

patient without major facial trauma

Surgical airways

jet insufflation

retrograde

cricothyrotomy

tracheostomy

Orotracheal intubation

Nasotracheal intubation: in breathing

patient without major facial trauma

Surgical airways

jet insufflation

retrograde

cricothyrotomy

tracheostomy


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Jet insufflation adapters


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How to perform cricothyroidotomyHow to perform cricothyroidotomyHow to perform cricothyroidotomyHow to perform cricothyroidotomy


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Tension pneumothoraxTension pneumothoraxTension pneumothoraxTension pneumothorax

Air leak through lung or chest wall

One-way valve lung collapse

Mediastinum shifts to opposite side Inferior vena cava kinks on diaphragmdecreased venous return

cardiovascular collapse

Air leak through lung or chest wall

One-way valve lung collapse

Mediastinum shifts to opposite side Inferior vena cava kinks on diaphragmdecreased venous return

cardiovascular collapse


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Inferior vena cava


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Tension pneumothoraxTension pneumothoraxTension pneumothoraxTension pneumothorax

Tension pneumothorax is not an x-raydiagnosis it MUST be recognizedclinically

Treatment is decompression needle into2nd intercostal space of mid-clavicular line

- followed by thoracotomy tube

Tension pneumothorax is not an x-raydiagnosis it MUST be recognizedclinically

Treatment is decompression needle into2nd intercostal space of mid-clavicular line

- followed by thoracotomy tube


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Insert needle here


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Open pneumothoraxOpen pneumothoraxOpen pneumothoraxOpen pneumothorax

Sucking Chest Wound

Normal ventilation requires negative intra-

thoracic pressure

Large open chest-wall defectimmediate equilibration of intra-thoracic

and atmospheric pressures If hole >2/3 tracheal diameter, air prefers

chest defect

Sucking Chest Wound

Normal ventilation requires negative intra-

thoracic pressure

Large open chest-wall defectimmediate equilibration of intra-thoracic

and atmospheric pressures If hole >2/3 tracheal diameter, air prefers

chest defect


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Initial treatment: seal defect and secureon three sides (total occlusion may lead to

tension pneumothorax Definitive repair of defect in O.R.

Initial treatment: seal defect and secureon three sides (total occlusion may lead to

tension pneumothorax Definitive repair of defect in O.R.


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Massive hemothoraxMassive hemothoraxMassive hemothoraxMassive hemothorax

Rapid accumulation of >1500 cc blood inchest cavity

Hypovolemia & hypoxemia

Neck veins may be:

Flat: from hypovolemia

Distended: intrathoracic blood

Absent breath sounds, DULL to percussion

Rapid accumulation of >1500 cc blood inchest cavity

Hypovolemia & hypoxemia

Neck veins may be:

Flat: from hypovolemia

Distended: intrathoracic blood

Absent breath sounds, DULL to percussion


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Massive hemothorax: treatmentMassive hemothorax: treatmentMassive hemothorax: treatmentMassive hemothorax: treatment

Large-bore (32 to 36 F) tube to drainblood

If moderate sized (500 to 1500 ml) andstops bleeding, closed drainage usuallysufficient

If initial drainage >1500 ml ORcontinuous bleeding >200 ml / hr, OPENTHORACOTOMY indicated

Large-bore (32 to 36 F) tube to drainblood

If moderate sized (500 to 1500 ml) andstops bleeding, closed drainage usuallysufficient

If initial drainage >1500 ml ORcontinuous bleeding >200 ml / hr, OPENTHORACOTOMY indicated


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Chest tube


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How to place a chest tubeHow to place a chest tubeHow to place a chest tubeHow to place a chest tube


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Pleural space


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l l hFl il h t

Fl il hFl il h t


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Flail chestFlail chestFlail chestFlail chest

Free-floating chestsegment, usually from

multiple ribs fractures Pain and restricted

movement paradoxical

movement of chest wallwith respiration

Free-floating chestsegment, usually from

multiple ribs fractures Pain and restricted

movement paradoxical

movement of chest wallwith respiration

Fl il hFl il h t

Fl il h tFl il h t


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Flail chestFlail chestFlail chestFlail chest


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Fl il t t t ( ld)Fl il t t t ( ld)



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Flail treatment (old)Flail treatment (old)Flail treatment (old)Flail treatment (old)




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Flail treatment (old)Flail treatment (old)Flail treatment (old)Flail treatment (old)

Fl il t t tFl il t t t

Fl il t t tFl il t t t


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Flail treatmentFlail treatmentFlail treatmentFlail treatment

Ventilate well

Humidify oxygen

Resuscitate with fluids

Manage pain (!!)

Stabilize chest

Internal ventilator

External sand bags(rare)

Ventilate well

Humidify oxygen

Resuscitate with fluids

Manage pain (!!)

Stabilize chest

Internal ventilator

External sand bags(rare)

C di t dC di t d

C di t dC di t d


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Cardiac tamponadeCardiac tamponadeCardiac tamponadeCardiac tamponade

Usually from penetrating injuries

Classic Becks triad

elevated venous pressure - neck veins

decreased arterial pressure - BP

muffled heart sounds

Blood in sac

prevents cardiac

activity

Usually from penetrating injuries

Classic Becks triad

elevated venous pressure - neck veins

decreased arterial pressure - BP

muffled heart sounds

Blood in sac

prevents cardiac

activity

C di t dC di t d

C di t dCa diac tamponade


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May find pulsus paradoxus - a decreaseof 10 mm Hg or greater in systolic BP

during inspiration Systolic to diastolic gradient of less than

30 mm Hg also suggestive

May find pulsus paradoxus - a decreaseof 10 mm Hg or greater in systolic BP

during inspiration Systolic to diastolic gradient of less than

30 mm Hg also suggestive

C di t dCa diac tamponade

C di t dCardiac tamponade


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Treatment is removalof small amount of

blood 15 to 20 mlmay be sufficient from pericardial sac

Treatment is removalof small amount of

blood 15 to 20 mlmay be sufficient from pericardial sac


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Pericardiocentesis


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Stab wound toright ventricle


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pericardium

epicardial fat


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Ten-m inutebreakTen-m inutebreak


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The Flock of Birds


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behind the heart

Esophagoose

Azygoose v.

Vagoose n.

Thoracic duck

6 Potential Life Threats6 Potential Life Threats

6 Potential Life Threats6 Potential Life Threats


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6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats6 Potential Life Threats

Pulmonary contusion

Myocardial contusion

Traumatic aortic rupture (TAR)

Traumatic diaphragmatic rupture

Tracheobronchial tree injury: larynx,trachea, bronchus

Esophageal trauma

Pulmonary contusion

Myocardial contusion

Traumatic aortic rupture (TAR)

Traumatic diaphragmatic rupture

Tracheobronchial tree injury: larynx,trachea, bronchus

Esophageal trauma


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Pulmonary contusionPulmonary contusion



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Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion

Potentially life-threatening condition withinsidious onset

Parenchymal injury without laceration More than 50% will develop pneumonia,

even with treatment

Up to 50% have only hemoptysis aspresenting symptom

Potentially life-threatening condition withinsidious onset

Parenchymal injury without laceration More than 50% will develop pneumonia,

even with treatment

Up to 50% have only hemoptysis aspresenting symptom


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Pulmonary contusionPulmonary contusionPulmonary contusionPulmonary contusion

Patients with pre-existing conditions(emphysema, renal failure) need early

intubation Treatment needs

to occur over time

as symptoms develop

Patients with pre-existing conditions(emphysema, renal failure) need early

intubation Treatment needs

to occur over time

as symptoms develop

Myocardial contusionMyocardial contusion



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Myocardial contusionMyocardial contusionMyocardial contusionMyocardial contusion

Blunt precordial chesttrauma

Difficult to diagnose Risk for dysrhythmia,

sudden death,

tamponade,pericarditis,ventricular aneurysm

Blunt precordial chesttrauma

Difficult to diagnose Risk for dysrhythmia,

sudden death,

tamponade,pericarditis,ventricular aneurysm




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Also may see:

myocardial concussion stunned

myocardium with no cell death coronary artery laceration

Diagnosis by:

trans-esophageal echocardiogram (TEE)

serial cardiac enzymes / markers

Also may see:

myocardial concussion stunned

myocardium with no cell death coronary artery laceration

Diagnosis by:

trans-esophageal echocardiogram (TEE)

serial cardiac enzymes / markers




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Question: Does it matter?

New nomenclature: Anterior Chest Wall

Syndrome

Question: Does it matter?

New nomenclature: Anterior Chest Wall

Syndrome


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Traumatic aortic ruptureTraumatic aortic rupture



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Traumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic ruptureTraumatic aortic rupture

90% or more dead at scene

90% mortality each undiagnosed day

Must have high index of suspicion

Disruption occurs at ligamentumarteriosum (ductus arteriosus)

Contained hematoma of 500 to 1000 mlof blood

90% or more dead at scene

90% mortality each undiagnosed day

Must have high index of suspicion

Disruption occurs at ligamentumarteriosum (ductus arteriosus)

Contained hematoma of 500 to 1000 mlof blood




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Radiographic signs

Wide mediastinum

(>8cm) Fractured 1st & 2nd rib

Obliterated aorticknob

Trachea deviated toright

Pleural cap

Radiographic signs

Wide mediastinum

(>8cm) Fractured 1st & 2nd rib

Obliterated aorticknob

Trachea deviated toright

Pleural cap

Elevated mainstembronchus with shift toright

Obliterated aorticwindow

Esophagus shifted to

right (NG at T4) Depressed left

mainstem bronchus

Elevated mainstembronchus with shift toright

Obliterated aorticwindow

Esophagus shifted to

right (NG at T4) Depressed left

mainstem bronchus


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dye leakage




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CT becoming imaging of choice

Must know site!

NPV of normal chest x-ray (good quality,upright): 98% (CT will find mediastinalhemorrhage in 3%, TAR in 0.4%)

78% of patients with post-traumatic widemediastinum on chest film have normalCT

CT becoming imaging of choice

Must know site!

NPV of normal chest x-ray (good quality,upright): 98% (CT will find mediastinalhemorrhage in 3%, TAR in 0.4%)

78% of patients with post-traumatic widemediastinum on chest film have normalCT




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Treatment -SURGICAL REPAIR

Treatment -SURGICAL REPAIR


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Traumatic diaphragmatic ruptureTraumatic diaphragmatic rupture



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Traumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureTraumatic diaphragmatic rupture

Blunt trauma: tears leading to immediateherniation

Penetrating trauma: small tears whichmay take years to develop herniation

Usually on left side

Blunt trauma: tears leading to immediateherniation

Penetrating trauma: small tears whichmay take years to develop herniation

Usually on left side


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Traumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureTraumatic diaphragmatic ruptureau at c d ap ag at c uptu e

Treatment: surgical repair Treatment: surgical repair

Tracheobronchial tree injuryTracheobronchial tree injury



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Tracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injuryTracheobronchial tree injury

Larynx - rare

Hoarseness

Subcutaneous emphysema

Palpable crepitus

Intubation may be difficult: tracheostomy

(not cricothyroidotomy) is treatment ofchoice

Larynx - rare

Hoarseness


Palpable crepitus

Intubation may be difficult: tracheostomy

(not cricothyroidotomy) is treatment ofchoice




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Trachea

Blunt or penetrating

Esophagus, carotidartery and jugular

vein may be involved

Noisy breathing partial airway

obstruction

Trachea

Blunt or penetrating

Esophagus, carotidartery and jugular

vein may be involved

Noisy breathing partial airway

obstruction




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Bronchus

1.5% blunt chest

trauma 80% due to

BLUNT trauma

within one inch ofcarina (tethered)

Bronchus

1.5% blunt chest

trauma 80% due to

BLUNT trauma

within one inch ofcarina (tethered)

Esophageal traumaEsophageal trauma



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Esophageal traumaEsophageal traumaEsophageal traumaEsophageal trauma

Penetrating > blunt

Lethal if not recognized

High suspicion if

left pneumothorax and hemothoraxwithout rib fracture

shock out of proportion to apparent bluntchest trauma

particulate matter in chest tube

Penetrating > blunt

Lethal if not recognized

High suspicion if

left pneumothorax and hemothoraxwithout rib fracture

shock out of proportion to apparent bluntchest trauma

particulate matter in chest tube




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Esophageal traumaEsophageal traumaEsophageal traumasop agea t au a




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Esophageal traumasop agea t au aEsophageal traumap g

Blunt trauma,most tears

superiorIf low esophagus leakage ofstomach contentsinto mediastinum

Blunt trauma,most tears

superiorIf low esophagus leakage of

stomach contentsinto mediastinum


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6 Other Frequent Injuries6 Other Frequent Injuries

6 Other Frequent Injuries6 Other Frequent Injuries


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6 Other Frequent Injuriesq j6 Ot e eque t ju esq j


Traumatic asphyxia

Simple pneumothorax

Hemothorax

Scapula fracture Rib fractures


Traumatic asphyxia

Simple pneumothorax

Hemothorax

Scapula fracture Rib fractures


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Subcutaneous emphysemaSubcutaneous emphysema

Subcutaneous emphysemaSubcutaneous emphysema


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ub u a ou p y ap yp yp y

Rice Krispies

May result from

airway injury lung injury

blast injury

No treatmentrequired address underlying problem

Rice Krispies

May result from

airway injury lung injury

blast injury

No treatmentrequired address underlying problem


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Traumatic asphyxiaTraumatic asphyxia

Traumatic asphyxiaTraumatic asphyxia


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p yp yp yp y

Purple face fromextravasation of blood

(Masqueecchymotique)

Major damage is to

underlying structures Purple face fades over

time in survivors

Purple face fromextravasation of blood

(Masqueecchymotique)

Major damage is to

underlying structures Purple face fades over

time in survivors


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Simple pneumothoraxSimple pneumothorax

Simple pneumothoraxSimple pneumothorax


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p pp pp pp p

Air enters potential space betweenvisceral and parietal pleura

Breath sounds down on affected side Percussion hyper-resonance

Treatment: chest tube in 4th or 5th

intercostal space anterior to mid-axillaryline

Air enters potential space betweenvisceral and parietal pleura

Breath sounds down on affected side Percussion hyper-resonance

Treatment: chest tube in 4th or 5th

intercostal space anterior to mid-axillaryline


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Medialpneumothorax


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Pocket shooter


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HemothoraxHemothorax

HemothoraxHemothorax


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Lacerated lung OR disrupted intercostalartery or internal mammary artery

Most are self-limiting Surgical consultation if

initial drainage of >20 cc/kg (~1500 cc)

continued flow of >200 cc/hr

Lacerated lung OR disrupted intercostalartery or internal mammary artery

Most are self-limiting Surgical consultation if

initial drainage of >20 cc/kg (~1500 cc)

continued flow of >200 cc/hr


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Scapula fracturesScapula fractures

Scapula fracturesScapula fractures


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p

Fractured scapulaor 1st & 2nd ribs

indicates majormechanism ofinjury; consider

underlyingdamage

Fractured scapulaor 1st & 2nd ribs

indicates majormechanism ofinjury; consider

underlyingdamage

Rib fracturesRib fractures



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Most frequent thoracic cage injury

Most commonly injured: 4th 9th

If 10th/ 11th/ 12th suspect liver or spleeninjury

If 1st/ 2nd/ 3rdworry about injury to head,

neck, spinal cords, lungs, great vessels

Most frequent thoracic cage injury

Most commonly injured: 4th 9th

If 10th/ 11th/ 12th suspect liver or spleeninjury

If 1st/ 2nd/ 3rdworry about injury to head,

neck, spinal cords, lungs, great vessels

Rib fractures treatmentRib fractures treatment

Rib fractures treatmentRib fractures treatment


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Intercostal blocks

Epidural anesthesia

Systemic analgesicsDo not use

taping

rib belts

external splints

Intercostal blocks

Epidural anesthesia

Systemic analgesicsDo not use

taping

rib belts

external splints




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Ribs x-rays

are expensive

are inaccurate for diagnosis (~50%sensitivity)

add nothing to treatment

require painful positioning of the patient

are, in general, not useful

Ribs x-rays

are expensive

are inaccurate for diagnosis (~50%sensitivity)

add nothing to treatment

require painful positioning of the patient

are, in general, not useful

In conclusion...In conclusion...

In conclusion...In conclusion...


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Chest trauma is common in themultiply-injured patient

Most conditions can be treated by theevaluating physician and do notrequire emergent thoracotomy

Airway management and ajudiciously placed needle can savemany lives

Chest trauma is common in themultiply-injured patient

Most conditions can be treated by theevaluating physician and do notrequire emergent thoracotomy

Airway management and ajudiciously placed needle can savemany lives

Next timeNext time

Next timeNext time


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February 27th, 2004February 27th, 2004

RespiratoryRespiratoryEmergenciesEmergencies

Joe LexJoe Lex

February 27th, 2004February 27th, 2004

RespiratoryRespiratoryEmergenciesEmergencies

Joe LexJoe Lex

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Chest Trauma Basics