Pathophysiology of Thoracic Trauma

Pathophysiology of Chest TraumaBlunt trauma.Force distributed over larger areaVisceral injuries occur from:DecelerationCompressionSheering forcesBurstingAge FactorsPediatric Thorax: More cartilage = Absorbs forcesGeriatric Thorax: Calcification & osteoporosis= More fractures

Pathophysiology of Chest TraumaPenetrating TraumaLow EnergyArrows, knives, handgunsInjury caused by direct contact and cavitationHigh EnergyMilitary, hunting rifles & high powered hand gunsExtensive injury due to high pressure cavitation

Trauma.orgInjuries Associated with Chest TraumaClosed pneumothoraxOpen pneumothorax (including sucking chest wound)Tension pneumothoraxPneumomediastinumHemothoraxHemopneumothoraxLaceration of vascular structuresTraumatic Asphyxia

Tracheobronchial tree lacerationsEsophageal lacerationsPenetrating cardiac injuriesPericardial tamponadeSkeletal injuriesFlail ChestDiaphragm traumaIntra-abdominal penetration with associated organ injurySternal Fracture & Dislocation

Associated with severe blunt anterior traumaDirect Blow (i.e. Steering wheel, das board)Incidence: 5-8%Mortality: 25-45%Myocardial contusionPericardial tamponadeCardiac rupturePulmonary contusionDislocation uncommon.Tracheal depression if posterior

Rib Fractures

>50% of significant chest trauma cases due to blunt trauma

Compressional forces flex and fracture ribs at weakest points

Ribs 1-3 requires great force to fracturePossible underlying lung injuryRibs 4-9 are most commonly fractured

Ribs 10-12 less likely to be fracturedTransmit energy of trauma to internal organsIf fractured, suspect liver and spleen injury

Hypoventilation is COMMON due to PAIN

Flail Chest

Two or more ribs are broken in two or more places that causes a free floating section.

Serious chest wall injury with underlying pulmonary injuryReduces volume of respirationAdds to increased mortality

Paradoxical flail segment movement

Positive pressure ventilation can restore tidal volume

Signs and symptoms of Flail ChestShortness of BreathParadoxical MovementBruising/SwellingCrepitus( Grinding of bone ends on palpation)

Management of Skeletal Injuries

ABCs with c-spine control as indicated (may include intubation)Establish IV accessHigh Flow oxygen that may include bag valve mask (BVM)Monitor Cardiac RhythmMonitor Patient for signs of pneumothorax or tension pneumothoraxIf Tension develops, needle decompress affected sideYou may need a splintMedical emergencyBulky Dressing for splint of Flail Chest

Use Trauma bandage and Triangular Bandages to splint ribs.Can also place a bag of D5W on area and tape down. (The only good use of D5W I can find)Pulmonary Contusion

Soft tissue contusion of the lung30-75% of patients with significant blunt chest traumaFrequently associated with rib fractureTypical mode of impactDecelerationChest impact on steering wheelBullet CavitationHigh velocity ammunitionMicrohemorrhage may account for 1- 1 L of blood loss in alveolar tissueProgressive deterioration of ventilatory statusHemoptysis typically presentSigns and Symptoms of Pulmonary ContusionMost Common result of blunt injurySigns & SymptomsErythemaEcchymosisDyspneaHYPOVENTILATIONBIGGEST CONCERN = HURTS TO BREATHE

Pulmonary Contusion Admission CXRPulmonary Contusion24 HoursSimple/Closed PneumothoraxOccurs when lung tissue is disrupted and air leaks into the pleural space

It is a non-expanding collection of air around the lung.

Progressive PathologyAir accumulates in pleural spaceLung collapsesAlveoli collapse (atelectasis)Reduced oxygen and carbon dioxide exchangeVentilation/Perfusion MismatchIncreased ventilation but no alveolar perfusionReduced respiratory efficiency results in HYPOXIA

It may progress to Tension Pneumothorax

Signs and Symptoms of Simple/Closed PneumothoraxChest PainDyspneaTachypneaDecreased Breath Sounds on Affected Side

Open PneumothoraxFree passage of air between atmosphere and pleural spaceCauses the lung to collapse due to increased pressure in pleural cavityMediastinum shifts to uninjured sideCan be life threatening and can deteriorate rapidly

Signs and Symptoms of Open PneumothoraxDyspneaSudden sharp painSubcutaneous EmphysemaDecreased lung sounds on affected sideRed Bubbles on Exhalation from wound ( a.k.a. Sucking chest wound)Hypovolemia

Open Pneumothorax

Open PneumothoraxInhaleOpen PneumothoraxExhaleOpen PneumothoraxInhaleOpen PneumothoraxExhaleOpen PneumothoarxInhaleOpen PnuemothoraxInhaleSubcutaneous EmphysemaAir collects in subcutaneous fat from pressure of air in pleural cavity

Feels like rice crispies or bubble wrap

Can be seen from neck to groin area Sucking Chest Wound

Hole in the chest wall that extends into the pleural space allowing are to move in and out of the pleural space interfering with breathing.Occlusive DressingAsherman Chest Seal

26Tension PneumothoraxBuildup of air under pressure in the thorax.Excessive pressure reduces effectiveness of respirationAir is unable to escape from inside the pleural spaceProgression of Simple or Open Pneumothorax

Bilateral tension pneumothoraces

Left tension pneumothoraxTension PneumothoraxEach time we inhale,the lung collapses further. Thereis no place for the air toescape..Tension PneumothoraxEach time we inhale,the lung collapses further. Thereis no place for the air toescape..Tension PneumothoraxHeart is beingcompressedThe trachea ispushed tothe good sideSigns & Symptoms of Tension Pneumothorax DyspneaTachypnea at firstProgressive ventilation/perfusion mismatchAtelectasis on uninjured sideHypoxemiaHyperinflation of injured side of chestHyperresonance of injured side of chest

Diminished then absent breath sounds on injured sideCyanosisDiaphoresisJVDHypotensionHypovolemiaTracheal Shifting

Needle DecompressionLocate 2-3 Intercostal space midclavicular line

Cleanse area using aseptic technique

Insert catheter ( 14g or larger) at least 3 in length over the top of the 3rd rib( nerve, artery, vein lie along bottom of rib)

Remove Stylette and listen for rush of air

Place Flutter valve over catheter

Reassess for Improvement

Needle Decompression

Flutter ValveAsherman Chest Seal makes good Flutter Valve .Also can use a Finger from a Latex Glove Or A Condom works also

HemothoraxAccumulation of blood in the pleural spaceSerious hemorrhage may accumulate 1,500 mL of bloodMortality rate of 75%Each side of thorax may hold up to 3,000 mLBlood loss in thorax causes a decrease in tidal volumeVentilation/Perfusion Mismatch & ShockTypically accompanies pneumothoraxHemopneumothoraxHemothoraxHemothoraxHemothoraxHemothoraxHemothoraxHemothoraxMay put pressure on the heartHemothorax

Lots of blood vesselsWhere does the blood come from.X-ray differrence between Hemothorax and Hemopneumothorax

Meniscus of haemopneumothoraxMeniscus of haemothoraxWhen a haemothorax is visible on the erect chest X-ray, the presence of a FLAT MENISCUS laterally indicates the presence of an associated pneumothorax.Signs & Symptoms of HemothoraxShockDyspneaTachycardiaTachypneaDiaphoresisHypotensionDull to percussion over injured side (stony dull)Frothy , bloody sputumFlat Neck Veins

Management of PneumothoraxABCs with c-spine as indicatedEstablish IV access and Draw Blood SamplesHigh Flow oxygen including BVMMonitor Cardiac RhythmTreat for S/S of ShockNeedle Decompression of Affected SideChest drainingConsider Left Lateral Recumbent position if not contraindicated

Summary of Physical Findings in Pulmonary InjuryTracheaExpansionBreath SoundsPercussionTension PneumothoraxAwayDecreased.Chest may be fixed in hyper-expansionDiminshed or absentHyper-resonantSimple PneumothoraxMidlineDecreasedMay be diminishedMay be hyper-resonant. Usually normalHaemothoraxMidlineDecreasedDiminished if large. Normal if smallDull, especially posteriorlyPulmonary ContusionMidlineNormalNormal. May have cracklesNormalLung collapseTowardsDecreasedMay be reducedNormal