Chest Trauma Management

General
Chest injuries may result from:
Gunshot wounds (GSW)
Shrapnel Explosions Motor vehicle crashes (MVC) Falls Crush injuries Stab wounds
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Assess the Casualty

Identify signs and symptoms:
Assess mental status (AVPU) Assess the airway Assess the breathing Assess the circulation

Signs Indicative of Chest Injury

Shock. Cyanosis. Hemoptysis. Chest wall contusion. Flail chest. Open wounds. Jugular vein distention (JVD). Tracheal deviation.
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Assess Respirations
Respiratory rate and effort:
Tachypnea Bradypnea Labored Retractions Progressive respiratory distress

Assess the Neck

Position of trachea. Subcutaneous emphysema.

JVD.
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Assess the Chest Wall

Contusions. Tenderness. Asymmetry. Open wounds or objects. Crepitation. Paradoxical movement.

impaled

Assess the Chest Wall

Lung sounds:
Absent or decreased Unilateral Bilateral Location Bowel sounds in

chest?

Assess the Chest Wall

Lung sounds Percussion.
Hyperresonance Pneumothorax Tension pneumothorax Hyporesonance (hemothorax)

Assess the Chest Wall

Compare both sides of the chest at the same time when assessing for asymmetry.

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Simple/Closed Pneumothorax
Opening in lung tissue that leaks air into chest cavity Blunt trauma is main cause May be spontaneous Usually self correcting

S/S of Simple/Closed Pneumothorax

Chest Pain Dyspnea Tachypnea Decreased Breath Sounds on Affected Side

Open Pneumothorax

Open Pneumothorax
Opening in chest cavity that allows air to enter pleural cavity Causes the lung to collapse due to increased pressure in pleural cavity Can be life threatening and can deteriorate rapidly

Open Pneumothorax
Inhale

Open Pneumothorax
Exhale

Open Pneumothorax
Inhale

Open Pneumothorax
Exhale

Open Pneumothoarx
Inhale

Open Pnuemothorax
Inhale

S/S of Open Pneumothorax

Dyspnea Sudden sharp pain Subcutaneous Emphysema Decreased lung sounds on affected side Red Bubbles on Exhalation from wound a.k.a. Sucking chest wound)

Open Pneumothorax
Management:
Ensure an open airway Close the chest wall defect, both entrance and exit with an occlusive dressing, petrolatum gauze or Asherman Chest Seal Place the casualty in the sitting position Monitor respirations after an occlusive dressing is applied
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Open Pneumothorax

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Open Pneumothorax
Petroleum Gauze can also be used to seal a sucking chest wound.

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"Asherman Chest Seal"

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Tension Pneumothorax
Air builds in pleural space with no where for the air to escape Results in collapse of lung on affected side that results in pressure on mediastium,the other lung, and great vessels

Tension Pneumothorax
One-way valve created from penetrating trauma. Air enters thoracic space but cannot escape. Pressure builds:

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Tension Pneumothorax
Each time we inhale, the lung collapses further. There is no place for the air to escape..

Tension Pneumothorax
Each time we inhale, the lung collapses further. There is no place for the air to escape..

Tension Pneumothorax
The trachea is pushed to the good side

Heart is being compressed

S/S of Tension Pneumothorax

Anxiety/Restlessness Severe Dyspnea Absent Breath sounds on affected side Tachypnea Tachycardia Poor Color Accessory Muscle Use JVD Narrowing Pulse Pressures Hypotension Tracheal Deviation (late if seen at all)

Treatment of Tension Pneumothorax

ABCs with c-spine as indicated High Flow oxygen including BVM Treat for S/S of Shock Notify Hospital and ALS unit as soon as possible If Open Pneumothorax and occlusive dressing present BURP occlusive dressing

Tension Pneumothorax

Air pushes over heart and collapses lung Air outside lung from wound

Heart compressed not able to pump well

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Needle Chest Decompression

Procedure:
Identify the second ICS on the anterior chest wall, MCL:

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Subcutaneous Emphysema
Air 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

Hemothorax
Occurs when pleural space fills with blood Usually occurs due to lacerated blood vessel in thorax As blood increases, it puts pressure on heart and other vessels in chest cavity Each Lung can hold 1.5 liters of blood

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

May put pressure on the heart

Hemothorax
Where does the blood come from.

Lots of blood vessels

S/S of Hemothorax
Anxiety/Restlessness Tachypnea Signs of Shock Frothy, Bloody Sputum Diminished Breath Sounds on Affected Side Tachycardia Flat Neck Veins

Treatment for Hemothorax

ABCs with c-spine control as indicated Secure Airway assist ventilation if necessary General Shock Care due to Blood loss Consider Left Lateral Recumbent position if not contraindicated RAPID TRANSPORT Contact Hospital and ALS Unit as soon as possible

Flail Chest

Flail Chest

S/S of Flail Chest

Shortness of Breath Paradoxical Movement Bruising/Swelling Crepitus( Grinding of bone ends on palpation)

Treatment of Flail Chest

ABCs with c-spine control as indicated High Flow oxygen that may include BVM Monitor Patient for signs of Pneumothorax or Tension Pneumothorax Use Gloved hand as splint till bulky dressing can be put on patient Contact hospital and ALS Unit as soon as possible

Bulky 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)

Therapy in multiple rib fractures

(not taking companion injuries into consideration)
Stable thoracic wall 1. Controlling pain Unstable thoracic wall Paradoxical respiration Analgesics (morphine derivatives) every 4h even if there are no pains

If necessary, intercostal nerve block If necessary, epidural anesthesia

2. Intensive breathing exercises

Only in cases of respiratory insufficiency Mechanical ventilation; prophylactic insertion of a chest tube

In exceptional cases, operative stabilization of the thoracic wall

Pericardial Tamponade

pericardial sac

Blood and fluids leak into the pericardial sac which surrounds the heart. As the pericardial sac fills, it causes the sac to expand until it cannot expand anymore

Pericardial Tamponade

Once the pericardial sac cant expand anymore, the fluid starts putting pressure on the heart Now the heart cant fully expand and cant pump

Pericardial Tamponade

With poor pumping the blood pressure starts to drop. The heart rate starts to increase to compensate but is unable The patients level of conscious drops, and eventually the patient goes in

S/S of Pericardial Tamponade

Distended Neck Veins Increased Heart Rate Respiratory Rate increases Poor skin color Narrowing Pulse Pressures Hypotension Death

Treatment of Pericardial Tamponade

ABCs with c-spine control as indicated High Flow oxygen which may include BVM Treat S/S of shock Rapid Transport Notify Hospital and ALS Unit as soon as possible

Pericardiocentesis
Using aseptic technique, Insert at least 3 needle at the angle of the Xiphoid Cartilage at the 7th rib Advance needle at 45 degree towards the clavicle while aspirating syringe till blood return is seen Continue to Aspirate till syringe is full then discard blood and attempt again till signs of no more blood Closely monitor patient due to small about of blood aspirated can cause a rapid change in blood pressure

Traumatic Asphyxia
Results from sudden compression injury to chest cavity Can cause massive rupture of Vessels and organs of chest cavity Ultimately Death

S/S of Traumatic Asphyxia

Severe Dyspnea Distended Neck Veins Bulging, Blood shot eyes Swollen Tounge with cyanotic lips Reddish-purple discoloration of face and neck Petechiae

Treatment for Traumatic Asphyxia

ABCs with c-spine control as indicated High Flow oxygen including use of BVM Treat for shock Care for associated injuries Rapid Transport Contact Hospital and ALS Unit as soon as possible

Insertion of Chest Tube

Incision over intercostal space Development of subcutaneous tract Penetration of Confirmation that lung parietal pleura is not adherent to chest wall at puncture site

Injuries of the diaphragm

Diaphragmatic Rupture: Incidence: In 3% of all sever thoracic injuries. Mechanism: Broad surface blow. Location: Left side in 85% of cases. Clinical picture. Acute: symptoms of companion injury and shock. Chronic: Intestinal obstruction or strangulation (usually)

Diaphragmatic ruptures (Cont.)

Radiological Ex.: Rupture of the diaphragm are frequently overlooked. Therapy: Is indicated for increasing impairment to respiration. Operative approach from chest or abdomen.

Traumatic Diaphragm atic Rupture

Traumatic Emphysema
Subcutaneous. Mediastinal Emphysema.

Present in about 27% of patients with blunt or penetrating chest injury

Traumatic Emphysema
Therapy: Despite its impressive appearance the treatment of subcutaneous emphysema it self is mostly unnecessary. Determite the site of origin. Treat underlying pneumothorax if present by tube thoracostomy. Treat tracheobronchial, or oesophageal rupture or tension pneumothorax in cases of mediastinal emphysema. Rarely, cervical mediastinotomy is needed for mediastinal enphysema.

Nonpenetratin g wounds of Heart

Cardiac Tamponade

Indications for Thoracotomy: Decision to Operate

Excluding minor surgical procedures such as tracheostomy pericardiocentesis, tube

thoracostomy, and suture of chest wall

lacerations, formal operations are required in

only 12 to 15 percent of patients with thoracic

trauma.

Indications for thoracotomy: ACUTE

Post-traumatic cardiovascular collapse Proved Esophageal injury Pericardial tamponade Vascular injury to the thoracic outlet

Great vessel injury Continuing Hemothorax

Traumatic thoracotomy
Massive Air leak Proved tracheobronchial injury

Mediastinal traversing
injury

Bullet Embolism Air Embolism