Chest trauama

Chest Trauma

H.R.Kadkhodaei MD.Associated professor of ThoracicSurgeryRasoul Akram Medical Complex

Statistics Chest injuries are the second leading cause of

trauma deaths each year. Most thoracic injuries (90% of blunt trauma and

70% to 85% of penetrating trauma) can be managed without surgery.

Main Causes of Chest Trauma

Blunt Trauma- Blunt force to chest.

Penetrating Trauma- Projectile that enters chest causing small or large hole.

Compression Injury- Chest is caught between two objects and chest is compressed.

Injuries of chest

Rib Fractures Flail Chest Simple/Closed Pneumothorax Open Pneumothorax Tension Pneumothorax

Traumatic Asphyxia Diaphragmatic Rupture Pulmonary contusion

Rib Fractures

Incidence– Infrequent until adult life– Significant force required– Most often elderly patients

Rib FracturesPathophysiology

Most often caused by blunt trauma Ribs 3 to 8 are fractured most often (they are thin

and poorly protected) Respiratory restriction as a result of pain and

splinting Intercostal vessel injury Associated complications

– First and second ribs are injured by severe trauma

– Tracheobronchial tree injury– Vascular injury

Rib Fractures

Assessment findings– Localized pain – Pain that worsens with movement, deep breathing,

coughing– Point tenderness

Most patients can localize the fracture by pointing to the area (confirmed by palpation).– Crepitus or audible crunch

Rib FracturesManagement

Airway and ventilation– High-concentration oxygen– Positive-pressure ventilation– Encourage coughing and deep breathing

Pharmacological– Analgesics– Intercostal block – Epidural block

Rib FracturesComplications

Splinting, which leads to atelectasis and ventilation-perfusion mismatch

Pneumonia can leads to empyema

Flail ChestPathophysiology

Two or more adjacent ribs fractured in two or more places producing a free-floating segment of chest wall

Flail chest usually results from direct impact.

Flail Chest

Flail ChestPathophysiology (2 of 2)

Respiratory failure due to: – Underlying pulmonary contusion

The blunt force of the injury typically produces an underlying pulmonary contusion.– Associated intrathoracic injury– Inadequate bellows action of the chest

S/S of Flail Chest

Chest wall contusion Respiratory distress Paradoxical chest wall movement Pleuritic chest pain Crepitus Pain and splinting of affected side Tachypnea Tachycardia

Flail Chest is a True Emergency

Flail ChestManagement

Airway and ventilation– High-concentration oxygen.– Positive-pressure ventilation may be needed.

»Reverses the mechanism of paradoxical chest wall movement

»Restores the tidal volume»Reduces the pain of chest wall movement »Assess for the development of a

pneumothorax– Evaluate the need for endotracheal intubation.– Stabilize the flail segment (controversial).

Bulky Dressing for splint of Flail Chest

Use Trauma bandage and Triangular Bandages to splint ribs.

Flail ChestMorbidity/Mortality

Significant chest trauma Mortality rates 20% to 40% due to

associated injuries Mortality increased with

– Advanced age– Seven or more rib fractures– Three or more associated injuries– Shock– Head injuries

Simple/Closed Pneumothorax

Opening in lung tissue that leaks air into chest cavity

Blunt trauma is main cause

Usually self correcting

Closed (simple) pneumothorax

– Incidence»10% to 30% in blunt chest trauma»Almost 100% with penetrating chest trauma

Closed (Simple) PneumothoraxPathophysiology

May occur in the absence of rib fractures from:– A sudden increase in intrathoracic pressure

generated when the chest wall is compressed against a closed glottis (the paper-bag effect)»Results in an increase in airway pressure and

ruptured alveoli, which lead to a pneumothorax

Small tears self-seal; larger ones may progress.

Ventilation/perfusion mismatch.

Closed PneumothoraxAssessment Findings

Tachypnea Tachycardia Respiratory distress Absent or decreased breath sounds on the affected side Hyperresonance Decreased chest wall movement Dyspnea Chest pain referred to the shoulder or arm on the affected

side pleuritic chest pain

Closed PneumothoraxManagement

Airway and ventilation– High-concentration oxygen.– Positive-pressure ventilation if necessary.– If respiration rate is <12 or >28 per minute,

ventilatory assistance with a bag-valve mask may be indicated.

Open Pneumothorax

Incidence– Usually the result of penetrating trauma

» Gunshot wounds» Knife wounds» Motor vehicle collisions» Falls

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 PneumothoraxPathophysiology (1 of 2)

An open defect in the chest wall (>3 cm)– If the chest wound opening is greater than two-

thirds the diameter of the trachea, air follows the path of least resistance through the chest wall with each inspiration.

– As the air accumulates in the pleural space, the lung on the injured side collapses and begins to shift toward the uninjured side.

Open Pneumothorax

Open PneumothoraxInhale

Open PneumothoraxExhale

Open PneumothoraxInhale

Open PneumothoraxExhale

Open PneumothoarxInhale

Open PnuemothoraxInhale

S/S of Open Pneumothorax

Dyspnea Sudden sharp pain Subcutaneous Emphysema Decreased lung sounds on affected side Red Bubbles on Exhalation from wound

( Sucking chest wound)

Open PneumothoraxManagement (1 of 2)

Airway and ventilation:– High-concentration oxygen.– Positive-pressure ventilation if necessary.– Assist ventilations with a bag-valve device and

intubation as necessary.– Monitor for the development of a tension

pneumothorax. Circulation—treat for shock with crystalloid

infusion.

Open PneumothoraxManagement (2 of 2)

Nonpharmacological– Occlude the open

wound—apply an occlusive petroleum gauze dressing (covered with sterile dressings) and secure it with tape.

Occlusive Dressing

Asherman Chest Seal

Plus Care

Monitor Heart Rhythm Establish IV Access and Draw Blood

Samples Airway Control that may include Intubation Monitor for Tension Pneumothorax

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 Pathophysiology

Occurs when air enters the pleural space from a lung injury or through the chest wall without a means of exit.

Results in death if it is not immediately recognized and treated.

When air is allowed to leak into the pleural space during inspiration and becomes trapped during exhalation, an increase in the pleural pressure results.

Tension Pneumothorax Pathophysiology (2 of 2)

Increased pleural pressure produces mediastinal shift.

Mediastinal shift results in:– Compression of the uninjured lung– Kinking of the superior and inferior vena cava,

decreasing venous return to the heart, and subsequently decreasing cardiac output

Tension PneumothoraxEach time we inhale,

the lung collapses further. Thereis no place for the air to

escape..

Tension PneumothoraxEach time we inhale,

the lung collapses further. Thereis no place for the air to

escape..

Tension Pneumothorax

Heart is beingCompressed and Decrease CO

The trachea ispushed to

the other side

Tension Pneumothorax Assessment Findings (1 of 3)

Extreme anxiety Cyanosis Increasing dyspnea Difficult ventilations while being assisted Tracheal deviation (a late sign) Hypotension

Tension Pneumothorax Assessment Findings (3 of 3)

Bulging of the intercostal muscles Subcutaneous emphysema Jugular venous distention (unless

hypovolemic) Unequal expansion of the chest (tension

does not fall with respiration) Hyperresonnace to percussion

Tension Pneumothorax Physical Findings

Tension Pneumothorax Management

Emergency care is directed at reducing the pressure in the pleural space.

Airway and ventilation:– High-concentration oxygen– Positive pressure ventilation if necessary

Circulation—relieve the tension pneumothorax to improve cardiac output.

Tension Pneumothorax Management (2 of

5) Nonpharmacological

– Occlude open wound– Needle thoracostomy– Tube thoracostomy—in-hospital management

Tension Pneumothorax Management (3 of

5) Needle thoracostomy

Tension Pneumothorax Management (4 of 5)

Tension pneumothorax associated with penetrating trauma– May occur when an open pneumothorax has been

sealed with an occlusive dressing.– Pressure may be relieved by momentarily

removing the dressing (air escapes with an audible release of air).

Tension Pneumothorax Management (5 of

5) Tension pneumothorax associated with closed

trauma– If the patient demonstrates significant dyspnea and

distinct signs and symptoms of tension pneumothorax: » Provide thoracic decompression with either a large-bore needle

or commercially available thoracic decompression kit.» Insert a 2-inch 14- or 16-gauge hollow needle or catheter into

the affected pleural space. Usually the second intercostal space in the midclavicular line

Insert the needle just above the third rib to avoid the nerve, artery, and vein that lie just beneath each rib.

Needle Decompression

Locate 2-3 Intercostal space midclavicular line Cleanse area using aseptic technique Insert catheter ( 14g or larger) over the top of the

3rd rib( nerve, artery, vein lie along bottom of rib) Place Flutter valve over catheter Reassess for Improvement

Needle Decompression

Flutter Valve

Asherman Chest Seal makes good Flutter Valve .

Also can use a Finger from a Latex Glove

Or A Condom works also

Pulmonary Contusion

A pulmonary contusion is the most common potentially lethal chest injury.

» Incidence Blunt trauma to the chest

– The most common injury from blunt thoracic trauma.

– 30% to 75% of patients with blunt trauma have pulmonary contusion.

Commonly associated with rib fracture High-energy shock waves from explosion High-velocity missile wounds Rapid deceleration

Pulmonary Contusion Assessment Findings

Tachypnea Tachycardia Cough Hemoptysis Apprehension Respiratory distress Dyspnea Evidence of blunt chest trauma Cyanosis

Pulmonary ContusionManagement

Airway and ventilation:– High-concentration oxygen– Positive-pressure ventilation if necessary

Circulation—restrict IV fluids (use caution restricting fluids in hypovolemic patients).

Transport considerations.

Pulmonary ContusionMorbidity/Mortality

May be missed due to the high incidence of other associated injuries

Mortality—between 14% and 20%

Hemothorax (2 of 2)

Incidence– Associated with pneumothorax.– Blunt or penetrating trauma.– Rib fractures are frequent cause.

Hemothorax

Occurs when pleural space fills with blood As blood increases, it puts pressure on heart

and other vessels in chest cavity Each Lung can hold 1.5 liters of blood

HemothoraxPathophysiology

Accumulation of blood in the pleural space caused by bleeding from – Penetrating or blunt lung injury– Chest wall vessels– Intercostal vessels

Hemothorax

Where does the blood come from.

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

May put pressure on the heart

HemothoraxAssessment Findings (1 of 2)

Tachypnea Dyspnea Cyanosis

– Often not evident in hemorrhagic shock Diminished or decreased breath sounds on

the affected side

HemothoraxAssessment Findings (2 of 2)

Hyporesonance (dullness on percussion) on the affected side

Hypotension Narrowed pulse pressure Tracheal deviation to the unaffected side

(rare) Pale, cool, moist skin

S/S of Hemothorax

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

Bledsoe et al., Essentials of Paramedic Care: Division 1II

© 2006 by Pearson Education, Inc. Upper Saddle River, NJ

Hemothorax Physical Findings

HemothoraxManagement

Airway and ventilation– High-concentration oxygen– Positive-pressure ventilation if necessary– Ventilatory support with bag-valve mask, intubation, or

both Circulation

– Administer volume-expanding fluids to correct hypovolemia

– Nonpharmacological—tube thoracostomy (in-hospital management)

– Transport considerations» Appropriate mode» Appropriate facility

Treatment for Hemothorax

ABC’s with c-spine control as indicated Secure Airway assist ventilation if necessary General Shock Care due to Blood loss RAPID TRANSPORT

HemothoraxMorbidity/Mortality

A life-threatening injury that frequently requires urgent chest tube placement and/or surgery

Associated with great vessel or cardiac injury– 50% of these patients will die immediately.– 25% of these patients live 5 to 10 minutes.– 25% of these patients may live 30 minutes or longer.

Traumatic Asphyxia

Incidence– A severe crushing injury to the chest and

abdomen» Steering wheel injury» Conveyor belt injury» Compression of the chest under a heavy object

Traumatic Asphyxia Pathophysiology

A sudden compressional force squeezes the chest.

An increase in intrathoracic pressure forces blood from the right side of the heart into the veins of the upper thorax, neck, and face.

Jugular veins engorge and capillaries rupture.

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

Traumatic AsphyxiaAssessment

Reddish-purple discoloration of the face and neck (the skin below the face and neck remains pink).

Jugular vein distention. Swelling of the lips and tongue. Swelling of the head and neck. Swelling or hemorrhage of the conjunctiva

(subconjunctival petechiae may appear). Hypotension results once the pressure is released.

Traumatic AsphyxiaManagement

Airway and ventilation– Ensure an open airway.– Provide adequate ventilation.

Circulation– IV access.– Expect hypotension and shock once the compression is

released.

Diaphragmatic Rupture

Incidence Penetrating trauma

– Blunt trauma– Injuries to the diaphragm account for 1% to 8%

of all blunt injuries.» 90% of injuries to the diaphragm are associated with

high-speed motor vehicle crashes.

Diaphragm Rupture

Diaphragmatic Rupture

Rupture can allow intra-abdominal organs to enter the thoracic cavity, which may cause the following:– Compression of the lung with reduced

ventilation– Decreased venous return– Decreased cardiac output– Shock

Diaphragmatic Rupture Pathophysiology

Can produce very subtle signs and symptoms

Bowel obstruction and strangulation Restriction of lung expansion

– Hypoventilation– Hypoxia

Mediastinal shift– Cardiac compromise– Respiratory compromise

Diaphragmatic Rupture Assessment Findings

Tachypnea Tachycardia Respiratory distress Dullness to percussion Scaphoid abdomen (hollow or empty appearance)

– If a large quantity of the abdominal contents are displaced into the chest

Bowel sounds in the affected hemithorax Decreased breath sounds on the affected side Possible chest or abdominal pain

S/S of Diaphragmatic Rupture

Abdominal Pain Shortness of Air Decreased Breath Sounds on side of rupture Bowel Sounds heard in chest cavity

Diaphragmatic Rupture Management

Airway and ventilation– High-concentration oxygen– Positive-pressure ventilation if necessary– Caution: positive pressure may worsen the injury

Circulation—IV access Nonpharmacological—do not place patient in

Trendelenburg position Transport considerations

– Appropriate mode– Appropriate facility

Plus Care

Cardiac Monitor Establish IV access and draw blood samples Airway management including Intubation Observe for Pneumothorax due to compression on

lung by abdominal contents Possible insertion of NG tube to help decompress

the stomach to relieve pressure Rapid transport

Summary

Chest Injuries are common and often life threatening in trauma patients. So, Rapid identification and

treatment of these patients is paramount to patient survival. Airway management is very important and

aggressive management is sometimes needed for proper management of most chest injuries.