The Dirty Dozen - Virginia Department of Health · The Dirty Dozen Beyond the Basics of ... cardiac arrest Needle-guided ... patient Thoracic Trauma Assessment Findings Cardiac arrhythmias

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Thoracic Trauma

The Dirty DozenThe Dirty Dozen

Beyond the Basics of Thoracic Trauma

Steven “Kelly” Grayson, CCEMT-P

Thoracic Trauma

ObjectivesObjectives

Review the epidemiology of thoracic trauma.Review the pathophysiology of thoracic trauma resulting from blunt and penetrating mechanisms.Discuss and describe clinical syndromes in various types of thoracic trauma.Discuss current treatment and management of the various types of thoracic trauma.

Thoracic Trauma

EpidemiologyEpidemiology

Second leading cause of trauma deaths25% of all trauma deaths45 – 50% of unrestrained drivers have thoracic injuries50% of all trauma patients have associated thoracic injuries2/3 reach the Emergency Department aliveOnly 15% require surgery

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Thoracic Trauma

Anatomy and PhysiologyAnatomy and Physiology

Thoracic Trauma


Thoracic Trauma



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Thoracic Trauma

The Big SixThe Big SixLife-threatening conditions that must be identified and treated immediately:

Airway obstructionTension pneumothoraxOpen pneumothorax (sucking chest wound)Flail chestMassive hemothoraxCardiac tamponade

Thoracic Trauma

The Dirty DozenThe Dirty Dozen

Lung contusionMyocardial contusionAortic ruptureDiaphragmatic ruptureTracheobronchialruptureEsophageal injury

Airway obstructionTension pneumothoraxOpen pneumothoraxFlail chestMassive hemothoraxCardiac tamponade


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Thoracic Trauma

AssessmentAssessment

Thoracic Trauma

AssessmentAssessmentInspection

BruisingAbrasionsParadoxical motion

PalpationCrepitusDeformityBilateral expansionTactile vocal fremitus

Thoracic Trauma

AssessmentAssessmentAuscultation

Presence/quality of breath soundsHeart tones

PercussionDullness/fullnessHyperresonance


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Thoracic Trauma

Airway ObstructionAirway ObstructionFollow the Airway Continuum

SuctionBLS adjunctsSupraglottic airwaysEndotracheal intubationCricthyoidotomy

Remember, supraglottic airways only manage a supraglottic obstruction!

Thoracic Trauma

ManagementManagement

The Gold Standard of airway management is not a tool, it’s an outcome.The goal is effective oxygenation and ventilation.

Thoracic Trauma

Tension PneumothoraxTension Pneumothorax

Blunt or penetrating traumaHypoventilation

HypoxiaHypercapnea

Cardiovascular compromiseShockCardiovascular collapse

Life-threatening if not treated early


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Tension PneumothoraxTension Pneumothorax

Thoracic Trauma

Simple Pneumothorax vsTension Pneumothorax

Simple Pneumothorax vsTension Pneumothorax

SimpleDegree of hypoxia directly related to size of lung area affectedResponds well to supplemental oxygenLittle or no hemodynamic compromiseRequires no EMS intervention other than oxygenation

TensionSevere hypoxiaWorsens despite supplemental oxygenPoor ventilatorycomplianceSevere hemodynamic compromiseLife-threatening if not treated immediately

Thoracic Trauma

Likely Assessment FindingsLikely Assessment FindingsSevere respiratory distressRestlessness, anxiety, agitationDecreased or absent breath soundsShockSubcutaneous emphysema

AxillaeNeck

Cardiovascular collapseTachycardiaWeak pulseHypotensionNarrow pulse pressure


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Thoracic Trauma

Unlikely Assessment FindingsUnlikely Assessment Findings

Jugular venous distensionabsent if also hypovolemic

Hyper-resonance to percussion Contralateral tracheal deviation

Late signSubtle finding

Cyanosis (late)

Thoracic Trauma

Progression of Tension Pneumothorax

Progression of Tension Pneumothorax

EarlyUnilaterally decreased breath soundsWorsening dyspnea despite treatment

Middle:Increased respirationsSubcutaneous emphysemaPoor ventilatory compliance

Late:Jugular venous distentionTracheal deviation Acute hypoxiaNarrowing pulse pressureDecompensated shock

Thoracic Trauma


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Thoracic Trauma

PathophysiologyPathophysiology

Air trapped in pleural space from damaged lung or chest wall Pressure collapses ipsilaterallungContralateral mediastinal shiftReduction in cardiac output

Increased intrathoracicpressureVena cava kinks, reducing preload

Thoracic Trauma


Maintain airwayConsider ETI

High flow O 2Ventilate PRNNeedle thoracentesis

2nd or 3 rd ICSAngle of LouisNo flutter valve necessaryCatheter length < 2 inches resulted in failure to reach pleural cavity in 65% of cases

Treat shock

Thoracic Trauma

Open PneumothoraxOpen Pneumothorax

Penetrating traumaSucking chest wounds

Air enters pleural space via hole in chest wallHole has to be large to suck air

Impaled objectsAvulsed wounds and open rib fractures due to blunt or crushing trauma.


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Thoracic Trauma


Opening in the chest wallSucking sound on inhalationTachycardiaTachypneaRespiratory distressSQ emphysemaDecreased lung sounds on affected side

Thoracic Trauma

PathophysiologyPathophysiologyAllows communication between pleural space and atmospherePrevents development of negative intrathoracicpressure

Profound hypoventilationV/Q mismatch

Shuntinghypoxialarge functional dead space

Pressure may build within pleural spaceReturn from Vena cava may be impaired

Results in ipsilateral lung collapse due to ineffect ive ventilation

Thoracic Trauma


Occlusive dressingHigh flow O 2

Assisted ventilations PRNBe alert for tension pneumothorax

Burp dressingNeedle decompression


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Thoracic Trauma


Thoracic Trauma

Flail ChestFlail Chest

3 or more ribs broken in 2 or more placesFree floating segment of chest wallParadoxical motionPulmonary contusionMortality rate 20-40% due to associated injuries

Thoracic Trauma

Assessment FindingsAssessment Findings

Chest wall contusionRespiratory distressPleuritic chest painSplinting of affected sideCrepitusTachypnea, tachycardiaParadoxical movement (possible)


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Impairment of bellows systemInadequate diaphragmatic movementPain and increased work of breathingIntra-alveolar bleedingHypoventilation:

HypoxiaHypercapnea

Thoracic Trauma


Suspect spinal injuriesEstablish airwayHigh flow O 2Assisted ventilations

Treat hypoxiaPromote full lung expansionConsider ETI and PEEP

Mechanical stabilization does not work

Thoracic Trauma

Massive HemothoraxMassive Hemothorax

If due to great vessel or cardiac injury:

50% die immediately25% live 5-10 minutes25% may live > 30 minutes

Blood loss results inHypovolemiaDecreased ventilation of affected lung


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Thoracic Trauma

Assessment FindingsAssessment FindingsTachypnea /dyspneaTachycardiaShock

Directly correlates to amount of blood loss

Pleuritic chest painDecreased lung soundsCollapsed neck veinsDullness on percussionBleeding may be severe enough to mimic tension pneumothorax

Thoracic Trauma

PathophysiologyPathophysiologyAccumulation of blood in pleural space

Each side can hold up to 3000 ml bloodPenetrating or blunt lung injury

Laceration of:Chest wall vesselsintercostal vesselsMyocardium

Massive hemothorax indicates great vessel or cardiac injuryIntercostal artery can bleed 50 cc/minResults in collapse of lung

Thoracic Trauma


Establish airwayHigh flow O 2Assisted ventilation PRNNeedle thoracentesis if tension suspectedChest tube or surgery in hospital


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Cardiac TamponadeCardiac Tamponade

Rapid accumulation of blood in the inelastic pericardiumUsually associated with penetrating traumaRare in blunt traumaOccurs in < 2% of thoracic traumaGSW wounds have higher mortality than stab woundsLower mortality rate if isolated tamponade

Thoracic Trauma


Beck’s Triad (hallmark sign)HypotensionJugular venous distensionMuffled heart sounds

Narrowing pulse pressurePulsus paradoxus

Radial pulse weakens on inhalation

Pulsus alternansElectrical alternans

Thoracic Trauma

Electrical AlternansElectrical Alternans


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Thoracic Trauma


Heart is compressed, resulting in:Impairment of Frank Starling mechanism

Decreased preloadDecreased stroke volume

Myocardial perfusion decreased due topressure effects on walls of heartdecreased diastolic pressures

Ischemic dysfunction may result in injuryRemoval of as little as 20 ml of blood may drastically improve cardiac output

Thoracic Trauma

ManagementManagementSecure airwayHigh flow O 2

PericardiocentesisRarely done by EMS, primarily reserved for cardiac arrestNeedle-guidedEchocardiogram-guidedRemoval of as little as 20 ml blood can improve CO greatly

Thoracic Trauma

Pulmonary ContusionPulmonary Contusion

Blunt trauma to the chest from:

Rapid deceleration forcesHigh energy shock waveshigh velocity projectilesLow velocity projectileMost common injury from blunt thoracic trauma30-75% of blunt traumaMortality 14-20%


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Thoracic Trauma


Tachypnea or respiratory distressTachycardiaEvidence of blunt chest traumaCough and / or hemoptysisApprehensionCyanosis

Thoracic Trauma


Rib fractures in many but not all casesRib fractures less common in children

Alveolar rupture with hemorrhage and edemaincreased capillary membrane permeability

Large vascular shunts developGas exchange disturbancesHypoxemiaHypercapnea

Thoracic Trauma


Supportive therapyEarly use of positive pressure ventilation reduces ventilator therapy durationAvoid aggressive crystalloid infusionSevere cases may require ventilator therapyEmergent transport


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Thoracic Trauma

PEEP/CPAPPEEP/CPAP

Thoracic Trauma

Myocardial ContusionMyocardial Contusion

Most common blunt injury to heartUsually due to steering wheelSignificant cause of morbidity and mortality in the blunt trauma patient

Thoracic Trauma


Cardiac arrhythmias following blunt chest traumaAngina-like pain unresponsive to nitroglycerinPrecordial discomfort independent of respiratory movementPericardial friction rub (late)


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Thoracic Trauma

EKG FindingsEKG Findings

Persistent tachycardiaST elevation, T wave inversionAtrial flutter or fibrillationRBBBPVCsPACs

Thoracic Trauma


Establish airwayHigh flow O 2Be cautious with fluid boluses12 Lead ECG if time permitsStandard antiarrhythmic therapy as neededConsider vasopressors for hypotensionEmergent transport

Thoracic Trauma

Aortic DissectionAortic Dissection

15% of all blunt trauma deaths1 of 6 MVC fatalities had aortic rupture

85% die on scene10-15% survive to hospital

1/3 die within 6 hours1/3 die within 24 hours1/3 survive 3 days or longer


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Thoracic Trauma


Retrosternal or interscapular painPain in lower back or one legRespiratory distressAsymmetrical perfusion

BP difference between armsIpsilateral pulse deficit

Upper extremity hypertension withDecreased femoral pulses, ORAbsent femoral pulses

Dysphagia

Thoracic Trauma


Separation of the tunica intima and mediaTears due to high-speed decelerationDescending aorta at the isthmus distal to left subc lavianartery is most common site

Fixation point – ligamentum arteriosumBlood enters tunica media through a small intimal te ar

Forms a false lumen between layersLumen expands and lengthens with each beat

Rupture results in circulatory collapse within seco nds

Thoracic Trauma


Establish airwayHigh flow O 2

Vascular access, but…… NS at TKO rate only!… the only fluid you should bolus is diesel!Transport to trauma center with vascular surgery


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Thoracic Trauma

Diaphragmatic HerniationDiaphragmatic Herniation

Thoracic Trauma


Decreased breath soundsUsually unilateralDullness to percussion

DyspneaScaphoid abdomen (hollow appearance)Suspect with lower rib fracturesBowel sounds resemble a diesel engine

Thoracic Trauma


Compression to abdomen resulting in increased intra-abdominal pressure

Abdominal contents rupture through diaphragm into chestBowel obstruction and strangulationRestriction of lung expansionMediastinal shift

90% occur on left side due to protection of right side by liver


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Thoracic Trauma

ManagementManagementEstablish airwayAssist ventilations with high flow O 2

Vascular accessMonitor ECGNasogastric tube if possible

Distal tip in pleural space on CXR is diagnosticAvoid

PASGTrendelenburg

Thoracic Trauma

Tracheobronchial RuptureTracheobronchial Rupture

< 3% of thoracic traumaBlunt or penetrating injuryHigh mortality rate (>30%)Associated with fracture of upper 3 ribs

Thoracic Trauma

Assessment FindingsAssessment FindingsTachypneaDyspneaObvious SQ emphysemaBright red hemoptysisSigns of tension pneumothoraxunresponsive to needle decompression


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Thoracic Trauma


Majority (80%) occur at or near carinaRapid movement of air into pleural spaceTension pneumothorax refractory to needle decompressionContinuous flow of air from needle of decompressed chest

Thoracic Trauma


Establish airwayAssisted ventilationConsider early ETIIntubate the mainstem bronchus!

Thoracic Trauma

Esophageal InjuryEsophageal InjuryPenetrating injury most frequent cause

Iatrogenic (Boerhaave Syndrome)Rare in blunt traumaCan perforate spontaneously

Violent emesis (Mallory Weiss tear)Carcinoma


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Thoracic Trauma

Assessment FindingsAssessment FindingsPain and local tendernessHoarseness and dysphagiaRespiratory distressResistance of neck on passive motionMediastinal esophageal perforation

Mediastinal emphysemaMediastinitisPneumomediastinumSQ emphysemaSplinting of chest wall

Shock

Thoracic Trauma

ManagementManagementEstablish airway

ETIAvoid supraglottic airways

IV crystalloids titrated to BP 90-100 systolicEmergent transport

Trauma center with surgical capability

Thoracic Trauma

SummarySummary

Thoracic trauma results in significant morbidity and mortality.Rapid recognition and treatment of the Big Six can save lives.Airway management and ventilation are the keys to proper care.


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Thoracic Trauma

Questions?

Thoracic Trauma

www.kellygrayson.com

www.ambulancedriverfiles.com

Thoracic Trauma

ReferencesReferencesInadequate needle thoracostomy rate in the prehospit al setting for presumed pneumothorax: an ultrasound study. Bla ivas M.J Ultrasound Med . 2010 Sep;29(9):1285-9.

Thoracic needle decompression for tension pneumotho rax: clinical correlation with catheter length. Ball CG, et al. Can J Surg . 2010 June; 53(3): 184–188. Needle thoracostomy in the prehospital setting. Ecks tein M, Suyehara D. Prehosp Emerg Care . 1998 Apr-Jun;2(2):132-5.


The Dirty Dozen - Virginia Department of Health · The Dirty Dozen Beyond the Basics of ... cardiac arrest Needle-guided ... patient Thoracic Trauma Assessment Findings Cardiac arrhythmias

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