Advanced trauma life support thoracic trauma
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Advanced Trauma Life Support Thoracic Trauma . Objectives. A-Identify and manage the following immediately life-threatening chest injuries evidenced in the primary survey: 1.Airway obstruction 2.Tension pneumothorax 3.Open pneumothorax (sucking chest wound)

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Objectives
Objectives

A-Identify and manage the following immediately life-threatening chest injuries evidenced in the primary survey:

1.Airway obstruction

2.Tension pneumothorax

3.Open pneumothorax (sucking chest wound)

4.Massive hemothorax

5.Flail chest

6.Cardiac tamponade


B-Identify and initiate treatment of the following potentially life-threatening injuries assessed during the secondary survey:

1.Pulmonarycontusion

2.Aortic disruption

3.Tracheobronchial disruption

4.Esophageal disruption

5.Traumatic diaphragmatic hernia

6.Myocardial contusion


Chest trauma 1 out of 4 deaths
Chest Trauma potentially life-threatening injuries assessed during the secondary survey:1 out of 4 deaths

  • Thoracic Injuries 85% Require :

  • Correct hypoxia

  • Improve circulation

  • Alleviate ventilatory obstruction


Etiology of hypoxia
Etiology of Hypoxia potentially life-threatening injuries assessed during the secondary survey:

  • Hypovolemia tissue hypoxia

  • Perfusion unventilated lung

  • Ventilation of unperfused lung

  • Abnormal pleural airway relationships


Primary survey
Primary Survey potentially life-threatening injuries assessed during the secondary survey:

  • Life threatening chest trauma

    Airway

    Breathing

    Circulation


Tension pneumothorax
Tension Pneumothorax potentially life-threatening injuries assessed during the secondary survey:

  • Air enters pleural space without exit

  • Collapse of affected lung

  • Impaired ventilation-unaffected lung

  • Mechanical ventilation with PEEP

  • Nonsealing

  • Emphysematous bullae lung injury

  • Tracheal deviation

  • Respiratory distress

  • Unilateral absence of breath sounds

  • Distended neck veins

  • Cyanosis - late


  • Treatment potentially life-threatening injuries assessed during the secondary survey:

  • Immediate decompression

  • Clinical diagnosis not radiologic

    Open Pneumothorax Management

  • Immediate covering of defect

  • Chest tube

  • Definitive operation


Massive hemothorax
Massive Hemothorax potentially life-threatening injuries assessed during the secondary survey:

  • 1500 ml + blood loss

  • Systemic of pulmonary vessel disruption

  • Flat vs. distended neck veins

  • Shock / no breath sounds or percussion dullness


Management
Management potentially life-threatening injuries assessed during the secondary survey:

  • Rapid volume restoration

  • Chest decompression & X-ray

  • Auto-transfusion

  • Operative intervention

  • Re-expand lung

  • Oxygen

  • Judicious fluid management

  • Selective intubation

  • Analgesia


Classic Findings potentially life-threatening injuries assessed during the secondary survey:

  • Narrowed pulse pressure

  • Elevated CVP

  • Muffled heart sounds

  • Distended neck veins

    Management

  • Patient airway

  • IV therapy

  • Pericardiocentesis

  • Open thoracotomy with repair


Secondary survey
Secondary Survey potentially life-threatening injuries assessed during the secondary survey:

  • In-depth physical exam

  • Upright chest film

  • ABGs

  • ECG

  • Pulmonary contusion

  • Aortic disruption

  • Tracheo-bronchial injury

  • Myocardial contusion


Pulmonary contusion
Pulmonary Contusion potentially life-threatening injuries assessed during the secondary survey:

  • Most common

  • Selective intubation & ventilation

  • Maintain adequate oxygenation


Major intrathoracic vascular injury
Major Intrathoracic Vascular Injury potentially life-threatening injuries assessed during the secondary survey:

  • 90% fatal at scene

  • 50% mortality each day treatment delayed

  • Common site: ligamentum arteriosum


Widened mediastinum on x ray
Widened Mediastinum On X-ray potentially life-threatening injuries assessed during the secondary survey:

Management

  • Direct repair

  • Resection & graft

  • Treatment by qualified surgeon


Tracheal injuries
Tracheal Injuries potentially life-threatening injuries assessed during the secondary survey:

  • Penetrating :

    ♦STAT surgical

    ♦repair

    ♦Associated

  • Blunt :

    ♦Subtle

    ♦History

    ♦Important


Laryngeal Fractures potentially life-threatening injuries assessed during the secondary survey:

  • Hoarseness

  • Subcutaneous emphysema

  • Palpable fracture creptius

    Tracheal Injuries

  • Partial vs. complete airway obstruction

  • Endoscopy-diagnostic aid

    Bronchial Injury

  • Frequently missed

  • Blunt trauma

  • 50% of deaths in 1 hour


Management potentially life-threatening injuries assessed during the secondary survey:

  • Airway maintenance

  • Surgical intervention

    Esophageal Trauma

  • Blunt vs. penetrating

  • Severe epigastric blow

  • Pain/shock, injury

  • Pneumo/hemothorax without fracture


Esophageal trauma
Esophageal Trauma potentially life-threatening injuries assessed during the secondary survey:

  • Chest tube-particulate matter

  • Chest tube-bubbles continuously

  • Mediastinal air/empyema

  • Gastrografin swallow/esophagoscopy

  • Management of Surgical Intervention


Traumatic diaphragmatic hernia
Traumatic Diaphragmatic Hernia potentially life-threatening injuries assessed during the secondary survey:

  • Diagnosed left side

  • Blunt: large tears

  • Penetration: small perforation

  • Misinterpreted X-ray

  • Contrast radiography


Myocardial Contusion potentially life-threatening injuries assessed during the secondary survey:

  • Blunt trauma

  • History

  • ECG changes

  • Serial enzyme changes

  • Treatment: observe/monitor

    Subcutaneous Emphysema

  • Airway injury

  • Pneumothorax

  • Blast injury


Pneumothorax
Pneumothorax potentially life-threatening injuries assessed during the secondary survey:

  • Blunt trauma

  • Ventilation/perfusion defect

  • Hyper-resonance

  • Decreased breath sounds

  • Treatment- tube thoracostomy


Hemothorax
Hemothorax potentially life-threatening injuries assessed during the secondary survey:

  • Etiology

    ♦Lung laceration

    ♦Vessel laceration

  • Treatment

    ♦Tube Thoracostomy for continued bleeding


Rib Fractures potentially life-threatening injuries assessed during the secondary survey:

  • Pain/splinting

  • Impaired ventilation

  • Increased secretions

  • Atelectasis/pneumonia

    Ribs # 1-3

  • Severe force

  • Associated injuries

  • 50% mortality


Ribs # 5-9 potentially life-threatening injuries assessed during the secondary survey:

  • Majority - blunt trauma

  • Bowing effect

  • Midshaft fracture

  • Intrathoracic

    Management

  • Obtain chest X-ray

  • Avoid

    ♦Systemic analgesics

    ♦Constrictive devices


Indications for chest tube insertion
Indications for Chest Tube Insertion potentially life-threatening injuries assessed during the secondary survey:

1. Pneumothorax

2. Hemothorax

3. Selected cases, suspected severe lung injury

4. Prophylaxis


Summary
Summary potentially life-threatening injuries assessed during the secondary survey:

  • Common in multiple injured patient

  • Cognitive knowledge to diagnose

  • Develop skills

  • ECG monitoring


Pitfalls in thoracic injuries
Pitfalls in Thoracic Injuries potentially life-threatening injuries assessed during the secondary survey:

  • Failure to obtain a chest X-ray soon after admission and again within 4-8 hours may result in significant intrathoracic injuries being overlooked

  • Excessive reliance on chest X-rays may lead to diagnostic errors

  • Without careful inspection of the chest wall, contusions, flail chest, intrathoracic bleeding, and open or "sucking" chest wounds may be overlooked


  • A fractured sternum can be easily missed unless the sternum is palpated carefully or special X-ray views are obtained

  • Cardiac arrest may occur suddenly and rapidly if there is any delay in relieving a suspected tension pneumothorax in a hypotensive patient. X-rays are not needed before treatment under such circumstances

  • Inserting a chest tube while the patient is lying flat increases the chances for injury to the diaphragm


  • If an air leak and pneumothorax space are allowed to persist together, the patient is apt to develop an empyema or bronchopleural fistula

  • If a patient with multiple injuries which include a flail chest is not given ventilatory assistance with a respirator soon after admission, he is apt to die of respiratory failure

  • If a diaphragmatic injury is not suspected and looked for in all patients with chest trauma, the diagnosis will probably be missed


  • If it is assumed that bleeding from the chest wound in a hypotensive patient is superficial in origin, the diagnosis and treatment of severe intrathoracic bleeding may be delayed

  • Repeated attempts to completely aspirate a small hemothorax with a needle or a syringe may cause a pneumothorax or empyema

  • Use of high ventilatory pressures to inflate the lungs following penetrating chest wounds may result in systemic air emboli


  • Failure to obtain an aortogram when there is superior mediastinal widening following blunt chest trauma may result in an inaccurate diagnosis and an unnecessary thoracotomy

  • Hypotension following blunt chest trauma is frequently due to intra-abdominal bleeding

  • Delay in closure or drainage of esophageal injuries result in a high morbidity and mortality; hence, early diagnosis and treatment are vital


  • Any delay in providing adequate ventilatory support greatly increases the risk of irreversible respiratory failure

  • Excessive administration of crystalloids greatly increases the risk of respiratory failure

  • Failure to empty the stomach with a tube soon after chest trauma greatly increases the risk of aspiration and severe ileus


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