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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

slide3
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 Trauma1 out of 4 deaths
  • Thoracic Injuries 85% Require :
  • Correct hypoxia
  • Improve circulation
  • Alleviate ventilatory obstruction
etiology of hypoxia
Etiology of Hypoxia
  • Hypovolemia tissue hypoxia
  • Perfusion unventilated lung
  • Ventilation of unperfused lung
  • Abnormal pleural airway relationships
primary survey
Primary Survey
  • Life threatening chest trauma

Airway

Breathing

Circulation

tension pneumothorax
Tension Pneumothorax
  • 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
slide8
Treatment
  • Immediate decompression
  • Clinical diagnosis not radiologic

Open Pneumothorax Management

  • Immediate covering of defect
  • Chest tube
  • Definitive operation
massive hemothorax
Massive Hemothorax
  • 1500 ml + blood loss
  • Systemic of pulmonary vessel disruption
  • Flat vs. distended neck veins
  • Shock / no breath sounds or percussion dullness
management
Management
  • Rapid volume restoration
  • Chest decompression & X-ray
  • Auto-transfusion
  • Operative intervention
  • Re-expand lung
  • Oxygen
  • Judicious fluid management
  • Selective intubation
  • Analgesia
slide11
Classic Findings
  • 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
  • In-depth physical exam
  • Upright chest film
  • ABGs
  • ECG
  • Pulmonary contusion
  • Aortic disruption
  • Tracheo-bronchial injury
  • Myocardial contusion
pulmonary contusion
Pulmonary Contusion
  • Most common
  • Selective intubation & ventilation
  • Maintain adequate oxygenation
major intrathoracic vascular injury
Major Intrathoracic Vascular Injury
  • 90% fatal at scene
  • 50% mortality each day treatment delayed
  • Common site: ligamentum arteriosum
widened mediastinum on x ray
Widened Mediastinum On X-ray

Management

  • Direct repair
  • Resection & graft
  • Treatment by qualified surgeon
tracheal injuries
Tracheal Injuries
  • Penetrating :

♦STAT surgical

♦repair

♦Associated

  • Blunt :

♦Subtle

♦History

♦Important

slide17
Laryngeal Fractures
  • 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
slide18
Management
  • Airway maintenance
  • Surgical intervention

Esophageal Trauma

  • Blunt vs. penetrating
  • Severe epigastric blow
  • Pain/shock, injury
  • Pneumo/hemothorax without fracture
esophageal trauma
Esophageal Trauma
  • Chest tube-particulate matter
  • Chest tube-bubbles continuously
  • Mediastinal air/empyema
  • Gastrografin swallow/esophagoscopy
  • Management of Surgical Intervention
traumatic diaphragmatic hernia
Traumatic Diaphragmatic Hernia
  • Diagnosed left side
  • Blunt: large tears
  • Penetration: small perforation
  • Misinterpreted X-ray
  • Contrast radiography
slide21
Myocardial Contusion
  • Blunt trauma
  • History
  • ECG changes
  • Serial enzyme changes
  • Treatment: observe/monitor

Subcutaneous Emphysema

  • Airway injury
  • Pneumothorax
  • Blast injury
pneumothorax
Pneumothorax
  • Blunt trauma
  • Ventilation/perfusion defect
  • Hyper-resonance
  • Decreased breath sounds
  • Treatment- tube thoracostomy
hemothorax
Hemothorax
  • Etiology

♦Lung laceration

♦Vessel laceration

  • Treatment

♦Tube Thoracostomy for continued bleeding

slide24
Rib Fractures
  • Pain/splinting
  • Impaired ventilation
  • Increased secretions
  • Atelectasis/pneumonia

Ribs # 1-3

  • Severe force
  • Associated injuries
  • 50% mortality
slide25
Ribs # 5-9
  • 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

1. Pneumothorax

2. Hemothorax

3. Selected cases, suspected severe lung injury

4. Prophylaxis

summary
Summary
  • Common in multiple injured patient
  • Cognitive knowledge to diagnose
  • Develop skills
  • ECG monitoring
pitfalls in thoracic injuries
Pitfalls in Thoracic Injuries
  • 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
slide29
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
slide30
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
slide31
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
slide32
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
slide33
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
ad