Exam IV: Thorax Trauma

Class I: Emergent- critical condition
Class II: Urgent- abdominal trauma
Class III: Minor- broken arm
Class IV: No treatment, minor first aid
Class V: Not alive

Thoracic injuries responsible for 25% of all trauma deaths in North America
Overall thoracic trauma mortality is 10%
Less than 10% of blunt force trauma requires thoracotomy
15-30% of penetrating injuries require thoracotomy

Many of these patients die after reaching the hospital
Most of these patients can be prevented with prompt diagnosis and treatment
Most of these patients can be managed by a General Practitioner with technical procedures taught in a common trauma course!

Military bullets are jacketed and only put a small hole in you, but civilian bullets expand and disperse through the body

Triage:
Civilian: focused on the individual starting with most critical patient
Military: doing the most for the most amount of people; if someone isn’t going to make it, they don’t use their resources to help them

Respiratory: bronchitis, pulmonary embolism, pneumonia, hemothorax, pneumothorax, tension pneumothorax, pleurisy, TB, lung malignancy

GI: gastroesophageal reflux disease (GERD) and other causes of heartburn, hiatus hernia, achalasia

Others: hyperventilation, carbon monoxide poisoning, sarcoidosis, lead poisoning, high abdominal pain may also mimic chest pain, prolapsed intervertebral disc

Ambulance:“Just drive”…….A.K.A. “load and go”
Package with C-spine- always even if patient says the neck is fine because they might be distracted with other more serious injuries
Generally resist interventions unless compelled… do nothing but load and go at the scene
Golden hour: patient treated within an hour
Know your “dead in the field” criteria- don’t fly dead people unless a very good reason exists

Field C-spine clearance- wait for imaging to do this… aka DON’T DO IT
Fluids- get the IV en route at the first stop sign/light
Needle thoracotomy- don’t do this en route
Lights and sirens

Hypoxia- from blood loss or alveolar collapse; always give O2 to patient even with minor injuries to avoid this

Hypercarbia: inadequate ventilation and level of consciousness; result of hypoxia

Acidosis and hypoperfusion (SHOCK)- result of hypoxia and hypercarbia

Hypovolemia- no blood in body, then no O2 of tissues

Ventilation- perfusion mismatch changes in intrathoracic pressure relationships Inadequate oxygen delivery to tissues

Blunt Force: MVA = 70-80%, falls (especially 7 ft. or more), act of violence like bat to chest, blast Injuries (steam, compressed air, water, etc.- manufacturing areas)

Penetrating:
Low Velocity- impalements, knife wound
Medium Velocity- bullets from most hand guns and air powered pellet guns.
High Velocity- rifles and military weapons.
*the more velocity, the more the damage that can occur from the point of penetration

Superior Border of Thorax -Thoracic Inlet which holds the major blood supply to and venous drainage from the neck.

Superior-lateral Border of Thorax -Thoracic Outlet, Brachial Plexus, Axillary Vein, Brachial Artery.

Inferior Border -hemidiaphragm -holds the diaphragmatic hiatus = Aorta, Esophagus, Vagal Nerve, Thoracic Duct and Vena Cava.

Esophagus lies posterior to the trachea.
To the right of it is the Aortic Arch.
To the left of it is the Descending Aorta.
Thoracic Duct runs posterior and is proximal to the spinal column, it enters the Left subclavian vein in the neck

ABCTDE
Airway: do they have one or not… if iffy need to stabilize it via ET tube or something
Breathing: is the patient breathing… tidal volume, how well are they breathing
Circulation: pulse quality, BP
Thoracotomy
Deficits: neuro exam with dates and times
E: exposure- remove all clothing, check ENTIRE BODY

Primary Survey: ABCDE/vitals
Hypoxia is most serious problem - early interventions aimed at reversing
Immediate life-threatening injuries treated quickly and simply - usually with a tube or a needle
Secondary survey guided by high suspicion for specific injuries

1. Airway obstruction- move soft tissues forward to remove foreign body

2. Tension pneumothorax- compresses lungs down and shift mediastinal structures, trachea and Adam’s apple; pick up using your eyes, hands, and stethoscope; don’t want this dx by radiologist… bad form on your part

3. Open pneumothorax “sucking chest wound”

4. Massive hemothorax
   5 .Flail chest- physical examination see there is something weird with the chest and one segment floating independently

5. Cardiac tamponade- heart cannot expand

Can pick these up with hands on and stethoscope aka primary survey
EKG: tamponade; intervene with decompression

1. Pulmonary contusion

2. Myocardial contusion

3. Traumatic aortic rupture

4. Traumatic diaphragmatic rupture

5. Tracheobronchial tree injury - larynx, trachea, bronchus

6. Esophageal trauma- sneaks up on you within 2-5 days

1. Subcutaneous emphysema- air in the skin and then blows up; need to find where is injury at and where is the air coming in

2. Traumatic asphyxia- crushing injury, trench walls collapse, car crushes them; blood is brought upwards; cyanotic… eyes bulging

3. Simple pneumothorax

4. Hemothorax

5. Scapula fracture- takes a lot of force to break a scapula; better start looking deep inside because could be enough force to damage organs, heart, etc.

6. Rib fractures

Listen for airway movement at patient’s nose and mouth- estimate air moving back and forth, any odors (sweet, bowel, alcohol, etc.)

Access intercostal and supraclavicular muscle retractions- see chest is moving is not enough of a sign for breathing

Assess oropharynx for foreign body obstruction, especially in an unconscious patient- MVA can be eating during the accident and food becomes lodged into throat (most efficient tool: fingers)

Outward signs of trauma

Jaw thrust - grasp angles of mandible and bring the jaw forward- increases diameter

Oropharyngeal airway

Nasopharyngeal airway

**Definitive management - endotracheal (ET) tube through vocal cords with balloon inflated!!

Answer: Well lubricated “trumpet” gently inserted through nostril

In breathing patient without major facial trauma surgical airways

If major trauma, could accidentally insert tube into brain, sinuses, etc.

Keep away from nasal septum because of the plexus there that can cause bleeding

Trigger device with high flow O2

Not a lot of surface area- need time to put O2 in and O2 out, so inject O2 every 3-4 seconds

Cricothyrotomy tracheostomy- insert 14 gauge needle

Before inserting jet, think about cricothyrotomy and tracheostomy

Expose patient’s chest

Observe, palpate and listen for respiratory movement

Rate of breathing

Breathing pattern -shallow breaths are ominous.

Cyanosis -late sign of hypoxia, and you missed the early signs.. BAD

Inserted in mouth behind tongue

DO NOT push tongue further back

DO NOT put this type of airway in conscious because of gag reflex and vomiting, ONLY unconscious

Check pulse for quality, rate, and regularity

Blood Pressure

Assess and palpate skin for color and temperature; skin changes can indicate patient going into shock

Check neck veins for distention -indication of cardiac tamponade that may be absent if patient is hypovolemic (mostly elderly)

Cardiac Monitor -dysrythmia, PVC (premature ventricular contraction), PEA (pulseless electrical activity)

Closed heart massage is ineffective in patient’s in PEA with hypovolemia (CPR)

Candidates for ED thoracotomy include patient’s with exsanguination, penetrating, precordial injuries who arrive in PEA and there is a SURGEON PRESENT

Thoracotomy is usually not effective in patients with blunt thoracic injuries in PEA

Head to foot exam, remember the back.

If the patient is unstable a brief history is applicable at this time =

S-subjective things patient says

A -allergies

M -medications

P –past medical history

L –last meal eaten

E -events of trauma

Pulmonary Contusion and Myocardial Contusion- leather like, air gradient shifts away from damage causing hypoxia; usually occurs 8-24 hours later

Aortic Disruption- wide mediastinum/dead on scene

Traumatic Diaphragmatic Rupture

Esophageal Rupture- won't happen until later

Blunt injuries to SVC (superior vena cava) and other major veins- major trauma to scapula can indicate deeper injuries

Rib Fractures

Clavicular Fractures

Scapular Fractures

Blunt injuries to Thoracic Duct.

*Pain upon palpation if broken rib and might hear cracking with stethoscope

Evidenced in blunt trauma, especially MVA and blast injuries

Will be seen in primary survey during airway step

Readjust head to sniffing position if C-spine has been cleared

Attempt direct visualization and removal.

May need fiberoptics for visualization

Airway obstruction: ET tube with balloon inflated beyond vocal cords

A one way air leak that collapses the affected lung with mediastinal and tracheal shift to the opposite side

Signs and Symptoms: respiratory distress, tachycardia, hypotension, tracheal deviation, unilateral absent breath sounds, neck vein distension, cyanosis

Cyanosis is a late sign of hypoxia and you lost the battle

Tension pneumothorax is not an x-ray diagnosis

It MUST be recognized clinically

Treatment: immediate decompression with a 14” gauge needle into the 2nd intercostal space at midclavicular line of affected side

Definitive treatment -insertion of a chest/thoracotomy tube into the fourth intercostal space anterior to mid-axillary line

Proper chest x ray: need to see apex of lungs, and the gutters aka need to see top to bottom

Posterior to anterior in normal chest x ray, but in trauma do an AP (anterior to posterior)

Glass appearance in lung= open cavity

Compressed lung is the globby stuff near the sternum

Hyaline structures on the right side of the heart= normal

Lines on normal lung(very hard to see)= normal

A large defect of the chest wall causing equilibration between the interthoracic and atmospheric pressure

If the opening is 2/3 or more in diameter of the trachea, air will prefer to pass through the open chest wound

Signs and Symptoms: a large open wound of the chest, respiratory distress

Sometimes need to have a big chest tube (sometimes 2) when blood draining, but small chest tube if just for air

Sucking slurping sound when they inhale and exhale

Promptly close the defect with a sterile dressing taped on 3 sides creating a flutter-type valve.

Closure of all 4 sides of the dressing could cause a tension pneumothorax if chest tube is not in place, 3 sides NOT 4

Definitive surgical closure of the defect is required

Rapid accumulation of >1500 cc blood in chest cavity; usually secondary to penetrating wound

Results in hypovolemia & hypoxemia

If less than 500 cc then see what happens with large test tube and if accumulates to more than you take them to the OR

Neck veins may be:

flat – from hypovolemia

distended - intrathoracic blood

Absent breath sounds, DULL to percussion

Signs and Symptoms: shock, absent breath sounds, dullness to percussion on one side of the chest

Secondary to multiple rib fractures

A segment of the chest wall does not have bony continuity with the rest of the thoracic cage

Major problem is from the injury to the underlying lung

Paradoxical motion alone does not cause hypoxia, it is the pain with restricted chest wall movement and lung injury

Poor inspiratory effort

Asymmetrical movement of thorax

Crepitus of rib or cartilage fractures

Hurts to take a deep breath because multiple fractures= poor inspiratory effort

Initial treatment: stabilize segment

Need at least three ribs to make a flail segment

6/12 hours later edema from bruising of lung aka the lungs don’t swell right away.. ICU and aggressive treatment

Usually a result of penetrating injuries

Only a small amount of blood in the pericardial sac is needed to restrict cardiac activity

Doesn’t take much fluid to squeeze the heart

Usually from penetrating injuries

CARDIAC TAMPONADE SECONDARY TO HEMOPERICARDIUM

Classic “Beck’s triad”- cardiac tamponade

elevated venous pressure – distended neck veins, absent in hypovolemia

decreased arterial pressure- hypotension

BP muffled heart sounds- blood in sac prevents cardiac activity

Hypotension

Pulsus Paradoxus –decreased pressure during inspiration in excess of 10mmHg.

Kussmaul’s Sign –rise in venous pressure with inspiration while breathing normal.

Pericardiocentesis –use a plastic sheathed needle if available and enter via subxyphoid route.

All patients with a positive pericardiocentesis secondary to trauma will require an open thoracotomy.

Open pericardiotomy may be required if blood in pericardial sac is clotted

Xiphoid process- needle with three pops and then draw fluid off… don’t stick needles in continuously because don’t know how much they are bleeding