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Chest Trauma

Chest Trauma. Espanola Valley Emergency Medical Services Espanola, NM. Factoids. 25% of trauma deaths 10% require surgery. Classifications. By mechanism penetrating blunt By injury. The chest - what’s in there?. Chest wall Pleura Lungs Mediastinum Diaphragm. Key Anatomy review.

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Chest Trauma

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  1. Chest Trauma Espanola Valley Emergency Medical Services Espanola, NM

  2. Factoids • 25% of trauma deaths • 10% require surgery

  3. Classifications • By mechanism • penetrating • blunt • By injury

  4. The chest - what’s in there? • Chest wall • Pleura • Lungs • Mediastinum • Diaphragm

  5. Key Anatomy review • Define the limits of the chest • Inspiration/expiration • Pleura/potential space • Neurovascular bundle • Pericardium

  6. What can go wrong • Chest wall • Rib fractures • Flail chest • Sternal fracture • Why do we care? • Pain • Markers for underlying injury • Pain limited respiration

  7. What can go wrong • Lungs • Pneumothorax • Open • Closed • Tension • Hemothorax • Hemopneumothorax • Pulmonary contusion • Michelin man syndrome

  8. What can go wrong • Mediastinum • Myocardial contusion • Pericardial tamponade • Aortic dissection • Myocardial rupture/penetration • Espophageal rupture • Diaphragm • Rupture • Traumatic asphyxia

  9. Pearls • Tension presents like tamponade • Both hypotension, neck vein distension and narrow pulse pressure • tension more common • tamponade usually with penetrating trauma • tension usually with blunt trauma • tamponade has normal lung sounds • you can treat tension • tamponade is going to the OR anyway

  10. Pearls • Flail segment may not be initially visible • Beck’s triad • Children more prone to contusions and tension pneumothorax • Tracheal deviation with tension is rare • Each side of chest can hold 3 liters of blood in adult • Need long needle for thoracostomy

  11. PPV Suspicions • Peak airway pressures > 50 cm H2O • PEEP > 15 cm H2O • ARDS, COPD, or asthma • Use of tidal volumes > 12 mL/kg

  12. Prehospital Treatment • Recognition: H and P • Oxygenate: high flow O2, intubation, RSA • But beware of positive pressure • Maintain perfusion: crystalloids, blood • No M.A.S.T. • Release tension: needle decompression • Rapid transport to hospital

  13. Needle Decompression • PPE • Assess the need • Clean and prep site ( 2ndintercostal space midclavicular) • Select appropiate size catheter • 12-14g 3 inch for adults, size appropiate for infants and children • Cook catheter

  14. Needle Decompression • Monitor for rush of air and may measure with syringe. • Reassess for hemodynamic and oxygenation improvement. • Documentation • Indications/Procedure • Location • Results

  15. ED treatment • Recognition: expensive tests • Oxygenate: high flow O2, intubation • Maintain perfusion: crystalloids and blood • Release tension: chest tube • Rapid transport to OR

  16. RSA Case review • 3 Cases

  17. RSA Case Review • Case #1 • 11/01/2009 1213hrs • Dispatched to an unresponsive 54 y.o. female. • 12:15 Enroute to Camino Santa Cruz. • 12:26 Arrive on scene. • 12:30 Initial physical exam and assessment • 12:42 Depart scene

  18. RSA Case Review • 1250 hrs RSA Procedure • 1315 hrs Post sedation • 1320 hrs Back in service

  19. HPI • Family members found patient unresponsive sitting on the toilet. • Two hours prior she had suffered a fall at home. • Earlier in the morning, prior to the fall, she had no complaints according to the family.

  20. PMHx • Traumatic brain injury 35 years ago. • Breast cancer • Closed head injury and left temporal scalp laceration repair with sutures in place from a recent fall.

  21. Meds/Allergies • Aromasin, Alendronate. • NKDA

  22. Initial Assessment • HR: 72, RR: 22, BP: 125/72, O2 Sat: 96% RA, NSR on cardiac monitor. • Not alert, not responsive. • Pupils unequal. • Skin pale. • Skull intact on palpation. • No obvious new trauma. • No respiratory distress, lungs clear to auscultation

  23. What Now?? • BGL-148mg/dl • Narcan 2 mg • Ponder? • Risk benefit analysis • Indications

  24. Treatment • IV, 20 gauge in the right hand. • Cardiac monitor • Oxygen (not specified) • Depart scene 1242 hrs • Where to transport? • Definitive care vs closest facility

  25. Reassessment • Not alert, not responsive • HR: 78, RR: 20, BP: 104/50, O2 Sat: 100% on 100% O2 via BVM, NSR on cardiac monitor.

  26. Discussion • BVM • Narcan • Nuerological assessment • GCS • Reflexes

  27. RSA Procedure • Etomidate 26 mg (route not specified). • Rocuronium 65 mg (route not specified). • #4 LMA placed and confirmed breath sounds, gastric tube placed, tube (not specified) secured.

  28. Reassessment • Not alert, not responsive. • HR: 70, RR: 12, BP: 108/50, O2 Sat: 100% on 100% O2 via BVM, NSR on cardiac monitor, ETCO2: 35 to 40.

  29. Versed 5 mg (route not specified) @ 1315 hrs. • Fentanyl 100 mcg (route not specified). • Patient care turned over to Care Flight 5 for transport to UNMH for “neuro”.

  30. Summary • Appropriate • Gastric tube placement • Documentation • ETCO2 Waveform • Post sedation time and dosage for increased ICP and MAP • Routes of administration • Weight • Confirm placement by receiving team

  31. Case #2 • 12/02/2009 12:21hrs • Dispatched to a “man down”. • 12:21hrs Enroute to Alcalde Quick-mart. • 12:27hrs Arrive on scene. • 12:32hrs Initial physical exam and assessment • 12:38, 12:43, 12:45hrs reassessments • 1245hrs RSA procedure with #4 LMA

  32. 1255hrs reassessment and LMA #4 removal. • 1258 hrs King LT #5 place and reassessed, versed given • 1305hrs Depart scene • 1315hrs Arrive Espanola Hospital • 1345hrs Back in service

  33. HPI • Found lying prone in a pool of vomit. Last seen 10 minutes ago walking around the Quick-mart. Appeared disoriented

  34. PMHx • Unknown • Unknown allergies and medications

  35. Initial Assessment • HR: 108, RR: 4, BP: 116/66, O2 Sat: 78% RA, RSR on cardiac monitor • BGL: 76 • GCS: 4 • Skin cyanotic. • No obvious trauma seen. • No JVD. • Pupils equal, 2mm round, sluggish reaction to light.

  36. What Next? • Ponder? • Risk benefit analysis

  37. Treatment • Narcan 2 mg IM left deltoid. • O2 at 15 L/min via NRB.

  38. 4 minutes later… • Re-assessment: • HR: 111, RR: 24, BP: 112/66, O2 Sat: 82% 15L/min via NRB, RSR, tachycardia without ectopy on cardiac monitor. • GCS: 4 • Skin pink, warm, dry. • Breath sounds shallow with crackles. • Gag reflex is intact. 

  39. Continued • Treatment: • IV, 18 gauge in left external jugular vein. • Narcan 4 mg IV.

  40. 5 minutes later • HR: 107, RR: 24, BP: 103/62, O2 Sat: 94% 100% via BVM, RSR on cardiac monitor. • GCS: 3 • Skin pink, warm, dry. • Treatment: • Narcan 2 mg

  41. What now??

  42. 2 minutes from last assessement • Re-assessment: • HR: 107, RR: 20, BP: 99/80, O2 Sat: 94% 100% via BVM, ETCO2: 40, RSR on cardiac monitor. • GCS: 3 • Skin pink, warm, dry.

  43. Continued • Treatment: • Rocuronium 75 mg IV • Etomidate 30 mg IV • Versed 5 mg IV • For airway control #4 LMA inserted with bilateral breath sounds and no epigastric sounds

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