chest trauma MajidPourfahraji
trauma • Trauma, or injury, is defined as cellular disruption caused by an exchange with environmentalenergy that is beyond the body's resilience. • Trauma remains the most common cause of death for all individuals between the ages of 1 and 44 years and is the third most common cause of death regardless of age.
primary survey • The initial management of seriously injured patients consists of performing the primary survey (the "ABCs"—Airway with cervicalspine protection, Breathing, and Circulation); the goals of the primary survey are to identify and treat conditions that constitute an immediate threat to life.
Main Causes of Chest Trauma • Blunt Trauma: Blunt force to chest. • Penetrating Trauma: Projectile that enters chest causing small or large hole. • Compression Injury: Chest is caught between two objects and chest is compressed.
Trauma to the chest • Chest wall * Rib fracture * Flail chest • Airway obstruction • Pneumothorax * Simple/Closed * Open Pneumothorax * Tension Pneumothorax • Hemothorax • Flail Chest and Pulmonary Contusion • Cardiac Tamponade • Traumatic Aortic Rupture • Diaphragmatic Rupture
rib fracture • Blunt And Penetrating • PAIN • Shallow breathing • Atelectasis • Shunt: lack of ventilation respiratory and metabolic acidosis
Simple Pneumothorax • Opening in lung tissue that leaks air into chest cavity • Blunt trauma is main cause • May be spontaneous : Cough • Usually self correcting • S/S • Chest Pain • Dyspnea • Tachycardia • Tachypnea • Decreased Breath Sounds on Affected Side
Treatment for Simple/Closed • ABC’s with C-spine control • Airway Assistance as needed • If not contraindicated transport in semi-sitting position • Provide supportive care • Contact Hospital and/or ALS unit as soon as possible
Treatment for Simple/Closed • Thoracocentesis • Chest Tube or throcostomy
Open pneumothorax • An open pneumothorax or "sucking chest wound" occurs with full-thickness loss of the chest wall • Causes the lung to collapse due to increased pressure inpleural cavity • Can be life threatening and can deteriorate rapidly • Results in hypoxia and hypercarbia • Complete occlusion of the chest wall defect without a tube thoracostomy may convert an open pneumothoraxto a tension pneumothorax • Temporary management of this injury includes covering the wound with an occlusive dressing that is taped on three sides. • Definitive treatment requires closure of the chest wall defect and tube thoracostomyremote from the wound.
S/S of Openpneumothorax • Dyspnea • Sudden sharp pain • Subcutaneous Emphysema • Decreased lung sounds on affected side • Red Bubbles on Exhalation from wound • …
Tensionpneomothorax • Respiratory distress • Tachypnea • Tachycardia • Poor Color • Anxiety/Restlessness • Accessory Muscle Use • *Hypotension* But JVP + • Tracheal deviation away from the affected side • Lack of or decreased breath sounds on the affected side • Subcutaneous emphysema on the affected side • Hypotension qualifies the pneumothorax • Needlethoracostomy with a 14-gauge angiocatheter in the secondintercostal space in the midclavicular line • Tube thoracostomy should be performed immediately
Tension pneomothorax • The normally negativeintrapleural pressure becomes positive, which depresses the ipsilateralhemidiaphragm and shifts the mediastinal structures into the contralateralchest • the contralateral lung is compressed and the heartrotates about the superior and inferior vena cava; this decreases venous return and ultimately cardiac output, which results in cardiovascular collapse
Flail chest • * Flail chest occurs when TWOor more contiguous ribs are fractured in at least twolocation • * additional work of breathing and chest wall pain caused by the flail segment is sufficient to compromise ventilation • * it is the decreased compliance and increased shunt fraction caused by the associated pulmonary contusion that is typically the source of post injury pulmonary dysfunction • * Treatment is intubation and mechanical ventilation (PEEP mode) • The patient's initial chest radiograph often underestimates the extent of the pulmonary parenchymal damage • Must chest tube if bleeding!
hemothorax • life-threatening injury number one • A massivehemothoraxis defined as >1500 mL of blood or, in the pediatric population, one third of the patient's blood volume in the pleural space • tube thoracostomyis the only reliable means to quantify the amount of hemothorax • After blunt trauma, a hemothorax usually is due to multiple ribfractures • occasionally bleeding is from lacerated lung parenchyma • a massivehemothorax is an indication for operativeintervention • Indication of emergency toracotomy
Cardiac tamponade • life-threatening injury number two • Acutely, <100 mL of pericardial blood may cause pericardial tamponade • The classic diagnostic Beck's triad—dilated neck veins, muffled heart tones, and a decline in arterial pressure—often is not observed in the trauma • Increased intrapericardial pressure also impedes myocardial blood flow, which leads to subendocardialischemia • Best way to diagnose is ultrasound of the pericardium • Early in the course of tamponade fluid administration • a pericardial drain is placed using ultrasound guidance • Pericardiocentesis is successful in decompressing tamponade in approximately 80% of cases : 15 to 20 cc