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Advanced Trauma Life Support Thoracic Trauma

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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Advanced Trauma Life Support Thoracic Trauma

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  1. Advanced Trauma Life SupportThoracic Trauma

  2. 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

  3. 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

  4. Chest Trauma1 out of 4 deaths • Thoracic Injuries 85% Require : • Correct hypoxia • Improve circulation • Alleviate ventilatory obstruction

  5. Etiology of Hypoxia • Hypovolemia tissue hypoxia • Perfusion unventilated lung • Ventilation of unperfused lung • Abnormal pleural airway relationships

  6. Primary Survey • Life threatening chest trauma Airway Breathing Circulation

  7. 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

  8. Treatment • Immediate decompression • Clinical diagnosis not radiologic Open Pneumothorax Management • Immediate covering of defect • Chest tube • Definitive operation

  9. Massive Hemothorax • 1500 ml + blood loss • Systemic of pulmonary vessel disruption • Flat vs. distended neck veins • Shock / no breath sounds or percussion dullness

  10. Management • Rapid volume restoration • Chest decompression & X-ray • Auto-transfusion • Operative intervention • Re-expand lung • Oxygen • Judicious fluid management • Selective intubation • Analgesia

  11. Classic Findings • Narrowed pulse pressure • Elevated CVP • Muffled heart sounds • Distended neck veins Management • Patient airway • IV therapy • Pericardiocentesis • Open thoracotomy with repair

  12. Secondary Survey • In-depth physical exam • Upright chest film • ABGs • ECG • Pulmonary contusion • Aortic disruption • Tracheo-bronchial injury • Myocardial contusion

  13. Pulmonary Contusion • Most common • Selective intubation & ventilation • Maintain adequate oxygenation

  14. Major Intrathoracic Vascular Injury • 90% fatal at scene • 50% mortality each day treatment delayed • Common site: ligamentum arteriosum

  15. Widened Mediastinum On X-ray Management • Direct repair • Resection & graft • Treatment by qualified surgeon

  16. Tracheal Injuries • Penetrating : ♦STAT surgical ♦repair ♦Associated • Blunt : ♦Subtle ♦History ♦Important

  17. 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

  18. Management • Airway maintenance • Surgical intervention Esophageal Trauma • Blunt vs. penetrating • Severe epigastric blow • Pain/shock, injury • Pneumo/hemothorax without fracture

  19. Esophageal Trauma • Chest tube-particulate matter • Chest tube-bubbles continuously • Mediastinal air/empyema • Gastrografin swallow/esophagoscopy • Management of Surgical Intervention

  20. Traumatic Diaphragmatic Hernia • Diagnosed left side • Blunt: large tears • Penetration: small perforation • Misinterpreted X-ray • Contrast radiography

  21. Myocardial Contusion • Blunt trauma • History • ECG changes • Serial enzyme changes • Treatment: observe/monitor Subcutaneous Emphysema • Airway injury • Pneumothorax • Blast injury

  22. Pneumothorax • Blunt trauma • Ventilation/perfusion defect • Hyper-resonance • Decreased breath sounds • Treatment- tube thoracostomy

  23. Hemothorax • Etiology ♦Lung laceration ♦Vessel laceration • Treatment ♦Tube Thoracostomy for continued bleeding

  24. Rib Fractures • Pain/splinting • Impaired ventilation • Increased secretions • Atelectasis/pneumonia Ribs # 1-3 • Severe force • Associated injuries • 50% mortality

  25. Ribs # 5-9 • Majority - blunt trauma • Bowing effect • Midshaft fracture • Intrathoracic Management • Obtain chest X-ray • Avoid ♦Systemic analgesics ♦Constrictive devices

  26. Indications for Chest Tube Insertion 1. Pneumothorax 2. Hemothorax 3. Selected cases, suspected severe lung injury 4. Prophylaxis

  27. Summary • Common in multiple injured patient • Cognitive knowledge to diagnose • Develop skills • ECG monitoring

  28. 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

  29. 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

  30. 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

  31. 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

  32. 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

  33. 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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