1. CHEST TRAUMA

2. CHEST TRAUMA • Second leading cause of trauma death • 20 % of all trauma deaths • 50% of trauma patients presenting to ER in respiratory distress will die • If in respiratory distress and shock 75% will die

4. INITIAL SURVEY • Examine chest immediately after ABC’s • Inspect: open wounds, tenderness, subcutaneous emphysema, unequal chest expansion • Auscultation: decreased breath sounds • Palpation: pain • Respiratory rate • History • From patients and witnesses • Seat belts, steering wheel, speed, nature of collision, what fell on patient, how long was patient crushed

5. MECHANISM OF INJURY

6. BLUNT vs PENETRATING • Blunt: common in all trauma patients • Injuries are principally a function of the magnitude of force and the location/direction over which it is applied • Get a good history • Support patient while injuries heal • Penetrating: Consider with suspicious chest wound and if patient remains hypotensive in spite of fluid therapy • Knife: Length of the instrument, velocity, angle of entry • Firearms: Type of gun, Range, • Limited range of problems • Hemothorax, pneumothorax, hemopericardium

8. RIB FRACTURE • Most common chest injury • Present in 10% of all traumatic injuries • More common in adults than childern • Especially common in elderly • Patients with 1 or 2 rib fractures had a 5% mortality rate and patients with 7 or more fractures have a 29% mortality rate • Ribs form rings • Consider possibility of break in two places

9. RIB FRACTURE • Fractures of the 1st and 2nd ribs require high force • Frequently have injury to aorta or bronchi • 30% will die • Most commonly 5th to 9th ribs • Poor protection

10. RIB FRACTURE • Fractures of the 8th to 12th ribs can damage underlying abdominal solid organs • Liver • Spleen • Kidneys

11. RIB FRACTURE • Signs and Symptoms • Dyspnea • Localized pain, tenderness • Increases when patient: • Coughs • Moves • Breathes deeply • Chest wall instability • Deformity, bony crepitus, ecchymosis • Associated pneumo or hemothorax

12. RIB FRACTURE • Management • High concentration oxygen • Splint using pillow, swathes • Encourage patient to deep breath • Monitor elderly and COPD patients carefully • Broken ribs can cause decompensation • Patients not breathing deeply will result in poor clearance of secretions

14. FLAIL CHEST • Two or more adjacent ribs broken in two or more places • Produces free-floating chest wall segment • Chest wall becomes unstable • Usually 2nd to blunt trauma • More common in older patients • The incidence of flail segments is 10-15% in patients with major chest trauma

15. FLAIL CHEST • Signs and Symptoms • Paradoxical movement • May NOT be present initially due to intercostal muscle spasms that splint the segment • Be suspicious in any patient with chest wall: • Tenderness • Crepitus of broken ribs • Dyspnea • Hypoxia • Usually not present unless underlying lung injury

16. FLAIL CHEST • Ramification • Pain, leading to decreased ventilation • Increased work of breathing • Inefficient respirations • Lung contusion

17. FLAIL CHEST • Management • Establish airway • Suspect spinal injuries • Assist ventilation with BVM and oxygen • Intubate large (>4-6 inches) flail segment and for underlying acute or chronic lung disease • Stabilize chest wall • Towel rolls, tape or sand bags • Pain relief • Narcotics, thoracic epidurals

19. STERNUM FRACTURE • Extremely painful • Associated with a steering wheel injury • Management • Monitor for cardiac arrhythmias and heart failure (secondary to myocardial contusion)

21. PULMONARY CONTUSION • Bruising of the lung • Injuries often involve high velocity rather than slow crushing • Usually associated with rib fractures/ flail chest. 20-40% of patients with rib fractures present with pulmonary contusions • Always associated with hypoxia • If tension pneumothorax has been ruled out then pulmonary contusion is the most likely cause of respiratory impairment

22. PULMONARY CONTUSION • Signs and Symptoms • Chest pain • Rales • Dyspnea • Tachypnea • Ineffective cough • Hemoptysis • Chest wall contusions • X-ray will show opacity • ABG will worsen in time due to edema

23. PULMONARY CONTUSION • Management • Oxygen • Continual reassessment/ Observation • Oxygenation and ventilation usually deteriorate over first 4 hours • Be aggressive if patient has respiratory distress, severe abdominal injury or COPD. • Intubate while lung recovers

25. PNEUMOTHORAX • Air in pleural space • Interfers with expansion of lung • Partial or complete lung collapse occurs • Respiratory distress is usually not seen until the pneumo exceeds 40% of lung volume or pre-existing lung disease • Patients with pulmonary disease tolerate pneumothoraces poorly

26. PNEUMOTHORAX • Causes • Blunt trauma to the chest • Fractured rib lacerating lung • Paper bag effect • Spontaneously • Exertion • Coughing • Air travel • Positive pressure ventilation

27. PNEUMOTHORAX • Signs and Symptoms • Pain on inhalation • Difficulty breathing • Tachypnea • Decreased or absent breath sounds • Hyperresonance on percussion • Pleuritic pain

28. PNEUMOTHORAX • Management • Establish airway • Suspect spinal injury based on mechanism • High concentration oxygen with NRB • Assist decreased or rapid respirations with BVM • Chest tube if > 20% • Monitor for tension pnemonthorax

30. OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) • Unusual motion during respiration • Retraction, shaking, burping • Hole in chest wall • Allows air to enter pleural space with inspiration • Small wound can form a one way valve • Larger wound, greater chance air will enter here than through the trachea

31. OPEN PNEUMOTHORAX (SUCKING CHEST WOUND) • Management • Cover with occlusive dressing • Vaseline gauze covered by 4x4’s • Tape dressing on three sides • High concentration oxygen • Assist ventilations • Consider transport on injured side • Monitor for tension pneumothorax • Form one way valve • Chest tube • Placed at 2nd site

33. TENSION PNEUMOTHORAX • One-way valve forms in lung or chest wall • Air enters pleural space; cannot leave • Air is trapped in the pleural space • Pressure rises • Pressure collapses lung • Mediastinal shift

34. TENSION PNEUMOTHORAX • Trapped air pushes heart and lungs away from injured side • Vena cava becomes kinked • Blood cannot return to heart • Cardiac output falls • Shock develops

35. Tension Pneumothorax clip

36. TENSION PNEUMOTHORAX • Signs and Symptoms • Extreme dyspnea • Restlessness, anxiety, agitation • Decreased breath sounds, unilateral absence of breath sounds • Hyperresonance to percussion • Cyanosis- late • Subcutaneous emphysema

37. TENSION PNEUMOTHORAX • Signs and Symptoms • Rapid, weak pulse • Hypotension • Tracheal shift away from injured side • Jugular vein distension • Respiratory distress • Shock

38. TENSION PNEUMOTHORAX • Management • Secure airway • High concentration oxygen • Consider ALS for pleural decompression • Severely compromised patient; insert a 12 g cannula into the 2nd intercostal space, mid clavicular line

40. HEMOTHORAX • Most common result of major chest wall trauma • The incidence of hemopneumothoraces in patients with rib fractures is 30%. • Blood in pleura space • Massive hemothorax due to bleeding from the major central chest vessels but occasionally an intercostal artery can bleed enough to cause a large amount of blood

41. HEMOTHORAX • Signs and Symptoms • Rapid, weak pulse • Cool clammy skin • Restlessness, anxiety • Chills • Hypotension • Collapsed neck veins • Chest pain

42. HEMOTHORAX • Signs and Symptoms • Decreased breath sounds on affected side • Dullness to percussion • Dyspnea • Ventilatory failure • Up to a liter of blood may be present and not seen on portable supine x-ray

43. HEMOTHORAX • Management • Secure airway • Assist breathing with high concentration oxygen • Rapid transport • Place a large chest tube (36-40) aimed posteriorly

45. TRAUMATIC ASPHYXIA • Blunt force to chest causes • Increased intrathoracic pressure • Backward flow of blood out of the heart into vessels of upper chest, neck, head • Name given because patients look like they have been strangled or hanged

46. TRAUMATIC ASPHYXIA • Signs and Symptoms • Possible sternal fracture or central flail chest • Shock • Purplish-red discoloration of head, neck, shoulders • Sub-conjunctival haemorrhage (Blood shot) protruding eyes • Swollen, cyanotic lips

47. TRAUMATIC ASPHYXIA • Management • Airway with C-spine percautions • Assist ventilations with high concentration oxygen • Spinal stabilization • Rapid transport

49. TRAUMATIC AIR EMBOLISM • Suspect in penetrating chest wounds where there is sudden deterioration in cardiac output after intubation • Immediately life-threatening • Neurological signs in the absence of a head injury • Hemoptysis

50. TRAUMATIC AIR EMBOLISM • Management • 100% O2 • minimise ventilation volumes and pressures • emergency thoracotomy to clamp ascending aorta, remove air source (by clamping pulmonary hilum) and aspirate air from LV and ascending