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Chapter 15: Thoracic Trauma : 

Chapter 15: Thoracic Trauma Galveston College EMS Critical Care Paramedic 2009

Introduction : 

Introduction Thoracic injury accounts for 25 percent of trauma deaths Second only to CNS injuries Contributing factor in an additional 25 percent of patients who die from traumatic injuries Most patients are managed without surgery

Pathophysiology : 

Pathophysiology Blunt versus penetrating injury Tissue hypoxia Secondary to inadequate delivery of oxygenated blood to tissues Hypovolemia Pulmonary insult Hypercarbia Secondary to decreased ventilation Acidosis Secondary to hypoperfusion Anaerobic metabolism

General Management : 

General Management Overall goal is to identify and correct life-threatening injuries

Initial Assessment and Management : 

Initial Assessment and Management Primary exam Centers around the ABCs A: Ensure patent airway B: Ensure adequate respiration/ventilation C: Control bleeding, ensure adequate perfusion D: Assess for neurologic deficits E: Expose patient to identify injuries, and keep patient warm

Detailed Exam : 

Detailed Exam Secondary exam Done after management of life-threatening injuries Covers head to toe Reassessment allows trend identification Patient history Mechanism of injury (MOI) Past medical history (PMH) Specific injuries and management Life-threatening injuries Potentially life-threatening injuries

Life-Threatening Injuries: Tension Pneumothorax (1 of 5) : 

Life-Threatening Injuries: Tension Pneumothorax (1 of 5) Pneumothorax may progress to tension pneumothorax Air collects in pleural space with each breath Increased intrapleural pressure collapses lung Mediastinal shift occurs with continued rising of intrapleural pressure Compression of uninjured lung further compromises ventilation

Life-Threatening Injuries: Tension Pneumothorax (2 of 5) : 

Life-Threatening Injuries: Tension Pneumothorax (2 of 5) Signs and symptoms include: Tachycardia, tachypnea Increasing respiratory distress Hypotension Jugular venous distention (JVD) Altered mental status (AMS), agitation, LOC Cyanosis Decreased or absent lung sounds on affected side Late in progression, decreased lung sounds on unaffected side Possible tracheal deviation late in progression

Life-Threatening Injuries: Tension Pneumothorax (3 of 5) : 

Life-Threatening Injuries: Tension Pneumothorax (3 of 5) Signs and symptoms include:

Life-Threatening Injuries: Tension Pneumothorax (4 of 5) : 

Life-Threatening Injuries: Tension Pneumothorax (4 of 5) Management Needle decompression on affected side Insert large-bore angiocatheter into the intrapleural space 10–14g Midclavicular line, second or third intercostal space Over top of inferior rib Insert catheter until rush of air appreciated If noisy environment prevents auscultation of rush of air, consider attaching 10 cc syringe barrel with approximately 5–8 cc/s of normal saline to catheter

Life-Threatening Injuries: Tension Pneumothorax (5 of 5) : 

Life-Threatening Injuries: Tension Pneumothorax (5 of 5) Management Needle decompression on affected side Bubbles visible in syringe barrel when air escapes After decompression, remove needle Check periodically for reaccumulation of air in intrapleural space Common for catheter to kink, occlude Insert new catheter if tension pneumothorax redevelops Ensure patent airway and adequate ventilation and oxygenation

Life-Threatening Injuries: Hemothorax (1 of 2) : 

Life-Threatening Injuries: Hemothorax (1 of 2) Accumulation of blood in the intrapleural space Blood loss can be significant Severe hemodynamic compromise possible Collapse of ipsalateral lung as blood accumulates Mediastinal shift and compression of contralateral lung possible Signs and symptoms Tachycardia, tachypnea Developing shock, hypotension Hypovolemia Decreased breath sounds on affected side

Life-Threatening Injuries: Hemothorax (2 of 2) : 

Life-Threatening Injuries: Hemothorax (2 of 2) Management Ensure patent airway Ensure adequate ventilation and oxygenation Administer judicious fluid Effect blood administration

Thoracostomy: Chest Tube Insertion (1 of 5) : 

Thoracostomy: Chest Tube Insertion (1 of 5) Use sterile technique throughout procedure Don gloves, goggles, gown, and face mask Prepare drainage system according to manufacturer’s guidelines Preload syringe with lidocaine solution Prepare suture materials, attach needle holder to suture Secure a large Kelley clamp to the proximal end of the tube (unless using the trocar technique)

Thoracostomy: Chest Tube Insertion (2 of 5) : 

Thoracostomy: Chest Tube Insertion (2 of 5) Prepare suction Patient condition permitting, elevate head of bed 30–60 Restrain arm on affected side over patient’s head Patient condition permitting, administer sedative and/or local anesthesia at insertion site Prepare insertion site with Betadine or another antiseptic solution and sterile drapes Anesthetize insertion site with generous amount of 1% lidocaine Use 5–20 cc minimum

Thoracostomy: Chest Tube Insertion (3 of 5) : 

Thoracostomy: Chest Tube Insertion (3 of 5) Measure and clamp thoracostomy tube Using No. 10 scalpel, make 3–4 cm transverse incision through skin and subcutaneous tissue over the inferior aspect of the rib below the insertion site The fifth or sixth rib in the midaxillary line is commonly used Perform blunt dissection with Kelly clamp or scissors by pushing forward while closed then spreading tip and pulling back Penetrate parietal pleura, spread distal points open Using gloved finger, probe track to verify that pleura has been entered and that no solid organs are present

Thoracostomy: Chest Tube Insertion (4 of 5) : 

Thoracostomy: Chest Tube Insertion (4 of 5) Keeping finger in track to act as guide, insert thoracostomy tube into chest cavity, directing tip with Kelly forceps Insert to level of marker clamp, ensuring that all tube fenestrations are in the chest cavity About 5 cm beyond the last fenestration and before releasing clamp, attach thoracostomy tube to previously assembled water seal or suction setup Confirm thoracostomy tube placement Secure thoracostomy tube

Thoracostomy: Chest Tube Insertion (5 of 5) : 

Thoracostomy: Chest Tube Insertion (5 of 5) Reprinted with permission from Kaiser, LR (1997). Tube thoracostomy. In L.R. Kaiser (Ed.), Atlas of general thoracic surgery (pp. 16-19). St. Louis: Mosby

Life-Threatening Injuries: Hemothorax (1 of 2) : 

Life-Threatening Injuries: Hemothorax (1 of 2) Recommended techniques for evaluating/managing drainage systems Tape all connections and possibly the chest tube to the chest wall Ensure that the tube and system components lack kinks Maintain appropriate fluid levels in the under-water seal and suction chambers Continuously reassess the patient for signs of hypoxia and developing tension pneumothorax Avoid clamping the chest tubes unless specifically indicated (i.,e. 1000cc of blood return)

Life-Threatening Injuries: Hemothorax (2 of 2) : 

Life-Threatening Injuries: Hemothorax (2 of 2) Troubleshooting the closed, under-water drainage system Continuous bubbling on inspiration indicates an “open” system Check for air leaks If tube obstructs, use alternating hand-over-hand squeezing technique to clear it

Life-Threatening Injuries: Open Pneumothorax (1 of 2) : 

Life-Threatening Injuries: Open Pneumothorax (1 of 2) Pneumothorax with open defect in chest wall Communication of intrapleural space with atmosphere Loss of negative intrapleural pressure Lung collapse Attenuation of normal intrathoracic pressure fluctuations may decrease venous return to some degree

Life-Threatening Injuries: Open Pneumothorax (1 of 2) : 

Life-Threatening Injuries: Open Pneumothorax (1 of 2) Signs/symptoms Obvious hole in chest wall Tachycardia, tachypnea Decreased lung sounds on affected side Management Ensure patent airway Ensure adequate ventilation and oxygenation Place occlusive dressing over sucking chest wounds Consider chest tube placement

Life-Threatening Injuries: Flail Chest (1 of 3) : 

Life-Threatening Injuries: Flail Chest (1 of 3) Three or more ribs fractured in two or more places Typically result of blunt trauma Anterior, lateral ribs affected Classic sign  Paradoxical movement of flail segment Flail chest accompanied by underlying pulmonary insult Contusion, minimally

Life-Threatening Injuries: Flail Chest (2 of 3) : 

Life-Threatening Injuries: Flail Chest (2 of 3) Signs/symptoms Chest trauma Paradoxical chest wall movement Not always obvious If not visible, palpation will expose movement Tachycardia, tachypnea Developing hypoxia, cyanosis Chest pain with respiration Decreased tidal volume

Life-Threatening Injuries: Flail Chest (3 of 3) : 

Life-Threatening Injuries: Flail Chest (3 of 3) Management Ensure patent airway Ensure adequate ventilation and oxygenation Consider ETI, BVM ventilation CPAP Stabilize flail segment

Life-Threatening Injuries: Pericardial Tamponade (1 of 6) : 

Life-Threatening Injuries: Pericardial Tamponade (1 of 6) Accumulation of blood in the pericardial sac Hemodynamic effect depends on: Rate of fluid accumulation Amount of fluid accumulation Increased intrapericardial pressure decreases relaxation and diastolic filling of ventricle Decreased preload Decreased CO Blood backup into venous system

Life-Threatening Injuries: Pericardial Tamponade (2 of 6) : 

Life-Threatening Injuries: Pericardial Tamponade (2 of 6) Signs/symptoms Beck’s triad JVD Diminished/muffled heart sounds Hypotension Pulses paradoxus Positive ultrasound

Life-Threatening Injuries: Pericardial Tamponade (3 of 6) : 

Life-Threatening Injuries: Pericardial Tamponade (3 of 6) Management Ensure patent airway Ensure adequate ventilation and oxygenation Administer fluid volume Improve ventricular filling pressures

Life-Threatening Injuries: Pericardial Tamponade (4 of 6) : 

Life-Threatening Injuries: Pericardial Tamponade (4 of 6) Pericardiocentesis Prepare all equipment and supplies Place patient with head elevated 60 if not contraindicated Prep the skin using an antiseptic solution Don PPEs Prepare a 50cc syringe with a three-way stopcock and 3-inch cardiac needle

Life-Threatening Injuries: Pericardial Tamponade (5 of 6) : 

Life-Threatening Injuries: Pericardial Tamponade (5 of 6) Pericardiocentesis If possible, attach the V1 lead of an ECG monitor to the needle with an alligator or a similar clip to help prevent ventricular puncture Continuously monitor ECG, VS, pulse oximetry, capnography, and any other invasive lines during needle aspiration, fluid withdrawal, and needle withdrawal Auscultate heart and breath sounds before and immediately after the procedure Using the subxiphoid approach, insert the needle at a 30 angle to the skin to provide negative pressure on the syringe until the pericardial fluid is aspirated

Life-Threatening Injuries: Pericardial Tamponade (6 of 6) : 

Life-Threatening Injuries: Pericardial Tamponade (6 of 6) Pericardiocentesis Place the fluid in a container to determine whether the fluid clots Withdraw the needle slowly, following the same path as entry Monitor for bleeding at the site as well as recurrence during transport Treat any dysrhythmias per ACLS standards Perform hemoglobin, hematocrit, and coagulation studies

Life-Threatening Injuries: Aortic Rupture (1 of 2) : 

Life-Threatening Injuries: Aortic Rupture (1 of 2) Mortality about 90 percent From 80 to 90 percent of patients with rupture die immediately Injury to aorta results in tear Rapid exsanguination Partial tear possible Advanticia remains intact Typical MOI of rapid deceleration

Life-Threatening Injuries: Aortic Rupture (2 of 2) : 

Life-Threatening Injuries: Aortic Rupture (2 of 2) Signs/symptoms External chest trauma Severe chest and back pain Back pain midscapular Hypertension in upper extremities Management Ensure patent airway Ensure adequate ventilation and oxygenation Avoid fluid volume administration when patient is not hypovolemic Use antihypertensives to control blood pressure when operative repair is delayed Rapid transport to trauma center

Life-Threatening Injuries: Myocardial Rupture : 

Life-Threatening Injuries: Myocardial Rupture Disruption of the myocardial wall Most often the result of blunt-force trauma Extremely high mortality Management Ensure patent airway Ensure adequate ventilation and oxygenation Complete volume resuscitation Transport rapidly to trauma center

Potentially Life-Threatening Injuries: Myocardial Contusion (1 of 3) : 

Potentially Life-Threatening Injuries: Myocardial Contusion (1 of 3) Bruising of the myocardium Can range from small areas of microhemorrhage to large areas of necrosis Hemodynamic compromise related to contusion size

Potentially Life-Threatening Injuries: Myocardial Contusion (2 of 3) : 

Potentially Life-Threatening Injuries: Myocardial Contusion (2 of 3) Signs/symptoms Chest trauma Chest pain ECG abnormalities ST segment changes Dysrhythmia Tachycardia Hypotension

Potentially Life-Threatening Injuries: Myocardial Contusion (3 of 3) : 

Potentially Life-Threatening Injuries: Myocardial Contusion (3 of 3) Management Ensure patent airway Ensure adequate ventilation and oxygenation Treat dysrhythmia according to protocol Avoid fluid volume administration when patient is not hypovolemic Give dobutamine for continued hypotension

Potentially Life-Threatening Injuries: Pulmonary Contusion (1 of 3) : 

Potentially Life-Threatening Injuries: Pulmonary Contusion (1 of 3) Common result of blunt chest trauma Also associated with penetrating trauma Bruising of the lung parenchyma Intraalveolar hemorrhage, capillary membrane leakage, interstitial edema Decreases lung compliance Disrupts gas exchange Increases ventilatory effort

Potentially Life-Threatening Injuries: Pulmonary Contusion (2 of 3) : 

Potentially Life-Threatening Injuries: Pulmonary Contusion (2 of 3) Chest trauma Tachycardia, tachypnea Difficulty breathing Rales/ronchi at injury site Hypoxia

Potentially Life-Threatening Injuries: Pulmonary Contusion (3 of 3) : 

Potentially Life-Threatening Injuries: Pulmonary Contusion (3 of 3) Management Ensure patent airway Ensure adequate ventilation and oxygenation Avoid fluid volume administration when patient is not hypovolemic PEEP

Potentially Life-Threatening Injuries: Diaphragmatic Rupture (1 of 3) : 

Potentially Life-Threatening Injuries: Diaphragmatic Rupture (1 of 3) Defect in diaphragm allows abdominal contents to herniate into chest cavity Results in: Cardiopulmonary insufficiency Gastric, intestinal obstruction Ischemia, gangrene from strangulation

Potentially Life-Threatening Injuries: Diaphragmatic Rupture (2 of 3) : 

Potentially Life-Threatening Injuries: Diaphragmatic Rupture (2 of 3) Signs/symptoms Varies with severity of injury Respiratory distress Chest and/or abdominal pain Decreased breath sounds on affected side Bowel sounds in chest

Potentially Life-Threatening Injuries: Diaphragmatic Rupture (3 of 3) : 

Potentially Life-Threatening Injuries: Diaphragmatic Rupture (3 of 3) Management Mostly supportive Ensure patent airway Ensure adequate ventilation and oxygenation Apply NG tube with suction Evacuate stomach Administer fluid volume when patient is hypotensive

Potentially Life-Threatening Injuries: Tracheobronchial Disruption (1 of 3) : 

Potentially Life-Threatening Injuries: Tracheobronchial Disruption (1 of 3) Most injuries due to sudden deceleration, shearing forces Most injuries occur within 2 cm of carina Tear in tracheobronchial tree Air leaks into pleural space, mediastinnum, surrounding tissue Risk of tension pneumothorax

Potentially Life-Threatening Injuries: Tracheobronchial Disruption (2 of 3) : 

Potentially Life-Threatening Injuries: Tracheobronchial Disruption (2 of 3) Signs/symptoms Chest trauma Chest pain, pain with respiration Sternal pain Decreased breath sounds Tension pneumothorax Dyspnea Hemoptysis Hypoxia Subcutaneous emphysema

Potentially Life-Threatening Injuries: Tracheobronchial Disruption (3 of 3) : 

Potentially Life-Threatening Injuries: Tracheobronchial Disruption (3 of 3) Management Ensure patent airway Ensure adequate ventilation and oxygenation ETI with distal balloon below site of injury, if possible Place chest tube when pneumothorax is present Complete needle decompression when tension pneumothorax is suspected

Potentially Life-Threatening Injuries: Esophageal Perforation (1 of 3) : 

Potentially Life-Threatening Injuries: Esophageal Perforation (1 of 3) High mortality Usually result of penetrating trauma Can also occur with blunt-force trauma Perforation of esophagus introduces gastrointestinal contents to mediastinum Contents pulled into pleura space via intrathoracic pressure fluctuations

Potentially Life-Threatening Injuries: Esophageal Perforation (2 of 3) : 

Potentially Life-Threatening Injuries: Esophageal Perforation (2 of 3) Signs/symptoms Can be vague Substernal pleuritic chest pain Neck or chest pain worse with swallowing, neck flexion Subcutaneous emphysema Dysphagia Fever

Potentially Life-Threatening Injuries: Esophageal Perforation (3 of 3) : 

Potentially Life-Threatening Injuries: Esophageal Perforation (3 of 3) Management Mostly supportive Ensure patent airway Ensure adequate ventilation and oxygenation Use NG tube with suction Evacuate stomach

Summary : 

Summary Aggressive airway management always first priority MOI, detailed physical exam helps identify injuries Familiarity with emergency procedures needed Needle decompression, pericardiocentesis, tube thoracostomy

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