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2/4/2019
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The ABC’s of Chest Trauma
J Bradley Pickhardt MD, FACS
Providence St Patrick Hospital
What’s the Problem?
2/3 of trauma patients have chest trauma
Responsible for 25% of all trauma deaths
Most injuries can be managed with simple maneuvers
Less than 10% require definitive operative repair
Immediate Priorities in Management of Chest Trauma
AirwayBreathingCirculation
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Case #1
40 year old male has fallen from a scaffold, landing on a pile of wooden pallets
What are your initial thoughts about possible injuries?
How are you going to determine his injuries? How likely are you to miss injuries if you don’t
expose and palpate the patient’s chest? What factors complicate chest assessment? What assessment findings would alert you that
this patient is in acute distress?
What Injuries are Possible?
Always Look at the Back!!
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Rib Fractures
What complications might this patient suffer?
How does pre-morbid status affect onset and severity of complications?
What can we do to prevent these complications from occurring, or at least lessen their severity?
Life Threatening Injuries
Tension Pneumothorax Flail Chest w/ pulmonary
contusion Open chest wounds Massive Pneumo/Hemothorax
Tracheo-bronchial disruption Cardiac Tamponade
Tension Pneumothorax
Common with both blunt an penetrating trauma
Diminished breath sounds (listen laterally)
Subcutaneous emphysema Hypotension
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Subcutaneous Emphysema
Treatment
Needle Thoracostomy
14 to 16 gauge needle
Mid-clavicular
Anterior axillary
Pitfalls of Needle Thoracostomy
May not decompress the tension
Bleeding/lung laceration
May kink
Mandates that patient gets a chest tube
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Case #2
22 year old male stabbed in left chest just lateral to the nipple
BP 120/78, O2 sat 95%
CXR shows 50% pneumothorax
Open Chest Wounds
Loss of chest wall support
Direct pulmonary injury
Magnitude of blood loss may be underappreciated
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Treatment for open chest wounds
Direct pressure to control bleeding
Semi-occlusive dressing
Chest tube
Early intubation to support ventilation
“There is no organ in the chest or abdomen that has not been injured by a chest tube.”
Pitfalls of Chest Tube Placement
Damage to heart/lung/vessels
Intra-abdominal placement with injury to spleen and/or liver
Subcutaneous placement
Last hole not in the thoracic cavity
Pain from the tube being in too far
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Case #2 continued
Heart rate now 130’s, BP upper 90’s
Chest tube output 500cc/2 hours
CXR shows some opacity over the left lung field
Indications for Thoracotomy
Greater than 1000-1500 cc initial output
200-250 cc bleeding over 2-4 hours
Hemodynamic instability
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Case #3
78 year old male driver of vehicle that struck a tree head on
Paradoxical chest wall movement easily seen
Multiple rib fractures seen on CT
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Flail chest/Pulmonary Contusion
3 or more ribs fractured in two or more places
Increased mechanical work of breathing
Impaired gas exchange due to underlying pulmonary contusion
Brad – video, scroll over and click play
Treatment: Flail chest
May require early intubation, mechanical ventilation
Pain control for rib fractures Oxygenation will worsen over
first 24 to 48 hours Rib plating External binding is not
beneficial
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What Does He Need?
Intubation/ventilation support
CVP/A-line
Euvolemia
Pain control
Tracheostomy
PEG
DVT prophylaxis
Consider transfer to higher level of care
Diaphragmatic Rupture
Most commonly presents on the left side
Often a delay in diagnosis if ventilated
Instability usually due to abdominal injury
Blunt Aortic Injury
Free rupture dies prior to the hospital
Most alive on admission are contained hematomas
Operative repair can be delayed with blood pressure control
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Blunt Cardiac Injury (AKA Cardiac Contusion)
Signs and Symptoms Chest pain and tenderness
Broken Steering Column
Arrhythmias
Diagnosis
Treatment- expectant,
monitor for 24-48 hr
Cardiac Tamponade
Most commonly due to penetrating trauma
Early signs may be subtle muffled heart tones
Jugular Venous Distension
hypotension
Requires a high index of suspicion
Case # 4
26 y/o male with GSW to R upper arm and multiple defensive stab wounds
Pt had significant bleeding from GSW site.
HR 81, BP 89/48, RR 20, O2 sats 92%, GCS 15
Actions?
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What injuries are possible?
Tracheobronchial Injuries
Penetrating or blunt injures
Often present with tension pneumothorax
Persistent, massive air leak
May be difficult to ventilate due to loss of tidal volume
Often require several chest tubes
What Next?
Blood, fluids
Chest tube
Intubation
CT if stable
OR if unstable
Bronch
Upper endoscopy
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Case #4
80 y/o male fell off skateboard
Sustained left rib fx 4-12
Admitted at outside facility 7 days--discharged home
Chest x-ray and CT done
Repeat chest x-ray for 2 days then DC x-ray
Discharge on day 7
Case #4 continued
Bounce back to ED a few hours later following DC with difficulty breathing, extreme chest pain and fever
Chest x-ray and CT;
What are these going to show?
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Trauma Center ICU
He was admitted to ICU
Thoracic Injury management Protocol ordered
Worked up for Sepsis
Pigtail drain placed by interventional radiology
No epidural placed
July 2018 started Protocol
Education to respiratory therapy, nursing, trauma advanced practice providers
Inclusion is 3 or more rib fractures
Implementation of Thoracic Injury Management Protocol
Thoracic Injury Management Protocol
Inclusion Criteria (Extubated or recently extubated)
GCS 13-15 (≥14 years of age)+Rib or Sternal fracture (Absence of high spinal cord injury)
ICU and Med Surg Floors
Provider
On admission order:
Nursing Communication order "pt on Thoracic Injury Protocol"
RT evaluate and treat consult order for Thoracic Injury Protocol
Document recent PIC scores in notesPulmonary Hygiene -IS, cough & DB Q1 hour WA
Minimize IVF
Mobilize at least TID if not contraindicated
HOB 30 degrees if not contraindicatedPain medication plan
Give patient instruction at discharge
RT to assess patient within an hour of consult:
Measure initial IS volumes
Set goal range (male 2500-3500, female 2000-3000, peds 500-2500, ex; 11 yo 1500ml)Routine clinical care:
IS monitoring Q6 & PRN (RT responsible for IS at 0800, 1400, 2000, & 0200)
Chart PIC score, pain & IS Q6 hour in Epic and on score board
Incorporate PIC score, I/S volumes and IS goal in daily rounds
**Notify RN when total PIC score ≤4 and /or a score of 1 point in any category after intervention
Nursing
Notify RT of pt admission
Place PIC score board in visible place in the room
Instruct pt and family on PIC scoring methods and rationale
Provide pt and family PIC educational handout
Routine clinical care:
Proper IS method and cough & DB Q1 hour WA
Educate and encourage use of splinting
Elevate HOB 30 degrees if not contraindicated
Mobilize at least TID if not contraindicated
Incorporate PIC score, I/S volumes, and goal in daily rounds
**Notify provider if total PIC score ≤4 and or a score of 1 point in any category after interventions
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First PICC Score:Pain: 2 - moderate
Inspiration: 3 – Goal to alert volume
Cough: 2 – weak
Total Score: 7
How will this information guide care?
What if his PICC score was this:Pain: 1-severe
Inspiration: 2 – below alert level
Cough: 2 – weak
Total score: 5
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Last PICC Score done day 3 of 8 transferred to floorPain: 3-controlledInspiration: 4-above goal volumeCough: 2-weakTotal: 9
CXR 6/25
PIC Statistics Improvements in Care
Incentive spirometer consistently in patients room on day one of initiation of PIC protocol
Increased patient education on need for IS, use of IS, deep breath, and cough
ICU readmit d/t respiratory failure decrease
Pain control improved (epidurals placed earlier in care process)
PIC Statistics Improvements in Care
0
50
100
150
200
250
300
350
2017 2018
274
331
Total Patients Seen July-December
0.0% 5.0% 10.0% 15.0% 20.0% 25.0%
% OF PATIENTS RE-ADMIT TO ICU
% OF PATIENTS W/ 3 OR MORE RIB FX
9.4%
19.3%
5.1%
23.9%
Trends Noticed Since Implementation of PIC Protocol
2017 2018
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Summary
Common
Mechanism of injury important
Course often very prolonged
Elderly and/or those with co-morbidities do poorly
Knowledge of natural history essential to anticipate/prevent complications as course evolves
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