thoracic trauma. introduction is a serious injury of the chest, 20% of all traumas a common cause of...
Post on 29-Dec-2015
214 Views
Preview:
TRANSCRIPT
Thoracic Trauma
Introduction
is a serious injury of the chest, 20% of all traumasa common cause of significant disability and mortality, the
leading cause of death from physical trauma after head and spinal cord injury
blunt thoracic injuries are the primary or a contributing cause of about a quarter of all trauma-related deaths.
Vital Structures Heart, Great Vessels, Esophagus,
Tracheobronchial Tree, & Lungs25% of MVC deaths are due to thoracic trauma
12,000 annually in USAbdominal injuries are common with chest trauma.
Anatomy and Physiology of the Thorax
Thoracic Skeleton 12 Pair of C-shaped ribs
Ribs 1-7: Join at sternum with cartilage end-points Ribs 8-10: Join sternum with combined cartilage at 7th rib Ribs 11-12: No anterior attachment
Sternum Manubrium
Joins to clavicle and 1st rib Jugular Notch
Body Sternal angle (Angle of Louis)
• Junction of the manubrium with the sternal body• Attachment of 2nd rib
Xiphoid process Distal portion of sternum
Anatomy and Physiology of the Thorax
Associated MusculatureShoulder girdleMuscles of respiration
Diaphragm Intercostal muscles
Contract to elevate the ribs and increase thoracic diameter
Increase depth of respiration
Sternocleidomastoid Raise upper rib and sternum
Anatomy and Physiology of the Thorax
Trachea, Bronchi & Lungs Pleura
Visceral Pleura Cover lungs
Parietal Pleura Lines inside of thoracic cavity
Pleural Space POTENTIAL SPACE
• Air in Space = PNEUMOTHORAX
• Blood in Space = HEMOTHORAX Serous (pleural) fluid within
• Lubricates & permits ease of expansion
Anatomy and Physiology of the Thorax
Heart Chambers Valves Vessels External Vessels
Coronary Arteries
Contraction Cycle Systole Diastole
Filling of the coronary arteries occur
Pathophysiology of Thoracic Trauma
Blunt Trauma Results from kinetic energy forces Subdivision Mechanisms
Blast Pressure wave causes tissue disruption Tear blood vessels & disrupt alveolar tissue Disruption of tracheobronchial tree Traumatic diaphragm rupture
Crush (Compression) Body is compressed between an object and a hard surface Direct injury of chest wall and internal structures
Deceleration Body in motion strikes a fixed object Blunt trauma to chest wall Internal structures continue in motion
• Ligamentum Arteriosum shears aorta Age Factors
Pediatric Thorax: More cartilage = Absorbs forces Geriatric Thorax: Calcification & osteoporosis = More
fractures
Pathophysiology of Thoracic Trauma
Penetrating Trauma Low Energy
Arrows, knives, handguns Injury caused by direct
contact and cavitation High Energy
Military, hunting rifles & high powered hand guns
Extensive injury due to high pressure cavitation
Trauma.org
Pathophysiology of Thoracic Trauma
Penetrating Injuries (cont.) Shotgun
Injury severity based upon the distance between the victim and shotgun & caliber of shot
Type I: >7 meters from the weapon Soft tissue injury
Type II: 3-7 meters from weapon Penetration into deep fascia and some internal organs
Type III: <3 meters from weapon Massive tissue destruction
Trauma.org
Injuries Associated with Penetrating Thoracic Trauma
Closed pneumothoraxOpen pneumothorax
(including sucking chest wound)
Tension pneumothoraxPneumomediastinumHemothoraxHemopneumothoraxLaceration of vascular
structures
Tracheobronchial tree lacerations
Esophageal lacerations
Penetrating cardiac injuries
Pericardial tamponadeSpinal cord injuriesDiaphragm traumaIntra-abdominal
penetration with associated organ injury
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Contusion Most Common result of blunt injury Signs & Symptoms
Erythema Ecchymosis DYSPNEA PAIN on breathing Limited breath sounds HYPOVENTILATION
BIGGEST CONCERN = “HURTS TO BREATHE” Crepitus Paradoxical chest wall motion
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Rib Fractures >50% of significant chest trauma cases due to
blunt trauma Compressional forces flex and fracture ribs at
weakest points Ribs 1-3 requires great force to fracture
Possible underlying lung injury Ribs 4-9 are most commonly fractured Ribs 9-12 less likely to be fractured
Transmit energy of trauma to internal organs If fractured, suspect liver and spleen injury
Hypoventilation is COMMON due to PAIN
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Sternal Fracture & Dislocation Associated with severe blunt anterior trauma Typical MOI
Direct Blow (i.e. Steering wheel) Incidence: 5-8% Mortality: 25-45%
Myocardial contusion Pericardial tamponade Cardiac rupture Pulmonary contusion
Dislocation uncommon but same MOI as fracture Tracheal depression if posterior
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Flail Chest Segment of the chest that becomes free to move
with the pressure changes of respiration Three or more adjacent rib fracture in two or
more places Serious chest wall injury with underlying
pulmonary injury Reduces volume of respiration Adds to increased mortality
Paradoxical flail segment movement Positive pressure ventilation can restore tidal
volume
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Simple Pneumothorax AKA: Closed Pneumothorax
Progresses into Tension Pneumothorax Occurs when lung tissue is disrupted and air leaks into the
pleural space Progressive Pathology
Air accumulates in pleural space Lung collapses Alveoli collapse (atelectasis) Reduced oxygen and carbon dioxide exchange Ventilation/Perfusion Mismatch
Increased ventilation but no alveolar perfusion Reduced respiratory efficiency results in HYPOXIA
Typical MOI: “Paper Bag Syndrome”
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Open Pneumothorax Free passage of air between atmosphere and
pleural space Air replaces lung tissue Mediastinum shifts to uninjured side Air will be drawn through wound if wound is 2/3
diameter of the trachea or larger Signs & Symptoms
Penetrating chest trauma Sucking chest wound Frothy blood at wound site Severe Dyspnea Hypovolemia
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Tension Pneumothorax Buildup of air under pressure in the thorax. Excessive pressure reduces effectiveness of
respiration Air is unable to escape from inside the pleural space Progression of Simple or Open Pneumothorax
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Tension Pneumothorax Signs & Symptoms
Dyspnea Tachypnea at first
Progressive ventilation/perfusion mismatch Atelectasis on
uninjured sideHypoxemiaHyperinflation of
injured side of chestHyperresonance of
injured side of chest
Diminished then absent breath sounds on injured side
CyanosisDiaphoresisAMSJVDHypotensionHypovolemiaTracheal Shifting
LATE SIGN
Puncture, drainage
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Hemothorax Accumulation of blood in the pleural space Serious hemorrhage may accumulate 1,500 mL of
blood Mortality rate of 75% Each side of thorax may hold up to 3,000 mL
Blood loss in thorax causes a decrease in tidal volume Ventilation/Perfusion Mismatch & Shock
Typically accompanies pneumothorax Hemopneumothorax
Trauma.org
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Hemothorax Signs & Symptoms
Blunt or penetrating chest traumaShock
Dyspnea Tachycardia Tachypnea Diaphoresis Hypotension
Dull to percussion over injured side
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Pulmonary Contusion Soft tissue contusion of the lung 30-75% of patients with significant blunt chest trauma Frequently associated with rib fracture Typical MOI
Deceleration Chest impact on steering wheel
Bullet Cavitation High velocity ammunition
Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar tissue Progressive deterioration of ventilatory status
Hemoptysis typically present
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Myocardial Contusion Occurs in 76% of patients with severe blunt chest trauma Right Atrium and Ventricle is commonly injured Injury may reduce strength of cardiac contractions
Reduced cardiac output
Electrical Disturbances due to irritability of damaged myocardial cells
Progressive Problems Hematoma Hemoperitoneum Myocardial necrosis Dysrhythmias CHF & or Cardiogenic shock
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Myocardial Contusion Signs & Symptoms
Bruising of chest wallTachycardia and/or irregular rhythmRetrosternal pain similar to MIAssociated injuries
Rib/Sternal fractures
Chest pain unrelieved by oxygen May be relieved with rest THIS IS TRAUMA-RELATED PAIN
Similar signs and symptoms of medical chest pain
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Pericardial Tamponade Restriction to cardiac filling caused by blood or
other fluid within the pericardium Occurs in <2% of all serious chest trauma
However, very high mortality Results from tear in the coronary artery or
penetration of myocardium Blood seeps into pericardium and is unable to escape 200-300 ml of blood can restrict effectiveness of cardiac
contractions Removing as little as 20 ml can provide relief
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Pericardial Tamponade Signs & Symptoms
DyspneaPossible cyanosisBeck’s Triad
JVD Distant heart tones Hypotension or
narrowing pulse pressure
Weak, thready pulseShock
Kussmaul’s sign Decrease or absence of
JVD during inspiration Pulsus Paradoxus
Drop in SBP >10 during inspiration
Due to increase in CO2 during inspiration
Electrical Alterans P, QRS, & T amplitude
changes in every other cardiac cycle
PEA
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Myocardial Aneurysm or Rupture Occurs almost exclusively with extreme blunt
thoracic trauma Secondary due to necrosis resulting from MI Signs & Symptoms
Severe rib or sternal fracture Possible signs and symptoms of cardiac tamponade If affects valves only
Signs & symptoms of right or left heart failure Absence of vital signs
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Traumatic Aneurysm or Aortic Rupture Aorta most commonly injured in severe blunt or
penetrating trauma 85-95% mortality
Typically patients will survive the initial injury insult 30% mortality in 6 hrs 50% mortality in 24 hrs 70% mortality in 1 week
Injury may be confined to areas of aorta attachment Signs & Symptoms
Rapid and deterioration of vitals Pulse deficit between right and left upper or lower
extremities
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Other Vascular Injuries Rupture or laceration
Superior Vena Cava Inferior Vena Cava General Thoracic Vasculature
Blood Localizing in Mediastinum Compression of:
Great vessels Myocardium Esophagus
General Signs & Symptoms Penetrating Trauma Hypovolemia & Shock Hemothorax or hemomediastinum
Pathophysiology of Thoracic Trauma Other Thoracic Injuries
Traumatic Esophageal Rupture Rare complication of blunt thoracic trauma 30% mortality Contents in esophagus/stomach may move into
mediastinum Serious Infection occurs Chemical irritation Damage to mediastinal structures Air enters mediastinum
Subcutaneous emphysema and penetrating trauma present
Assessment of the Thoracic Trauma Patient
Scene Size-upInitial AssessmentRapid Trauma Assessment
Observe JVD, SQ Emphysema, Expansion of chest
Question Palpate Auscultate Percuss Blunt Trauma Assessment Penetrating Trauma Assessment
Ongoing Assessment
Management of the Chest Injury PatientGeneral Management
Ensure ABC’s High flow O2 via NRB Intubate if indicated Consider RSI Consider overdrive ventilation
If tidal volume less than 6,000 mL BVM at a rate of 12-16
May be beneficial for chest contusion and rib fractures Promotes oxygen perfusion of alveoli and prevents atelectasis
Anticipate Myocardial CompromiseShock Management
Consider PASG Only in blunt chest trauma with SP <60 mm Hg
Fluid Bolus: 20 mL/kg AUSCULTATE! AUSCULATE! AUSCULATE!
Management of the Chest Injury Patient
Rib Fractures Consider analgesics for pain and to improve chest
excursion Versed Morphine Sulfate
CONTRAINDICATION Nitrous Oxide
May migrate into pleural or mediastinal space and worsen condition
Management of the Chest Injury Patient
Sternoclavicular Dislocation Supportive O2 therapy Evaluate for concomitant injury
Flail Chest Place patient on side of injury
ONLY if spinal injury is NOT suspected Expose injury site Dress with bulky bandage against flail segment
Stabilizes fracture site High flow O2
Consider PPV or ET if decreasing respiratory status DO NOT USE SANDBAGS TO STABILIZE FX
Trauma.org
Management of the Chest Injury Patient
Open Pneumothorax High flow O2
Cover site with sterile occlusive dressing taped on three sides
Progressive airway management if indicated
Management of the Chest Injury Patient
Tension Pneumothorax Confirmation
Auscultaton & Percussion Pleural Decompression
2nd intercostal space in mid-clavicular line TOP OF RIB
Consider multiple decompression sites if patient remains symptomatic
Large over the needle catheter: 14ga
Create a one-way-valve: Glove tip or Heimlich valve
Management of the Chest Injury Patient
Hemothorax High flow O2 2 large bore IV’s
Maintain SBP of 90-100 EVALUATE BREATH SOUNDS for fluid overload
Myocardial Contusion Monitor ECG
Alert for dysrhythmias IV if antidysrhythmics are needed
Management of the Chest Injury Patient
Pericardial Tamponade High flow O2
IV therapy Consider pericardiocentesis; rapidly deteriorating
patientAortic Aneurysm
AVOID jarring or rough handling Initiate IV therapy enroute
Mild hypotension may be protective Rapid fluid bolus if aneurysm ruptures
Keep patient calm
Management of the Chest Injury Patient
Tracheobronchial Injury Support therapy
Keep airway clear Administer high flow O2
Consider intubation if unable to maintain patient airway Observe for development of tension pneumothorax and SQ
emphysemaTraumatic Asphyxia
Support airway Provide O2
PPV with BVM to assure adequate ventilation 2 large bore IV’s Evaluate and treat for concomitant injuries If entrapment > 20 min with chest compression
Consider 1mEq/kg of Sodium Bicarbonate
top related