Thoracoabdominal Thoracoabdominal TraumaTrauma

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OBJECTIVES

• ABDOMINAL TRAUMA– Anatomy & Physiology– MOI– Patient Assessment– General Treatment– Specific Injuries

• Thoracic Trauma– Anatomy & Physiology– Patient Assessment– Specific Injuries

Abdominal Trauma: Facts

• 7%-15% of all trauma deaths

• Penetrating – Most Common; 5% mortality

• Blunt – Most difficult to diagnose; 10%-30% mortality

• 75% of blunt abd blunt trauma is caused by high speed motor vehicle crashes (MVC’s)

ABDOMINAL A&P

• Abdominal cavity bounded by pelvis, diaphragm, anterior abdominal muscles, vertebral column and ribs, flank muscles

• Peritoneum– Parietal – Visceral– Mesenteries

• Peritoneal cavity– Potential space between visceral and parietal pleura

• Abdominal Cavity – Divided into 2 spaces:– Retro peritoneal space – Kidneys, ureters, bladder, reproductive

organs, inferior vena cava, aorta, pancreas, duodenum colon, & rectum

– Peritoneal space – bowel, spleen, liver, stomach, & gall bladder

MECANISM OF INJURY (MOI)

• Solid organs bleed

• Hollow organs – discharge contents into the peritoneum which leads to peritonitis

• Fx ribs/sternum – usually injures liver/spleen

• Fx pelvis – injures bladder, reproductive organs, intestines

MOI (CONT’D.)

• Steering wheel impacts may rupture abdominal cavity w/ herniation of left diaphragm

• Stab wounds – possible to predict path of object, less able to predict injuries with GSW

• Compression injuries – organs sheared at impact with other objects (ex: Liver)

PATIENT ASSESSMENT– Observe MOI and maintain index of suspicion– Suspect intrabdominal bleeding when:

• Echymosis

• Distention

• Hematuria

• Blood return in NG Tube

• Pain

•Abd. Tenderness

•Abd. Rigidity

•Unexplained shock

•Testicular pain = retroperitoneal injury

•L shoulder pain = Spleen

•R Shoulder pain = Liver

PT. ASSESSMENT (CON’D)

• Difficult to assess pain (abd. Vs. ribs) • Pain may be masked by drugs, head injury, ETOH• Observation

– Distention – Contusions

• Cullens sign – echymosis around umbilicus = spleenic injury

• Grey Turners sign – Flank echymosis• Kehrs sign – referred pain to shoulders from abd. Injury,

worse when lying flat = diaphragm and phrenic nerve)

PT. ASSESSMENT (CON’D)

• Observation (con’d)– Penetration

– Evisceration

– Impaled object

– Obvious bleeding

– Scaphoid abdomen – Sn of herniated diaphragm

– Encapsulating Injury – bleeding into itself without rupturing. (Ex. Spleen or Liver)

PT. ASSESSMENT (CON’D)

• Palpation – Avoid deep palpation– Abdominal wall defects– Tenderness– Pelvic instability

GENERAL TREATMENT

• Remember ABC’s!!!• Rapid assessment, packaging, and Transport• High flow O• IV Lines –Up to 3 L on way to ER (PHTLS)• MAST (no abd. Section)• Treat other injuries

THORACIC TRAUMA-FACTS

• Second leading cause of trauma deaths• Accounts for 25% of all trauma deaths• 85% can be managed outside of the

operating room• Major causes of Blunt Thoracic Trauma:

– Steering wheel, bicycle handlebars, baseball

• Major causes of Penetrating Trauma:– GSW and Stabbings

THORACIC A&P

• Cavity is bounded by ribs, spine, and diaphragm• Pleura

– Parietal

– Visceral

– Potential space can hold 3 liters on each side

• Right lung – 3 lobes• Left lung – 2 lobes• Mediastinum - •Heart

•Great vessels

•Esophagus

•trachea

•Mainstem bronchi

PHYSIOLOGY

• Respiration– Requires intercostal muscles and diaphragm – Operates on pressure gradient– During exhalation, diaphragm elevated to 4th

intercostal space– Driven by PCO2 levels (chemoreceptors in

brainstem)– COPD patients driven by PO2 receptors in

aortic arch and carotid arteries

PATIENT ASSESSMENT

• Signs & Symptoms– Dyspnea– Pleuritic chest pain– Splinting– Echymosis– Cyanosis– Lacerations– Asymmetrical chest– Crepitus– Flail segment

–Puncture wounds

–Neck vein distention

–Tracheal deviation

–SQ emphysema

–Sucking chest wound

–Deformity

–Paradoxical chest

–Tenderness

–+/- lung sounds

RIB FRACTURES– Most commonly fx are 3-8 (thin)– 8-12 assoc. with spleen, kidney or liver injuries– 1&2 have high mortality because of the forces necessary to fx

these ribs – produce serious injuries– Pain upon movement– Crepitus– Deformity– Local tenderness– Hypoventilation– Potential for:

• Pneumo/hemothorax• Atelectasis/pneumonia

SIMPLE PNEUMOTHORAX

• Air in the pleural space

• Affected lung begins to collapse as pleural space expands

• Caused by puncture wound, rib fx, or lung defect

• Simple pneumo usually well tolerated in young, healthy adult

• S&S: dyspnea, pleuritic chest pain, tachypnea, decreased lung sounds

• Treatment: anticipate development of tension, semi-sitting position unless contraindicated, O2, assist ventilations PRN, IV, EKG, treat other injuries

OPEN PNEUMOTHORAX (Sucking Chest Wound)

• Open chest wall injury• Stab wounds usually self-sealing• GSW more extensive damage• Air passes through opening into pleural space and

remains outside of lung• S&S: gurgling sound during air movement, bubbling

wound, dyspnea, tachypnea, diminished breath sounds.• Treatment: anticipate tension, cover wound w/

occlusive dressing to form flutter valve, O2, assist ventilations PRN, IV, EKG, treat other injuries

TENSION PNEUMOTHORAX

• Air enters pleural space and becomes trapped – leads to pressure increase

• Increased pressure further collapses lung and shifts mediastinum to unaffected side

• Increased dyspnea and compressed heart and great vessels leads to decreased cardiac output and shock

• S&S & Treatment: Con’d on next slide

TENSION PNEUMOTHORAX CON’D• Signs & Symptoms:

– Dyspnea– Tachypnea– Anxiety– Cyanosis– Diminished lung

sounds– Hypotension– SQ emphysema– Paradoxical pulse

–Asymmetrical chest

–JVD

–Tachycardia

–Narrow pulse pressure

–Tracheal deviation

–shock

TENSION PNEUMOTHORAX CON’D

• Treatment– Remove dressing over open pneumo– If no improvement, open the wound then reseal– Needle decompression– Assist ventilations PRN– IV– EKG– Treat other injuries

DECOMPRESSING A TENSION PNEUMOTHORAX

• Ensure tension exists and determine which side• 2nd or 3rd midclavicular ICS or 4th or 5th midaxillary ICS• Prep site• Insert 14 ga. Catheter on top of rib• Prepare valve

– McSwain dart– Condom– Stopcock– Water valve– Latex glove – no longer recommended

• Secure in place• Monitor patient closely

ABDOMINAL TRAUMA

• Instructor Name:

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OVERVIEW

• Review anatomy

• Review types of injuries– Blunt– Penetrating

• Evaluation of abdominal trauma

• Management of abdominal trauma

ANATOMY

• Three regions– Thoracic abdomen

– True abdomen

– Retroperitoneal abdomen• Bleeding into this area does not

cause abdominal rigidity

ANATOMY

Intrathoracic Abdomen True Abdomen

ANATOMY RETROPERITONEAL

ABDOMEN

TYPES OF INJURIES

• Blunt trauma

• Penetrating trauma

BLUNT ABDOMINAL TRAUMA

• Mortality 10-30%– Associated with injuries to other systems

– Internal bleeding may be severe

– Tenderness may not be present during early exam

– Early onset of signs & symptoms suggests severe injury

• Watch for development of shock

BLUNT FORCES CAUSE

• Fracture of solid organs– Hemorrhage

• Rupture of hollow organs– High risk of peritonitis

• Tearing of organs, blood vessels, and mesentery (attachments)

• Fractures of lower ribs associated with high incidence of liver or spleen injury

PENETRATING WOUNDS

• Gunshot wounds– Have higher mortality (up to 15%)

due to higher rates of damage to abdominal viscera

• Stab wounds– Mortality 1-2%

• All penetrating abdominal wounds should be evaluated in the hospital

PENETRATING WOUNDS• Causes of mortality

– Hypovolemic shock– Injury to abdominal viscera– Sepsis and/or peritonitis are late causes of death

• Internal path of penetrating object may not be apparent from external wound

– Stab to the chest may penetrate the abdomen and vice versa

– Stab to the buttocks has 50% chance of significant intra-abdominal injury

EVALUATION SCENE SIZE-UP

• Extremely important• Provides clues to

– Type of injury– Path followed– Forces involved

• Important factors– Weapon or object involved– Distance– Force applied

EVALUATION BTLS PRIMARY SURVEY

• Initial Assessment– ABCs

• Rapid Trauma Survey– Head, Neck, Chest– Abdomen

• Look for wounds, bruises, distention

• Feel for guarding, tenderness, rigidity

EVALUATIONBTLS PRIMARY SURVEY

• Signs of intra-abdominal injury usually develop late

– After arrival at the hospital

• Abdominal pain or tenderness present at the scene suggests severe injury

• Patients are likely to develop shock• Penetrating wounds to the upper

abdomen may cause chest injury

MANAGEMENT

• Treat problems found in the BTLS Primary Survey

• 100% oxygen

• If abdominal tenderness Load & Go

• Dress wounds

• Two large bore IVs en route – NS or RL to maintain BP of 90-100 systolic

MANAGEMENT EVISCERATION

• Cover protruding organs with moist sterile dressing and/or nonadherent material

• Do not try to put organs back into the abdomen

• Load & Go

SUMMARY

• Second leading cause of preventable death from trauma

• Most deaths from delayed treatment• Be alert to mechanisms of injury• Maintain high index of suspicion• Abdominal pain = impending shock• Penetrating wounds of the abdomen or

tender abdomen mean Load & Go

QUESTIONS?