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Chest Trauma

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Maria Uzcategui

on 17 February 2016

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Transcript of Chest Trauma

CHEST TRAUMA
Maria Uzcategui, MD
Chest Trauma
Minimizing Bad Outcomes
Early deaths - 30 minutes to 3 hours
tension
pneumothorax
cardiac
tamponade
airway
obstruction
uncontrolled
hemorrhage
Risk Stratification
LOW vs. HIGH RISK
Vital Signs
Chief
Complaints
Bony Injuries
Rib
Fractures
Sternum
Fractures
Clavicular
Fractures
Pulmonary Injuries
Pulmonary
Contusion
Cardiac Injuries
Blunt Cardiac Injury
Vascular Injury
Traumatic Aortic Dissection
Rib Fractures
Fractures of ribs 9 to 11 are associated with intra-abdominal injury
1st & 2nd
Rib Fractures
May indicate severe
intrathoracic injury
Suggestive of
high energy trauma
Imaging: Chest CT scan
with IV contrast
Diagnostic
Strategies
- Plain Films
Often miss 50% of fractures
Rib series
Oblique views
Expiratory views
Should not be
routinely
used
Chest CT Scan
Can suggest other intrathroraric injuries
Management
- Adequate pain relief
- Maintenance of adequate
pulmonary function
Oral analgesia
IV opioids
Epidural Blocks
Incentive Spirometry
FLAIL CHEST
3 or more adjacent ribs fracture at 2 or more points
FLAIL CHEST
Associated with significant morbidity from PULMONARY CONTUSION
Abnormal motion may be difficult to identify
Start O2 and monitor for respiratory compromise
- O2 Pulse oximetry
Rib Stabilization
(ORIF)
NIPPV vs ETT
Monitor for HYPOXIA
FLAIL CHEST
Respiratory decompensation is the #1 indication for intubation
Other indications for
EARLY
ventilatory support
SHOCK
Severe
Head Injury
Co-morbid
Pulmonary Disease
Fracture of
8 or more ribs
Other
Associated Injuries
> 65 years of age
RSI
Sternum Fracture
Diagnosis by:
Lateral
Chest X- ray
Chest
CT scan
Isolated Fracture = Low Mortality
(<1%)
Patient with < 65 years of age
Normal Vital Signs
Normal Initial EKG
Repeat EKG at 6 hours, if unchanged, no further workup for cardiac injury
Admit patients with:
- > 65 years of age
- Associated Intrathoracic Injuries
- Severe Pain
- Poor Pulmonary Reserve
Clavicle Fractures
Fractures of the medial end of the clavicle.
Throckmorton, et al. J Shoulder Elbow Surg (2007)
- 84% were caused by MVC
- 90% involved multisystem trauma
- 20% of patients died within a month of their injuries
Treatment
Non Displaced
Fractures
Displaced and Open Fractures
- Arm Sling
- Analgesia
- Ice Packs
Orthopedic Surgery Consult
Complications
Non Union
Post Traumatic
Arthritis
Mechanism
of Injury
General and Clinical Appearance
Triage and Initial Evaluation
Pneumothorax
Hemothorax
Pericardial Tamponade
ED Management
Pulmonary Contusion
Two stages in the pathophysiology
Clinical Manifestations
Dyspnea
Tachypnea
Cyanosis
Tachycardia
Hypotension
Chest wall bruising
Rales/Crackles
Silent Breath Sounds
Direct injury to
lung parenchyma
Resuscitative measures
IVF administration
Special Considerations
3X Risk for
Hepatic Injury
4X Risk for
Splenic Injury
Long Term
Immediate
Tracheal compression
Neuro / Vascular
compromise
Diagnosis
Chest X Ray
Clavicle X Ray (bilateral)
Chest CT scan with IV contrast
Mechanism
of Injury
Physical
Examination
Hemodynamic
&
Respiratory
Parameters
Abnormal
Findings
on the CXR
Clinical
Evidence
of Multiple
Rib Fractures
pulmonary vascular resistance
Alveolar edema
& hemorrhage
Hydrostatic capillary pressure
leakage of blood and fluid
into the interstitium and alveoli
pulmonary shunting & resistance to airflow
lung elasticity
work of breathing
Hypoxia
Hypercarbia
Respiratory Acidosis
Imaging Studies
Minutes
Rapidity of changes on CXR visualization usually correlates with the severity of the contusion.
Some authors suggest that pulmonary contusions only visible on CT scan and not on CXR may NOT be clinically significant.
6 Hours
Arterial
Blood
Gases
Low PaO2
Hypoxia
PaO2 / FiO2
Ratio
A - a
Gradient
Management
Pain control
O2 Supplementation
Nasotracheal Suctioning
NIPPV
Mechanical Ventilation
Continuous Pulse Oximetry
Lung
Protective
Mechanical Ventilation
Tidal Volume
4 - 6 mL/kg
IBW
Minimum
Peep
Oxygenation

PaO2: 55 - 80 mmHg
SpO2: 88 - 95%
pH 7.30 - 7.45
Plateau
Pressure
< 30 cm H2O
Ultrasound
B Lines
Pneumothorax
Clinical Manifestations
Tension Pneumothorax
Simple Pneumothorax
No communication with the atmosphere
No shift of the mediastinum or diaphragm
Communicating Pneumothorax
Sucking Chest Wound
Chest Wall Defect
Severe Ventilatory Disturbance
Air can be heard flowing in & out of the defect
Progressive accumulation of air under pressure
Shifting of the
mediastinum to the opposite side
One-Way Valve
Cardinal Signs

Tachycardia
JVD
Absent Breath Sounds
Hypotension
Chest Pain
Shortness of Breath
Diagnostic Strategies
CXR
US
Chest CT Scan
Initial study
Greater sensitivity
than CXR
Very Sensitive
Sea
Shore
Barcode
Avoid Over Hydration
Management
Chest Tube Thoracostomy
Indications for Chest Tube Thoracostomy
in the Trauma Patient
Open - sucking chest wound
Tension pneumothorax - after needle decompresison
Hemothorax
Hemo/pneumothorax
Hemodynamically unstable patients with penetrating chest injury
Patients with chest trauma who are going to be air lifted and have small pneumothorax
Patient that requires ventilatory support
Respiratory symptoms regardless of size of pneumothorax
An occlusive dressing with petroleum gauze can be applied
Pre-Hospital Care
The defect should be covered immediately
Converts the condition to a closed pneumothorax
Warning: Beware of tension pneumothorax, especially in patients in positive pressure mechanical ventilation
Hemothorax
25% cases associated with pneumothorax
Most common cause - Hemorrhage from
lung parenchyma
Intercostals or mammary arteries - secondary causes
Pulmonary
Injuries

Cardiac
Injuries

Vascular
Injuries

Bony Injuries
Sternum View
Chest Tube Thoracostomy Procedure
Lateral border of pectoralis major
Line parallel
to the nipple
Anterior border of latissimus dorsi
Tube Size ?
Indications For Thoracotomy
Initial drainage of 1,500 mL
Continuous drainage of 200mL/hour for the next 3 hours
Increasing size of the hemothorax seen in the follow up CXR
Patient remains hypotensive despite blood products and exclusion of blood loss elsewhere
Management
Diagnostic Strategies
CXR
Chest CT Scan
Upright X ray requires 200-300 mL
of fluid for blunting of costophrenic angles
25% of hemothoraces diagnosed by CT are NOT detected on CXR
Chest Tube
Thoracostomy
(36 - 40 F)
Restoring
circulating
blood volume
Close monitoring
of the chest
tube output
IV Antibiotic
for the first
24 hours
Complications
Unrecognized hemothorax
Hypovolemic / Hemorrhagic SHOCK
Chest Tube Misplacement
EMPYEMA
FIBROTHORAX
A TRUE EMERGENCY!
Chest Wall
Thickness
3.5 - 4.5 cm
Blunt Cardiac Injury
Blunt Cardiac Injury
NO “gold standard”
NO guideline
NO clear definition
The absence of criteria makes reporting difficult
The incidence is unknown
Rupture
of the valves,
septum, or
ventricular
wall
Things to
consider when
evaluating
blunt
chest trauma
Arrythmia
Cardiac wall
motion
abnormalities
Potential to
progress to
cardiogenic
shock
Mechanism Of Injury
Deceleration is the MOST COMMON Cause
Compression between
the spine and the sternum
Direct precordial impact
Hydraulic effect resulting
in cardiac rupture
Blast injury
Rib fx can directly
traumatize the heart
Right side of the
heart is usually
Injured
Closest to the
anterior chest wall
Injury involves more
than one chamber in more
than half of the reported
cases
Diagnostic Strategies
EKG
Cardiac
Biomarkers
Echo
CXR
Hemorrhage is the cause
of the sinus tachycardia
in the trauma patient
until proven otherwise.
Arrhythmias
Conduction
Disorders
Myocardial
Injury
Nonspecific
Abnormalities
sinus
tachycardia
sinus
bradycardia
atrial
fibrillation
PACs & PVCs
atrial
tachycardia
ventricular
fibrillation
ventricular
tachycardia
AV nodal
conduction disorders
fascicular
block
RBBB
new Q wave
ST segment
changes
pericarditis-like
ST segmentelevation
prolonged QT
syndrome
contractility

CO & SV

Lactate levels

Right sided cardiac
pressures
Controversial
Normal initial troponin + normal EKG = 100% of Negative Predictive Value
If EKG changes
Initial cardiac enzymes should be ordered + a secondary measurement at 4 - 6 hours
Marked elevation has been associated with:

Ventricular dysrythmias

Left ventricular dysfunction
Clinically significant
BCI can occur w/o
elevation of troponins


Hemodynamic instability
Signs of severe shock
EKG with significant abnormalities
Co-existing CAD
A Chest X ray should always be
ordered in the case of blunt chest trauma
Bedside
Non invasive
Wall motion abnormalities
Ejection fraction
Valvular abnormalities
Pericardial effusion / tamponade
TEE is an alternative for patients with painful chest wall injuries
Acute MI Secondary to Trauma
Aspirin & Thrombolytics are CONTRAINDICATED
Acute Cardiac
Tamponade
Clinical Features
Compensatory
Mechanism to Reduced Stroke Volume
Diagnostics
Strategies
Muffled heart sounds
Beck's Triad
Tachycardia
CVP > 15 mmHg
JVD
Hypotension
60 - 100 mL of
Blood can cause
H/D instability
Beware: The patient can be well appearing in the initial phases.
US
2% penetrating trauma
HR
TPR
CVP
Ultrasound
Chest X Ray
Pericardiocentesis
A large portion of the blood in the pericardial cavity is clotted
If 20 mL of blood can be drawn out easily and rapidly, it usually indicates
that the blood is being aspirated from the Rt ventricle
Iatrogenia – perforation of Rt ventricle or a coronary artery – tamponade…
A falsely negative procedure may delay needed surgery
Removal of as little as 5-10 mL may increase SV by 25 to 50%, leading to a dramatic increase in CO and BP
5th or 6th intercostal space at the
Lt sternal border
Subxyphoid approach
Electrocardiography
Indications for
ED thoracotomy
Penetrating Traumatic Cardiac Arrest
Cardiac arrest at any point with initial signs of life in the field
Blood pressure <50 mm Hg systolic after fluid resuscitation
Blunt Trauma
Cardiac arrest in
the emergency department
Severe shock with clinical signs of cardiac tamponade
Trauma Surgery
Consult
Pneumothroax
Medical Management
Imaging Studies
Clinical Features
Traumatic Aortic Dissection
Traumatic Aortic
Dissection
Majority of patients die at the scene

Only 20% of patients survive long enough to be treated

Of those who make it to be treated, 70 to 90% survive
their repair

Overall survival of 10 to 20%
30 % of pts with blunt aortic injury who survive long enough to reach the hospital will die within 24 hours if untreated

Clinical factors that the risk for aortic injury:

Rapid deceleration
Fall over 3 meters (10 ft)
Change in velocity of >20 mph
High speed MVC (>40 mph)


Rupture of the intima and medial layer occurs

Interval of unpredictable duration

Rupture of the adventitia
Aortic Rupture Phases
Type 1
Intimal Tear

Type 2
Intramural Hematoma

Type 3
Pseudoaneurysm

Type 4
Free rupture or periaortic hematoma
Aortic Injury Grading
Surgical
Repair
Intrascapular pain in the
abscense of spine fx

Difficulty breathing or swallowing
Steering wheel or seatbelt imprint

Cardiac or interscapular murmur

Left subclavicular hematoma

Pseudocoartation
(upper ext HTN w B/L
femoral pulse deficit)
Symptoms
Signs
Wide mediastinum

Supine CXR > 8 cm

Upright CXR >6 cm
Wide Mediastinum
Enlarged Aortic Knob
Left Apical Cap
Large Hemothorax
(750 mL)
Rightward Trachea Deviation
Wide Paravertebral Stripe
CXR
Chest CT scan
with IV contrast
TEE
Has replaced aortography
Non Invasive
Patient has to be stable
May be most useful in
hemodynamically UNSTABLE
patient.
Can be performed in the
ER or in the OR.
Can provide information
regarding cardiac function.
Type and Cross for 8 - 10 units of PRBCs
Tight BP Control
Consult Trauma Surgery early
B Blockers
Esmolol
Labetalol (bolus)
Nicardipine or Cleviprex
Targets
HR: 60 - 80 bpm
Systolic BP < 100 mmHg
Take Home Message
It is better to over diagnose than to under diagnose.
CT scan of the chest
1st & 2nd Rib Fx
Medial 1/3 Clavicular Fx
Hemothorax
Scapular Fx
High energy mechanism of trauma
Suspicious CXR
Pneumomediastinum/Pneumopericardium
References
Marx, J. Rosen's Emergency Medicine.
7th Edition. 2010. p: 387 - 409.
Tintinalli, J. Emergency Medicine, A comprehensive study guide. 7th edition. 2011. p: 1745 - 1765.
Uzcategui, M. EMCNA. Critical skills and procedures in emergency medicine. 2013. p: 291- 334.
Thank You!!!
Maria Uzcategui
mucmd@yahoo.com
- Capnography
Deep Breathing
Do not underestimate the patient with chest trauma.
Chest CT scan
Emergency Medicine
Trauma Surgery Critical Care

APRV
Early positive pressure stents the alveoli open
Continuous pressure prevents alveoli edema formation
Consider:
FREE

Swan Ganz Catheter
Most common injury requires surgical repair
Full transcript