Chapter Klkoihkiokl

8/13/2019 Chapter Klkoihkiokl

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Initial Assessment and Management

Committee on Trauma Presents

Thoracic

Trauma


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Case Scenario

27-year-old male brought to trauma

center

Unrestrained driver in high-speed,frontal-impact collision

Prolonged extrication at scene


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Case Scenario

Blood pressure: 90/70; heart rate: 110;

respiratory rate: 36

Initial assessment: GCS score 15,patent airway

What features suggest that this patient

may have thoracic in jur ies?


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Objectives

Identify and treat life-threatening

injuries found during the primary

survey.

Identify and treat potentially life-

threatening injuries found during

the secondary survey.


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Thoracic Trauma

Significant cause of mortality

Blunt : < 10% require operation

Penetrat ing: 15-30% require operation

Majori ty: Require simple procedures

Most life-threatening injuries areidentified during the pr imary survey


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Thoracic Trauma

Laryngeotracheal injury / Airwayobstruction

Tension pneumothorax

Open pneumothorax

Flail chest and pulmonary contusion

Massive hemothorax

Cardiac tamponade

What are the immediately l i fe-threatening

chest in jur ies?


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Thoracic Trauma

Hypoxia Hypoventilation

Acidosis

Respiratory

Metabolic

Inadequate tissue

perfusion

What are the pathoph ysiolog ic

consequences o f these chest in jur ies?

Manage in

the primary

survey as

identified


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Laryngeotracheal Injury

Airway Obstruction

Rare

Hoarseness

Subcutaneous emphysema

Manage in the primary survey as

soon as possible Intubate cautiously

Tracheostomy


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Tension Pneumothorax

Respiratory distress

Shock

Distended neck veins

Unilateral decrease in

breath sounds

Hyperresonance

Cyanosis (late sign)


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Tension Pneumothorax

Clinical diagnosis,

not by x-ray

Immediatedecompression

Needle

Chest tube


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Open Pneumothorax


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Open Pneumothorax

3-sided cover over

defect

Chest tube

Definitive operation


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Flail Chest and Pulmonary Contusion


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Flail Chest and Pulmonary Contusion

Oxygen

Reexpand lung

Intubate as

indicated

Judicious fluids

Analgesia


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Massive Hemothorax

Systemic / pulmonary

vessel disruption

> 1500 mL blood loss

Flat vs. distended

neck veins

Shock with no breathsounds and/or

percussion dullness


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Massive Hemothorax

Rapid volume

restoration

Chest decompressionand x-ray

Autotransfusion

Operative intervention


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Cardiac Tamponade

Decreased arterial

pressure

Distended neck veins

Muffled heart sounds

Pulseless electrical

activity

Radio antenna


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Cardiac Tamponade

A Secure airway

B Ventilate and oxygenate

C Volume resuscitation

FAST, operation


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Resuscitative Thoracotomy

When shou ld I cons ider resusci tat ive

thoracotomy?


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Resuscitative Thoracotomy

Patients with penetrat ingthoracic injury

arriving with PEA maybe a candidate

When a surgeon with appropriate skills

is present

ED thoracotomy not indicated in blunttrauma with PEA

When shou ld I cons ider resusci tat ive

thoracotomy?


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Thoracic Trauma

What are the potential ly l i fe-threatening

chest in jur ies?

How do I ident i fy them?

When and how do I correct the prob lem?


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Thoracic Trauma

Tracheobronchial tree injury

Simple pneumothorax

Pulmonary contusion

Hemothorax


chest in jur ies?


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Thoracic Trauma

Blunt cardiac injury

Traumatic aortic disruption

Blunt esophageal rupture

Traumatic diaphragmatic injury


chest in jur ies?


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Thoracic Trauma

Physical examination

Chest x-ray

Pulse oximetry

ABG

ECG

How do I identi fy potential ly l i fe-threatening

thoracic in jur ies?


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Simple Pneumothorax

Penetrating / blunt

trauma

Ventilation / perfusiondefect

Hyperresonance

Decreased breath

sounds

Tube thoracostomy


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Pulmonary Contusion

Common

Oxygenate and

ventilate

Selective intubation

Delayed X-ray

changes


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Hemothorax

Chest wall injury

Lung / vessel

laceration

Tube thoracostomy


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Blunt Cardiac Injury

Injury spectrum

Abnormal ECG / monitor changes

Echocardiography

Treat

Dysrhythmias

Perfusion Complications


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Traumatic Aortic Disruption

Rapid acceleration /

deceleration

mechanism

X-ray signs

High index of

suspicion

Surgical consult


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Traumatic Aortic Disruption

Diagnosis by Helical CT or Aortography


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Blunt Esophageal Rupture

Blunt vs. penetrating injury

Severe epigastric blow

Pain / shock out of proportion to

injury

Left pneumothorax or hemothorax

without rib fracture


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Diaphragmatic Injury

Most diagnosed on left

Blunt: Large tears

Penetrating: Small

perforations

Misinterpreted x-ray

Contrast radiography

Operation


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Traumatic Asphyxia

Petechiae

Swelling

Plethora

Cerebral edema


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Subcutaneous Emphysema

Airway injury

Pneumothorax

Blast injury

Iatrogenic


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Fractures and Associated Injuries

Ribs 1-3

Severe force

Associated injuries have high mortality risk

Ribs 4-9

Pulmonary contusion and pneumothorax

Ribs 10-12

Suspect abdominal injury

Sternum, Scapular, and Rib


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Pitfalls

Simple pneumothorax converts to

tension pneumothorax

Retained hemothorax

Diaphragmatic injury

Severity of rib fractures / pulmonarycontusion

Extremes of age

Pitfalls


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Summary

Common in multiply injured patients

Life-threatening injuries

Potentially-lethal injuries

Initial stabilization by simple techniques

in the majority of cases

Goal: Resto re no rmal gas exchange and perfusio n

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