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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
What are the potential ly l i fe-threatening
chest in jur ies?
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Thoracic Trauma
Blunt cardiac injury
Traumatic aortic disruption
Blunt esophageal rupture
Traumatic diaphragmatic injury
What are the potential ly l i fe-threatening
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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