Advanced Trauma Life Support
Thoracic Trauma
Objectives
A-Identify and manage the following
immediately life-threatening chest injuries
evidenced in the primary survey:
1.Airway obstruction
2.Tension pneumothorax
3.Open pneumothorax (sucking chest wound)
4.Massive hemothorax
5.Flail chest
6.Cardiac tamponade
B-Identify and initiate treatment of the
following potentially life-threatening injuries
assessed during the secondary survey:
1.Pulmonarycontusion
2.Aortic disruption
3.Tracheobronchial disruption
4.Esophageal disruption
5.Traumatic diaphragmatic hernia
6.Myocardial contusion
Chest Trauma
1 out of 4 deaths
Thoracic Injuries 85% Require :
*Correct hypoxia
*Improve circulation
*Alleviate ventilatory obstruction
Etiology of Hypoxia
*Hypovolemia tissue hypoxia
*Perfusion unventilated lung
*Ventilation of unperfused lung
*Abnormal pleural airway relationships
Primary Survey
Life threatening chest trauma
*Airway
*Breathing
*Circulation
Tension Pneumothorax
*Air enters pleural space without exit
*Collapse of affected lung
*Impaired ventilation-unaffected lung
*Mechanical ventilation with PEEP
*Nonsealing
*Emphsematous bullae lung injury
*Tracheal deviation
*Respiratory distress
*Unilateral absence of breath sounds
*Distended neck veins
*Cyanosis-late
Treatment
*Immediate decompression
*Clinical diagnosis not radiologic
Open Pneumothorax Management
*Immediate covering of defect
*Chest tube
*Definitive operation
Massive Hemothorax
*1500 ml + blood loss
*Systemic of pulmonary vessel disruption
*Flat vs. distended neck veins
*Shock / no breath sounds or percussion
dullness
Management
*Rapid volume restoration
*Chest decompression & X-ray
*Auto-transfusion
*Operative intervention
*Re-expand lung
*Oxygen
*Judicious fluid management
*Selective intubation
*Analgesia
Classic Findings
*Narrowed pulse pressure
*Elevated CVP
*Muffled heart sounds
*Distended neck veins
Management
*Patient airway
*IV therapy
*Pericardiocentesis
*Open thoracotomy with repair
Secondary Survey
*In-depth physical exam
*Upright chest film
*ABGs
*ECG
*Pulmonary contusion
*Aortic disruption
*Tracheo-bronchial injury
*Myocardial contusion
Pulmonary Contusion
*Most common
*Selective intubation & ventilation
*Maintain adequate oxygenation
Major Intrathoracic Vascular Injury
*90% fatal at scene
*50% mortality each day treatment delayed
*Common sit: ligamentum arteriosum
Widened Mediastinum On X-ray
Management
*Direct repair
*Resection & graft
*Treatment by qualified surgeon
Tracheal Injuries
*Penetrating:♦STAT surgical
♦repair
♦Associated
Blunt:♦Subtle
♦History
♦Important
Laryngeal Fractures
*Hoarseness
*Subcutaneous emphysema
*Palpable fracture creptius
Tracheal Injuries
*Partial vs. complete airway obstruction
*Endoscopy-diagnostic aid
Bronchial Injury
*Frequently missed
*Blunt trauma
*50% of deaths in 1 hour
Management
*Airway maintenance
*Surgical intervention
Esophageal Trauma
*Blunt vs. penetrating
*Severe epigastric blow
*Pain/shock, injury
*Pneumo/hemothorax without fracture
Esophageal Trauma
*Chest tube-particulate matter
*Chest tube-bubbles continuously
*Mediastinal air/empyema
*Gastrografin swallow/esophagoscopy
Management of Surgical Intervention
Traumatic Diaphragmatic Hernia
*Diagnosed left side
*Blunt: large tears
*Penetration: small perforation
*Misinterpreted X-ray
*Contrast radiography
Myocardial Contusion
*Blunt trauma
*History
*ECG changes
*Serial enzyme changes
*Treatment: observe/monitor
Subcutaneous Emphysema
*Airway injury
*Pneumothorax
*Blast injury
Pneumothorax
*Blunt trauma
*Ventilation/perfusion defect
*Hyper-resonance
*Decreased breath sounds
*Treatment- tube thoracostomy
Hemothorax
*Etiology
♦Lung laceration
♦Vessel laceration
*Treatment
♦Tube Thoracostomy for continued bleeding
Rib Fractures
*Pain/splinting
*Impaired ventilation
*Increased secretions
*Atelectasis/pneumonia
Ribs # 1-3
*Severe force
*Associated injuries
*50% mortality
Ribs # 5-9
*Majority - blunt trauma
*Bowing effect
*Midshaft fracture
*Intrathoracic
Management
*Obtain chest X-ray
*Avoid
♦Systemic analgesics
♦Constrictive devices
Indications for Chest Tube Insertion
1. Pneumothorax
2. Hemothorax
3. Selected cases, suspected severe lung injury
4. Prophylaxis
Summary
*Common in multiple injured patient
*Cognitive knowledge to diagnose
*Develop skills
*ECG monitoring
Pitfalls in Thoracic Injuries
*Failure to obtain a chest X-ray soon after
admission and again within 4-8 hours may result
in significant intrathoracic injuries being
overlooked
*Excessive reliance on chest X-rays may lead to
diagnostic errors
*Without careful inspection of the chest wall,
contusions, flail chest, intrathoracic bleeding,
and open or "sucking" chest wounds may be
overlooked
*A fractured sternum can be easily missed
unless the sternum is palpated carefully or
special X-ray views are obtained
*Cardiac arrest may occur suddenly and
rapidly if there is any delay in relieving a
suspected tension pneumothorax in a
hypotensive patient. X-rays are not needed
before treatment under such circumstances
*Inserting a chest tube while the patient is lying
flat increases the chances for injury to the
diaphragm
*If an air leak and pneumothorax space are
allowed to persist together, the patient is apt to
develop an empyema or bronchopleural fistula
*If a patient with multiple injuries which
include a flail chest is not given ventilatory
assistance with a respirator soon after
admission, he is apt to die of respiratory failure
*If a diaphragmatic injury is not suspected and
looked for in all patients with chest trauma, the
diagnosis will probably be missed
*If it is assumed that bleeding from the chest
wound in a hypotensive patient is superficial in
origin, the diagnosis and treatment of severe
intrathoracic bleeding may be delayed
*Repeated attempts to completely aspirate a
small hemothorax with a needle or a syringe
may cause a pneumothorax or empyema
*Use of high ventilatory pressures to inflate the
lungs following penetrating chest wounds may
result in systemic air emboli
*Failure to obtain an aortogram when there is
superior mediastinal widening following blunt
chest trauma may result in an inaccurate
diagnosis and an unnecessary thoracotomy
*Hypotension following blunt chest trauma is
frequently due to intra-abdominal bleeding
*Delay in closure or drainage of esophageal
injuries result in a high morbidity and
mortality; hence, early diagnosis and treatment
are vital
*Any delay in providing adequate ventilatory
support greatly increases the risk of irreversible
respiratory failure
*Excessive administration of crystalloids greatly
increases the risk of respiratory failure
*Failure to empty the stomach with a tube soon
after chest trauma greatly increases the risk of
aspiration and severe ileus