Chest trauma


	CHEST TRAUMA BLUNT CHEST TRAUMA No reason to OPEN CHEST if pt is DOA s/p Blunt Chest Trauma Sternum/Rib Fx: pt c/o pain, has deformity, bruises, crepitus r/o associated injuries to major vessels, heart, liver/spleen, especially when scapular, 1^st and/or 2d rib fx are present obtain lateral view CXray for sternum and/or rib series consider admission for sternum or multiple rib fx Treatment c/o pain control and pulmonary toilet. Fat emboli is a possible complication Flail Chest: 2ry to multiple rib fx consequences are pulmonary contusion (may flourish in first 72 hours), paradoxical movement, splinting with 2ry hypoventilation CXray, blood gasses, selective intubation ( when pt develops respiratory failure or if multiple fxs > 7 rib are fx that will predict ventilatory failure), pain control, incentive spirometry. Prophylactic intubation (ETT) in case of multiple fxs, as a preventive tool for pntx and hemothorax, can be helpful. Pulmonary Contusion : severe impact causes leak of blood/proteins into alveoli with consequent atelectasis/ARDS pt c/o pain, SOB, +/- hemoptysis, cough,¯ O2, tachypnea ABG initially may show respiratory alkalosis followed by respiratory acidosis. CXray: this may lag behind clinical picture for 6-12hrs and also can miss small injuries, thus, although used for initial assessment, it is not a perfect tool for complete evaluation CT is a much better tool, but if injury is too small to be picked up by the Xray, it is probably of no clinical significance. Treatment is like flail chest: pain control, pulm toilet, intubation prn. Laryngotracheal Injury: See neck trauma Esophageal Injury: See neck trauma Aortic Dissection: occurs 2ry to deceleration @ >30mph or > 60ft fall. >80% are distal to SC artery pt c/o C.P., ischemia to the arm, BP discrepancy between the upper and lower-extremities ( pseudocoarctation ), +/-murmur, ¯ pulses, ¯ motor strength CXray: Look for mediastinal width, obscured aortic knob, ¯ L main bronchus, deviated esophagus/ trachea, L pleural effusion, L apical cap Angio is a must prior to surgery. It is the "gold standard". Also visualizes other vessels andsmall tears CT done on stable pt. Does not have other advantages of Angio TEE is an excellent tool for unstable pt but can not see aorta well at distal portion and arch In unstable pt perform Thoracotomy ( to clamp aorta) and BP control Myocardial Contusion: For anatomical reasons R atrium/ventricle are more commonly injured Diagnosis is made by: Ø EKG - persistent tachycardia,¯ STT or , PVCs. Ø CP, tachycardia, ecchymosis to chest wall, S+S of ¯C.O. in 40-50% of pts may all be present. Ø Presence of broken sternum or CPK are not enough criteria to label pt withmdiagnosis of myocardial contusion. Generally pt with above S & S is admitted to telemetry for monitoring. If patient has hymodynamic instability and/or new heart murmur, then echo is indicated. No role for CPK enzymes in setting of contusion. Otherwise, if patient improves or fails to demonstrate significant arrhythmias in first 24 hrs, patient may be discharged. Pts with a contusion are at risk for rupture, aneurysm, mural thrombi, pericardial effusion, cardiogenic shock, arrhythmias. Pneumothorax: SOB, C.P. ¯BS, sq emphysema, hyperresonance CXray: PNTX can be estimated and treated according to %: Ø < 20% ( 2 cm of air on the Xray) ® observe. Repeat CXray in 8hrs Ø 30% ( 3cm of air ) and more chest tube Hemothorax : SOB, C.P. ¯BS, dullness CXray: one needs 250-300ml of blood to be visualized on upright or lateral decubiti Xray. If only supine film is obtained one can miss 1000ml of blood. Chest tube. Use autotransfusion if >500ml of blood were obtained with thoracostomy. Perform Thoracotomy if 1500ml of blood is drained upon chest tube insertion. Perform Thoracotomy if > 2-3ml/kg/hr drained over hr. after tube insertion. Tension PNTX: SOB, C.P., hypotension, JVD, ¯BS, deviated trachea. insert STAT 14 gauge needle in 2nd IC space followed by chest tube. PENETRATING CHEST TRAUMA Overview: If VS were never obtained ® DOA. Pt is pronounced dead. If VS were present in field but lost on the way to ER do Primary Survey. Some studies showed that the outcome was dim if en route resuscitation efforts to ER were longer than 10 min. ER Thoracotomy has been advocated in this setting. Do not probe the wound and do not remove FB from wound. CT Scan has limited value in chest trauma as compare to head and abdo trauma.. If pt s/p trauma is considered for intubation it is advisable to insert Chest Tube since there is a possibility of developing PNTX. Once intubated or even "ambubaged", by applying pressure pt may suddenly develop TPNX. Thus after positive pressure vemntilation, listen to lung fields to detect TPNX. Chest STAB wounds: if normal POx, normal CXRay and normal Hct upon arrival and after 6hrs of observation in the ER, pt can be sent home. This is a general rule only and is subject to variations upon the location of the wound ( peripheral, central, close to L nipple, posterior scapula, etc.,). Chest GSW are admitted for 24 hr. observation regardless the initial w/u. Laryngotracheal Injury - see NECK Esophageal Injury - see NECK Great Vessels Injury: Findings: ¯pulses, change in BP between two extremities, expanding hematoma, acute SVC symptoms, hematoma compressing trachea, AV fistula, tamponade, air embolism, CVA. Dx: - Xray, Angio. Therapy: This is guided by results of diagnostic studies. If pt is unstable ® 2-3L IVF in 20 min followed by PRBC and thoracotomy if it it is impossible to control bleed and maintain SBP > 90mmHg. Open Pneumothorax =Sucking Chest Wall =2ry to penetration with big defect in chest wall. Findings: sonorous breath sounds. Therapy: Put square dressing and tape only 3 sides to create escape valve. If this is not done tension pneumothorax develops. After initial management chest tube is placed away from wound. If upon insertion of CT 1500ml of blood came out or 300ml/hr x 2-3hrs then thoracotomy is performed Consider Autotransfusion if >500ml blood is detected. Chest STAB / GSW Wounds: see Overview Air Emboli: Occurs 2ry to AV fistula, during intubation (air from injured bronchus may penetrate the circulation). 1. Findings: ischemia to coronaries ( arrhythmia develops or pt drops BP ), limbs, spine, CNS. 2. Therapy: put pt in Left Trendelenberg. If this is not helpful ® thoracotomy ® clump aorta ® aspirate air from LV. Pericardial Tamponade: Pt is in shock - BP, tachycardia, tachypnia Findings: Beck's triad - JVD, muffled heart sounds, BP, Pulses paradoxus, narrowing of pulse pressure. Dx: EKG - electrical alternans CVP - if ECHO not available this can provide additional information. ECHO - @ bed side Therapy: if stable ® pericardiocenthesis. if unstable ( i.e. narrowing of BP, loosing VS ) ® thoracotomy. ThoracoAbdominal Injury: If this is suspected proceed as follows: Dx: DPL, CT, IVP - all prn Therapy: Guided by diagnostic w/u. All pts are admitted for observation. Spinal Injury: see Spine Hemorrhagic Shock: Class I <15% blood loss( <700ml), HR <100bpm, RR <20, SBP = N. Give IVF Class II >15% blood loss(>700ml), HR >100bpm, RR >20, SBP = N. Give IVF. Class III >30% blood loss (1500ml), HR >120bpm, RR >30, SBP <90. Give PRBC. Class IV >40% blood loss (2000ml), HR >140bpm, RR >40, SBP <70. Give PRBC. S & S: ¯BP, ¯HR, ¯ UO, ¯ MS, Tachypnea SBP is: 60 if carotid pulse is detected 70 if femoral pulse is detected 80 if radial pulse is detected Treatment: Two large bore IVF, O2, Cardiac monitor Pt in hemorrhagic shock is given about 2L IVF ( in class I and II ) Pt in hemorrhagic shock, if intubated, is given RR 10 and TV of 8-10 in order not to compromise venous return. Cardiac Arrest in Penetrating Trauma: This occurs 2ry to tamponade, vessel injury, air emboli, intrathoracic hemorrhage, hemorrhagic shock. Close CPR is futile A - Airway/C-spine B - Breathing : this in case of arrest mandates bilateral chest tubes. C - Circulation : this in case of penetrating cardiac arrest mandates thoracotomy. This allows open heart CPR, pericardiotomy, clamp the aorta. IVF and PRBC. O.R. ASAP

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