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THORACIC TRAUMA

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REFERENCES
Pre Hospital Trauma Life Support (PHTLS)
Military 7th ed. 2011 ISBN 978-0-323-06503-0

CHAPTER 11, pp. 291-313


Special Operations Forces Medical Handbook
US Special Operations Command 2nd ed. 2010 ISBN 978-0-16-084744-8

PART 7

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LEARNING OBJECTIVES
PHYSIOLOGY OF THE RESPIRATION
CHEST EXAMINATION
MECHANISMS OF CHEST INJURIES
PATHO-PHISIOLOGY AND TREATMENT

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SIMPLE PNEUMOTHORAX

OPEN CHEST WOUND

TENSION PNEUMOTHORAX

MASSIVE HEMOTHORAX

FLAIL CHEST

CARDIAC TAMPONADE

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CHEST TRAUMA IS THE


3rd LEADING CAUSE OF TRAUMA DEATHS ON COMBAT EVEN IF THE INCIDENCE
WAS REDUCED DUE TO THE USE OF BODY ARMOR

SOME CHEST INJURIES ARE


IMMEDIATELY LIFE-THREATENING

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RESPIRATION
INHALATION

AIR & O2 ENTERS LUNGS

EXHALATION

AIR & CO2 MOVES FROM LUNGS

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GAS EXCHANGE
BLOOD FROM VEINS
ARRIVES THROUGH
PULMONARY ARTERY

THE GAS EXCHANGE


TAKES PLACE IN THE
ALVEOLUS

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RESPIRATORY DYSFUNCTION
FOLLOWING TRAUMA

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ALTERED MOVEMENT OF THE CHEST AND DECREASE IN:


THE AREA AVAILABLE FOR GAS EXCHANGE
BLOOD GETTING TO THE LUNGS
O2 GETTING TO THE ALVEOLI
CO2 BEING RELEASED INTO THE ALVEOLI

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Recovery position

Previous guidelines were to place the casualty with the injured side down
IOT facilitate the good side expansion and ventilation

Injured side up: more recent studies demonstrated instead that


perfusion is the first concern, and IOT ensure the best perfusion
to the non-injured side this one has to be placed down
Two additional comments about having injured side is up are:
Less chest pain
Treatments are easier to reassess
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CHEST EXAMINATION
INSPECT & CHECK THE BACK (IT IS A PART OF THE
CHEST INSPECTION)

PALPATE

AUSCULTATE + MARK THE PMI

PERCUSS

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INSPECTION
THE INSPECTION OF THE CHEST STARTS ALWAYS
FROM THE NECK! THERE YOU LOOK FOR:
WOUNDS

STAB WOUNDS

GSW

TRACHEA DEVIATION
JUGULAR VEINS DISTENSION (JVD)

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INSPECTION
THEN, YOU HAVE TO INSPECT THE THORACIC
REGION. THERE YOU LOOK FOR

BILATERAL RISE AND FALL OF THE CHEST


WOUNDS
WOUNDS IN HIDDEN PLACES (ARMPITS)

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INSPECTION
BILATERAL
WOUNDS
RISEWOUNDS
AND
IN HIDDEN
FALL OF
PLACES
THE CHEST

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Assess and treat the wound

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CHECK THE BACK!


THE THORAX CONSISTS OF FRONT AND BACKSIDE!
NO CHEST EXAMINATION IS DONE WITHOUT CHECKING THE BACK!
IF YOU DISCOVER AN INJURY ON THE CHEST, CHECK THE BACK
IMMEDIATELY!!!

IF YOU NEED TO LOG-ROLL YOUR PATIENT, ALWAYS CHECK THE STABILITY OF


NECK, PELVIS, PUBIS AND FEMURS IN ADVANCE!!!

KEEP ALWAYS IN MIND THE MECHANISM OF INJURY!


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PALPATION
DONT BE AFRAID TO TOUCH YOUR PATIENT
CHECK IF THE RIBCAGE IS STABLE
CHECK THE RIBS AND THE STERNUM FOR
CREPITUS & STABILITY
CHECK THE REACTIONS OF YOUR CASUALTY
WHILE PALPATING

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AUSCULTATION
THE LUNGS ARE CHECKED
LISTENING TO THREE POINTS
ON EACH SIDE OF THE CHEST,
ALWAYS STARTING FROM THE
GOOD SIDE AND COMPARING
THE FINDINGS
1

4
5

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3
6

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POINT OF MAJOR IMPULSE (PMI)


THE PMI IS THE SPOT WHERE IT IS POSSIBLE TO
HEAR THE HEARTBEAT THE MOST CLEARLY
IN THE MAJORITY OF CASES
IT IS LOCATED BELOW THE
LEFT NIPPLE, A BIT TOWARDS
THE MIDLINE. THIS IS YOUR
STARTING POINT FOR THE
CHECK!

BE AWARE: THE PMI POSITION


IS DIFFERENT FROM PERSON
TO PERSON! ALWAYS CHECK
YOUR FINDINGS!
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PERCUSSION
SITES & SEQUENCE LIKE
AUSCULTATION

PLACE ONE FINGER


BETWEEN TWO RIBS,
THEN KNOCK ON THAT
FINGER

LISTEN!!!

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3
6

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PERCUSSION - ABNORMAL SOUNDS


HIGH, HOLLOW SOUND:
AIR IS COLLECTED IN THE PLEURASPACE. THIS IS A SIGN
FOR A POSSIBLE PNEUMOTHORAX OR A TENSION-PNX
THE SOUND YOU GET IS CALLED HYPER-RESONANCE

LOW, DULL SOUND:


THIS SOUND INDICATES A COLLECTION OF FLUID IN THE
PLEURA SPACE. MAINLY CAUSED BY A HEMOTHORAX
THE SOUND YOU GET IS CALLED DULL-RESONANCE

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CHEST TRAUMA
THE VAST MAJORITY OF CHEST TRAUMA CAN BE MANAGED
WITH SIMPLE PROCEDURES, WITHOUT SURGERY
IF MISSED CAN IMPAIR
VENTILATION
O2/CO2 EXCHANGE
BLOOD pH BALANCE

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MECHANISMS OF INJURY
BLUNT TRAUMA
DEFINITION: INJURY INCURRED WHEN THE HUMAN BODY HITS OR
IS HIT BY A LARGE OUTSIDE OBJECT
BLAST WAVE
FALLING ACCIDENT
CAR ACCIDENT
HITTING THE STEERING WHEEL WITH THE CHEST

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MECHANISMS OF INJURY
PENETRATING TRAUMA
DEFINITION: INJURY INCURRED WHEN AN OBJECT PENETRATES
INTO THE BODY

GUN SHOT WOUND


KNIFE ATTACK
SHRAPNEL THAT HIT THE BODY

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MECHANISMS OF INJURY
PENETRATING TRAUMA
KEEP IN MIND THAT THE DAMAGE CAUSED BY A
PENETRATING WOUND IS ALWAYS RELATED TO:
SITE AND DEPTH OF PENETRATION
TYPE OF WOUNDING AGENT

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Everything could be affected

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THORACIC INJURIES
THORACIC INJURIES CAN BE CLASSIFIED AS:
MINOR INJURIES
INJURY CAN BE DEALT WITH EASILY
NO DIRECT DANGER FOR THE LIFE OF THE CASUALTY
CAN BE HANDLED AS A ROUTINE

IMMIDIATE LIFE-THREATENING INJURIES


ACT AS FAST AS POSSIBLE! EVERY MINUTE COUNTS!
THIS PATIENT IS URGENT

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MINOR INJURIES
SIMPLE PNEUMOTHORAX
MINOR HEMOTHORAX
THORACIC FRACTURES (STERNUM AND RIBS)

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WHAT IS PNEUMOTHORAX

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SIMPLE PNEUMOTHORAX
AIR IN THE PLEURAL SPACE
WHICH SEPARATES THE TWO PLEURAL SURFACES

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SIMPLE PNEUMOTHORAX
IT CAN BE SPONTANEOUS

OR TRAUMATIC

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SIMPLE PNEUMOTHORAX
EXAMINATION
INSPECTION
UNEQUAL RISE AND FALL OF THE CHEST
WOUNDS (BRUISES)
PALPATION
RIBCAGE INSTABILITY
AUSCULTATION
DECREASED BREATH SOUNDS
PERCUSSION
BELL TYMPANISM (HYPER RESONANCE)
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SIMPLE PNEUMOTHORAX
SIGNS & SYMPTOMS
SIGNS
TACHYPNEA (RAPID BREATHING)
TACHYCARDIA (FAST HEART RATE)

SYMPTOMS
CHEST PAIN
DYSPNEA (DIFFICULT BREATHING)

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LIFE-THREATENING CONDITIONS
OPEN CHEST WOUND
TENSION PNEUMOTHORAX
MASSIVE HEMOTHORAX
FLAIL CHEST
CARDIAC TAMPONADE
TRACHEAL AND BRONCHIAL RUPTURE
DISRUPTED AORTA

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OPEN CHEST WOUND


RESULTS IN A OPEN PNEUMOTHORAX
AIR CAN FLOW DIRECTLY INSIDE THE PLEURAL
CAVITY. IF THE DIAMETER OF THE WOUND IS 2/3
AND MORE THAN THE TRACHEA DIAMETER THE
AIR WILL PASS PREFERENTIALLY THROUGH THIS
ROUTE
SUCKING CHEST WOUND: THE WOUND ACT AS
A VALVE ALLOWING THE AIR TO GO INTO BUT
NOT OUT OF THE PLEURAL CAVITY

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OPEN CHEST WOUND

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OPEN CHEST WOUND

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CHEST SEALS,THE WINNER IS

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HyFin CHEST SEAL

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SAM CHEST SEAL

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TENSION PNEUMOTHORAX
CAUSED BY ONE-WAY VALVE
PLEURAL SPACE FILLED WITH
AIR
AFFECTED LUNG COLLAPSED
TRACHEA & MEDIASTINUM
SHIFTED AWAY FROM
AFFECTED LUNG
OPPOSITE LUNG, MEDIASTINIC
VESSELS & HEART
COMPRESSED
DEATH RAPID UNLESS TREATED

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EARLY SIGNS & SYMPTOMS


OF TENSION PNEUMOTHORAX
AS SIMPLE PNEUMOTHORAX
EXAMINATION

UNEQUAL RISE AND FALL OF THE CHEST


WOUNDS (BRUISES)
RIBCAGE INSTABILITY
DECREASED BREATH SOUNDS
BELL TYMPANISM (HYPER RESONANCE)

SIGNS & SYMPTOMS

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TACHYPNEA
TACHYCARDIA
CHEST PAIN
DYSPNEA (DIFFICULT BREATHING)
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SUSPECT A BUILDING
TENSION PNEUMOTHORAX IF

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PROGRESSIVE RESPIRATORY DISTRESS =


INCREASING DIFFICULT AND RAPID BREATHING
MECHANISM OF INJURY (open chest wound)
UNEQUAL MOVEMENT OF CHEST
SUBCUTANEOUS EMPHYSEMA
(NOT ALWAYS BUT DIAGNOSTIC)

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LATE SIGNS OF TENSION


PNEUMOTHORAX

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JUGULAR VEINS DISTENSION (JVD)


TRACHEAL DEVIATION
SHIFT OF THE PMI
CYANOSIS

15.25 h
15.10 h

DONT WAIT FOR LATE SIGNS, DECOMPRESS THE


AFFECTED SIDE IF YOU SUSPECT A TENSION PNX
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NEEDLE DECOMPRESSION FAILURES


GIVEN THE CORRECT PROCEDURE
NO TENSION PNX
WRONG SIDE
SKIN PLUG: a syringe pre-filled with
10cc NaCl connected to the 14G needle
will allow you to push it away
Flush the catheter with 1-2cc
Remove the plunger
bubbles indicate released tension
NaCl flowing inside indicates no
tension into the pleural cavity

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NEEDLE DECOMPRESSION

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NEEDLE DECOMPRESSION
EMERGENCY PROCEDURE TO RELIEVE THE TENSION
INSIDE THE PLEURAL CAVITY
AN APPROPRIATE LARGE NEEDLE IS NEEDED
(14-16 GAUGE 3.25)
IT BUYS TIME
IT IS EASY TO PERFORM
NOTE: it takes 1-2hrs for a tension PNX to develop and it
takes 9sec-2min for the pressure to be released when an
effective needle-decompression is performed
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NEEDLE DECOMPRESSION
MIDCLAVICULAR LINE

ANTERIOR AXILLARY LINE (AAL)

Lewis angle
2 INTERCOSTAL SPACE,
ABOVE THE THIRD RIB
nd

4-5th INTERCOSTAL SPACE, NIPPLE


LEVEL, ABOVE THE RIB
5th rib

6th rib

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AIR RELEASE SYSTEM (ARS)

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NEEDLE DECOMPRESSION

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NEEDLE DECOMPRESSION - HAZARDS

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MASSIVE HEMOTHORAX
COLLECTION OF LARGE VOLUMES OF
BLOOD IN PLEURAL CAVITY (EACH
PLEURAL SPACE CAN BE FILLED WITH BLOOD
UP TO 3-3.5 LITERS)

DOUBLE JEOPARDY OF BREATHING


IMPAIRMENT AND HYPOVOLEMIC
SHOCK

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SIGNS OF MASSIVE HEMOTORAX

DIFFICULT AND RAPID BREATHING

SIGNS OF HYPOVOLEMIC SHOCK

TACHYCARDIA WITH WEAK PULSE

DECREASED BREATH SOUNDS

DULL PERCUSSION SOUND ON AFFECTED SITE

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HEMOTHORAX FLUID LINE


THE AFFECTED SIDE OF THE CHEST
CAN BE ALMOST COMPLETELY
FILLED WITH BLOOD

TO ASSESS THE SEVERITY OF THE BLEEDING ON THE


FIELD IS RECOMMENDED TO DRAW A LINE THAT
FOLLOWS THE DULLNESS ON THE CHEST AND
MARK THE TIME IN
ORDER TO CHECK
THE PROGRESSION
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1300

1230
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FLAIL CHEST
MULTIPLE RIB FRACTURES
ABNORMAL MOVEMENT OF THE
FRACTURED SEGMENT WITH
REDUCTION OF VITAL CAPACITY
LIKELIHOOD OF SEVERE UNDERLYING
LUNG DAMAGE
SEVERE HYPOXIA RESULTS DUE TO
PAIN ASSOCIATED WITH INSPIRATION
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FLAIL CHEST

STABILIZE & OXYGENATE


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FLAIL CHEST

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FLAIL CHEST

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FLAIL CHEST - TREATMENT


STABILIZE
CORRECT HYPOXIA
POSITIONING
INTERCOSTAL BLOCKS
PAIN KILLERS ? DRUGS WITHOUT
SIDE EFFECTS DEPRESSING THE
RESPIRATION!

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CARDIAC TAMPONADE
COLLECTION OF FLUID IN PERICARDIUM
DUE TO PENETRATING OR BLUNT TRAUMA
POOR CARDIAC FILLING AND CONTRACTION

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CARDIAC TAMPONADE
THE MORE THE BLOOD
FILLS THE PERICARDIUM,
THE MORE THE HEART IS
COMPRESSED

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CARDIAC TAMPONADE
SIGNS & TREATMENT
SIGNS
ELEVATED VENOUS PRESSURE ( JVD)
SHOCK (CARDIOGENIC)
MUFFLED HEART SOUNDS

TREATMENT
PERICARDIOCENTESIS
(NOT TAUGHT IN THIS COURSE)

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