Thoracic Trauma

Bisatyo Mardjikoen Universitas Islam Negeri Syarif Hidayatullah Fakultas Kedokteran & Ilmu Kesehatan Program Studi Ilmu Kedokteran

Chest Trauma


Second leading cause of trauma deaths after head injury About 20% of all trauma deaths

Anatomy

Type of Chest Injuries



Penetrating


the forces are distributed over a small area

Blunt
the forces are distributed over a larger area  occur from compression or shearing force


Assessment


Signs and symptoms of chest trauma:



Shortness of breath

 Tachypnea

Chest pain

Chest Injuries: Physical Examination



LOOK : bruises, lacerations, distended neck veins,tracheal deviation, open chest wounds, lack of symmetrical chest rise, paradoxical chest movement, cyanosis
.

FEEL : tenderness, bony crepitus, subcutaneous emphysema and an unstable chest wall segment LISTEN : presence or absence of breath sounds, and bilateral symmetry of air movement
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Chest Trauma


Initial exam directed toward:

Open pneumothorax  Flail chest  Tension pneumothorax  Massive hemothorax  Cardiac tamponade


Rib Fracture
   

Most common chest injury More common in adults than children Especially common in elderly Ribs form rings


Consider possibility of break in two places

Rib Fracture
  

Most commonly 5th to 9th ribs Poor protection Associated injuries:

pulmonary contusion  laceration of the intercostals artery an/or vein with resulting hemothorax & pneumothorax


Rib Fracture
  

Fractures of 1st, 2nd ribs require high force Frequently have injury to aorta or bronchi 30% will die

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Rib Fracture


Fractures of 8th to 12th ribs can damage underlying abdominal solid organs:  Liver  Spleen  Kidneys

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Rib Fracture


Signs and Symptoms

Localized pain, tenderness  Increases when patient:  Coughs  Moves  Breathes deeply  Chest wall instability  Associated pneumo or hemothorax


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Rib Fracture


Management
Oxygenation, if necessary  Encourage patient to breath deeply


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Flail Chest


  

Two or more adjacent ribs broken in two or more places Produces freefree-floating chest wall segment Usually secondary to blunt trauma More common in older patients

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Flail Chest


Signs and Symptoms



Paradoxical movement  May NOT be present initially due to intercostal muscle spasms  Be suspicious in any patient with chest wall:  Tenderness  Crepitus

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Flail Chest


Consequences
Pain, leading to decreased ventilation  Increased work of breathing  Contusion of lung


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Flail Chest


Management
Establish airway  Suspect spinal injuries  Oxygenation


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Simple Pneumothorax
Air in pleural space  Partial or complete lung collapse occurs


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Simple Pneumothorax


Causes
Chest wall penetration  Fractured rib lacerating lung  Paper bag effect  May occur spontaneously following:  Exertion  Coughing  Air Travel

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Simple Pneumothorax


Signs and Symptoms

Pain on inhalation  Difficulty breathing  Tachypnea  Decreased or absent breath sounds


Severity of symptoms depends on size of pneumothorax, speed of lung collapse, and patients health status
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Simple Pneumothorax


Management
Establish airway  Suspect spinal injury based on mechanism  High concentration O2  Monitor for tension pneumothorax


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Open Pneumothorax
  

Hole in chest wall Allows air to enter pleural space Larger hole = Greater chance air will enter there than through trachea

Sucking Chest Wound

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Sucking Chest Wound: First Aid

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Open Pneumothorax


Management
Close hole with occlusive dressing  High concentration O2  Assist ventilations  Consider transport on injured side  Monitor for tension pneumothorax


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Tension Pneumothorax
    

Onene-way valve forms in lung or chest wall Air enters pleural space; cannot leave Air is trapped in pleural space Pressure rises Pressure collapses lung

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Tension Pneumothorax


  

Trapped air pushes heart, lungs away from injured side Vena cavae become kinked Blood cannot return to heart Cardiac output falls

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Tension Pneumothorax


Signs and Symptoms

 

 

 

Extreme dyspnea Restlessness, anxiety, agitation Decreased breath sounds Hyperresonance to percussion Cyanosis Subcutaneous emphysema

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Tension Pneumothorax


Signs and Symptoms

Rapid, weak pulse  Decreased BP  Tracheal shift away from injured side  Jugular vein distension


Early dyspnea/hypoxia - Late shock

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Tension Pneumothorax


Management
Secure airway  High concentration O2  If available, request ALS intercept for pleural decompression


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Hemothorax
  

Blood in pleural space Most common result of major chest wall trauma Present in 70 to 80% of penetrating, major nonnonpenetrating chest trauma

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Hemothorax


Signs and Symptoms

      

Rapid, weak pulse Cool, clammy skin Restlessness, anxiety Thirst Chills Hypotension Collapsed neck veins

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Hemothorax


Signs and Symptoms

Decreased breath sounds  Dullness to percussion  Dyspnea  Ventilatory failure


Shock precedes ventilatory failure

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Hemothorax


Management
Secure airway  Assist breathing with high concentration O2  Rapid transport


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Traumatic Asphyxia


Blunt force to chest causes

Increased intrathoracic pressure  Backward flow of blood out of heart into vessels of upper chest, neck, head


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Traumatic Asphyxia


Signs and Symptoms

  

 

Possible sternal fracture or central flail chest Shock PurplishPurplish -red discoloration of:  Head  Neck  Shoulders Blood shot, protruding eyes Swollen, cyanotic lips
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Traumatic Asphyxia

Name given because patients looked like they had been strangled or hanged

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Traumatic Asphyxia


Management
Airway with CC-spine control  Assist ventilations with high concentration O2  Spinal stabilization  Rapid transport


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Cardiovascular Trauma
Any patient with significant blunt or penetrating trauma to chest has heart/great vessel injury until proven otherwise

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Myocardial Contusion
  

Bruise of heart muscle Most common blunt cardiac injury Usually due to steering wheel impact

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Myocardial Contusion


Behaves like acute MI

 May

produce arrhythmias  May cause cardiogenic shock, hypotension

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Myocardial Contusion


Signs and Symptoms

Cardiac arrhythmias after blunt chest trauma  Angina Angina-like pain unresponsive to nitroglycerin  Chest pain independent of respiratory movement


Suspect in all blunt chest trauma

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Myocardial Contusion


Management
High concentration O2  Transport  Consider ALS intercept


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Cardiac Tamponade


  

Rapid accumulation of blood in space between heart, pericardium Heart compressed Blood entering heart decreases Cardiac output falls

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Cardiac Tamponade

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Cardiac Tamponade


Signs and Symptoms

Hypotension unresponsive to treatment  Increased central venous pressure (distended neck/arm veins in presence of decreased arterial BP)  Small quiet heart (decreased heart sounds)


Becks Triad
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Cardiac Tamponade


Signs and Symptoms

Narrowing pulse pressure  Pulsus paradoxicus



Radial pulse becomes weak or disappears when patient inhales

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Cardiac Tamponade


Management
Secure airway  High concentration O2  Rapid transport  Definitive treatment is pericardiocentesis followed by surgery


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Traumatic Aortic Aneurysm



Caused by sudden decelerations, massive blunt force:

Vehicle collisions  Falls from heights  Crushing chest trauma  Blunt chest trauma  Animal kicks


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Traumatic Aortic Aneurysm



Rupture usually occurs just beyond left subclavian artery Attachment of aorta to pulmonary artery at this point produces shearing force on aortic arch

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Traumatic Aortic Aneurysm



Signs and Symptoms

Increased BP in arms in absence of head injury  Decreased femoral pulses with full arm pulses  Respiratory distress  Ache in chest, shoulders, lower back, abdomen. (Only 25% of patients)


Detection requires high index of suspicion

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Traumatic Aortic Aneurysm



Management


  

High concentration oxygen Assist ventilation Suspect spinal injury Rapid transport

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Associated Abdominal Trauma



Diaphragm forms dome that extends up into rib cage Trauma to chest below 4th rib = Abdominal injury until proven otherwise

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