Thoracic Trauma
Introduction to Thoracic Injury
Vital Structures Heart, Great Vessels, Esophagus, Tracheobronchial Tree, & Lungs 25% of MVC deaths are due to thoracic trauma 12,000 annually in US Abdominal injuries are common with chest trauma. Prevention Focus Gun Control Legislation Improved motor vehicle restraint systems
Passive Airbags
Restraint Systems
Anatomy and Physiology of the Thorax
Thoracic Skeleton 12 Pair of C-shaped ribs
Sternum
Ribs 1-7: Join at sternum with cartilage end-points Ribs 8-10: Join sternum with combined cartilage at 7th rib Ribs 11-12: No anterior attachment
Manubrium
Body
Joins to clavicle and 1st rib Jugular Notch Sternal angle (Angle of Louis) Junction of the manubrium with the sternal body Attachment of 2nd rib Distal portion of sternum
Xiphoid
process
Anatomy and Physiology of the Thorax
Thoracic Skeleton Topographical Thoracic Reference Lines
Intercostal space
Midclavicular line Anterior axillary line Mid-axillary line Posterior axillary line
Thoracic Inlet
Artery, Vein and Nerve on inferior margin of each rib Superior opening of the thorax Curvature of 1st rib with associated structures Inferior opening of the thorax 12th rib and associated structures & Xiphisternal joint
Thoracic Outlet
Anatomy and Physiology of the Thorax
Diaphragm
Muscular, dome-like structure Separates abdomen from the thoracic cavity Affixed to the lower border of the rib cage Central and superior margin extends to the level of the 4th rib anteriorly and 6th rib posteriorly Major muscle of respiration
Draws
downward during inspiration Moves upward during exhalation
Anatomy and Physiology of the Thorax
Associated
Musculature
Shoulder girdle Muscles of respiration
Diaphragm
Intercostal muscles Contract to elevate the ribs and increase thoracic diameter Increase depth of respiration Sternocleidomastoid Raise upper rib and sternum
Anatomy and Physiology of the Thorax
Physiology of Respiration
Changing pressure assists:
Inhalation
Venous return to heart Pumping blood to systemic circulation Diaphragm contracts and flattens Intercostals contract expanding ribcage Thorax volume increases Less internal pressure than atmospheric Air enters lungs Musculature relaxes Diaphragm & intercostals return to normal Greater internal pressure than atmospheric Air exits lungs
Exhalation
Anatomy and Physiology of the Thorax
Trachea, Bronchi & Lungs
Trachea
Hollow & cartilage supported structure Right & left extend for 3 centimeters Enters lungs at Pulmonary Hilum Also where pulmonary arteries & veins enter Further subdivide and terminate as alveoli Basic unit of structure & function in the lungs Single cell membrane External versus Internal Respiration Right = 3 lobes Left = 2 lobes
Bronchi
Lungs
Anatomy and Physiology of the Thorax
Trachea, Bronchi & Lungs
Pleura
Visceral Parietal Pleural
Pleura Pleura
Cover lungs Lines inside of thoracic cavity
Space
Air in Space = PNEUMOTHORAX
Blood in Space = HEMOTHORAX Lubricates & permits ease of expansion
POTENTIAL SPACE
Serous (pleural) fluid within
Anatomy and Physiology of the Thorax
Mediastinum Central space within thoracic cavity Boundaries
Structures
Lateral: Lungs Inferior: Diaphragm Superior: Thoracic outlet Heart Great Vessels Esophagus Trachea Nerves Thoracic Duct
Vagus Phrenic
Anatomy and Physiology of the Thorax
Heart
Chambers Valves Vessels External Vessels
Coronary
Arteries
Contraction Cycle
Systole Diastole
Filling
of the coronary arteries occur
Anatomy and Physiology of the Thorax
Heart General Structure
Pericardium
Nervous Structure
SA Node
Right Atrium
Surrounds heart Visceral Parietal Serous 35-50 ml fluid
Intra-atrial Pathways AV Node
AV Junction
Epicardium
Bundle of His Left & Right Bundle Branches Purkinje Fibers
Outer Layer
Myocardium
Muscular layer
Endocardium
Innermost layer
Anatomy and Physiology of the Thorax
Great Vessels Aorta
Fixed at three sites Annulus Attaches to heart Ligamentum Arteriosum Near bifurcation of pulmonary artery Aortic hiatus Passes through diaphragm
Esophagus Enters at thoracic inlet Posterior to trachea Exits at esophageal hiatus
Superior Vena Cava Inferior Vena Cava Pulmonary Arteries Pulmonary Veins
Pathophysiology of Thoracic Trauma
Blunt Trauma Results from kinetic energy forces Subdivision Mechanisms
Blast
Crush (Compression) Deceleration
Pressure wave causes tissue disruption Tear blood vessels & disrupt alveolar tissue Disruption of tracheobronchial tree Traumatic diaphragm rupture
Body is compressed between an object and a hard surface Direct injury of chest wall and internal structures Body in motion strikes a fixed object Blunt trauma to chest wall Internal structures continue in motion
Age Factors
Ligamentum Arteriosum shears aorta
Pediatric Thorax: More cartilage = Absorbs forces Geriatric Thorax: Calcification & osteoporosis = More fractures
Pathophysiology of Thoracic Trauma
Penetrating Trauma
Low Energy
Arrows,
knives, handguns Injury caused by direct contact and cavitation
High Energy
Military,
hunting rifles & high powered hand guns Extensive injury due to high pressure cavitation
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Pathophysiology of Thoracic Trauma
Penetrating Injuries (cont.)
Shotgun
Injury
severity based upon the distance between the victim and shotgun & caliber of shot Type I: >7 meters from the weapon Soft tissue injury Type II: 3-7 meters from weapon Penetration into deep fascia and some internal organs Type III: <3 meters from weapon Massive tissue destruction
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Injuries Associated with Penetrating Thoracic Trauma
Closed pneumothorax Open pneumothorax (including sucking chest wound) Tension pneumothorax Pneumomediastinum Hemothorax Hemopneumothorax Laceration of vascular structures
Tracheobronchial tree lacerations Esophageal lacerations Penetrating cardiac injuries Pericardial tamponade Spinal cord injuries Diaphragm trauma Intra-abdominal penetration with associated organ injury
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Contusion
Most Common result of blunt injury Signs & Symptoms
Erythema Ecchymosis
DYSPNEA
PAIN
on breathing Limited breath sounds HYPOVENTILATION
BIGGEST CONCERN = HURTS TO BREATHE
Crepitus Paradoxical
chest wall motion
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Rib Fractures
>50% of significant chest trauma cases due to blunt trauma Compressional forces flex and fracture ribs at weakest points Ribs 1-3 requires great force to fracture
Ribs 4-9 are most commonly fractured Ribs 9-12 less likely to be fractured
Transmit Possible
underlying lung injury
Hypoventilation is COMMON due to PAIN
energy of trauma to internal organs If fractured, suspect liver and spleen injury
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Sternal Fracture & Dislocation
Direct
Associated with severe blunt anterior trauma Typical MOI
Incidence: 5-8% Mortality: 25-45%
Myocardial
Blow (i.e. Steering wheel)
Dislocation uncommon but same MOI as fracture
Tracheal
contusion Pericardial tamponade Cardiac rupture Pulmonary contusion
depression if posterior
Pathophysiology of Thoracic Trauma Chest Wall Injuries
Flail Chest
Segment of the chest that becomes free to move with the pressure changes of respiration Three or more adjacent rib fracture in two or more places Serious chest wall injury with underlying pulmonary injury
Reduces
volume of respiration Adds to increased mortality
Paradoxical flail segment movement Positive pressure ventilation can restore tidal volume
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Simple Pneumothorax
AKA: Closed Pneumothorax
Progresses into Tension Pneumothorax
Occurs when lung tissue is disrupted and air leaks into the pleural space
Progressive Pathology
Air accumulates in pleural space Lung collapses Alveoli collapse (atelectasis) Reduced oxygen and carbon dioxide exchange
Ventilation/Perfusion
Mismatch
Increased ventilation but no alveolar perfusion Reduced respiratory efficiency results in HYPOXIA
Typical MOI: Paper Bag Syndrome
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Open Pneumothorax
Free passage of air between atmosphere and pleural space Air replaces lung tissue Mediastinum shifts to uninjured side Air will be drawn through wound if wound is 2/3 diameter of the trachea or larger Signs & Symptoms
Penetrating
chest trauma Sucking chest wound Frothy blood at wound site Severe Dyspnea Hypovolemia
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Tension
Pneumothorax
Buildup of air under pressure in the thorax. Excessive pressure reduces effectiveness of respiration Air is unable to escape from inside the pleural space Progression of Simple or Open Pneumothorax
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Tension Pneumothorax Signs & Symptoms
Dyspnea Tachypnea at first Progressive ventilation/perfusion mismatch Atelectasis on uninjured side Hypoxemia Hyperinflation of injured side of chest Hyperresonance of injured side of chest
Diminished then absent breath sounds on injured side Cyanosis Diaphoresis AMS JVD Hypotension Hypovolemia Tracheal Shifting LATE SIGN
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Hemothorax
Accumulation of blood in the pleural space Serious hemorrhage may accumulate 1,500 mL of blood
Mortality
rate of 75% Each side of thorax may hold up to 3,000 mL
Blood loss in thorax causes a decrease in tidal volume
Ventilation/Perfusion
Mismatch & Shock
Typically accompanies pneumothorax
Hemopneumothorax
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Pathophysiology of Thoracic Trauma Pulmonary Injuries
Blunt
or penetrating chest trauma Shock
Dyspnea Tachycardia Tachypnea Diaphoresis Hypotension
Dull
Hemothorax Signs & Symptoms
to percussion over injured side
Pathophysiology of Thoracic Trauma Pulmonary Injuries
Pulmonary Contusion
Soft tissue contusion of the lung 30-75% of patients with significant blunt chest trauma Frequently associated with rib fracture Typical MOI
Deceleration
Chest impact on steering wheel
Bullet Cavitation
High velocity ammunition
Microhemorrhage may account for 1- 1 L of blood loss in alveolar tissue
Progressive deterioration of ventilatory status
Hemoptysis typically present
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Myocardial Contusion
Occurs in 76% of patients with severe blunt chest trauma
Right Atrium and Ventricle is commonly injured Injury may reduce strength of cardiac contractions
Reduced cardiac output
Electrical Disturbances due to irritability of damaged myocardial cells Progressive Problems
Hematoma Hemoperitoneum
Myocardial necrosis
Dysrhythmias CHF & or Cardiogenic shock
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Myocardial Contusion Signs & Symptoms
Bruising of chest wall Tachycardia and/or irregular rhythm Retrosternal pain similar to MI Associated injuries
Rib/Sternal fractures
Chest pain unrelieved by oxygen
May be relieved with rest THIS IS TRAUMA-RELATED PAIN
Similar
signs and symptoms of medical chest pain
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Pericardial Tamponade
Restriction to cardiac filling caused by blood or other fluid within the pericardium Occurs in <2% of all serious chest trauma
However,
very high mortality
Results from tear in the coronary artery or penetration of myocardium
Blood
seeps into pericardium and is unable to escape 200-300 ml of blood can restrict effectiveness of cardiac contractions
Removing as little as 20 ml can provide relief
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Pericardial Tamponade Signs & Symptoms
Dyspnea Possible cyanosis Becks Triad
JVD Distant heart tones Hypotension or narrowing pulse pressure
Weak, thready pulse Shock
Kussmauls sign Decrease or absence of JVD during inspiration Pulsus Paradoxus Drop in SBP >10 during inspiration Due to increase in CO2 during inspiration Electrical Alterans P, QRS, & T amplitude changes in every other cardiac cycle PEA
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Myocardial Aneurysm or Rupture
Occurs almost exclusively with extreme blunt thoracic trauma Secondary due to necrosis resulting from MI Signs & Symptoms
Severe
rib or sternal fracture Possible signs and symptoms of cardiac tamponade If affects valves only
Signs & symptoms of right or left heart failure
Absence
of vital signs
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Traumatic Aneurysm or Aortic Rupture
Aorta most commonly injured in severe blunt or penetrating trauma
85-95% mortality
Typically patients will survive the initial injury insult
30% mortality in 6 hrs
50% mortality in 24 hrs 70% mortality in 1 week
Injury may be confined to areas of aorta attachment
Signs & Symptoms
Rapid and deterioration of vitals Pulse deficit between right and left upper or lower extremities
Pathophysiology of Thoracic Trauma Cardiovascular Injuries
Other Vascular Injuries
Rupture or laceration
Superior Vena Cava Inferior Vena Cava General Thoracic Vasculature
Blood Localizing in Mediastinum Compression of:
Great vessels Myocardium Esophagus Penetrating Trauma Hypovolemia & Shock Hemothorax or hemomediastinum
General Signs & Symptoms
Pathophysiology of Thoracic Trauma Other Thoracic Injuries
Traumatic Esophageal Rupture
Rare complication of blunt thoracic trauma 30% mortality Contents in esophagus/stomach may move into mediastinum
Serious
Infection occurs Chemical irritation Damage to mediastinal structures Air enters mediastinum
Subcutaneous emphysema and penetrating trauma present
Pathophysiology of Thoracic Trauma Other Thoracic Injuries
Tracheobronchial Injury
MOI
Blunt trauma Penetrating trauma
50% of patients with injury die within 1 hr of injury Disruption can occur anywhere in tracheobronchial tree Signs & Symptoms
Dyspnea Cyanosis Hemoptysis Massive subcutaneous emphysema Suspect/Evaluate for other closed chest trauma
Pathophysiology of Thoracic Trauma Other Thoracic Injuries
Traumatic Asphyxia
Results from severe compressive forces applied to the thorax Causes backwards flow of blood from right side of heart into superior vena cava and the upper extremities Signs & Symptoms
Head
JVD
Skin becomes deep red, purple, or blue NOT RESPIRATORY RELATED
& Neck become engorged with blood
Hypotension,
Hypoxemia, Shock Face and tongue swollen Bulging eyes with conjunctival hemorrhage
Assessment of the Thoracic Trauma Patient
Scene Size-up Initial Assessment Rapid Trauma Assessment
Ongoing Assessment
Observe JVD, SQ Emphysema, Expansion of chest Question Palpate Auscultate Percuss Blunt Trauma Assessment Penetrating Trauma Assessment
Management of the Chest Injury Patient
General Management
Ensure ABCs
High flow O2 via NRB Intubate if indicated Consider RSI Consider overdrive ventilation
If tidal volume less than 6,000 mL BVM at a rate of 12-16
Anticipate Myocardial Compromise Shock Management
Consider PASG
May be beneficial for chest contusion and rib fractures Promotes oxygen perfusion of alveoli and prevents atelectasis
Fluid Bolus: 20 mL/kg AUSCULTATE! AUSCULATE!
Only in blunt chest trauma with SP <60 mm Hg
AUSCULATE!
Management of the Chest Injury Patient
Rib
Fractures
Consider analgesics for pain and to improve chest excursion
Versed
Morphine
Sulfate
CONTRAINDICATION
Nitrous
Oxide
May migrate into pleural or mediastinal space and worsen condition
Management of the Chest Injury Patient
Sternoclavicular Dislocation Supportive O2 therapy Evaluate for concomitant injury Flail Chest Place patient on side of injury
ONLY
Expose injury site Dress with bulky bandage against flail segment High flow O2
Consider Stabilizes
if spinal injury is NOT suspected
fracture site
DO NOT USE SANDBAGS TO STABILIZE FX
PPV or ET if decreasing respiratory status
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Management of the Chest Injury Patient
Open Pneumothorax
High flow O2 Cover site with sterile occlusive dressing taped on three sides Progressive airway management if indicated
Management of the Chest Injury Patient
Tension Pneumothorax Confirmation
Auscultaton & Percussion 2nd intercostal space in mid-clavicular line
TOP OF RIB
Pleural Decompression
Consider multiple decompression sites if patient remains symptomatic Large over the needle catheter: 14ga Create a one-wayvalve: Glove tip or Heimlich valve
Management of the Chest Injury Patient
Hemothorax
High flow O2 2 large bore IVs
Maintain
SBP of 90-100 EVALUATE BREATH SOUNDS for fluid overload
Myocardial
Alert
Contusion
Monitor ECG
for dysrhythmias
IV if antidysrhythmics are needed
Management of the Chest Injury Patient
Pericardial Tamponade
High flow O2 IV therapy Consider pericardiocentesis; rapidly deteriorating patient
Aortic Aneurysm
AVOID jarring or rough handling Initiate IV therapy enroute
Mild
hypotension may be protective Rapid fluid bolus if aneurysm ruptures
Keep patient calm
Management of the Chest Injury Patient
Tracheobronchial Injury
Support therapy
Traumatic Asphyxia
Support airway
Keep airway clear Administer high flow O2 Consider intubation if unable to maintain patient airway Observe for development of tension pneumothorax and SQ emphysema
2 large bore IVs Evaluate and treat for concomitant injuries If entrapment > 20 min with chest compression
Provide O2 PPV with BVM to assure adequate ventilation
Consider 1mEq/kg of Sodium Bicarbonate
