chest trauma management

Chest Trauma Chest Trauma ManagementManagement & &

Various Chest IncisionsVarious Chest Incisions

Dr sumer Dr sumer yadavyadav

Organs of the ThoraxOrgans of the Thorax

TracheaTrachea BronchiBronchi LungsLungs

MediastinuMediastinumm

Anatomy of chestAnatomy of chest

Chest injuries may result from:Chest injuries may result from:

Gunshot wounds (GSW)Gunshot wounds (GSW)ExplosionsExplosionsMotor vehicle crashes (MVC) Motor vehicle crashes (MVC)

FallsFallsCrush injuriesCrush injuriesStab woundsStab wounds

GeneralGeneral

Chest Trauma Chest Trauma ManagementManagement

COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

Penetrating trauma.Penetrating trauma.– GSW or stab woundsGSW or stab wounds– Concentrates forces Concentrates forces over smaller areaover smaller area

– Bullet trajectories Bullet trajectories unpredictableunpredictable

Determine the MOIDetermine the MOI

Determine the MOI cont.Determine the MOI cont.

Blunt trauma.Blunt trauma.–Force distributed over Force distributed over larger arealarger area

–Visceral injuries occur Visceral injuries occur from:from:

•DecelerationDeceleration•CompressionCompression•Sheering forcesSheering forces

Assess the CasualtyAssess the Casualty Identify signs and symptoms:Identify signs and symptoms:

Assess mental status Assess mental status (AVPU)(AVPU)

Assess the airwayAssess the airwayAssess the breathingAssess the breathingAssess the circulationAssess the circulation

Signs Indicative of Chest Signs Indicative of Chest InjuryInjury

Shock.Shock. Cyanosis.Cyanosis. HemoptysisHemoptysis

.. Chest wall Chest wall

contusion..contusion..

Flail chest.Flail chest. Open wounds.Open wounds. Jugular vein Jugular vein

distention distention (JVD).(JVD).

Tracheal Tracheal deviationdeviation

Assess RespirationsAssess Respirations

Respiratory rate and effort:Respiratory rate and effort:TachypneaTachypneaBradypneaBradypneaLaboredLaboredRetractionsRetractionsProgressive respiratory Progressive respiratory distressdistress

Assess the NeckAssess the Neck

Position of trachea.Position of trachea.

Subcutaneous Subcutaneous emphysema. emphysema.

JVP.JVP.

Assess the Chest WallAssess the Chest Wall

Contusions.Contusions. Tenderness.Tenderness. Asymmetry.Asymmetry. Open wounds or Open wounds or

impaled objects. impaled objects. Crepitation.Crepitation. Paradoxical movement.Paradoxical movement.


Lung sounds:Lung sounds:Absent or decreasedAbsent or decreased

UnilateralUnilateralBilateralBilateral

LocationLocationBowel sounds in Bowel sounds in chest? chest?


Lung sounds – Percussion.Lung sounds – Percussion.HyperresonanceHyperresonance

PneumothoraxPneumothorax

Tension pneumothoraxTension pneumothoraxHyporesonance Hyporesonance (hemothorax)(hemothorax)


Compare Compare both sides of both sides of the chest at the chest at the same the same time when time when assessing for assessing for asymmetry.asymmetry.

Chest PhysiologyChest Physiology

Chest normally has negative pressure.Chest normally has negative pressure. Penetrating wound creates a positive Penetrating wound creates a positive

pressure in chest cavity.pressure in chest cavity. Air will enter the easiest route. If a Air will enter the easiest route. If a

hole in the chest is smaller than 2/3 hole in the chest is smaller than 2/3 the size of the trachea, air will enter the size of the trachea, air will enter through the trachea preferentially and through the trachea preferentially and not through the hole in the chest. not through the hole in the chest.

Injuries of chestInjuries of chest

Rib FractureRib FractureFlail Chest Flail Chest Simple/Closed Simple/Closed Pneumothorax Pneumothorax

Open PneumothoraxOpen PneumothoraxTension PneumothoraxTension Pneumothorax

injuries of chest contd.injuries of chest contd.

HaemothoraxHaemothoraxCardiac TamponadeCardiac TamponadeTraumatic Aortic RuptureTraumatic Aortic RuptureTraumatic AsphyxiaTraumatic AsphyxiaDiaphragmatic RuptureDiaphragmatic Rupture

Rib FractureRib Fracture 11. . Most common chest wall injury from Most common chest wall injury from

direct traumadirect trauma 2.More common in adults than 2.More common in adults than

children children

3.Especially common in elderly3.Especially common in elderly 4.Most commonly 5th - 9th ribs 4.Most commonly 5th - 9th ribs

Rib FractureRib Fracture Rib Fracture Fractures of 1st and 2nd Rib Fracture Fractures of 1st and 2nd

second require high force second require high force Frequently have injury to aorta or Frequently have injury to aorta or

bronchi bronchi Occur in 90% of patients with Occur in 90% of patients with

tracheobronchial rupture tracheobronchial rupture

May injure subclavian artery/vein May injure subclavian artery/vein

May result in pneumothorax May result in pneumothorax

Rib FractureRib Fracture

Rib Fracture Fractures of 10 to 12th Rib Fracture Fractures of 10 to 12th ribs can cause damage to underlying ribs can cause damage to underlying abdominal solid organs:- abdominal solid organs:-

1 Liver 1 Liver 2.Spleen 2.Spleen 3.Kidneys 3.Kidneys

Rib FractureRib Fracture Assessment Findings:- Assessment Findings:- 1.Localized pain, tenderness 1.Localized pain, tenderness

2.Increases on palpation or when patient: 2.Increases on palpation or when patient: Coughs ,Moves , Breathes deeply Coughs ,Moves , Breathes deeply

3.Splinted Respirations 3.Splinted Respirations 4.Instability in chest wall 4.Instability in chest wall 5.Crepitus 5.Crepitus 6.Associated pneumo or hemothorax 6.Associated pneumo or hemothorax

Rib FractureRib Fracture ManagementManagement

High concentration O2 High concentration O2

Positive pressure ventilation Positive pressure ventilation

Encourage pt to breath deeply Encourage pt to breath deeply Analgesics for isolated trauma Analgesics for isolated trauma Non-circumferential splinting Non-circumferential splinting

Flail ChestFlail Chest

The breaking of The breaking of 2 2

or more ribs or more ribs in 2 in 2

or more or more placesplaces

Flail ChestFlail Chest

S/S of Flail ChestS/S of Flail Chest

Shortness of Breath Shortness of Breath Paradoxical MovementParadoxical Movement Bruising/Swelling Bruising/Swelling Crepitus( Grinding of bone Crepitus( Grinding of bone

ends on palpationends on palpation

Treatment of Flail ChestTreatment of Flail Chest ABC’s with c-spine control as ABC’s with c-spine control as

indicatedindicated High Flow oxygen High Flow oxygen Monitor Patient for signs of Monitor Patient for signs of

Pneumothorax or Tension Pneumothorax or Tension PneumothoraxPneumothorax

Use Gloved hand as splint till bulky Use Gloved hand as splint till bulky dressing can be put on patientdressing can be put on patient

Bulky Dressing for splint of Bulky Dressing for splint of Flail ChestFlail Chest

Use Trauma Use Trauma bandage and bandage and Triangular Triangular Bandages to splint Bandages to splint ribs.ribs.

Simple/Closed Simple/Closed PneumothoraxPneumothorax

Opening in lung Opening in lung tissue that leaks tissue that leaks air into chest air into chest cavitycavity

Blunt trauma is Blunt trauma is main cause main cause

May be May be spontaneousspontaneous

Usually self Usually self correctingcorrecting

S/S of Simple/Closed S/S of Simple/Closed PneumothoraxPneumothorax

Chest Pain Chest Pain DyspneaDyspneaTachypneaTachypneaDecreased Breath Sounds Decreased Breath Sounds

on Affected Sideon Affected Side

Treatment for Treatment for Simple/Closed Simple/Closed PneumothoraxPneumothorax

ABC’s with C-spine controlABC’s with C-spine controlAirway Assistance as neededAirway Assistance as neededIf not contraindicated If not contraindicated transport in semi-sitting transport in semi-sitting positionposition

Provide supportive careProvide supportive care

Open PneumothoraxOpen Pneumothorax

Opening in chest Opening in chest cavity that allows cavity that allows air to enter air to enter pleural cavitypleural cavity

Causes the lung to Causes the lung to collapse due to collapse due to increased increased pressure in pressure in pleural cavitypleural cavity

Open PneumothoraxOpen PneumothoraxInhale

Open PneumothoraxOpen PneumothoraxExhale

Open PneumothoraxOpen PneumothoraxInhale

Open PnuemothoraxOpen PnuemothoraxInhale

S/S of Open S/S of Open PneumothoraxPneumothorax

DyspneaDyspneaSudden sharp painSudden sharp painSubcutaneous EmphysemaSubcutaneous EmphysemaDecreased lung sounds on Decreased lung sounds on

affected sideaffected sideRed Bubbles on Exhalation Red Bubbles on Exhalation

from woundfrom wound

Subcutaneous Subcutaneous EmphysemaEmphysema

Air collects in subcutaneous Air collects in subcutaneous fat from pressure of air in fat from pressure of air in pleural cavitypleural cavity

Feels like rice crispies or Feels like rice crispies or bubble wrapbubble wrap

Can be seen from neck to Can be seen from neck to groin area groin area

Sucking Chest WoundSucking Chest Wound

Open PneumothoraxOpen Pneumothorax Management:Management:

Ensure an open airwayEnsure an open airway

Close the chest wall defect, both Close the chest wall defect, both

entrance and exit with an occlusive entrance and exit with an occlusive

dressing, petrolatum gauze or dressing, petrolatum gauze or

Asherman Chest SealAsherman Chest Seal®®

Place the casualty in the sitting Place the casualty in the sitting

positionposition

Monitor respirations after an Monitor respirations after an

occlusive dressing is appliedocclusive dressing is applied

Open PneumothoraxOpen Pneumothorax Petroleum Gauze can also be used to seal Petroleum Gauze can also be used to seal a sucking chest wound.a sucking chest wound.

"Asherman Chest Seal"Asherman Chest Seal""

Tension PneumothoraxTension Pneumothorax

Air builds in pleural space Air builds in pleural space with no where for the air to with no where for the air to escapeescape

Results in collapse of lung on Results in collapse of lung on affected side that results in affected side that results in pressure on mediastium,the pressure on mediastium,the other lung, and great vesselsother lung, and great vessels

Tension PneumothoraxTension PneumothoraxEach time we inhale,

the lung collapses further. Thereis no place for the air to

escape..


Heart is beingcompressed

The trachea ispushed to

the good side

S/S of Tension S/S of Tension PneumothoraxPneumothorax

Anxiety/RestlessnessAnxiety/RestlessnessSevere DyspneaSevere DyspneaAbsent Breath sounds on Absent Breath sounds on

affected sideaffected sideTachypneaTachypneaTachycardiaTachycardiaPoor ColorPoor Color

S/S of Tension S/S of Tension Pneumothorax cont.Pneumothorax cont.

Accessory Muscle UseAccessory Muscle Use JVDJVDNarrowing Pulse PressuresNarrowing Pulse PressuresHypotensionHypotensionTracheal DeviationTracheal Deviation

(late if seen at all)(late if seen at all)


Air pushes over heart and collapses lung

Heart compressed not able to pump well

Air outside lung from wound


Heart is beingcompressed

The trachea ispushed to

the good side


Management:Management:Ensure an open airwayEnsure an open airwayDecompress the affected sideDecompress the affected side

Indications:Indications:– Penetrating chest wound with Penetrating chest wound with progressive respiratory progressive respiratory distressdistress

Needle Chest Needle Chest DecompressionDecompression

Procedure:Procedure: Identify the second ICS on Identify the second ICS on the anterior chest wall, the anterior chest wall, MCL:MCL:


If a tension pneumothorax is If a tension pneumothorax is present, a" hiss present, a" hiss of air” may be heard of air” may be heard escaping from the escaping from the chest cavity.chest cavity.

Remove the needle, leave Remove the needle, leave the catheter in place.the catheter in place.


Insert a 14 ga. Catheter Insert a 14 ga. Catheter at at a 90 a 90 angle over the angle over the top of top of the 3 the 3rdrd rib, into the rib, into the 22ndnd ICS ICS at the MCL. at the MCL.

Needle should be long Needle should be long enough to enter the enough to enter the chest chest cavity (2 cavity (2½½ – 3 inches). – 3 inches).

HemothoraxHemothoraxOccurs when pleural space Occurs when pleural space

fills with blood .Usually fills with blood .Usually occurs due to lacerated blood occurs due to lacerated blood vessel in thoraxvessel in thorax

As blood increases, it puts As blood increases, it puts pressure on heart and other pressure on heart and other vessels in chest cavityvessels in chest cavity

Each Lung can hold 1.5 liters Each Lung can hold 1.5 liters of bloodof blood

HemothoraxHemothorax


May put pressure on the heart


Lots of blood vessels

Where does the blood come from.

S/S of HemothoraxS/S of Hemothorax

Anxiety/RestlessnessAnxiety/RestlessnessTachypneaTachypneaSigns of ShockSigns of ShockFrothy, Bloody SputumFrothy, Bloody SputumDiminished Breath Sounds Diminished Breath Sounds

on Affected Sideon Affected SideTachycardiaTachycardia

Treatment of Treatment of HaemothoraxHaemothorax

Establish airway High Establish airway High concentration O2concentration O2

Drainage by chest Drainage by chest tube tube

ThoracotomyThoracotomy

Chest Drainage tube Chest Drainage tube IndicationsIndications

Traumatic haemothoraxTraumatic haemothoraxTraumatic Traumatic pneumothoraxpneumothorax

Drainage of empyemaDrainage of empyemaFollowing thoracotomy Following thoracotomy

Chest Drainage tubeChest Drainage tube

Complications of Chest Complications of Chest Drainage tubeDrainage tube

HemorrhageHemorrhageDamage to intercostal Damage to intercostal vessels and nervesvessels and nerves

Lung and mediastinal Lung and mediastinal injuryinjury

Infection Infection

Indications of Indications of thoracotomythoracotomy

In pneumothoraxIn pneumothorax

1.continuing air leak for 1.continuing air leak for more than 7 daysmore than 7 days

2.massive air leak suggesting 2.massive air leak suggesting major air -way injurymajor air -way injury

3.associated lung contusions3.associated lung contusions

Indications of Indications of thoracotomythoracotomyIn haemothoraxIn haemothorax

1. massive bleeding more 1. massive bleeding more than 1 Ltr.statthan 1 Ltr.stat

2. continuing bleeding 2. continuing bleeding more than 200 Ml/hr over 3 more than 200 Ml/hr over 3 hrshrs

3.brisk bleeding more than 3.brisk bleeding more than 100 Ml every 15 min for 1 100 Ml every 15 min for 1 hrhr

Pericardial TamponadePericardial Tamponade Blood and fluids Blood and fluids

leak into the leak into the pericardial sac pericardial sac which surrounds which surrounds the heart.the heart.

As the pericardial As the pericardial sac fills, it causes sac fills, it causes the sac to expand the sac to expand until it cannot until it cannot expand anymoreexpand anymore

pericardial sac

Pericardial TamponadePericardial Tamponade Once the Once the

pericardial sac pericardial sac can’t expand can’t expand anymore, the anymore, the fluid starts fluid starts putting pressure putting pressure on the hearton the heart

Now the heart Now the heart can’t fully can’t fully expand and expand and can’t pump can’t pump effectively. effectively.

S/S of Pericardial S/S of Pericardial TamponadeTamponadeDistended Neck VeinsDistended Neck Veins

Increased Heart RateIncreased Heart RateRespiratory Rate increasesRespiratory Rate increasesPoor skin colorPoor skin colorNarrowing Pulse PressuresNarrowing Pulse PressuresHypotensionHypotension DeathDeath

Pericardial Tamponade Pericardial Tamponade ManagementManagement

Secure airway Secure airway High concentration O2High concentration O2 Definite treatment is Definite treatment is

pericardiocentesis followed pericardiocentesis followed by surgery by surgery

PericardiocentesisPericardiocentesis Using aseptic technique, Insert at Using aseptic technique, Insert at

least 3” needle at the angle of the least 3” needle at the angle of the Xiphoid Cartilage at the 7Xiphoid Cartilage at the 7thth rib rib

Advance needle at 45 degree Advance needle at 45 degree towards the clavicle while towards the clavicle while aspirating syringe till blood return aspirating syringe till blood return is seenis seen

Continue to Aspirate till syringe is Continue to Aspirate till syringe is full then discard blood and attempt full then discard blood and attempt again till signs of no more bloodagain till signs of no more blood

Traumatic Aortic Traumatic Aortic RuptureRupture

The heart, more or less, justhangs from the aortic archMuch like a big pendulum.

If enough motion is placed onthe heart (i.e.. DecelerationFrom a motor vehicle accident, striking a tree while skiing etc) the heart may tear away from the aorta.

Traumatic Aortic Traumatic Aortic RuptureRupture

The chances of survival arevery slim and are based on thedegree of the tear.

If there is just a small tear thenthe patient may survive. If theaorta is completely transectedthen the patient will die instantaneously

S/S Of Traumatic Aortic S/S Of Traumatic Aortic RuptureRupture

Burning or Tearing Sensation in Burning or Tearing Sensation in chest or shoulder bladeschest or shoulder blades

Rapidly dropping Blood PressureRapidly dropping Blood PressurePulse Rapidly IncreasingPulse Rapidly IncreasingDecreased or loss of pulse or b/p Decreased or loss of pulse or b/p

on left side compared to right on left side compared to right sideside

Rapid Loss of ConsciousnessRapid Loss of Consciousness

Treatment of Traumatic Treatment of Traumatic Aortic RuptureAortic Rupture

ABC’s with c-spine control as ABC’s with c-spine control as indicatedindicated

High Flow oxygenHigh Flow oxygenTreatment for ShockTreatment for ShockRAPID TRANSPORTRAPID TRANSPORTContact Hospital and ALS Unit Contact Hospital and ALS Unit

As soon as possibleAs soon as possible

Traumatic AsphyxiaTraumatic AsphyxiaResults from sudden Results from sudden compression injury to compression injury to chest cavitychest cavity

Can cause massive Can cause massive rupture of Vessels and rupture of Vessels and organs of chest cavityorgans of chest cavity

Ultimately DeathUltimately Death

S/S of Traumatic S/S of Traumatic AsphyxiaAsphyxia

Severe DyspneaSevere DyspneaDistended Neck VeinsDistended Neck VeinsBulging, Blood shot eyesBulging, Blood shot eyesSwollen Tounge with cyanotic Swollen Tounge with cyanotic

lipslipsReddish-purple discoloration of Reddish-purple discoloration of

face and neckface and neckPetechiaePetechiae

Treatment for Traumatic Treatment for Traumatic AsphyxiaAsphyxia

ABC’s with c-spine control ABC’s with c-spine control as indicatedas indicated

High Flow oxygenHigh Flow oxygenTreat for shockTreat for shockCare for associated Care for associated injuriesinjuries

Diaphragmatic RuptureDiaphragmatic RuptureA tear in the Diaphragm that A tear in the Diaphragm that

allows the abdominal organs allows the abdominal organs enter the chest cavityenter the chest cavity

More common on Left side More common on Left side due to liver helps protect the due to liver helps protect the right side of diaphragm right side of diaphragm

Associated with multiple Associated with multiple injury patientsinjury patients

Diaphragm RuptureDiaphragm Rupture

S/S of Diaphragmatic S/S of Diaphragmatic RuptureRupture

Abdominal PainAbdominal PainShortness of AirShortness of AirDecreased Breath Sounds Decreased Breath Sounds on side of ruptureon side of rupture

Bowel Sounds heard in Bowel Sounds heard in chest cavitychest cavity

Treatment of Treatment of Diaphragmatic RuptureDiaphragmatic Rupture

ABC’s with c-spine control ABC’s with c-spine control as indicatedas indicated

High Flow oxygen High Flow oxygen Treat Associated InjuriesTreat Associated InjuriesDefinitive treatment is Definitive treatment is surgerysurgery

Various chest incisionsVarious chest incisions

Commonly used chest incisionsCommonly used chest incisions

1.Median sternotomy1.Median sternotomy

2.posterolateral thoracotomy2.posterolateral thoracotomy

3.Anterior thoracotomy3.Anterior thoracotomy

4.thoracoabdominal4.thoracoabdominal

Indications of Indications of mmedian edian sternotomysternotomy

Surgery forSurgery for

1.thymus1.thymus

2.heart and great 2.heart and great vesselsvessels

3.both pleural sac3.both pleural sac

mmedian sternotomyedian sternotomy

Posterolateral Posterolateral thoracotomythoracotomy

An incision is made in An incision is made in the bed of the 5th rib the bed of the 5th rib (5th intercostals space). (5th intercostals space).

Used mainly for hilum Used mainly for hilum and lung surgery and lung surgery eg.pneumonectomyeg.pneumonectomy

Posterolateral Posterolateral thoracotomythoracotomy

ThoracoabdomiThoracoabdominalnal

Used in surgery of lower Used in surgery of lower oesophagus,gastric oesophagus,gastric cardia ,stomach,pancreacardia ,stomach,pancreas,diaphragms,diaphragm

chest trauma management

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