chest trauma management

chest trauma

1. Chest Trauma ManagementChest Trauma Management
& &
Various Chest IncisionsVarious Chest Incisions
Dr sumer yadavDr sumer yadav

2. Organs of the ThoraxOrgans of the Thorax
TracheaTrachea
BronchiBronchi
LungsLungs
MediastinumMediastinum

3. Anatomy of chestAnatomy of chest

4. Chest injuries may result from:Chest injuries may result from:
Gunshot wounds (GSW)Gunshot wounds (GSW)
ExplosionsExplosions
Motor vehicle crashes (MVC) Motor vehicle crashes (MVC)
FallsFalls
Crush injuriesCrush injuries
Stab woundsStab wounds
GeneralGeneral

5. Chest Trauma Chest Trauma
ManagementManagement
COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

6. Penetrating trauma.Penetrating trauma.
–GSW or stab woundsGSW or stab wounds
–Concentrates forces over Concentrates forces over
smaller areasmaller area
–Bullet trajectories Bullet trajectories
unpredictableunpredictable
Determine the MOIDetermine the MOI

7. Determine the MOI cont.Determine the MOI cont.
Blunt trauma.Blunt trauma.
–Force distributed over larger Force distributed over larger
areaarea
–Visceral injuries occur from:Visceral injuries occur from:
•DecelerationDeceleration
•CompressionCompression
•Sheering forcesSheering forces

8. Assess the CasualtyAssess the Casualty
Identify signs and symptoms:Identify signs and symptoms:
Assess mental status (AVPU)Assess mental status (AVPU)
Assess the airwayAssess the airway
Assess the breathingAssess the breathing
Assess the circulationAssess the circulation

9. Signs Indicative of Chest InjurySigns Indicative of Chest Injury
Shock.Shock.
Cyanosis.Cyanosis.
Hemoptysis.Hemoptysis.
Chest wall Chest wall
contusion..contusion..
Flail chest.Flail chest.
Open wounds.Open wounds.
Jugular vein Jugular vein
distention (JVD).distention (JVD).
Tracheal Tracheal
deviationdeviation

10. Assess RespirationsAssess Respirations
Respiratory rate and effort:Respiratory rate and effort:
TachypneaTachypnea
BradypneaBradypnea
LaboredLabored
RetractionsRetractions
Progressive respiratory distressProgressive respiratory distress

11. Assess the NeckAssess the Neck
Position of trachea.Position of trachea.
Subcutaneous Subcutaneous
emphysema.emphysema.

JVP.JVP.

12. 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.

13. Assess the Chest WallAssess the Chest Wall
Lung sounds:Lung sounds:
Absent or decreasedAbsent or decreased
UnilateralUnilateral
BilateralBilateral
LocationLocation
Bowel sounds in Bowel sounds in
chest? chest?

14. Assess the Chest WallAssess the Chest Wall
Lung sounds – Percussion.Lung sounds – Percussion.
HyperresonanceHyperresonance
PneumothoraxPneumothorax
Tension pneumothoraxTension pneumothorax
Hyporesonance (hemothorax)Hyporesonance (hemothorax)

15. Assess the Chest WallAssess the Chest Wall
Compare both Compare both
sides of the sides of the
chest at the chest at the
same time when same time when
assessing for assessing for
asymmetry.asymmetry.

16. 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.

17. Injuries of chestInjuries of chest
Rib FractureRib Fracture
Flail Chest Flail Chest
Simple/Closed Pneumothorax Simple/Closed Pneumothorax
Open PneumothoraxOpen Pneumothorax
Tension PneumothoraxTension Pneumothorax

18. injuries of chest contd.injuries of chest contd.
HaemothoraxHaemothorax
Cardiac TamponadeCardiac Tamponade
Traumatic Aortic RuptureTraumatic Aortic Rupture
Traumatic AsphyxiaTraumatic Asphyxia
Diaphragmatic RuptureDiaphragmatic Rupture

19. 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

20. 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

21. 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

22. Rib FractureRib Fracture
Assessment Findings:- Assessment Findings:-

1.Localized pain, tenderness 1.Localized pain, tenderness

2.Increases on palpation or when 2.Increases on palpation or when
patient: 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

23. Rib FractureRib Fracture Management Management

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

24. Flail ChestFlail Chest
The breaking of 2 The breaking of 2
or more ribs in 2 or more ribs in 2
or more placesor more places

25. Flail ChestFlail Chest

26. 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 ends on Crepitus( Grinding of bone ends on
palpationpalpation

27. 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

28. Bulky Dressing for splint of Flail Bulky Dressing for splint of Flail
ChestChest
Use Trauma bandage Use Trauma bandage
and Triangular and Triangular
Bandages to splint ribs.Bandages to splint ribs.

29. Simple/Closed PneumothoraxSimple/Closed Pneumothorax
Opening in lung Opening in lung
tissue that leaks air tissue that leaks air
into chest cavityinto chest cavity
Blunt trauma is Blunt trauma is
main cause main cause
May be May be
spontaneousspontaneous
Usually self Usually self
correctingcorrecting

30. S/S of Simple/Closed PneumothoraxS/S of Simple/Closed Pneumothorax
Chest Pain Chest Pain
DyspneaDyspnea
TachypneaTachypnea
Decreased Breath Sounds on Decreased Breath Sounds on
Affected SideAffected Side

31. Treatment for Simple/Closed Treatment for Simple/Closed
PneumothoraxPneumothorax
ABC’s with C-spine controlABC’s with C-spine control
Airway Assistance as neededAirway Assistance as needed
If not contraindicated transport If not contraindicated transport
in semi-sitting positionin semi-sitting position
Provide supportive careProvide supportive care

32. Open PneumothoraxOpen Pneumothorax
Opening in chest Opening in chest
cavity that allows cavity that allows
air to enter pleural air to enter pleural
cavitycavity
Causes the lung to Causes the lung to
collapse due to collapse due to
increased pressure increased pressure
in pleural cavityin pleural cavity

33. Open PneumothoraxOpen Pneumothorax

34. Open PneumothoraxOpen Pneumothorax
Inhale

35. Open PneumothoraxOpen Pneumothorax
Exhale

36. Open PneumothoraxOpen Pneumothorax
Inhale

37. Open PnuemothoraxOpen Pnuemothorax
Inhale

38. S/S of Open PneumothoraxS/S of Open Pneumothorax
DyspneaDyspnea
Sudden sharp painSudden sharp pain
Subcutaneous EmphysemaSubcutaneous Emphysema
Decreased lung sounds on affected Decreased lung sounds on affected
sideside
Red Bubbles on Exhalation from Red Bubbles on Exhalation from
woundwound

39. Subcutaneous EmphysemaSubcutaneous Emphysema
Air collects in subcutaneous fat Air collects in subcutaneous fat
from pressure of air in pleural from pressure of air in pleural
cavitycavity
Feels like rice crispies or bubble Feels like rice crispies or bubble
wrapwrap
Can be seen from neck to groin Can be seen from neck to groin
area area

40. Open PneumothoraxOpen Pneumothorax

41. Sucking Chest WoundSucking Chest Wound

42. 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 Asherman dressing, petrolatum gauze or Asherman
Chest SealChest Seal
®®
Place the casualty in the sitting positionPlace the casualty in the sitting position
Monitor respirations after an occlusive Monitor respirations after an occlusive
dressing is applieddressing is applied

43. 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.

44. "Asherman Chest Seal"Asherman Chest Sealââ""

45. Tension PneumothoraxTension Pneumothorax
Air builds in pleural space with Air builds in pleural space with
no where for the air to escapeno where for the air to escape
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

46. Tension PneumothoraxTension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

47. Tension PneumothoraxTension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

48. Tension PneumothoraxTension Pneumothorax
Heart is being
compressed
The trachea is
pushed to
the good side

49. S/S of Tension PneumothoraxS/S of Tension Pneumothorax
Anxiety/RestlessnessAnxiety/Restlessness
Severe DyspneaSevere Dyspnea
Absent Breath sounds on affected Absent Breath sounds on affected
sideside
TachypneaTachypnea
TachycardiaTachycardia
Poor ColorPoor Color

50. S/S of Tension Pneumothorax cont.S/S of Tension Pneumothorax cont.
Accessory Muscle UseAccessory Muscle Use
JVDJVD
Narrowing Pulse PressuresNarrowing Pulse Pressures
HypotensionHypotension
Tracheal DeviationTracheal Deviation
(late if seen at all)(late if seen at all)

51. Tension PneumothoraxTension Pneumothorax
Air pushes over heart
and collapses lung
Heart compressed not able
to pump well
Air
outside
lung from
wound

52. Tension PneumothoraxTension Pneumothorax
Heart is being
compressed
The trachea is
pushed to
the good side

53. Tension PneumothoraxTension Pneumothorax
Management:Management:
Ensure an open airwayEnsure an open airway
Decompress the affected sideDecompress the affected side
Indications:Indications:
–Penetrating chest wound with Penetrating chest wound with
progressive respiratory distressprogressive respiratory distress

54. Needle Chest DecompressionNeedle Chest Decompression
Procedure:Procedure:
Identify the second ICS on the Identify the second ICS on the
anterior chest wall, MCL:anterior chest wall, MCL:

55. Needle Chest DecompressionNeedle Chest Decompression
If a tension pneumothorax is present, If a tension pneumothorax is present,
a" hiss of air” may be a" hiss of air” may be
heard escaping from the heard escaping from the
chest cavity.chest cavity.
Remove the needle, leave the catheter Remove the needle, leave the catheter
in place.in place.

56. Needle Chest DecompressionNeedle Chest Decompression
Insert a 14 ga. Catheter at Insert a 14 ga. Catheter at
a a
9090°° angle over the top angle over the top
of of
the 3the 3
rdrd
rib, into the 2 rib, into the 2
ndnd
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).

57. HemothoraxHemothorax
Occurs when pleural space fills Occurs when pleural space fills
with blood .Usually occurs due to with blood .Usually occurs due to
lacerated blood vessel in thoraxlacerated blood vessel in thorax
As blood increases, it puts pressure As blood increases, it puts pressure
on heart and other vessels in chest on heart and other vessels in chest
cavitycavity
Each Lung can hold 1.5 liters of Each Lung can hold 1.5 liters of
bloodblood

58. HemothoraxHemothorax

59. HemothoraxHemothorax

60. HemothoraxHemothorax
May put pressure on the heart

61. HemothoraxHemothorax
Lots of blood vessels
Where does the blood come
from.

62. S/S of HemothoraxS/S of Hemothorax
Anxiety/RestlessnessAnxiety/Restlessness
TachypneaTachypnea
Signs of ShockSigns of Shock
Frothy, Bloody SputumFrothy, Bloody Sputum
Diminished Breath Sounds on Diminished Breath Sounds on
Affected SideAffected Side
TachycardiaTachycardia

63. Treatment of HaemothoraxTreatment of Haemothorax
Establish airway High Establish airway High
concentration O2concentration O2
Drainage by chest tube Drainage by chest tube
ThoracotomyThoracotomy

64. Chest Drainage tube IndicationsChest Drainage tube Indications
Traumatic haemothoraxTraumatic haemothorax
Traumatic pneumothoraxTraumatic pneumothorax
Drainage of empyemaDrainage of empyema
Following thoracotomy Following thoracotomy

65. Chest Drainage tubeChest Drainage tube

66. Complications of Chest Drainage Complications of Chest Drainage
tubetube
HemorrhageHemorrhage
Damage to intercostal vessels Damage to intercostal vessels
and nervesand nerves
Lung and mediastinal injuryLung and mediastinal injury
Infection Infection

67. Indications of thoracotomyIndications of thoracotomy
In pneumothoraxIn pneumothorax
1.continuing air leak for more 1.continuing air leak for more
than 7 daysthan 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

68. Indications of thoracotomyIndications of thoracotomy
In haemothoraxIn haemothorax
1. massive bleeding more than 1 1. massive bleeding more than 1
Ltr.stat Ltr.stat
2. continuing bleeding more 2. continuing bleeding more
than 200 Ml/hr over 3 hrsthan 200 Ml/hr over 3 hrs
3.brisk bleeding more than 100 3.brisk bleeding more than 100
Ml every 15 min for 1 hrMl every 15 min for 1 hr

69. 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

70. Pericardial TamponadePericardial Tamponade
Once the pericardial Once the pericardial
sac can’t expand sac can’t expand
anymore, the fluid anymore, the fluid
starts putting starts putting
pressure on the heartpressure on the heart
Now the heart can’t Now the heart can’t
fully expand and can’t fully expand and can’t
pump effectively. pump effectively.

71. Pericardial TamponadePericardial Tamponade
Once the pericardial Once the pericardial
sac can’t expand sac can’t expand
anymore, the fluid anymore, the fluid
starts putting starts putting
pressure on the heartpressure on the heart
Now the heart can’t Now the heart can’t
fully expand and can’t fully expand and can’t
pump effectively. pump effectively.

72. S/S of Pericardial TamponadeS/S of Pericardial Tamponade
Distended Neck VeinsDistended Neck Veins
Increased Heart RateIncreased Heart Rate
Respiratory Rate increasesRespiratory Rate increases
Poor skin colorPoor skin color
Narrowing Pulse PressuresNarrowing Pulse Pressures
HypotensionHypotension
DeathDeath

73. Pericardial Tamponade Pericardial Tamponade
ManagementManagement
Secure airway Secure airway
High concentration O2High concentration O2
Definite treatment is pericardiocentesis Definite treatment is pericardiocentesis
followed by surgery followed by surgery

74. PericardiocentesisPericardiocentesis
Using aseptic technique, Insert at least Using aseptic technique, Insert at least
3” needle at the angle of the Xiphoid 3” needle at the angle of the Xiphoid
Cartilage at the 7Cartilage at the 7
thth
rib rib
Advance needle at 45 degree towards Advance needle at 45 degree towards
the clavicle while aspirating syringe till the clavicle while aspirating syringe till
blood return is seenblood return is seen
Continue to Aspirate till syringe is full Continue to Aspirate till syringe is full
then discard blood and attempt again then discard blood and attempt again
till signs of no more bloodtill signs of no more blood

75. Traumatic Aortic RuptureTraumatic Aortic Rupture
The heart, more or less, just
hangs from the aortic arch
Much like a big pendulum.
If enough motion is placed on
the heart (i.e.. Deceleration
From a motor vehicle
accident, striking a tree while
skiing etc) the heart may tear
away from the aorta.

76. Traumatic Aortic RuptureTraumatic Aortic Rupture
The chances of survival are
very slim and are based on the
degree of the tear.
If there is just a small tear then
the patient may survive. If the
aorta is completely transected
then the patient will die
instantaneously

77. S/S Of Traumatic Aortic RuptureS/S Of Traumatic Aortic Rupture
Burning or Tearing Sensation in Burning or Tearing Sensation in
chest or shoulder bladeschest or shoulder blades
Rapidly dropping Blood PressureRapidly dropping Blood Pressure
Pulse Rapidly IncreasingPulse Rapidly Increasing
Decreased or loss of pulse or b/p Decreased or loss of pulse or b/p
on left side compared to right sideon left side compared to right side
Rapid Loss of ConsciousnessRapid Loss of Consciousness

78. Treatment of Traumatic Aortic Treatment of Traumatic Aortic
RuptureRupture
ABC’s with c-spine control as ABC’s with c-spine control as
indicatedindicated
High Flow oxygenHigh Flow oxygen
Treatment for ShockTreatment for Shock
RAPID TRANSPORTRAPID TRANSPORT
Contact Hospital and ALS Unit As Contact Hospital and ALS Unit As
soon as possiblesoon as possible

79. Traumatic AsphyxiaTraumatic Asphyxia
Results from sudden Results from sudden
compression injury to chest compression injury to chest
cavitycavity
Can cause massive rupture of Can cause massive rupture of
Vessels and organs of chest Vessels and organs of chest
cavitycavity
Ultimately DeathUltimately Death

80. S/S of Traumatic AsphyxiaS/S of Traumatic Asphyxia
Severe DyspneaSevere Dyspnea
Distended Neck VeinsDistended Neck Veins
Bulging, Blood shot eyesBulging, Blood shot eyes
Swollen Tounge with cyanotic lipsSwollen Tounge with cyanotic lips
Reddish-purple discoloration of Reddish-purple discoloration of
face and neckface and neck
PetechiaePetechiae

81. Treatment for Traumatic AsphyxiaTreatment for Traumatic Asphyxia
ABC’s with c-spine control as ABC’s with c-spine control as
indicatedindicated
High Flow oxygenHigh Flow oxygen
Treat for shockTreat for shock
Care for associated injuriesCare for associated injuries

82. Diaphragmatic RuptureDiaphragmatic Rupture
A tear in the Diaphragm that A tear in the Diaphragm that
allows the abdominal organs enter allows the abdominal organs enter
the chest cavitythe chest cavity
More common on Left side due to More common on Left side due to
liver helps protect the right side of liver helps protect the right side of
diaphragm diaphragm
Associated with multiple injury Associated with multiple injury
patientspatients

83. Diaphragm RuptureDiaphragm Rupture

84. S/S of Diaphragmatic RuptureS/S of Diaphragmatic Rupture
Abdominal PainAbdominal Pain
Shortness of AirShortness of Air
Decreased Breath Sounds on Decreased Breath Sounds on
side of ruptureside of rupture
Bowel Sounds heard in chest Bowel Sounds heard in chest
cavitycavity

85. Treatment of Diaphragmatic Treatment of Diaphragmatic
RuptureRupture
ABC’s with c-spine control as ABC’s with c-spine control as
indicatedindicated
High Flow oxygen High Flow oxygen
Treat Associated InjuriesTreat Associated Injuries
Definitive treatment is surgeryDefinitive treatment is surgery

86. 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

87. Indications of Indications of mmedian edian
sternotomysternotomy
Surgery forSurgery for
1.thymus1.thymus
2.heart and great vessels2.heart and great vessels
3.both pleural sac3.both pleural sac

88. mmedian sternotomyedian sternotomy

89. Posterolateral thoracotomyPosterolateral thoracotomy
An incision is made in the bed An incision is made in the bed
of the 5th rib (5th intercostals of the 5th rib (5th intercostals
space). space).
Used mainly for hilum and lung Used mainly for hilum and lung
surgery eg.pneumonectomysurgery eg.pneumonectomy

90. Posterolateral thoracotomyPosterolateral thoracotomy

91. ThoracoabdominalThoracoabdominal
Used in surgery of lower Used in surgery of lower
oesophagus,gastric cardia oesophagus,gastric cardia
,stomach,pancreas,diaphragm,stomach,pancreas,diaphragm