Thoracic Trauma

Capt Mike Bevers, PA
173rd MDF

1. 1
Thoracic TraumaThoracic Trauma
Capt Mike Bevers, PA
173
rd
MDF

2. 2
Thoracic TraumaThoracic Trauma
lSecond leading cause of trauma
deaths after head injury (in USA)
lCause of about 10-20% of all trauma
deaths
lMany deaths due to thoracic trauma
are preventable

3. 3
Thoracic TraumaThoracic Trauma
lMechanisms of Injury
Blunt Injury
lDeceleration
lCompression
Penetrating Injury
Both

4. 4
Thoracic TraumaThoracic Trauma
lAnatomical Injuries
Thoracic Cage (Skeletal)
Cardiovascular
Pleural and Pulmonary
Mediastinal
Diaphragmatic
Esophageal
Penetrating Cardiac
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Thoracic TraumaThoracic Trauma
lGeneral Pathophysiology
Impairments in ventilatory efficiency
lchest excursion compromise
–pain
–air in pleural space
–asymmetrical movement
lbleeding in pleural space
lineffective diaphragm contraction

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Thoracic TraumaThoracic Trauma
lGeneral Pathophysiology
Impairments in gas exchange
latelectasis
lpulmonary contusion
lrespiratory tract disruption

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Thoracic TraumaThoracic Trauma
lInitial exam directed toward life
threatening:
Injuries
lOpen pneumothorax
lFlail chest
lTension pneumothorax
lMassive hemothorax
lCardiac tamponade
Conditions
lApnea
lRespiratory Distress

8. 8
Thoracic TraumaThoracic Trauma
lAssessment Findings
Mental Status (decreased)
Pulse (absent, tachy or brady)
BP (narrow PP, hyper- or hypotension,
pulsus paradoxus)
Ventilatory rate & effort (tachy- or
bradypnea, labored, retractions)
Skin (diaphoresis, pallor, cyanosis, open
injury, ecchymosis)

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Thoracic TraumaThoracic Trauma
lAssessment Findings
Neck (tracheal position, SQ emphysema,
JVD, open injury)
Chest (contusions, tenderness, asymmetry,
absent or decreased lung sounds, bowel
sounds, abnormal percussion, open injury,
impaled object, crepitus, hemoptysis)
Heart Sounds (muffled, distant, regurgitant
murmur)
Upper abdomen (contusion, open injury)

10. 10
Thoracic TraumaThoracic Trauma
lHistory
Dyspnea
Pain
Past hx of cardiorespiratory disease
Restraint devices used
Item/Weapon involved in injury

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Rib FractureRib Fracture
lMost common chest wall injury from
direct trauma
lMore common in adults than children
lEspecially common in elderly
lRibs form rings
Possibility of break in two places
lMost commonly 5th - 9th ribs
Poor protection

12. 12
Rib FractureRib Fracture
lFractures of 1st and 2nd second require
high force
Frequently have injury to aorta or bronchi
Occur in 90% of patients with tracheo-
bronchial rupture
May injure subclavian artery/vein
May result in pneumothorax
l30% will die

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Rib FractureRib Fracture
lFractures of 10 to 12th ribs can cause
damage to underlying abdominal solid
organs:
Liver
Spleen
Kidneys

14. 14
Rib FractureRib Fracture
lAssessment Findings
Localized pain, tenderness
Increases on palpation or when patient:
lCoughs
lMoves
lBreathes deeply
“Splinted” Respirations
Instability in chest wall, Crepitus
Deformity and discoloration
Possible pneumo or hemothorax

15. 15
Rib FractureRib Fracture
lManagement
High concentration O
2
Positive pressure ventilation as needed
Splint using pillow or swathes
Encourage pt to breath deeply
Non-circumferential splinting

16. 16
Sternal FractureSternal Fracture
lUncommon, 5-8% in blunt chest trauma
lLarge traumatic force
lDirect blow to front of chest by
Deceleration
lsteering wheel
ldashboard
Other object

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Sternal FractureSternal Fracture
l25 - 45% mortality due to associated trauma:
Disruption of thoracic aorta
Tracheal or bronchial tear
Diaphragm rupture
Flail chest
Myocardial trauma
lHigh incidence of myocardial contusion,
cardiac tamponade or pulmonary contusion

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Sternal FractureSternal Fracture
lAssessment Findings
Localized pain
Tenderness over sternum
Crepitus
Tachypnea, Dyspnea
Hx/Mechanism of blunt chest trauma

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Sternal FractureSternal Fracture
lManagement
Establish airway
High concentration oxygen
Assist ventilations with BVM as needed
IV NS/LR
lRestrict fluids
Emergent Transport
lHospital

20. 20
Flail ChestFlail Chest
Two or more adjacent ribs
fractured in two or more places
producing a free floating
segment of the chest wall

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Flail ChestFlail Chest
lUsually secondary to blunt trauma
Most commonly in MVC
Also results from
lfalls from heights
lindustrial accidents
lassault
lMore common in older patients

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Flail ChestFlail Chest
lMortality rates 20-40% due to associated
injuries
lMortality increased with
advanced age
seven or more rib fractures
three or more associated injuries
shock
head injuries

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Flail ChestFlail Chest
lAssessment Findings
Chest wall contusion
Respiratory distress
Pleuritic chest pain
Splinting of affected side
Crepitus
Tachypnea, Tachycardia
Paradoxical movement (possible)

24. 24
Flail ChestFlail Chest
lManagement
Suspect spinal injuries
Establish airway
High concentration oxygen
Assist ventilation with BVM
lTreat hypoxia from underlying contusion
lPromote full lung expansion
Consider need for intubation and PEEP
Mechanically stabilize chest wall
lquestionable value

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Flail ChestFlail Chest
lManagement
IV of LR/NS
lAvoid rapid replacement in hemodynamically
stable patient
lContused lung cannot handle fluid load
Emergent Transport
lHospital

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Simple PneumothoraxSimple Pneumothorax
lIncidence
10-30% in blunt chest trauma
almost 100% with penetrating chest trauma
Morbidity & Mortality dependent on
lextent of atelectasis
lassociated injuries

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Simple PneumothoraxSimple Pneumothorax
lCauses
Commonly a fx rib lacerates lung
Paper bag effect
May occur spontaneously in tall, thin
young males following:
lExertion
lCoughing

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Simple PneumothoraxSimple Pneumothorax
lAssessment Findings
Tachypnea, Tachycardia
Difficulty breathing or respiratory distress
Pleuritic pain
lmay be referred to shoulder or arm on affected side
Decreased or absent breath sounds
lnot always reliable
lpatients with multiple ribs fractures may splint
injured side by not breathing deeply

29. 29
Simple PneumothoraxSimple Pneumothorax
lManagement
Establish airway
High concentration O
2
with NRB
Assist with BVM
ldecreased or rapid respirations
linadequate TV
IV of LR/NS
Monitor for progression to tension pneumo
Usually Non-emergent transport

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Open PneumothoraxOpen Pneumothorax
lAssessment Findings
Opening in the chest wall
Sucking sound on inhalation
Tachycardia
Tachypnea
Respiratory distress
SQ Emphysema
Decreased lung sounds on affected side

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Open PneumothoraxOpen Pneumothorax
lManagement
Cover chest opening with occlusive dressing
High concentration O
2
Assist with positive pressure ventilations prn
Monitor for progression to tension
pneumothorax
IV with LR/NS
Emergent Transport
lHospital

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Tension PneumothoraxTension Pneumothorax
lIncidence
Penetrating Trauma
Blunt Trauma
lMorbidity/Mortality
Severe hypoventilation
Immediate life-threat if not managed early

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Tension PneumothoraxTension Pneumothorax
lAssessment Findings - Most Likely
Severe dyspnea  extreme resp distress
Restlessness, anxiety, agitation
Decreased/absent breath sounds
Worsening or Severe Shock / Cardiovascular
collapse
lTachycardia
lWeak pulse
lHypotension
lNarrow pulse pressure

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Tension PneumothoraxTension Pneumothorax
lAssessment Findings - Less Likely
Jugular Vein Distension
labsent if also hypovolemic
Subcutaneous emphysema
Tracheal shift away from injured side (late)
Cyanosis (late)

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Tension PneumothoraxTension Pneumothorax
lManagement
Recognize & Manage early
Establish airway
High concentration O
2

Positive pressure ventilations w/BVM prn
Needle thoracostomy
IV of LR/NS
Emergent Transport
lConsider need to intubate
lHospital

36. 36
Tension PneumothoraxTension Pneumothorax
lManagement
Needle Thoracostomy Review
lDecompress with 14g (lg bore), 2-inch needle
lMidclavicular line: 2nd intercostal space
lMidaxillary line: 4-5th intercostal space
lGo over superior margin of rib to avoid blood
vessels
lBe careful not to kink or bend needle or catheter
lIf available, attach a one-way valve

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HemothoraxHemothorax
lAssessment Findings
Tachypnea or respiratory distress
Shock
lRapid, weak pulse
lHypotension, narrow pulse pressure
lRestlessness, anxiety
lCool, pale, clammy skin
lThirst
Pleuritic chest pain
Decreased lung sounds
Collapsed neck veins
Dullness on percussion

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HemothoraxHemothorax
lManagement
Establish airway
High concentration O
2
Assist Ventilations w/BVM prn
+ MAST in profound hypotension?
Needle thoracostomy if tension & unable to
differentiate from Tension Pneumothorax
IVs x 2 with LR/NS
Emergent transport to hospital

39. 39
Pulmonary ContusionPulmonary Contusion
lAssessment Findings
Tachypnea or respiratory distress
Tachycardia
Evidence of blunt chest trauma
Cough and/or Hemoptysis
Apprehension
Cyanosis

40. 40
Pulmonary ContusionPulmonary Contusion
lManagement
Supportive therapy
Early use of positive pressure ventilation
reduces ventilator therapy duration
Avoid aggressive crystalloid infusion
Severe cases may require ventilator therapy
Emergent Transport
lHospital

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Myocardial ContusionMyocardial Contusion
lAssessment Findings
Cardiac arrhythmias following blunt chest
trauma
Angina-like pain unresponsive to
nitroglycerin
Precordial discomfort independent of
respiratory movement
Pericardial friction rub (late)

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Myocardial ContusionMyocardial Contusion
lManagement
Establish airway
High concentration O
2
IV LR/NS
lCautious fluid administration due to injured myocardium
Emergent Transport
lHospital

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Pericardial TamponadePericardial Tamponade
lIncidence
Usually associated with penetrating
trauma
Rare in blunt trauma
Occurs in < 2% of chest trauma
GSW wounds have higher mortality
than stab wounds
Lower mortality rate if isolated
tamponade

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Pericardial TamponadePericardial Tamponade
lSigns and Symptoms
Beck’s Triad
lResistant hypotension
lIncreased central venous pressure
(distended neck/arm veins in presence of
decreased arterial BP)
lSmall quiet heart (decreased heart
sounds)

45. 45
Pericardial TamponadePericardial Tamponade
lSigns and Symptoms
Narrowing pulse pressure
Pulsus paradoxicus
lRadial pulse becomes weak or disappears
when patient inhales
lIncreased intrathoracic pressure on
inhalation causes blood to be trapped in
lungs temporarily

46. 46
Pericardial TamponadePericardial Tamponade
lManagement
Secure airway
High concentration O
2
Pericardiocentesis
lOut of hospital, primarily reserved for cardiac arrest
Rapid transport
lHospital
IVs of LR/NS

47. 47
Traumatic Aortic Traumatic Aortic
Dissection/Rupture Dissection/Rupture
lAssessment Findings
Retrosternal or interscapular pain
Pain in lower back or one leg
Respiratory distress
Asymmetrical arm BPs
Upper extremity hypertension with
lDecreased femoral pulses, OR
lAbsent femoral pulses
Dysphagia

48. 48
Traumatic Aortic Traumatic Aortic
Dissection/Rupture Dissection/Rupture
lManagement
Establish airway
High concentration oxygen
Maintain minimal BP in dissection
lIV LR/NS TKO
–minimize fluid administration
lAvoid PASG
Emergent Transport
lHospital

49. 49
Traumatic AsphyxiaTraumatic Asphyxia
Name given to these patients
because they looked like they
had been strangled or hanged

50. 50
Traumatic AsphyxiaTraumatic Asphyxia
lAssessment Findings
Purplish-red discoloration of:
lHead and Face
lNeck
lShoulders
Blood shot, protruding eyes
JVD
? Sternal fracture or central flail
Shock when pressure released

51. 51
Traumatic AsphyxiaTraumatic Asphyxia
lManagement
Airway with C-spine control
Assist ventilations with high concentration O
2
Spinal stabilization
IV of LR
+ MAST in severely hypotensive patients?
Rapid transport
lHospital

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Diaphragmatic RuptureDiaphragmatic Rupture
lAssessment Findings
Decreased breath sounds
lUsually unilateral
lDullness to percussion
Dyspnea or Respiratory Distress
Scaphoid Abdomen (hollow appearance)
Usually impossible to hear bowel sounds

53. 53
Diaphragmatic RuptureDiaphragmatic Rupture
lManagement
Establish airway
Assist ventilations with high concentration O
2
IV of LR
NG tube if possible
Avoid
lMAST
lTrendelenburg position

54. 54
Diaphragmatic PenetrationDiaphragmatic Penetration
lSuspect intra-abdominal trauma with
any injury below 4th ICS
lSuspect intrathoracic trauma with
any abdominal injury above
umbilicus

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Esophageal InjuryEsophageal Injury
lAssessment Findings
Pain, local tenderness
Hoarseness, Dysphagia
Respiratory distress
Resistance of neck on passive motion
Mediastinal esophageal perforation
lmediastinal emphysema / mediastinal crunch
lmediastinitis
lSQ Emphysema
lsplinting of chest wall
Shock

56. 56
Esophageal InjuryEsophageal Injury
lManagement
Establish Airway
Consider early intubation if possible
IV LR/NS titrated to BP 90-100 mm Hg
Emergent Transport
lHospital
lSurgical capability

57. 57
Tracheobronchial RuptureTracheobronchial Rupture
lAssessment Findings
Respiratory Distress
lDyspnea
lTachypnea
Obvious SQ emphysema
Hemoptysis
lEspecially of bright red blood
Signs of tension pneumothorax unresponsive
to needle decompression

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Tracheobronchial RuptureTracheobronchial Rupture
lManagement
Establish airway and ventilations
Consider early intubation
lEmergent Transport
lHospital

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Pitfalls to AvoidPitfalls to Avoid
lElderly do not tolerate relatively minor
chest injuries
Anticipate progression to acute respiratory
insufficiency
lChildren may sustain significant
intrathoracic injury w/o evidence of
thoracic skeletal trauma
Maintain a high index of suspicion