torso trauma.pptx torso trauma in humans medicine an treatment

torso trauma in humans medicine an treatment

1. Torso Trauma By Shane Stanley 35781

2. overview Anatomy Types of Injury Physical exams Surgical intervention Non operative management

3. Anatomy

4. For trauma purpose, torso is divided into thorax and the abdomen. Thoracic Cavity Anatomy I. Chest wall II. Mediastinum: A. Anterior compartment B. Visceral compartment C. Paravertebral sulci III. Lungs and tracheobronchial tree Abdomen for trauma purposed is everything below the nipple line, inferior to the pubic line. Includes. Peritoneum- liver spleen stomach last ¼ of duodenum small bowl, transverse colon . Retroperitoneum - first ¾ of the duodenum, pancreas, kidneys, colon, major vessels. Pelvic, blader urethra rectum, prostate, ovaries uterus.

5. Types of Injury Penetrative - Most commonly due to stabbing or GSW Blunt force - MV accidents, sheering force, deceleration injury, crush injury.

6. Thoracic injuries

7. Principles of chest trauma Specific considerations in chest trauma include an emphasis on a proper airway and breathing All pts should be put on 100% O2 NRB mask Hypoxia is the most important feature of chest injury Shock may ensue from blood loss (great vessels, esp.), inc. intrapleural pressure, vascular disruption, myocardial dysfunction-watch BP. Chest wall pain will result in more frequent, shallow breaths. Less deep breaths means a higher risk for atelectasis and pneumonia, so adequate control of pain and breathing are both important when managing these patients!

8. Tension Pneumothorax Disruption of tissue causing progressive accumulation of air in the pleural space (one-way valve mechanism); the increased pressure reflects back to the heart, reducing output. Key Sx is distended jugular veins and absent breath sounds on one (affected) side. The affected side will also be hyper resonant to percussion. If a C-XR has been attained, the affected side will demonstrate the collapse (loss of vascular markings) Tx: Needle decompression f/b chest-tube placement Use 2nd IC space at the midclavicular line

9. Tension Pneumothorax Needle thoracostomy

10. Open Pneumothorax (Sucking chest wound) Large pneumothorax resulting in equilibration of atmospheric and hemi-intrathoracic pressure. The lung expands only by development of a negative hemi- intrathroacic pressure the Like tension pneumothorax, the lung is collapsed and cannot exchange oxygen. There is often dyspnea. No lung sounds will be heard on the affected side and there is often hyperresonance to percussion. Unlike tension pneumothorax, the open pneumothorax does not trap pressure into the hemithorax. Hence, there is no compression on the heart or vena cavae . Dx: Clinical; based on the presence of a chest injury and physical exam findings. C-XR should be obtained provided pt is stable. Tx: Sterile gauze and three-sided taping of wound, followed by tube thoracostomy and wound closure.

11. Open Pneumothorax (Sucking chest wound) Three-sided wound closure Should be Followed up with- *tube thoracostomy *definitive wound closer.

12. Hemothorax The accumulation of blood in the pleural space, usually due to trauma damaging the chest wall, lung parenchyma, or other vascular structures More often seen w/ penetrating chest trauma Sx depend on severity and amount of blood loosed, often include respiratory distress, tachypnea, hypoxia, in some cases hypotension w/ narrow pulse pressure. Dull to percussion in dependent areas on affected side. Dx can be made either clinically (emergent) or via C-XR (upright and AP) Tx: Tube thoracostomy is the initial management of choice in most pts. Ensure hemodynamic stability. Have O- or crossmatched blood on hand for transfusion.

13. Hemothorax Proceed to the OR for open thoracostomy if: If more than 1,000 cc of blood is retrieved from initial tube drainage, or 200 cc/ hr is drained for 4 continuous hours, or. Pt decompensates after initial stabilization

14. Tube Thoracostomy

15. Open Thoracostomy Used to explore the chest cavity to find the source of the bleeding.

16. Rib Fracture Most common injury sustained during blunt trauma to the chest, and usually associated w/ MVAs. Sx include exquisite pain, local crepitation, dyspnea, shallow tachypnea (due to pain); features of hemothorax, pneumothorax, or flail chest may be present Dx: When suspecting rib fracture, the best dx test is C-XR. Tx: Focused on preventing complications (namely, atelectasis and pneumonia) by maintaining good ventilatory function Pain management: Acetaminophen, NSAIDs, opiates, intercostal nerve block, Incentive spirometry. With rib fractures alone, healthy pts w/ mild-moderate pain can usually be sent home w/ instructions. Pts w/ severe injuries or w/ respiratory illnesses (i.e., COPD) should be admitted for observation. We are not worried about the young patients who are healthy with this condition, we should take it seriously when there is an older patient who can have complications very easily.

17. Rib Fracture Major complications of rib fracture: * Flail chest * Pulmonary contusion *Atelectasis *pneumonia – tuns into – Pneumothorax * Hemothorax

18. Cardiac Tamponade Accumulation of blood in the pericardial space, reducing the heart's pumping ability and diminishing cardiac output Acute and chronic forms; chest trauma causes acute cardiac tamponade and is more fulminant Key Sx is distended jugular veins due to R. heart congestion. Breath sounds will be normal bilaterally on auscultation, though the heart sounds may be muffled or distant. Other sx : Pulsus paradoxus (≥ 10mmHg drop on inspiration), EKG: decreased QRS amplitude, ST changes. Get dx via sonography. Tx surgically via pericardiocentesis. If the pt is unstable, decompress pericardial sac via emergent thoracotomy.

19. Myocardial Contusion Injury of the cardiac tissue typically due to blunt trauma to the chest, there may be resulting arrhythmias and cardiac arrest Sx : There are no specific findings for myocardial contusion; it should be suspected whenever there is blunt trauma to the chest. Sternal fractures are highly associated w/ myocardial contusion. Dx: The best initial step in investigating for myocardial contusion is EKG; abnormalities can be further investigated w/ echocardiogram. Any arrhythmias/complications are treated as normally. Pts w/ myocardial contusions should be considered for preclinical aortic disruption via chest CT. The right ventricle is the most common part to be injured.

20. Traumatic Rupture of the Aorta Common cause of death in blunt trauma; typically results from deceleration injury. Location of injury is most commonly around the origin of the L subclavian artery. 80% of traumatic ruptures of the aorta will be DOA; the other 20% tend to have slower bleeds that may be Prognosis is still poor. caught in the hospital. Sx : Chest pain, back pain, pseudocoarctation, murmur, pulse deficits/asymmetry Dx: If the pt is stable, the best e best initial step is a spiral CT (more accurate, C-XR has likely already been done). If the pt is unstable, the best initial step is emergent thoracotomy. Tx: Surgical repair. Pharmacologic management of BP (high BP can exacerbate tear.) Pain control.

21. wide mediastinum sign

22. Diaphragm rupture

23. Abdominal injuries

24. Physical exam signs Sx : Seat belt sign: Diagonal and lower abdominal abrasion, secondary to restraining belt. Consider fracture of lumbar spine (Chance fracture) and bladder and/or bowel perforation. * Cullen's sign: Periumbilical ecchymoses. Points to hemorrhage in the peritoneum. * Grey-Turner's sign: Flank ecchymoses. Points to hemorrhage in the retroperitoneum. Kehr's sign: L shoulder/neck pain associated w/ injury to the spleen. Can elicit especially w/ LUQ palpation.

25. Physical exam signs

26. Types of injury Penetrating abdominal injury Cause: GSW , stabbing Organ most commonly damaged: Liver Blunt abdominal injury Cause: Direct blow, crush injury, deceleration injury Organ most commonly dargaged : Spleen, li

27. Penetrating Abdominal Injury * Most commonly due to GSWs and stab wounds * GSWs virtually always penetrate the peritoneum/retroperitoneum Severity of stab wounds vary based on depth Initial management: ABCS-Primarily concerned with blood loss. Fluid replacement to maintain systolic pressure > 90 mmHg. * Focused physical examination Trauma labs, plain films Stable pts should get CT to assess damage In more urgent scenarios, FAST may be done.Any violation of the peritoneum/retroperitoneum requires prophylactic antibiotics (cover GI flora) and tetanus booster Surgical management: Stab wounds may be treated conservatively or require exploratory laparotomy

28. Diagnostic modalities Plain films - Will be ordered on all abdominal trauma pts. Chest X-ray ( CXR ), abdominal X-ray ( AXR ) should be ordered. Cervical and lumbar spine films may be useful as well. * CT-The most common and the most accurate diagnostic modality for penetrating and blunt abdominal injury. * Should only be performed if the pt is hemodynamically stable * If there is an absolute indication for exploratory laparotomy, don't waste time with a CT. Focused abdominal sonography for trauma (FAST) - A series of ultrasound readings, looking for bleeding in the abdomen (as well as in pericardium.) Performed in most pts. Ideal for non-stable pts because of its relative efficiency

29. Blunt Abdominal Injury * Most commonly due to MVAs, shearing forces, deceleration injury, crushing injury Initial management ABCs: Shock in the blunt abdominal injury pt is very likely a splenic injury. Palpate the LUQ to get a better idea. * Focused physical examination Be vigilant for peritoneal sx . This automatically warrants ex lap * Trauma labs, plain films * Stable pts should get CT to assess damage Unstable pts may get FAST * Operative management Exploratory laparotomy performed as indicated

30. Indications for exploratory laparotomy * Abdominal trauma + hemodynamic instability * Peritoneal irritation * Evisceration * Suspected/known diaphragmatic injury * Rectal perforation ◆ Bleed per stomach * Free intraperitoneal or retroperitoneal air * Positive DPL

31. Thank you!