Thoracic Trauma

Thoracic Trauma

Dave Lloyd, MD
Introduction to Thoracic Injury
* Vital Structures
* 25% of MVC deaths are due to thoracic trauma
* Abdominal injuries are common with chest trauma.
* Prevention Focus

Anatomy and Physiology of the Thorax
* Thoracic Skeleton
* Diaphragm
* Associated Musculature
* Physiology of Respiration
* Trachea, Bronchi & Lungs
* Mediastinum
* Heart
* Contraction Cycle
* Great Vessels
* Esophagus
* Blunt Trauma
* Penetrating Trauma
Pathophysiology of Thoracic Trauma
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
* Rib Fractures
* Sternal Fracture & Dislocation
* Flail Chest
* Simple Pneumothorax
* Open Pneumothorax
* Tension Pneumothorax
* Dyspnea
* Progressive ventilation/perfusion mismatch
* 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
* Hemothorax
* Blunt or penetrating chest trauma
* Shock
* Dull to percussion over injured side
* Pulmonary Contusion
* Myocardial Contusion
* Bruising of chest wall
* Tachycardia and/or irregular rhythm
* Retrosternal pain similar to MI
* Associated injuries
* Chest pain unrelieved by oxygen
* Pericardial Tamponade
* Dyspnea
* Possible cyanosis
* Beck’s Triad
* Weak, thready pulse
* Shock
* Kussmaul’s sign
* Pulsus Paradoxus
* Electrical Alterans
* PEA
* Myocardial Aneurysm or Rupture
* Traumatic Aneurysm or Aortic Rupture
* Other Vascular Injuries
* Traumatic Esophageal Rupture
* Tracheobronchial Injury
* Traumatic Asphyxia
* Scene Size-up
* Initial Assessment
* Rapid Trauma Assessment
* Ongoing Assessment
* Ensure ABC’s
* Anticipate Myocardial Compromise
* Shock Management
* Rib Fractures
* Sternoclavicular Dislocation
* Flail Chest
* Open Pneumothorax
* Tension Pneumothorax
* Hemothorax
* Myocardial Contusion
* Pericardial Tamponade
* Aortic Aneurysm
* Tracheobronchial Injury
* Traumatic Asphyxia

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Artificial Airways

Artificial Airways

Definition
* A tube or tube-like device that is inserted through the nose, mouth, or into the trachea to provide an opening for ventilation

Types of Artificial Airways
* Oropharyngeal airways
* Nasopharyngeal tubes
* Orotracheal tubes
* Nasotracheal tubes
* Tracheostomy tubes
* Esophageal obturator airway
* Cricothyroid tubes

Indications for Artificial Airways
* Relief of airway obstruction -guarantees the patency of upper airway regardless of soft tissue obstruction.
* Protecting or maintaining an airway N. have 4 main airway protect. reflexes 1. Pharyngeal reflex - 9th & 10th cranial nerves gag and swallowing
* Reflexes (cont’d) 2.Laryngeal -vagovagal reflex - will cause laryngospasm 3.Tracheal -vagovagal reflex - cough when a foreign body or irritation in trachea 4.Carinal -cough with irritation of carina
* Facilitation of tracheobronchial clearance
- mobilization of secretions from the trachea requires either an adequate cough or direct suctioning of the trachea
* Facilitation of artificial ventilation
- ventilation with a mask should on be used for short periods d/t gastric insufflation

Hazards of Artificial Airways
* Infection d/t bypassing the normal defense mechanisms that prevent bacterial contamination
* Ineffective cough maneuver
* Impaired verbal communication
* Loss of personal dignity

Oropharyngeal Airway
* Device designed for insertion along the tongue until the teeth &/or gingiva limit the insertion
* Lies between the posterior pharynx and the tongue and pushes the tongue forward
* Will activate the gag reflex, should use on unconscious patient
* Correct sizing of airway is imperative

Hazards of Oropharyngeal Airway
* If too small, may not displace tongue or may cause tongue to obstruct airway or may aspirated
* It too large, may cause epiglottis impaction
* Roof of mouth may be lacerated upon insertion
* Aspiration from intact gag reflex

Nasopharyngeal Airway
* Located so that it can provide a clear path for gas flow into the pharynx
* Is a soft rubber catheter
* Can be tolerated by the conscious patient
* Useful for patient with a soft tissue obstruction who have jaw injury or spasm of jaw muscles
* Proper sizing and insertion

Orotracheal Airway
* Used in conditions of, or leading to respiratory failure
* Usually the method of choice in emergencies that do not involve trauma to the mouth or mandible
* Oral route in usually easiest
* Accomplished by using a laryngoscope to directly visualize the trachea

Nasotracheal Airway
* More difficult route than oral
* Requires a longer and more flexible tracheal tube
* Insert through nose by touch and when in oropharynx use larynoscope and forceps (can perform “blind”)
* Usually N. T. tube is better tolerated by patient than oral

Tracheostomy Tube
* Tracheostomy is performed through the anterior tracheal wall either by the open method or percutaneous method
* Performed usually to prevent or treat long-term respiratory failure
* Decreases anatomic deadspace by 50%

Complications and Hazards of Tracheostomies
* Postsurgical bleeding
* Infection
* Mediastinal emphysema
* Pneumothorax
* Subcutaneous emphysema
* Stoma collapse (should not be moved or changed first 36 hours)

Esophageal Obturator Airway (EOA)
* Place in the esophagus to prevent stomach contents from entering the lungs while the patient is being artificially ventilated
* Cuff must be passed beyond carina before inflated
* Inflated cuff with 35 cc air
* Mask must fit tightly to ensure ventilation

Pharyngealtracheal Lumen Airway (PTL)
* Double-lumen airway combining an EOA and an endotracheal tube
* Designed to be inserted blindly
* Has an oropharyngeal cuff and a cuff that can seal off either the trachea or the esophagus

Other Specialized ET Tubes
* Rae Tube, directs the airway connection away from the surgical field
* Endotrol Tube, controls the distal tip for intubation
* Hi-Lo Jet Tube, for high freq. jet ventilation
* Laser Flex Tube, reflects a diffused beam if comes in contact with tube
* Endobronchial Tubes

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Thoracic Trauma

Thoracic Trauma
By:EMS Professions
Temple College

Thoracic Trauma
* Second leading cause of trauma deaths after head injury
* Cause of about 10-20% of all trauma deaths
* Many deaths due to thoracic trauma are preventable
* Prevention Strategies
* Mechanisms of Injury
* Anatomical Injuries


What structures may be involved with each injury?
* Often result in:
o Hypoxia
o Hypercarbia
o Acidosis
* Ventilation & Respiration Review
* General Pathophysiology
* Initial exam directed toward life threatening:
o Injuries
o Conditions
* Assessment Findings

Specific Injuries
Rib Fracture
* Management
Sternal Fracture
* Management
Flail Chest
* Management
Simple Pneumothorax
* Management
Open Pneumothorax
* Management
Tension Pneumothorax
* Management
Hemothorax
* Management
Pulmonary Contusion
* Management
Cardiovascular Trauma
Myocardial Contusion
* Management
Pericardial Tamponade
* Management
Traumatic Aortic Dissection/Rupture
* Management
Traumatic Asphyxia
* Management
Diaphragmatic Rupture
* Management
Diaphragmatic Penetration
Esophageal Injury
* Management
Tracheobronchial Rupture
* Management
Pitfalls to Avoid

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