Transcript chest trauma - joshcorwin.com

Introduction to Emergency Medicine
Victor Politi, M.D., FACP
AmericanSVCMC
College
of Emergency
Medical Director,
Division
of Allied
Health, Physician Assistant
Program
Physicians
1
Specialty Selection
Top Ten Leading Causes of Death in the U.S.
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Heart Disease: 726,974
Cancer: 539,577
Stroke: 159,791
Chronic Obstructive Pulmonary Disease: 109,029
Accidents: 95,644
Pneumonia/Influenza: 86,449
Diabetes: 62,636
Suicide: 30,535
Nephritis, Nephrotic Syndrome, and Nephrosis
25,331
Chronic Liver Disease and Cirrhosis: 25,175
Appeal of Emergency
Medicine
Make an immediate difference
Life threatening injuries and illnesses
Undifferentiated patient population
Challenge of “anything” coming in
Emergency / invasive procedures
Safety net of healthcare
Appeal of Emergency
Medicine
Team approach
Patient advocacy
Open job market
Academic opportunities
Shift work / set hours
Evolving specialty
Downside to Emergency
Medicine
Interaction with difficult,
intoxicated, or violent patients
Finding follow-up or care for
uninsured
Work in a “fishbowl”
without 20/20 hindsight
Working as a patient
advocate
Subspecialties in Emergency
Medicine
Pediatric Emergency Medicine
Toxicology
Emergency Medical Services
Sports Medicine
Areas of Expertise
Toxicology
Emergency medical services
Mass gatherings
Disaster management
Wilderness medicine
Upcoming Areas of
Emergency Medicine
Hyperbaric medicine
Observation units
ED ultrasound
International emergency medicine
Introduction to Trauma
Trauma is a major cause of
death in young people. The cost
in human lives and economic
terms is tremendous
Trauma is the leading cause of death
for all age groups under the age of 44
In the US - it is the leading cause of
death in children
Trauma Statistics
 4th
leading cause of death of Americans
of all ages
 Nearly
150,000 people of all ages in the
US die from trauma each year
• 60 million injuries annually
• 30 million need medical treatment
• 3.6 million need hospitalization
Trauma Statistics
Impact of trauma is greatest in
children and young adults
Trauma cost the American public over
$300 billion annually including lost
wages, medical expenses,
administrative costs, employer
expense
Approximately 40% of health care
monies are spent on trauma
Trauma Statistics
Traumatic injuries, including
unintentional injuries cause  43%
of all deaths ages 1 to 4
 49% of all deaths ages 5 to 14
 64% of all deaths ages 15 to 24
Trauma Statistics
Leading cause of accidental death in
US - motor vehicle accidents
drinking is a factor in 49% of these
cases
Trauma Statistics
Falls  2nd
leading cause of accidental death
for ages 45 to 75 years and
 #1
cause of unintentional death for
persons age 75 and older
Seatbelt Injury
Trauma Statistics
Drowning is the 4th most common
cause of unintentional injury death
for all ages
 It
ranks 1st for persons age 25 to 44
 It ranks 2nd for ages 5 to 44
Designated Trauma Centers
Designated Trauma Centers
 Immediate
availability of necessary
resources
 Designated •
•
•
•
Regional
Area
Level I
Level II
Tri-modal distribution of
Trauma Death
 First peak: second - minutes
 brain injury, high spinal cord, large vessels,
cardiac arrest
 best treated by prevention
 Second peak: minutes - hours
 sub/epidurals, HTX/PTX, spleen, liver lac
 best treated by applying principles of ATLS
 Third peak: days-weeks
 sepsis, multi-organ failure
 directly correlated to earlier Rx
Primary Evaluation
Airway maintenance with c-spine
control
Breathing and ventilation
Circulation with hemorrhage control
Disability or neurological status
Exposure and environmental control
Control the airway with basic
maneuvers
 suction
 administer
100% oxygen
 hyperventilate
 prepare to intubate
 paralyze the patient
 use appropriate Rx considering
?elevated
ICP
 intubate, maintaining in-line traction
Circulation
Control exsanguinating hemorrhage
control external bleeding promptly
establish at least 2 R.L. wide-bore Ivs
 large
diameter/short length Ivs
 ideally 14 ga. 1 1/4”
 add pressure bags
Shock Classification
 Class I
percentage loss up to 15%
 amount of loss up to 750ml
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 Class II
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percentage loss 15-30%
amount of loss 750-1500ml
 Class III
 percentage
loss 30-
40%
 amount of loss
1500-2000ml
 Class IV
 percentage
loss
more than 40%
 amount of loss
>200ml
Treatment of Hemorrhagic Shock
due to trauma
Defined as B/P less than 90 systolic
in an adult
The treatment of shock should be
directed not toward the class of
shock but to the response to initial
therapy
Class III Blood Loss
Respond to initial fluid bolus
 was
initial bolus inadequate?
 is patient experiencing ongoing
hemorrhage?
As fluids are slowed, patient
deteriorates
Class III Blood Loss
Usually indicates 20-40% blood loss
Requires continued fluids, blood
products
The response to blood products
dictates speed of surgical
intervention
Fingertip amputation
Identify the Site
Most obvious source is external
hemorrhage
Next consider hemothorax
Consider abdominal source
 spleen
laceration
 hemoperitoneum
 renal hematoma
 liver laceration
 injury to a great vessel
Identify the Site
Consider mechanism of injury
Every trauma victim should have a
finger or tube in every hole
Battle’s sign - base of skull
injury
'Racoon Eyes' sign of base of skull fracture
Minimal or No Response to
Fluid Resuscitation
Seen in small percentage of patients
usually dictates need for immediate
surgical intervention to control
exsanguinating hemorrhage
Prepare the OR
If penetrating chest trauma consider cardiac injury
gunshot wound left fronto-parietal
region
entrance wound (close-up)
Golden Hour
The hemodynamically unstable trauma
patient needs only two things …
 hot
lights
 cold steel
Aggressive fluid resuscitation must
be initiated not when blood pressure
is falling/absent but as soon as the
early signs/symptoms of blood loss
are suspected
Decreasing BP increasing pulse
Disorientation - confusion
Mechanism of injury
High voltage wiring injury
Blood Transfusion
No substitute for the real thing
cross match if time permits
compatible with ABO and Rh blood
types
 minor
occur
antibody incompatibilities may
cutting two fingers off in a meat slicer
Universal Donor
Type O negative is available
immediately
used in exsanguinating hemorrhage
used in patient with minimal or no
response to initial crystalloid fluids
bolus
Remember  “Give
Blood Save A Life”
Radiologic Studies
C-spine, chest and pelvis x-rays
CAT scan or specific x-rays that are
indicated based on mechanism of
injury and primary exam
Right pulmonary contusion, left
chest wall defect with lung hernia
Pulmonary Contusion
C-Spine
Don’t become distracted by trying to
clear the c-spine
A properly applied cervical collar
never killed anyone!
Don’t remove cervical collar until cspine is cleared
 continue
to protect c-spine during
treatment
Fracture-dislocation C7-T1
Chest Radiograph
Rule-out PTX/HTX - need immediate
treatment
Provides clues as to condition of  heart,
lung, parenchyma, mediastinum,
great vessels, bronchus, diaphragm
Almost unheard of to have significant
chest injury w/o signs of same on
CXR
 CXR
are frequently misinterpreted and
injuries are frequently overlooked
Chest Radiograph
Check position of tubes
Locate foreign bodies (i.e. bullets)
Free air under diaphragm or on
lateral means perforated viscus
Cardiac tamponade
Right diaphragm laceration
on chest x-ray
Abdominal Trauma
Remove all clothing including
undergarments
Perform adequate visual exam for
injuries
Don’t forget the rectal exam
Spleen Laceration on CT Grade III
Abdominal Trauma
 CAT scan with contrast
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utilizes PO and IV contrast
May require NGT for administration of contrast
Risk of vomiting and aspiration
Risk of allergic reaction to contrast
Intubation to protect airway requiring sedation
Difficult to obtain CT in unstable patient
Renal retroperitoneal hematoma
Grade IV
Pelvic Trauma
Evaluate for pelvic, femoral neck,
femur fractures
Provides clues as to condition of  abdominal
viscera
 bladder
Patients can bleed out into thigh
Mules and packers  products
in distal colon
Ultrasound
Dynamic study performed in trauma
room
 no
need to move patient to x-ray or CT
 can immediately visualize heart,
pericardium
 can visualize liver, spleen, kidney lacs
 can visualize ~ 50 cc blood, fluid in
abdomen
 takes approximately 5 minutes
 highly operator dependent
Trauma Code: ETA 5 minutes
Stick with the basics - remember ABC’s
Constantly re-evaluate patient not lab’s
Don’t raise your voice - remain calm
You are not alone, consult the experts
 don’t get in over your head
 Take a step back  What are you missing ?
 What did you overlook ?
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CHEST TRAUMA
splinter
Incidence of Chest Trauma
 Cause 1 of 4 American trauma deaths
 Contributes to another 1 of 4
 Many die after reaching hospital - could
be prevented if recognized
 <10% of blunt chest trauma needs surgery
 1/3 of penetrating trauma needs surgery
 Most life-saving procedures do NOT
require a thoracic surgeon
Pathophysiology of Chest Trauma
hypovolemia
ventilationperfusion
mismatch
changes in
intrathoracic
pressure
relationships
Inadequate oxygen
delivery to tissues
TISSUE
HYPOXIA
Pathophysiology of Chest Trauma
 Tissue hypoxia
 Hypercarbia
 Respiratory acidosis - inadequate
ventilation
 Metabolic acidosis - tissue
hypoperfusion (e.g., shock)
Initial assessment and management
Primary survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care
Initial assessment and management
Hypoxia is most serious problem early interventions aimed at reversing
Immediate life-threatening injuries
treated quickly and simply - usually
with a tube or a needle
Secondary survey guided by high
suspicion for specific injuries
6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
“sucking chest wound”
Massive hemothorax
Flail chest
Cardiac tamponade
6 Potential Life Threats
 Pulmonary contusion
 Myocardial contusion
 Traumatic aortic rupture
 Traumatic diaphragmatic
rupture
 Tracheobronchial tree
injury - larynx, trachea,
bronchus
 Esophageal trauma
6 Other Frequent Injuries
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures
Primary Survey
Airway
Breathing
Circulation
A = Airway
Assess for airway patency and air
exchange - listen at nose & mouth
Assess for intercostal and
supraclavicular muscle retractions
Assess oropharynx for foreign body
obstruction
B = Breathing
Assess respiratory movements
and quality of respirations look, listen, feel
Shallow respirations are
early indicator of distress
- cyanosis is late
C = Circulation
Assess pulses for quality, rate,
regularity
Assess blood pressure
and pulse pressure
Skin - look and feel for color,
temperature, capillary refill
Look at neck veins - flat vs. distended
Cardiac monitor
Thoracotomy
Closed heart massage is ineffective in
a hypovolemic patient
Left anterior thoracotomy with
cross-clamping of descending thoracic
aorta and open-chest massage may be
useful in pulseless victim of
penetrating trauma
Thoracotomy
6 Immediate Life Threats
Airway obstruction
Tension pneumothorax
Open pneumothorax
“sucking chest wound”
Massive hemothorax
Flail chest
Cardiac tamponade
Airway Obstruction
Chin-lift - fingers under mandible, lift
forward so chin is anterior
Airway Obstruction
Airway Obstruction
Jaw thrust - grasp angles of mandible
and bring the jaw forward
Airway Obstruction
Oropharyngeal
airway inserted in
mouth behind tongue.
DO NOT push
tongue further back.
Airway Obstruction
Nasopharyngeal airway - well
lubricated
“trumpet”
gently
inserted
through
nostril
Airway Obstruction
Definitive
management tube in trachea
through vocal cords
with balloon
inflated.
Airway Obstruction
Orotracheal intubation
Nasotracheal intubation - in
breathing patient without major
facial trauma
surgical airways
 jet
insufflation
 cricothyrotomy
 tracheostomy
Airway Obstruction
Jet insufflation adapters
Airway Obstruction
Tracheotomy tubes
Tension pneumothorax
Air leaks through lung or chest wall
“One-way” valve with lung collapse
Mediastinum shifts to opposite side
Inferior vena cava “kinks” on
diaphragm, leading to decreased
venous return and cardiovascular
collapse
Inferior vena cava
Tension pneumothorax
Tension pneumothorax is not an xray diagnosis - it MUST be
recognized clinically
Treatment is decompression
- needle into 2nd intercostal
space of mid-clavicular line followed by thoracotomy
tube
Open pneumothorax
“Sucking Chest Wound”
Normal ventilation requires negative
intra-thoracic pressure
Large open chest-wall defect leads to
immediate equilibration of intrathoracic and atmospheric pressures
If hole is >2/3 tracheal diameter, air
prefers chest defect
Open pneumothorax
Initial treatment - seal defect and
secure on three sides (total occlusion
may lead to tension pneumothorax
Definitive repair of defect in O.R.
Massive hemothorax
Rapid accumulation of >1500 cc blood
in chest cavity
Hypovolemia & hypoxemia
Neck veins may be:
 flat
- from hypovolemia
 distended - intrathoracic blood
Absent breath sounds, DULL to
percussion
Massive hemothorax - treatment
Large-bore (32 to 36 F) tube to drain
blood
If moderate sized - 500 to 1500 ml and stops bleeding, closed drainage
usually sufficient
If initial drainage >1500 ml OR
continuous bleeding >200 ml / hr,
OPEN THORACOTOMY indicated
Flail chest
“Free-floating” chest segment, usually
from multiple ribs fractures
Pain and restricted
movement
“Paradoxical
movement” of
chest wall with
respiration
Flail chest - treatment
Adequate ventilation
Humidified oxygen
Fluid resuscitation
PAIN MANAGEMENT
Stabilize the chest
 internal
- ventilator
 external - sand bags
Cardiac tamponade
Usually from penetrating injuries
Classic “Beck’s triad”
 elevated
venous pressure - neck veins
 decreased arterial pressure - BP
 muffled heart sounds
Blood in sac
prevents cardiac
activity
Cardiac tamponade
May find “pulsus paradoxus” - a
decrease of 10 mm Hg or greater in
systolic BP during inspiration
Systolic to diastolic gradient of less
than 30 mm Hg also suggestive
Cardiac tamponade
Treatment is removal of small amount
of blood - 15 to 20 ml may be
sufficient - from pericardial sac
Stab wound to
right ventricle
pericardium
epicardial fat
6 Potential Life Threats
Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture
Traumatic diaphragmatic rupture
Tracheobronchial tree injury larynx, trachea, bronchus
Esophageal trauma
Pulmonary contusion
Potentially life-threatening condition
with insidious onset
Parenchymal injury without laceration
More than 50% will develop
pneumonia, even with treatment
Up to 50% have only hemoptysis as
presenting symptom
Pulmonary contusion
Patients with pre-existing conditions
- emphysema, renal failure - need
early intubation
Treatment needs to occur over time
as symptoms develop
Myocardial contusion
Blunt precordial chest trauma
Difficult to diagnose
Risk for dysrhythmias, sudden death,
tamponade, pericarditis, ventricular
aneurysm
Myocardial contusion
Also may see:
myocardial concussion - “stunned”
myocardium with no cell death
coronary artery laceration
Diagnosis by:
trans-esophageal echocardiogram
serial cardiac enzymes
Traumatic aortic rupture
90% or more dead at scene
90% mortality each undiagnosed day
Must have high index of suspicion
Disruption occurs at ligamentum
arteriosum (ductus arteriosus)
Contained hematoma of 500 to 1000
ml of blood
Traumatic aortic rupture
 Radiographic signs
 wide
mediastinum
 1st & 2nd rib fx
 obliteration of
aortic knob
 tracheal deviation
to right
 pleural cap
 depression left
mainstem bronchus
 elevation
and right
shift mainstem
bronchus
 obliteration “aortic
window”
 deviation of
esophagus to right
Traumatic aortic rupture
Treatment SURGICAL REPAIR
Traumatic diaphragmatic rupture
Blunt trauma - tears leading to
immediate herniation
Penetrating trauma - small tears
which may take years to develop
herniation
Usually on left side
Traumatic diaphragmatic rupture
Treatment - surgical repair
Tracheobronchial tree injury
Larynx - rare
 hoarseness
 subcutaneous
emphysema
 palpable crepitus
Intubation may be difficult
 tracheostomy
(not cricothyroidotomy) is
treatment of choice
Tracheobronchial tree injury
Trachea
 blunt
or penetrating
 esophagus, carotid
artery and jugular
vein may be involved
 noisy breathing 
partial airway
obstruction
Tracheobronchial tree injury
Bronchus
 rare
and lethal
 usually BLUNT
trauma within
one inch of
carina
Esophageal trauma
Most commonly penetrating
May be lethal if not recognized
High suspicion if
 left
pneumothorax and hemothorax
without rib fracture
 shock out of proportion to apparent
blunt chest trauma
 particulate matter in chest tube
Esophageal trauma
If blunt trauma, linear tear in lower
esophagus with leakage of stomach
contents into mediastinum
6 Other Frequent Injuries
Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures
Subcutaneous emphysema
“Rice Krispies”
May result from
 airway
injury
 lung injury
 blast injury
No treatment
required - address underlying
problem
Traumatic asphyxia
“Masque ecchymotique” - purple face
from extravasation of blood
 Major damage is to underlying
structures
Purple face fades over time in
survivors
Simple pneumothorax
Air enters potential space between
visceral and parietal pleura
Breath sounds down on affected side
Percussion shows hyper-resonance
Treatment: chest tube in 4th or 5th
intercostal space anterior to midaxillary line
Hemothorax
Lung laceration OR disruption of
intercostal artery or internal
mammary artery
Most are self-limiting
Surgical consultation for
 initial
flow of >20 cc/kg (~1500 cc)
 continued flow of >200 cc/hr
Scapula fractures
Fractures of scapula or 1st & 2nd ribs
may indicate major mechanism of
injury
Rib fractures
Ribs - most frequently injured part of
thoracic cage
Most commonly injured - 4th  9th
If 10th/11th/12th, be suspicious for
liver or spleen injuries
If 1st/2nd/3rd, worry about injury to
head, neck, spinal cords, lungs, and
great vessels
Rib frac
tures
Treatment consists of…
 intercostal
blocks
 epidural anesthesia
 systemic analgesics
Contraindications include…
 taping
 rib
belts
 external splints
In conclusion...
Chest trauma is very common in the
multi-injured patient
Airway management and a judiciously
placed needle can save many lives
Trauma Code: ETA 5 minutes
Stick with the basics - remember ABC’s
Constantly re-evaluate patient not lab’s
Don’t raise your voice - remain calm
You are not alone, consult the experts
 don’t get in over your head
 Take a step back  What are you missing ?
 What did you overlook ?
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Questions