6. Penetrating trauma.Penetrating trauma.
– GSW or stab woundsGSW or stab wounds
– Concentrates forces overConcentrates forces over
smaller areasmaller area
– Bullet trajectoriesBullet trajectories
unpredictableunpredictable
Determine the MOIDetermine the MOI
7. Determine the MOI cont.Determine the MOI cont.
Blunt trauma.Blunt trauma.
– Force distributed over largerForce 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
15. Assess the Chest WallAssess the Chest Wall
Compare bothCompare both
sides of thesides of the
chest at thechest at the
same time whensame time when
assessing forassessing for
asymmetry.asymmetry.
16. Chest PhysiologyChest Physiology
Chest normally has negative pressure.Chest normally has negative pressure.
Penetrating wound creates a positivePenetrating wound creates a positive
pressure in chest cavity.pressure in chest cavity.
Air will enter the easiest route. If aAir will enter the easiest route. If a
hole in the chest is smaller than 2/3hole in the chest is smaller than 2/3
the size of the trachea, air will enterthe size of the trachea, air will enter
through the trachea preferentially andthrough the trachea preferentially and
not through the hole in the chest.not through the hole in the chest.
19. Rib FractureRib Fracture
11.. Most common chest wall injury fromMost common chest wall injury from
direct traumadirect trauma
2.More common in adults than2.More common in adults than
childrenchildren
3.Especially common in elderly3.Especially common in elderly
4.Most commonly 5th - 9th ribs4.Most commonly 5th - 9th ribs
20. Rib FractureRib Fracture
Rib Fracture Fractures of 1st and 2ndRib Fracture Fractures of 1st and 2nd
second require high forcesecond require high force
Frequently have injury to aorta orFrequently have injury to aorta or
bronchibronchi
Occur in 90% of patients withOccur in 90% of patients with
tracheobronchial rupturetracheobronchial rupture
21. Rib FractureRib Fracture
Rib Fracture Fractures of 10 to 12thRib Fracture Fractures of 10 to 12th
ribs can cause damage to underlyingribs can cause damage to underlying
abdominal solid organs:-abdominal solid organs:-
1 Liver1 Liver
2.Spleen2.Spleen
3.Kidneys3.Kidneys
22. Rib FractureRib Fracture
Assessment Findings:-Assessment Findings:-
1.Localized pain, tenderness1.Localized pain, tenderness
2.Increases on palpation or when2.Increases on palpation or when
patient:patient:
Coughs ,Moves , Breathes deeplyCoughs ,Moves , Breathes deeply
3.Splinted Respirations3.Splinted Respirations
23. Rib FractureRib Fracture ManagementManagement
High concentration O2High concentration O2
Positive pressure ventilationPositive pressure ventilation
Encourage pt to breath deeplyEncourage pt to breath deeply
Analgesics for isolated traumaAnalgesics for isolated trauma
Non-circumferential splintingNon-circumferential splinting
24. Flail ChestFlail Chest
The breaking of 2The breaking of 2
or more ribs in 2or more ribs in 2
or more placesor more places
26. S/S of Flail ChestS/S of Flail Chest
Shortness of BreathShortness of Breath
Paradoxical MovementParadoxical Movement
Bruising/SwellingBruising/Swelling
Crepitus( Grinding of bone ends onCrepitus( Grinding of bone ends on
palpationpalpation
27. Treatment of Flail ChestTreatment of Flail Chest
ABC’s with c-spine control asABC’s with c-spine control as
indicatedindicated
High Flow oxygenHigh Flow oxygen
Monitor Patient for signs ofMonitor Patient for signs of
Pneumothorax or TensionPneumothorax or Tension
PneumothoraxPneumothorax
Use Gloved hand as splint till bulkyUse Gloved hand as splint till bulky
dressing can be put on patientdressing can be put on patient
28. Bulky Dressing for splint of FlailBulky Dressing for splint of Flail
ChestChest
Use Trauma bandageUse Trauma bandage
and Triangularand Triangular
Bandages to splint ribs.Bandages to splint ribs.
29. Simple/Closed PneumothoraxSimple/Closed Pneumothorax
Opening in lungOpening in lung
tissue that leaks airtissue that leaks air
into chest cavityinto chest cavity
Blunt trauma isBlunt trauma is
main causemain cause
May beMay be
spontaneousspontaneous
Usually selfUsually self
correctingcorrecting
30. S/S of Simple/Closed PneumothoraxS/S of Simple/Closed Pneumothorax
Chest PainChest Pain
DyspneaDyspnea
TachypneaTachypnea
Decreased Breath Sounds onDecreased Breath Sounds on
Affected SideAffected Side
31. Treatment for Simple/ClosedTreatment 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 transportIf not contraindicated transport
in semi-sitting positionin semi-sitting position
Provide supportive careProvide supportive care
32. Open PneumothoraxOpen Pneumothorax
Opening in chestOpening in chest
cavity that allowscavity that allows
air to enter pleuralair to enter pleural
cavitycavity
Causes the lung toCauses the lung to
collapse due tocollapse due to
increased pressureincreased pressure
in pleural cavityin pleural cavity
38. S/S of Open PneumothoraxS/S of Open Pneumothorax
DyspneaDyspnea
Sudden sharp painSudden sharp pain
Subcutaneous EmphysemaSubcutaneous Emphysema
Decreased lung sounds on affectedDecreased lung sounds on affected
sideside
Red Bubbles on Exhalation fromRed Bubbles on Exhalation from
woundwound
39. Subcutaneous EmphysemaSubcutaneous Emphysema
Air collects in subcutaneous fatAir collects in subcutaneous fat
from pressure of air in pleuralfrom pressure of air in pleural
cavitycavity
Feels like rice crispies or bubbleFeels like rice crispies or bubble
wrapwrap
Can be seen from neck to groinCan be seen from neck to groin
areaarea
42. Open PneumothoraxOpen Pneumothorax Management:Management:
Ensure an open airwayEnsure an open airway
Close the chest wall defect, bothClose the chest wall defect, both
entrance and exit with an occlusiveentrance and exit with an occlusive
dressing, petrolatum gauze or Ashermandressing, petrolatum gauze or Asherman
Chest SealChest Seal®®
Place the casualty in the sitting positionPlace the casualty in the sitting position
Monitor respirations after an occlusiveMonitor respirations after an occlusive
dressing is applieddressing is applied
43. Open PneumothoraxOpen Pneumothorax
Petroleum Gauze can also be used to sealPetroleum Gauze can also be used to seal
a sucking chest wound.a sucking chest wound.
45. Tension PneumothoraxTension Pneumothorax
Air builds in pleural space withAir builds in pleural space with
no where for the air to escapeno where for the air to escape
Results in collapse of lung onResults in collapse of lung on
affected side that results inaffected side that results in
pressure on mediastium,thepressure on mediastium,the
other lung, and great vesselsother lung, and great vessels
49. S/S of Tension PneumothoraxS/S of Tension Pneumothorax
Anxiety/RestlessnessAnxiety/Restlessness
Severe DyspneaSevere Dyspnea
Absent Breath sounds on affectedAbsent 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)
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 withPenetrating chest wound with
progressive respiratory distressprogressive respiratory distress
54. Needle Chest DecompressionNeedle Chest Decompression
Procedure:Procedure:
Identify the second ICS on theIdentify 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 bea" hiss of air” may be
heard escaping from theheard escaping from the
chest cavity.chest cavity.
Remove the needle, leave the catheterRemove the needle, leave the catheter
in place.in place.
56. Needle Chest DecompressionNeedle Chest Decompression
Insert a 14 ga. Catheter atInsert a 14 ga. Catheter at
aa
9090°° angle over the topangle over the top
ofof
the 3the 3rdrd
rib, into the 2rib, into the 2ndnd
ICSICS
at the MCL.at the MCL.
Needle should be longNeedle should be long
enough to enter theenough to enter the
57. HemothoraxHemothorax
Occurs when pleural space fillsOccurs when pleural space fills
with blood .Usually occurs due towith blood .Usually occurs due to
lacerated blood vessel in thoraxlacerated blood vessel in thorax
As blood increases, it puts pressureAs blood increases, it puts pressure
on heart and other vessels in cheston heart and other vessels in chest
cavitycavity
Each Lung can hold 1.5 liters ofEach Lung can hold 1.5 liters of
bloodblood
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 onDiminished Breath Sounds on
Affected SideAffected Side
TachycardiaTachycardia
63. Treatment of HaemothoraxTreatment of Haemothorax
Establish airway HighEstablish airway High
concentration O2concentration O2
Drainage by chest tubeDrainage by chest tube
ThoracotomyThoracotomy
66. Complications of Chest DrainageComplications of Chest Drainage
tubetube
HemorrhageHemorrhage
Damage to intercostal vesselsDamage to intercostal vessels
and nervesand nerves
Lung and mediastinal injuryLung and mediastinal injury
InfectionInfection
67. Indications of thoracotomyIndications of thoracotomy
In pneumothoraxIn pneumothorax
1.continuing air leak for more1.continuing air leak for more
than 7 daysthan 7 days
2.massive air leak suggesting2.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 11. massive bleeding more than 1
Ltr.statLtr.stat
2. continuing bleeding more2. continuing bleeding more
than 200 Ml/hr over 3 hrsthan 200 Ml/hr over 3 hrs
3.brisk bleeding more than 1003.brisk bleeding more than 100
Ml every 15 min for 1 hrMl every 15 min for 1 hr
69. Pericardial TamponadePericardial Tamponade
Blood and fluidsBlood and fluids
leak into theleak into the
pericardial sacpericardial sac
which surroundswhich surrounds
the heart.the heart.
As the pericardialAs the pericardial
sac fills, it causessac fills, it causes
the sac to expandthe sac to expand
until it cannotuntil it cannot
expand anymore
pericardial sac
70. Pericardial TamponadePericardial Tamponade
Once the pericardialOnce the pericardial
sac can’t expandsac can’t expand
anymore, the fluidanymore, the fluid
starts puttingstarts putting
pressure on the heartpressure on the heart
Now the heart can’tNow the heart can’t
fully expand and can’tfully expand and can’t
pump effectively.pump effectively.
71. Pericardial TamponadePericardial Tamponade
Once the pericardialOnce the pericardial
sac can’t expandsac can’t expand
anymore, the fluidanymore, the fluid
starts puttingstarts putting
pressure on the heartpressure on the heart
Now the heart can’tNow the heart can’t
fully expand and can’tfully expand and can’t
pump effectively.pump effectively.
74. PericardiocentesisPericardiocentesis
Using aseptic technique, Insert at leastUsing aseptic technique, Insert at least
3” needle at the angle of the Xiphoid3” needle at the angle of the Xiphoid
Cartilage at the 7Cartilage at the 7thth
ribrib
Advance needle at 45 degree towardsAdvance needle at 45 degree towards
the clavicle while aspirating syringe tillthe clavicle while aspirating syringe till
blood return is seenblood return is seen
Continue to Aspirate till syringe is fullContinue to Aspirate till syringe is full
then discard blood and attempt againthen 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 inBurning 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/pDecreased 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 AorticTreatment of Traumatic Aortic
RuptureRupture
ABC’s with c-spine control asABC’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 AsContact Hospital and ALS Unit As
soon as possiblesoon as possible
79. Traumatic AsphyxiaTraumatic Asphyxia
Results from suddenResults from sudden
compression injury to chestcompression injury to chest
cavitycavity
Can cause massive rupture ofCan cause massive rupture of
Vessels and organs of chestVessels 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 ofReddish-purple discoloration of
face and neckface and neck
PetechiaePetechiae
81. Treatment for Traumatic AsphyxiaTreatment for Traumatic Asphyxia
ABC’s with c-spine control asABC’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 thatA tear in the Diaphragm that
allows the abdominal organs enterallows the abdominal organs enter
the chest cavitythe chest cavity
More common on Left side due toMore common on Left side due to
liver helps protect the right side ofliver helps protect the right side of
diaphragmdiaphragm
Associated with multiple injuryAssociated with multiple injury
patientspatients
84. S/S of Diaphragmatic RuptureS/S of Diaphragmatic Rupture
Abdominal PainAbdominal Pain
Shortness of AirShortness of Air
Decreased Breath Sounds onDecreased Breath Sounds on
side of ruptureside of rupture
Bowel Sounds heard in chestBowel Sounds heard in chest
cavitycavity
85. Treatment of DiaphragmaticTreatment of Diaphragmatic
RuptureRupture
ABC’s with c-spine control asABC’s with c-spine control as
indicatedindicated
High Flow oxygenHigh 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 ofIndications of mmedianedian
sternotomysternotomy
Surgery forSurgery for
1.thymus1.thymus
2.heart and great vessels2.heart and great vessels
3.both pleural sac3.both pleural sac
89. Posterolateral thoracotomyPosterolateral thoracotomy
An incision is made in the bedAn incision is made in the bed
of the 5th rib (5th intercostalsof the 5th rib (5th intercostals
space).space).
Used mainly for hilum and lungUsed mainly for hilum and lung
surgery eg.pneumonectomysurgery eg.pneumonectomy