A ppt prepared by Morriyam. Contains clear discriptions about chest trauma

1. KOTEBE METROPOLITAN UNIVERSITY
COLLEGE OF MENELIK II MEDICAL & HEALTH
SCIENCE
DEPARTMENT OF EMERGENCY & CRITICAL CARE
DEC.2018 G.C.

2. 10/21/2022 2
SEMINAR ON; CHEST TRAUMA
BY MORRIYAM MENGIST /3rd YEAR ECCN/

3. 10/21/2022 3
MODERATOR
 Mr. ADUGNA C. / Msc IN EM & CC/
ASSESOR
 Mr. NEWAY G. / Msc IN EM & CC/

4. 10/21/2022 4
OUTLINE
Objectives
Introduction
 Definition
Concept of initial ass’t
Mechanisms of injury
Ass’t & mgt of immediately life threatening injuries
Summary
References

5. 10/21/2022 5
Objective
At the end of the session, the students will be able to:
- Define chest trauma
- Explain mechanisms of injury
-Identify life-threatening chest injuries found during the primary
survey.
-
-Treat these immediately life threatening chest injuries.

6. 10/21/2022 6
Case scenario
A 34 yrs old man sustain MVC while he was riding a bicycle against with
Sino truck at 7:30. He arrived at Aabet Hospital post two hours with
streture. On arrival he is conscious.
P/e – v/s, BP= 80/55 mmhg, PR= 112b/m, RR= 28b/m, sp02=86% at room
air, GCS= 15. RBS= 105mg/dl.
Inspection- there is laceration over the chest wall with flat jagular
vein and with normal and symmetrical chest movement both on inspiration
& expiration.

7. 10/21/2022 7
Palpation- There is no any criptus over the chest wall with normal
tracheal alignment .
On Percussion- there is resonant sound over the chest and tympanic on
the abdomen.
An auscultation- There is normal air entry over the chest wall with
reduced heart sound but no murmur or gallop.
An EKG shows reduced amplitude of the waves.

8. 10/21/2022 8
Based on the case
 what will be the possible dx?
 what is your approach for those patient?
what will be your specific management?

9. 10/21/2022 9
INTRODUCTION
The chest wall, defined here as the bony and muscular structures
covering the entire thoracic cavity, protects internal thoracic organs (heart
and lungs), mediastinal structures (esophagus and trachea), and major
vasculature (aorta and vena cava).
Damage to the chest wall may coincide with significant injury to certain of
these internal structures and thus, warrants careful evaluation.

10. 10/21/2022 10
Definition
A chest trauma is any form of physical injury to the chest including
the ribs ,heart , great vessel, lungs & esophagus.
 Chest injuries are potential life threatening because of the immediate
disturbance of the cardio respiratory physiology and hemorrhage and later
developments of infection, damaged lungs etc.

11. 10/21/2022 11
Anatomy and physiology
The rib cage, intercostal muscles, and costal cartilage form the basic
structure of the chest wall.
In addition, neurovascular bundles comprised of an intercostal nerve,
artery, and vein run along each rib.
 The inner lining of the chest wall is the parietal pleura.
.

12. 10/21/2022 12
Anatomy & physiology con’t….
Visceral pleura covers the major thoracic organs.
Between the two is a potential space with a small amount of lubricating
fluid.
The anterior chest wall also contains the sternum and pectoralis
major and minor muscles, as well as the clavicle at its superior border.
Posteriorly, the scapula provides added protection to the superior thorax

13. 10/21/2022 13
Anatomy & physiology con’t….
The chest wall has two important functions:
To assist in the mechanics of respiration and
To protect the intra thoracic organs.
Adequate ventilation is accomplished by creating negative intra thoracic
pressure during inspiration and positive pressure during expiration.

14. 10/21/2022 14
Anatomy & physiology con’t….
During inspiration, a combination of diaphragmatic excursion and
contraction of the inter costal muscles to raise the ribs which increases
intra thoracic volume and decreases intra thoracic pressure, which then
pulls air passively into the lungs.
In expiration, this process is reversed: all the muscles relax and
intra thoracic pressure passively increases and volume decreases, forcing
air out of the lungs

15. 10/21/2022 15
Anatomy & physiology con’t….
The mediastinum is an anatomic division of the thorax extending from the
diaphragm inferiorly to the thoracic inlet superiorly.
Its borders include the sternum anteriorly, the vertebral column posteriorly,
and the parietal pleura laterally.
Contained within the mediastinum are the heart, aorta, trachea, and
esophagus.
 Injuries to any of these structures are potentially life-threatening. One
lung is located lateral to each side of the mediastinum.

16. 10/21/2022 16

17. 10/21/2022 17

18. 10/21/2022 18
Mechanisms of injury
1) Blunt chest trauma
 Most common cause of serious chest injuries
- RTA, falls, direct blows, crushing injuries.
2) Penetrating trauma.
 Immediate result can be severe bleeding or
impaired breathing.
•Injuries to the heart, lungs, and great vessels
•can quickly lead to shock and cardiac arrest.
10/21/2022 18

19. 10/21/2022 19
 Immediate life threatening injuries
 Injuries that can cause death in a matter of minutes and, therefore,
must be identified and treated during the primary evaluation and
resuscitation.
Chest injuries can be divided into
•Immediate life threatening injuries
•Potentially life threatening injuries

20. 10/21/2022 20
Immediate life threatening injuries includes
Airway obstruction/ laryngeo tracheal injury.
Open pneumothorax.
Managed at primary survey
Tension pneumothorax (it is our focus )
Massive hemothorax.
Cardiac tamponade.
Flail chest.
con’t….

21. 10/21/2022 21
con’t….
Potentially life threatening injuries
Pulmonary contusion.
Myocardial contusion.
Aortic disruption.
Managed at secondary survey
Traumatic diaphragmatic rupture.
Tracheo bronchial disruption.
Esophageal disruption.

22. 10/21/2022 22
PATHOPHYSIOLOGY
Blunt & / penetrating chest injured
injury to the tissues themselves effect of hampered ventilation
oxygen supply
to meet the
increased
metabolic
demands after
trauma cannot
be met
supply-demand mismatch
Hypotension, hypoxia and acidosis, exacerbating all other injuries.

23. 10/21/2022 23
General management of trauma
As in any patient with trauma, the evaluation and treatment of chest
trauma patient is based on ATLS protocol. These include:
1. Primary Survey and resuscitation (ABC of life)
2. Secondary survey/ sample/
3. Definitive management

24. 10/21/2022 24
con’t….
The Primary Assessment constitutes the basis of trauma care and
adheres to the following sequence: ABCDE
A- Asses and manage the airway, apply C-collar
Ensure airway is adequate
 Open air way using jaw thrust
Insert the adjuncts/OPA, NPA/ if necessary
 Suction the air way if there is any secretion
Intubate the patient if necessary

25. 10/21/2022 25
B- asses and manage breathing.
 Asses RR, SP02,lung sounds, chest symmetry, cyanosis color etc.
 OR you can use L= Look chest raise
L=Listen for air escape
F= Feel the air
 Adequate supplemental oxygen using either non invasive
method or put on mechanical ventilation depend on the cause and severity
of the illness.

26. 10/21/2022 26
con’t….
During Assessing the trauma patient’s breathing aims at identifying
thoracic injuries that will cause rapid respiratory failure.
These include
• tension pneumothorax,
•open pneumothorax,
•massive haemothorax
•flail chest.

27. 10/21/2022 27
C= asses and manage circulation
 Asses temperature, PR, BP, UOP, capillary refill time
 mental status change for organ perfusion /brain/
 Open IV line & send sample
 Maintain adequate circulation status by administering
fluids depend up on patient status.
During assessing of circulation, cardiac tamponade must be rule out as it
is life threatening injury which affect circulation

28. 10/21/2022 28
D= asses neurology/ disability/
 Asses consciousness using time, place and person.
 Asses mental status change using
- AVPU
- GCS
 RBS
 Anti pain

29. 10/21/2022 29
E- Expose and evaluate for hidden injuries
- Prevent hypothermia

30. 10/21/2022 30
ADJUVANTS TO PRIMARY SURVEY
1) Imaging: X-ray of the chest / pelvis / cervical and thoraco lumbar spine
should always be performed, and make sure that the films are checked
thoroughly by an experienced enough person. For the cervical spine the
minimum requirement is a lateral film that shows all seven cervical
vertebrae and T1.

31. 10/21/2022 31
con’t….
2) Take blood for
a. Cross match of urgent blood products;
b. Electrolytes, basic haematology, clotting screen, arterial blood gases,
serum amylase or lactate: when resources are limited these should not be
done routinely but ask what the clinical usefulness of each result will be in
this patient;
c. Blood cultures (or pus for gram stain and culture) if the patient is septic.

32. 10/21/2022 32
con’t….
3) Urine catheter, but always check for possible urethral injury first.
4) Severely injured patients at risk of rapid exsanguination might need
emergency damage control surgery as part of resuscitation.

33. 10/21/2022 33
Check list for trauma patient mgt
Did I complete primary survey (ABCDE)?
 Have I completed resuscitation?
-O₂?
-IV fluids?
- Blood
Did I complete secondary assessment?
-History (Reports)?
-Complete physical examination?
-Chart review (Vital signs, Fluid balance, Drugs)
- Results?

34. 10/21/2022 34
Con’t…
Is my patient…
 STABLE?
UNSTABLE?
Am I unsure?
 Is the problem…
Diagnostic
Therapeutic
 Both
Do I need to intervene…
 Diagnostic?
 Therapeutic?
Ask for help

35. 10/21/2022 35
Laryngeo tracheal injury/Airway obstruction/
Airway obstruction can be a primary problem or the result of other injury.
The most common causes of airway obstruction are the tongue, avulsed
teeth, dentures, secretions, and blood.
It includes damage to the trachea & bronchi, which can result from:
-trauma to the neck or chest,
-inhalation & aspiration.
- maxillofacial injuries
- oropharyngeal injuries

36. 10/21/2022 36
S & S
Anxiety, hoarseness, stridor,
 Hypoventilation, apnea,
 Use of accessory muscles,
Altered mental status, and cyanosis.

37. 10/21/2022 37
RX
 Establish a patent airway with c.collar
Jaw thrust
Remove foreign bodies
Suction for secretion
Insert an airway
ETT
Tracheostomy
O2

38. 10/21/2022 38
Open Pneumothorax(sucking chest wound)
An injury in which an open wound in the chest wall has exposed
pleural space to atmosphere.
The open wound allows air mov`t through the defect during
spontaneous respiration, causing ineffective alveolar ventilation.
 The atmospheric & intra thoracic pressure is equal which leads to in
effective ventilation , results in hypoxia and hypercarbia.

39. 10/21/2022 39
S & S
difficulty breathing/severe dyspnea
Respiratory distress
Frothy blood at wound site
Hypovolemia , cyanosis
Diminished breath sounds

40. 10/21/2022 40
Diagnostic evaluation
 C/M
Physical examination
Ultrasound
Chest X-ray
CT/MRI

41. 10/21/2022 41
Mgt
Assess & manage ABCDEs
Three sided Cover with occlusive dressing
Transport with unaffected side slightly elevated
Insertion of a thoracostomy tube
 Definitive closure of wound is necessary.

42. 10/21/2022 42
Tension pneumo thorax
One way valve air leak occurs either from the lung or chest wall.(air
forced in to the thoracic cavity without any means of escaping ,completely
collapsing the affected lung )
 Caused by ppv & mis guided
central venous access.

43. 10/21/2022 43
S/ S
Decreased/Absent breath sounds
Shift of trachea
 sed BP, Tachycardia, Tachypnia
Early dyspnea/hypoxia
Late cyanosis & shock

44. 10/21/2022 44
Diagnostic evaluation
History collection
Physical examination
Ultrasound
Chest X-ray
CT/MRI

45. 10/21/2022 45
Mgt
Assess & manage ABCDEs
Rapidly inserting a needle into the 2nd ICS
in the MCL of affected hemi
thorax.
Definitive treatment requires insertion
of chest tube into 5th ICS (nipple
level), anterior to mid-axillary line.

46. 10/21/2022 46
Cardiac Tamponade
Compression of the heart as the result of
accumulation of fluid within the pericardial
space.
Caused by a large or uncontrolled
pericardial effusion, i.e. The build up of fluid
inside the pericardium

47. 10/21/2022 47
Patho-physiology
The outer layer of the heart is made of fibrous tissue which does not easily
stretch, so once fluid begins to enter the pericardial space because of the
etiological factors.
The pressure inside the pericardium starts to increase.
The fluid pressure is applied over the ventricles of the heart. It leads to
decrease in the preload and of the ventricles.
Leading to decreased stroke volume, hypotension and hypovolemic shock

48. 10/21/2022 48
S/ S
 Beck’s triad
Elevated central venous pressure (2-6 mm of Hg/ 2-8 cm of H2O)
Pulses paradoxus (paradoxical pulse, is an abnormally large decrease
insystolic blood pressure and pulse wave amplitude )
Dyspnea, Cyanosis, Hypovolemic shock
 ECG amplitude is decreased.

49. 10/21/2022 49
Diagnostic evaluation
 C/M
Physical examination
ECG- Changes in the ST & QRS complex
Echocardiogram-to identify the accumulation of fluid.
Chest x-ray
CT/MRI
Monitoring CVP

50. 10/21/2022 50
Mgt
 Asses and manage ABCDs
For penetrating trauma, Prepare for emergency thoracotomy to control
bleeding.
Assist in pericardiocentesis.
Monitor CVP
Obtain urinary output hourly to evaluate tissue perfusion.
Continuous ECG monitoring to identify dysrhythmias
In heart surgery patients post op, the nurses monitor the amount of chest
tube drainage.

51. 10/21/2022 51
Needle pericardiocenthesis and chest Thoracotomy

52. 10/21/2022 52
Cardiac Tamponade vs. Tension Pneumothorax
Clinical Sign Cardiac Tamponade Tension Pneumothorax
Blood Pressure Low Low
Cardiac Tones Muffled Normal
Breath Sounds Normal Absent / affected side/
Neck Veins Distended/ flat Distended/ flat
Respirations ± Normal Tachypnia
Treatment Needle/drain Needle/tube chest

53. 10/21/2022 53
Massive Hemothorax
Blood in the pleural space as the result of penetrating or blunt chest
trauma.
This excess blood can interfere with normal breathing by limiting the
expansion of the lungs.
Due to rapid accumulation of blood more
than 1.5L(1/3rd)of total blood volume.

54. 10/21/2022 54
Con’t…
It is most commonly caused by a penetrating wound that disrupts the
systemic vessels.

55. 10/21/2022 55
Patho physiology
Its cause is usually traumatic, from a blunt or penetrating injury to
the thorax.
Resulting in a rupture of the pleural cavity of the lungs and also rupture of
the blood vessels surrounding the lungs .
This rupture allows blood to spill into the pleural space.
Each side of the thorax can hold 30 to 40% of a person's blood volume.

56. 10/21/2022 56
Interfere with the normal movement of the lungs, resulting in dyspnea,
poor ventilation, and abnormal oxygenation, tachypnea
•Cyanosis
•Decreased or absent breath sounds on affected side
•Tracheal deviation to unaffected side
•Unequal chest rise
•Tachycardia

57. 10/21/2022 57
Diagnosis
S/S
 P/E
 X-ray
 U/S
 MRI/ CT

58. 10/21/2022 58
Mgt
Rapid crystalloid infusion and blood
A single chest tube (#38 fr) is inserted at the nipple level, anterior to
mid axillary line/ hemopneumo thorax/
If 1.5L is evacuated, it is highly likely that pt will require an early
thoracotomy.

59. 10/21/2022 59
FLAIL CHEST AND PULMONARY CONTUSION
Loss of stability of chest walls as a result of multiple rib fractures or
combined rib and sternum fractures.
When two or more adjacent ribs #ed at two
or more points.
Allowing freely moving segment of chest
wall to move in paradoxical motion.
Underlying pulmonary contusion is considered
to be the major cause of respiratory insufficiency
with flail chest

60. 10/21/2022 60
Patho physiology
Because of vehicle collisions and falling. Their will a multiple rib fractures
or combined rib and sternum fractures.
When this occurs, one portion of the chest has lost its bony connection to
the rest of the rib cage.
During respiration, the detached part of the chest will be pulled in and
blown out (paradoxial movements)
Normal mechanism of breathing is impaired

61. 10/21/2022 61
It leads to the following signs and symptoms like,
•Dyspnea.
•Cyanosis.
•Fractured ribs are likely to eventually puncture the pleural sac and lung,
possibly causing a pneumothorax.
•Respiratory failure.
•Severe pain during respiration.

62. 10/21/2022 62
DX
- Clinical - P/E
-Chest radiography - Ultrasonography
-Computed tomography -ABG

63. 10/21/2022 63
Mgt
Assess & manage ABCDEs
analgesia
Stabilize flail segment ,fixation, chest physiotherapy
Chest tube, careful fluid mgt
 Definitive Rx- re-expand the lung.

64. 10/21/2022 64
Summary
Chest injuries are potential life threatening because of the immediate
disturbance of the cardio respiratory physiology and hemorrhage and later
developments of infection .
These patients can usually be treated or their conditions temporarily
relieved by relatively simple measures such as intubation, ventilation , tube
thoracostomy, fluid resuscitation and needle pericardiocentesis.
The ability to recognize this important injuries and the skill to perform the
necessary procedures can be life saving.

65. 10/21/2022 65
Reference
 Best Emergency book manual
 upto date 21.6
 Critical care Emergency Medicine
 Tintinalis Emergency Medicine
 Internet power point slide share

66. 10/21/2022 66