Self Explanatory.

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Thoracic Trauma

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Overview
Major signs and symptoms
• Immediate life-threatening injuries
Pathophysiology and management
• Open pneumothorax
• Tension pneumothorax
• Massive hemothorax
• Flail chest
• Cardiac tamponade
Cardiac involvement with blunt injury
Other thoracic injuries
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Thoracic Trauma
Thoracic injury is common.
• 50% of multiple trauma
• 25% of trauma deaths
Potentially fatal thoracic injuries saved by
rapid recognition and intervention.
• Many require surgical intervention
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Chest Anatomy
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Mechanism of Injury
Blunt
• Direct compression
 Fracture of solid organs
 Blowout of hollow organs
• Deceleration forces
Tearing of organs and blood vessels
• Direct trauma to organ and vasculature
• Energy transmitted from mass and velocity
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Tissue Hypoxia
Inadequate oxygen delivery
Hypovolemia
Ventilation/perfusion mismatch
Pleural pressure changes
Pump failure
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Thoracic Trauma
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 Shortness of breath
 Chest pain
 Hemoptysis (the
coughing up of blood
from the respiratory
tract)
 Cyanosis
 Neck veins distended
 Tracheal deviation
 Asymmetrical
movement
Signs and symptoms
Thoracic Trauma -
 Chest wall contusion
 Open wounds
 Subcutaneous emphysema
 Shock
 Tenderness, instability,
crepitation (TIC)
 Breath sounds abnormal

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Primary Survey
“Deadly Dozen”
1. Airway obstruction
2. Open pneumothorax
3. Flail chest
4. Tension pneumothorax
5. Massive hemothorax
6. Cardiac tamponade
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Secondary Survey
“Deadly Dozen”
7. Myocardial contusion
8. Traumatic aortic rupture
9. Tracheal or bronchial tree injury
10. Diaphragmatic tears
11. Esophageal injury
12. Pulmonary contusion
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Primary “Deadly Dozen”
Airway obstruction
• Secondary hypoxia
 Common cause of preventable death
 Foreign body, tongue, aspiration
• Always assume cervical spine injury
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Open pneumothorax
• “Sucking chest wound”
Air enters pleural space
Ventilation impaired
Hypoxia results
• Signs and symptoms
Proportional to size of
defect
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Primary “Deadly Dozen”

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Open pneumothorax
• “Sucking chest wound”
 Air enters pleural space
 Ventilation impaired
 Hypoxia results
• Signs and symptoms
 Proportional to size of defect
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Primary “Deadly Dozen”

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Open pneumothorax
• Close chest wall defect
• Load-and-go
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Primary “Deadly Dozen”

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Flail chest
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Primary “Deadly Dozen”

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Flail chest
• Assist ventilation
• Load-and-go
• Stabilize flail segment
• Monitor for:
 Pulmonary contusion
 Hemothorax
 Pneumothorax
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Primary “Deadly Dozen”

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Tension pneumothorax
• Dyspnea
• Anxiety
• Tachypnea
• Distended neck veins
• Tracheal deviation (rare)
• Breath sounds diminished
 Hypertympany if percussed
• Shock with hypotension
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Primary “Deadly Dozen”

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Massive hemothorax
• Anxiety and confusion
• Neck veins
 Flat: hypovolemia
 Distended:
mediastinal compression
• Breath sounds decreased
 Hypotympany if percussed
• Shock
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Primary “Deadly Dozen”

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Massive hemothorax
• Load-and-go
• Treat for shock
• Monitor for:
 Hemopneumothorax
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Primary “Deadly Dozen”

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Cardiac tamponade
• Beck’s triad
 Hypotension
 Neck veins distended
 Heart sounds muffled
• Paradoxical pulse
• Breath sounds equal
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Primary “Deadly Dozen”

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Cardiac tamponade
• Load-and-go
• Treat for shock
• Monitor
• Monitor for:
 Hemothorax
 Pneumothorax
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Primary “Deadly Dozen”

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Secondary “Deadly Dozen”
Myocardial contusion
•Most common cardiac injury
 Blunt anterior chest injury
• Same as myocardial infarction
 Chest pain
 Dysrhythmias
 Cardiogenic shock (rare)
• Treat as cardiac tamponade
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Secondary “Deadly Dozen”
Traumatic aortic rupture
•Most common cause of immediate death
 Motor-vehicle collisions or falls from heights
 90% die immediately
• Scene Size-up and history extremely important
 No obvious sign of chest trauma
 Hypertension in upper extremities
and hypotension in lower extremities (rare)
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Secondary “Deadly Dozen”
Tracheal or bronchial tree injury
•Subcutaneous emphysema (Subcutaneous emphysema can
often be seen as a smooth bulging of the skin. When a medic palpates the skin, an
unusual crackling sensation can be felt as the gas is pushed through the tissue)
 Chest, face, neck
• Ensure adequate airway
• Monitor for:
 Pneumothorax
 Hemothorax
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Secondary “Deadly Dozen”
Diaphragmatic tear (a tear of the diaphragm, the muscle across the
bottom of the ribcage that plays a crucial role in respiration)
• Severe blow to abdomen
• Herniation of abdominal organs
 More common on left
 Breath sounds diminished
 Bowel sounds auscultated in chest (rare)
 Abdomen appears scaphoid
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Secondary “Deadly Dozen”
Esophageal injury
• Penetrating trauma
• Difficult to assess in field
• If unrecognized, may be lethal
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Secondary “Deadly Dozen”
Pulmonary contusion
• Common from blunt trauma
• Hours to develop
• Marked hypoxemia
Impaled object
• Do not remove
• Gently stabilize object
• Avoid movement
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Other Chest Injuries
Traumatic asphyxia
• Severe compression
• Ruptures capillaries
 Cyanosis above crush
 Swelling of head, neck
 Swollen tongue, lips
 Conjunctival hemorrhage
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Other Chest Injuries
Simple pneumothorax
• Fractured ribs
• Pleuritic chest pain
• Dyspnea
• Decreased breath sounds
• Hypertympany if percussed
• Monitor for:
 Tension pneumothorax
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Other Chest Injuries
Sternal fracture
• Significant blunt trauma to anterior chest
• Signs of fracture on palpation
• Myocardial contusion presumed
Simple rib fracture
• Most frequent chest injury
• Monitor for:
 Pneumothorax
 Hemothorax
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Summary
Chest injuries common
Often life-threatening
• Require prompt recognition
• Require prompt intervention
• Frequently require load-and-go
Airway and oxygenation always priority
Frequent Ongoing Exams
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Discussion
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