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Penetrating chest trauma it's prognosis and management
1. Penetrating Chest Wounds,
Pneumothorax, Tension
Pneumothorax and Hemothorax
Gary L. Weinstein M.D.
Director of Pulmonary
and Critical Care
Medicine
Presbyterian Hospital of
Dallas
September 14, 2006
2. Normal Physiology
Breathing
• Inspiration –
– The diaphragm contracts and moves downward
enlarging the chest cavity
– And the rib muscles contract, widening the chest
cavity causing air to fill the lungs through suction.
• Expiration- The diaphragm and rib muscles then
relax, decreasing the chest size and forcing air
out of the lungs.
4. Penetrating Chest Wounds
• Anything that disrupts
these normal
relationships can cause
problems
– A hole in the chest, lets
air collect in the
pleural space
10. Pneumothorax
• Pneumothorax - air gets
between your lungs and
your chest wall and the
lung collapses.
• Normally, two thin layers
of tissue (pleura) separate
the lung and chest wall.
• Any air that leaks into this
space (pleural space) will
cause the lung to collapse..
11. Pneumothorax
• Air can collect inside
the chest for many
reasons, such as:
– An injury that
damages the chest
wall, such as a stab or
gunshot wound
– A broken rib that
punctures the lung
12. Pneumothorax
• Signs and symptoms
of a pneumothorax
include:
– Sudden, sharp chest
pain
– Shortness of breath
– Chest tightness
– Rapid pulse
– Rapid, shallow breaths
16. Tension Pneumothorax
• If air continues to enter the
pleural space, a tension
pneumothorax occurs.
• The air may compress the heart
and cause a fall in B.P.
• This is life-threatening and
requires immediate treatment to
release the pressure.
• Treatment can life-saving.
17. Tension Pneumothorax
Symptoms of a tension
pneumothorax may
include:
• Shift of the trachea
•Loss of
consciousness
•Sweating
•Gasping
•Shock
•Rapid HR
18. Hemothorax
• Blood can also collect
in the pleural space
and cause all the same
signs and symptoms
and problems as a
pneumothorax
including a tension
hemothorax
19. Classical physical examination
findings:
The size of the injury, and position of the patient will affect the
clinical findings. For example, a small hemothorax may have
no clinical signs at all. A moderate hemothorax will be dull to
percussion with absent breath sounds at the bases in the erect
patient, whereas signs will be posterior in the supine patient.
This is also reflected in chest X-ray findings.
20. Assesment of patient with Blunt or
Penetrating chest trauma
Look
• Determine the respiratory rate and depth
Look for chest wall asymmetry. Paradoxical chest wall motion
Look for bruising, seat belt or steering wheel marks, penetrating wounds
Feel
• Feel the trachea for deviation
Assess whether there is adequate and equal chest wall movement
Feel for chest wall tenderness or rib 'crunching' indicating rib fractures
Feel for subcutaneous emphysema
Listen
• Listen for normal, equal breath sounds on both sides.
Listen especially in the apices and axillae and at the back of the chest (or as far as you
can get while supine).
Percuss
• Percuss both sides of the chest looking for dullness or resonance (more difficult to
appreciate in the trauma room).
21. Trachea Chest expansion Breath Sounds Percussion
Tension Away Decreased; Diminished or Hyper-resonant
Pnuemothorax Chest may be absent
fixed in
hyperexpansion
Simple Midline Decreased May be May be hyper-
Pneumothorax diminished resonant; Usually
normal
Hemothorax Midline Decreased Diminished if Dull, especially
large; Normal posteriorly
if small
Pulmonary Midline Normal Normal; May Normal
Contusion have crackles
Lung Collapse/ Towards Decreased May be Normal
Atelectasis reduced
Physical Exam in Chest Trauma
32. Suction Systems
A - Suction Port/Connection
C - Water Seal Fill Port
G - Suction Setting
I -
J - Collection
Chamber
K - Suction Indicator
L - Chest Tube Connector
33. Take Home Points
•Simple Pneumothorax/Hemothorax should be expected
with penetrating chest wounds and rarely kills
•Tension pneumothorax can occur rapidly
•Tension pneumothorax can KILL rapidly
•Treatment SAVES lives
•Needle decompression will never harm and may
SAVE A LIFE!!
34. Questions?????
Drs Kumar and Weinmeister want
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