1/4

American trauma deaths

Contributes to another 1 of 4
Many die after reaching hospital preventable if recognized
<10% blunt needs surgery
~1/3 penetrating needs surgery
Most life-saving procedures do NOT
require thoracic surgeon

hypovolemia
ventilationperfusion
mismatch
changes in
intrathoracic
pressure
relationships

Inadequate oxygen
delivery to tissues

TISSUE
HYPOXIA

 Tissue

hypoxia
Hypercarbia
Respiratory acidosis: inadequate
ventilation
Metabolic acidosis: tissue
hypoperfusion (e.g., shock)

Splinter

 Airway

obstruction
Tension pneumothorax
Open pneumothorax
sucking chest wound
Massive hemothorax
Flail chest
Cardiac tamponade

 Lung

contusion
Heart contusion
Aorta rupture
Diaphragm rupture
Tracheobronchial tree injury larynx, trachea, bronchus
Esophagus trauma

 Subcutaneous

emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures

Airway
Breathing
Circulation

 Assess

for airway patency and air exchange listen at nose & mouth
Assess for intercostal and supraclavicular
muscle retractions
Assess oropharynx for foreign body
obstruction

 Assess

respiratory movements and quality of

respirations look, listen, feel
Shallow respirations are early indicator of
distress cyanosis is late

 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

 Chest:

listen, do chest x-ray

Abdomen: do DPL or CT or US
Retroperitoneum: do CT
Thigh: physical examination
Street: ask paramedic
...and in children, add
Head

Primary

survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care

 Hypoxia

most serious problem: early

interventions aimed at reversing
Immediate life-threatening injuries treated
quickly and simply, usually with tube or a
needle
Secondary survey guided by high suspicion
for specific injuries

 Closed

heart massage is ineffective in a

hypovolemic patient
Left anterior thoracotomy with crossclamping of descending thoracic aorta and
open-chest massage may be useful in
pulseless victim of penetrating trauma

Emergency department
thoracotomy for patients
without cardiac activity
who are victims of blunt
thoracic injuries is
ineffective

 Airway

obstruction
Tension pneumothorax
Open pneumothorax
sucking chest wound
Massive hemothorax
Flail chest
Cardiac tamponade

 Airway

obstruction at alveolar level: assessed

and managed during 2o survey
Upper airway obstruction immediate life
threat which must be dealt with in primary
survey
Most common cause: patients tongue

 Chin-lift:

fingers
under mandible, lift
forward so chin is
anterior

 Jaw

thrust: grasp angles of mandible and bring jaw

forward

 Oropharyngeal

airway:
insert into mouth behind
tongue
DO NOT push tongue
further back

 Nasopharyngeal

airway: gently insert

well-lubricated
trumpet through
nostril

Definitive Airway
Management: tube
in trachea through
vocal cords with
balloon inflated

 Orotracheal

intubation
Nasotracheal intubation: in breathing patient
without major facial trauma
Surgical airways

jet insufflation
retrograde
cricothyrotomy
tracheostomy

 Air

leak through lung or chest wall

One-way valve lung collapse
Mediastinum shifts to opposite side
Inferior vena cava kinks on diaphragm
decreased venous return cardiovascular
collapse

Inferior vena cava

 Tension

pneumothorax is not an x-ray

diagnosis it MUST be recognized clinically
Treatment is decompression needle into
2nd intercostal space of mid-clavicular line followed by thoracotomy tube

Insert needle here

 Sucking

Chest Wound
Normal ventilation requires negative intrathoracic pressure
Large open chest-wall defect immediate
equilibration of intra-thoracic and
atmospheric pressures
If hole >2/3 tracheal diameter, air prefers
chest defect

 Initial

treatment: seal defect and secure on

three sides (total occlusion may lead to
tension pneumothorax
Definitive repair of defect in O.R.

 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

 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

Chest tube

 Free-floating

chest segment,
usually from multiple ribs
fractures
Pain and restricted movement
paradoxical movement of
chest wall with respiration

 Ventilate

well
Humidify oxygen
Resuscitate with fluids
Manage pain (!!)
Stabilize chest

Internal ventilator
External sand bags (rare)

 Usually

from penetrating injuries

Classic Becks triad

elevated venous pressure - neck veins

decreased arterial pressure - BP
muffled heart sounds

Blood

in sac
prevents cardiac
activity

 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

 Treatment

is removal of
small amount of blood 15
to 20 ml may be sufficient
from pericardial sac

Pericardiocentesis

Stab wound to
right ventricle

pericardium
epicardial fat

The Flock of Birds

behind the heart

Vagoose n.
Azygoose v.
Esophagoose

Thoracic duck

 Pulmonary

contusion
Myocardial contusion
Traumatic aortic rupture (TAR)
Traumatic diaphragmatic rupture
Tracheobronchial tree injury: larynx,
trachea, bronchus
Esophageal trauma

 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

 Patients

with pre-existing conditions

(emphysema, renal failure) need early
intubation
Treatment needs
to occur over time
as symptoms develop

 Blunt

precordial chest
trauma
Difficult to diagnose
Risk for dysrhythmia,
sudden death, tamponade,
pericarditis, ventricular
aneurysm

Also may see:

myocardial concussion stunned
myocardium with no cell death
coronary artery laceration
Diagnosis by:
trans-esophageal echocardiogram (TEE)
serial cardiac enzymes / markers

 Question:

Does it matter?
New nomenclature: Anterior Chest Wall
Syndrome

 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

Radiographic signs
Wide mediastinum
(>8cm)
Fractured 1st & 2nd rib
Obliterated aortic
knob
Trachea deviated to
right
Pleural cap

Elevated

mainstem
bronchus with shift to
right
Obliterated aortic
window
Esophagus shifted to
right (NG at T4)
Depressed left
mainstem bronchus

dye leakage

 CT

becoming imaging of choice

Must know site!
NPV of normal chest x-ray (good quality,
upright): 98% (CT will find mediastinal
hemorrhage in 3%, TAR in 0.4%)
78% of patients with post-traumatic wide
mediastinum on chest film have normal CT

 Treatment

REPAIR

- SURGICAL

 Blunt

trauma: tears leading to immediate

herniation
Penetrating trauma: small tears which may
take years to develop herniation
Usually on left side

 Treatment:

surgical repair

Larynx - rare
Hoarseness
Subcutaneous emphysema
Palpable crepitus
Intubation may be difficult: tracheostomy (not
cricothyroidotomy) is treatment of choice

Trachea
Blunt or penetrating
Esophagus, carotid
artery and jugular
vein may be involved
Noisy breathing
partial airway
obstruction

Bronchus
1.5% blunt chest
trauma
80% due to BLUNT
trauma within one
inch of carina
(tethered)

 Penetrating

> blunt
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

Blunt trauma,
most tears
superior
If low esophagus
leakage of
stomach contents
into mediastinum

Subcutaneous

emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures

 Rice

Krispies
May result from

airway injury
lung injury
blast injury

No

treatment
required address underlying problem

 Purple

face from
extravasation of blood
(Masque ecchymotique)
Major damage is to
underlying structures
Purple face fades over time
in survivors

 Air

enters potential space between visceral

and parietal pleura
Breath sounds down on affected side
Percussion hyper-resonance
Treatment: chest tube in 4th or 5th intercostal
space anterior to mid-axillary line

Medial
pneumothorax

Pocket shooter

 Lacerated

lung OR disrupted intercostal

artery or internal mammary artery
Most are self-limiting
Surgical consultation if
initial drainage of >20 cc/kg (~1500 cc)
continued flow of >200 cc/hr

Fractured scapula
or 1st & 2nd ribs
indicates major
mechanism of
injury; consider
underlying
damage

 Most

frequent thoracic cage injury

Most commonly injured: 4th 9th
If 10th / 11th / 12th suspect liver or spleen
injury
If 1st / 2nd / 3rd worry about injury to head,
neck, spinal cords, lungs, great vessels

Intercostal

blocks
Epidural anesthesia
Systemic analgesics
Do not use
taping
rib belts
external splints

Ribs x-rays
are expensive
are inaccurate for diagnosis (~50% sensitivity)
add nothing to treatment
require painful positioning of the patient
are, in general, not useful

Chest

trauma is common in the

multiply-injured patient
Most conditions can be treated
by the evaluating physician and
do not require emergent
thoracotomy
Airway management and a
judiciously placed needle can
save many lives

February 27th, 2004

Respiratory
Emergencies
Joe Lex
joe@joelex.net