3/26/2019 Thoracic Trauma PFN: SOMEML1D Hours: 3.0 JSOMTC, - - PDF document

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Slide 1 JSOMTC, SWMG(A)

Thoracic Trauma PFN: SOMEML1D

Hours: 3.0

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Terminal Learning Objective

 Action: Communicate knowledge of

thoracic trauma

 Condition: Given a lecture in a classroom

environment

 Standard: Received a minimum score of

75% on the written exam IAW course standards

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References

 Needle Versus Tube Thoracostomy in a

Swine Model of Tension Hemopneumothorax: Prehospital Emergency Care, January/March 2009, volume 13, number 1

 Chest Wall Thickness in Military Personnel:

Implications for Needle Thoracentesis in tension Pneumothorax Military Medicine, Volume 172, Dec 2007, pg. 1260

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References

 Ant. Vs Lat. Needle Decompression of

Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement ACADEMIC EMERGENCY MEDICINE 2011; 18:1022–1026 ª 2011 by the Society for Academic Emergency Medicine

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References

 Are needle decompressions for tension

pneumothoracentesis being performed appropriately for appropriate indications? American Journal of Emergency Medicine (2008) 26, 597–602 Received 1 June 2007; revised 14 August 2007; accepted 15 August 2007

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Reason

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Agenda

 Identify the causes of thoracic trauma  Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of blast lung

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of tracheobronchial injuries

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of rib fractures

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Agenda

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Flail Chest

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Pulmonary Contusion

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Open Pneumothorax

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Agenda

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Closed/Tension Pneumothorax

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Hemothorax

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Myocardial Contusion

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Agenda

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Pericardial Tamponade

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Aortic Rupture

 Identify the Pathophysiology, Pre‐Hospital

Presentation, and Management of Diaphragmatic Rupture

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Agenda

 Participate in a class discussion of a

Thoracic Trauma Patient Scenario

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Causes of Thoracic Trauma

Motor Vehicle Accident (MVA)

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Causes of Thoracic Trauma

 Falls

• 3 times patient’s height
• Even with minor injuries, patients are treated

according to the trauma protocols

• Airborne operations
• Fast roping
• Mountain climbing
• Rappelling

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Causes of Thoracic Trauma

 Blast injuries (IED)

• Overpressure
• Plasma forced into alveoli

 Chest compression injuries

• Paper bag effect

 Gun shot wounds (GSW)  Blunt trauma

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Pathophysiology, Pre‐Hospital Presentation, and Management of Blast Lung

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Blast Lung Pathophysiology

 Primary blast injuries are caused solely by

the direct effect of blast overpressure on tissue

• Air is easily compressible, unlike water
• Almost always affects air‐filled structures such

as the ears, lungs, and gastrointestinal (GI) tract

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Blast Lung Pathophysiology

 Most common fatal primary blast injury

among initial survivors

 Signs are usually present at the time of

initial evaluation, but they have been reported as late as 48 hours after the explosion

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Blast Lung Pre‐Hospital Presentation

 Pulmonary injuries are the most common

and serious trauma associated with injury

 Patient may show signs and symptoms of

pulmonary edema

• Caution: Pulmonary injury may not manifest

itself immediately

 Blast lung should be suspected for anyone

with dyspnea, associated cough, hemoptysis, or chest pain following blast exposure

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Blast Lung Management

 IAPP the Chest  Treat associated injuries  Caution using positive pressure due to

alveolar‐capillary wall damage

 If lung injury is suspected, transport

immediately

 Position with head lower, due to possible

air emboli

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Blast Lung Management

 EFAST exam to assess for lung slide

bilateral

 Chest x‐ray if available

• Recommended for all exposed persons

 Prophylactic chest tube (thoracostomy)

• Recommended before general anesthesia or

air transport if blast lung is suspected

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Pathophysiology, Pre‐Hospital Presentation, and Management of Tracheobronchial Injury

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Tracheobronchial Injury Pathophysiology

 Injuries to the major bronchi occur

primarily due to rapid deceleration injuries

 Forced expiration against a closed glottis

and compressive forces on the pulmonary tree against the vertebral column may also cause injury to these structures

 Most tracheobronchial injuries occur within

2 cm of the carina or at the origin of lobar bronchi

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Tracheal Tear Before and After



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Tracheobronchial Injury Management

 Primary assessment

• Assess for life threatening injuries first then

maintain a patent airway with a full set of vitals to include pulse oximetry

• If necessary, an ET tube can be placed into the

uninjured bronchus, and a single lung can be ventilated

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Tracheobronchial Injury Management

 Secondary Assessment

• Monitor patient for surrounding injuries to

include pulmonary and cardiac contusions (Beck’s Triad) and subcutaneous emphysema

 Treatment

• Surgical intervention

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Pathophysiology, Pre‐Hospital Presentation, and Management of Rib Fracture

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Rib Fracture Pathophysiology

 Fractures of the scapula, or the first and

second ribs often indicate major injury to the head, neck, spinal cord, lungs, and/or the great vessels

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Rib Fracture Pathophysiology

 Ribs 1‐2

• 30% die due to

force required

• 5% have aortic

rupture

 Ribs 3‐8

• Fractures common
• n lateral aspect

due to decreased musculature

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Rib Fracture Pathophysiology

 Ribs 8‐12

• May cause injury to

the spleen, kidney

• r liver

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Rib Fracture Pre‐Hospital Presentation

 Suspect the Mechanism Of Injury (MOI)  Very painful with movement  Patients can often localize the fracture by

finger pointing

 Crepitus and grimace  Associated injuries

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Rib Fracture Radiograph

Patient’s Right Patient’s Left

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Rib Fracture Management

 Dyspnea must be controlled with analgesics  Sling and swathes  Fractured rib should not be stabilized by

taping or any other firm bandaging or binding that encircles the chest

 Encourage deep breaths and coughing to

prevent atelectasis

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Rib Fracture Management

 Intercostal nerve blocks can be done to

ease the pain and allow for full expansion

• f the chest wall

 A good nerve block will provide anesthesia

duration between 8 to 18 hours

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Intercostal Nerve Block

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Intercostal Nerve Block

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Pathophysiology, Pre‐Hospital Presentation, and Management of Flail Chest

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Flail Chest Pathophysiology

 Compromise to the structural integrity of

the chest wall

 Typically defined as 2 or more adjacent ribs

fractured in 2 or more places

 Can also be caused by depression of the

anterior chest wall

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Flail Chest Pathophysiology

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Anterior Chest Wall Deformity

 High energy trauma

• Road traffic accidents
• Sternum striking the steering wheel

 Sports related

• Rugby, wrestling, and bench press

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Flail Chest Pathophysiology

 Possible underlying pulmonary contusion

could lead to hypoxia

• Contusion develops and lung compliance falls

 Decreased ventilatory efficiency and

increased work of breathing

 A vicious cycle of decreasing ventilation,

increasing fatigue, and hypoxemia may develop, resulting ultimately in sudden respiratory arrest

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Flail Chest Pre‐Hospital Presentation

 MOI  Area tenderness  Bony crepitus on palpation

• Defer palpation and percussion if obvious

 Decreased breath sounds

• Crackles on auscultation

 Hypoxemia

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Flail Chest Pre‐Hospital Presentation

 Paradoxical motion

• Inward movement of the involved portion of

the chest wall during spontaneous inspiration and outward movement during expiration

• Hypoxemia

 Significant increase in work of breathing

• Often associated with pulmonary contusion
• May have caused pneumothorax and/or

hemothorax

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Paradoxical Motion

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Paradoxical Motion

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Flail Chest Pre‐Hospital Presentation

 Muscle splinting may hide paradoxical

movement from 15 minutes to 2 hours

 Fluid moves into pulmonary contusion

• Lung compliance falls
• More pressure required to inflate lungs

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Flail Chest Pre‐Hospital Presentation

 Increasing pressure differential overcomes

muscle resistance

• Increased paradox and work of breathing
• Decreased ventilatory efficiency

 Ventilatory fatigue may lead to respiratory

failure and/or arrest

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Flail Chest Radiograph

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Flail Chest Management

 Supplemental oxygen  Ventilatory support for falling oxygen

saturation

 Restriction of IV fluids to prevent volume

• verload

 Pain management with analgesics or

intercostal nerve blocks

 Frequent coughing, deep breathing, and

incentive spiratomy

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Flail Chest Management

 Pulmonary toilet or

hygiene

• Attempts to clear mucus

and secretions from the trachea and bronchial tree by deep breathing, incentive spirometry, postural drainage, and percussion

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Pathophysiology, Pre‐Hospital Presentation, and Management of Pulmonary Contusion

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Pulmonary Contusion Pathophysiology

 Pulmonary contusion occurs in 25% to 35%

• f all blunt chest trauma
• Usually caused by rapid deceleration that results

when the moving chest strikes a fixed object

 Leads to capillary damage

• Blood and other fluids accumulate in lung tissue
• Excess fluid interferes with gas exchange,

potentially leading to inadequate oxygen levels (hypoxia)

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Pulmonary Contusion Pathophysiology

 Bruising of the lung  Rapid deceleration

forces

 Blunt force trauma

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Pulmonary Contusion Pathophysiology

 Most common potentially lethal chest

injury seen

 Respiratory complications are related to

the size of contused area

 Hypoxia, hypoxemia, and/or pulmonary

edema may develop

 Respiratory failure can develop in the first 8

to 24 hours

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Pulmonary Contusion Pre‐Hospital Presentation

 MOI  Fractured ribs  Flail chest  Chest ecchymosis  Subtle initially  Progressive dyspnea

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Pulmonary Contusion Radiograph

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Pulmonary Contusion Management

 Secure airway as needed  Support breathing

• Oxygen
• BVM
• Ventilator with peep (positive end‐expiratory

pressure)

 Reassess regularly

• Vital signs

 Heals spontaneously over several weeks

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Pathophysiology, Pre‐Hospital Presentation, and Management of Open Pneumothorax

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Open Pneumothorax Pathophysiology

 Penetrating trauma to the chest wall  Small and self‐sealing  Large and sucking

• Sucking chest wound

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Open Pneumothorax Pathophysiology

 Sucking chest wound

• Develops when penetrating injuries to the

chest create a defect large enough that air sucks in between the parietal and visceral pleura

• During negative pressure inspiration air is

sucked in through the chest wall due to it being the path of least resistance

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Open Pneumothorax Pathophysiology

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Open Pneumothorax Pathophysiology

 Sucking chest wound

• Severity is directly proportional to the size of

the wound

• Path of least resistance
• What may cause a SCW?
• GSW
• Stab wounds
• Impaled objects, etc…

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Open Pneumothorax Pathophysiology

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Open Pneumothorax Pathophysiology

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Open Pneumothorax Pre‐Hospital Presentation

 Shortness of breath (SOB)  Pain  Sucking or gurgling sound as air moves in

and out of the pleural space through the wound (SCW)

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Open Pneumothorax Pre‐Hospital Presentation

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Open Pneumothorax Management

 Close the defect quickly

• Stop gap
• Apply a vented chest seal
• If a vented chest seal is not available, a non‐vented

chest seal is acceptable

• If a tension pneumothorax is suspected,

immediately perform needle decompression

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Open Pneumothorax Management

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Open Pneumothorax Management

 Oxygen, intubation and/or BVM as needed  Treat for shock with fluid resuscitation  Reassess for tension pneumothorax!  Definitive treatment is closed tube

thoracostomy

• Chest tube 5th ICS MAL

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Pathophysiology, Pre‐Hospital Presentation, and Management of Closed/Tension Pneumothorax

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Closed/Tension Pneumothorax Pathophysiology

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Closed/Tension Pneumothorax Pathophysiology

 Progressive build up of air within the

pleural space

• Usually due to a lung laceration which allows

air to escape into the pleural space but not to return

 Air enters thoracic cavity via “one way

valve” type defect and cannot exit the pleural space

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Closed/Tension Pneumothorax Pre‐ Hospital Presentation

 Initial signs and symptoms

• Unilateral decreased or absent breath sounds
• n the affected side
• Increased dyspnea and tachypnea
• Anxiety

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Closed/Tension Pneumothorax Pre‐ Hospital Presentation

 Progressive signs and symptoms

• Increasing dyspnea and tachypnea
• Tachycardia
• Subcutaneous emphysema
• Increased difficulty bagging an intubated

patient

• Cyanosis

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Closed/Tension Pneumothorax Pre‐ Hospital Presentation

 Late signs and symptoms

• Jugular vein distension (JVD) and tracheal

deviation

• Patient may also have lost a considerable

amount of blood, so that JVD may not be present

• Tympany (hyper‐resonance)
• Narrowing pulse pressure
• Unilateral rise and fall of the chest

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JVD and Tracheal Shift

 Increased pressure moves

mediastinum and compresses the lung on the uninjured side

 Decreased cardiac

input/output of the heart with kinking of the great vessels

 35 to 40 lbs of pressure

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Closed/Tension Pneumothorax Radiograph

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Closed/Tension Pneumothorax Management

 Chest decompression

• Needle thoracentesis

 A casualty with torso trauma or polytrauma

with no pulse or respirations will receive a bilateral needle decompression

 Flutter valve  High flow oxygen  BVM  Intubation

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Closed/Tension Pneumothorax Management

 Chest tube

• Up for air
• A pneumothorax associated with persistent

large air leak after tube thoracostomy suggests a bronchi injury

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Needle Thoracentesis Steps

 Take and maintain BSI precautions  Open/remove patient's IBA and shirt to

expose chest

 Assess casualty for indications for needle

decompression

 Inspect for bilateral rise and fall of the

chest, Auscultate for bilateral breath sounds, Palpates for crepitus and grimace, Percuss for hyper or hyporesonnance

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Needle Thoracentesis Steps

 Assemble necessary equipment  Identify second intercostal space (ICS) on

anterior chest wall Mid‐clavicular line (MCL) on same side as injury; approximately two‐finger widths below the clavicle Or

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Needle Thoracentesis Steps

 Identifies fourth or fifth intercostal space

(ICS) on the anterior axillary line (AAL) on the same side as the injury

 Ask patient about allergies  Prep site with alcohol and betadine  Selects and inspects 3.25 inch 14 gauge or

10 gauge needle

 Removes plastic cap and flash chamber

cover from needle

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Needle Thoracentesis Steps

 Insert needle into skin over superior border

• f the third rib, MCL, (lateral to the nipple

line) or 5th rib on the Anterior Axillary Line and direct the needle into the appropriate ICS at 90 degree angle.

 Advance needle and catheter together all

the way to the hub and leave in place for 5‐ 10 seconds to allow for full decompression

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Needle Thoracentesis Steps

 Remove the needle to decrease the

likelihood of injury. Leave the catheter in place to provide continued decompression

 Reassess breathing and conduct secondary

IAPP (may defer percussion over an injury)

 Document procedure on appropriate

medical form

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Needle Thoracentesis Landmarks

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Needle Thoracentesis Placement

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Needle Thoracentesis Procedure

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Needle Thoracentesis Procedure

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Needle Thoracentesis Procedure

 Patients with thoracic trauma or

polytrauma who have sustained a traumatic cardiac arrest should receive bilateral decompression to ensure arrest is not due to an unrecognized tension pneumothorax on either side of the chest.

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Pathophysiology, Pre‐Hospital Presentation, and Management of Hemothorax

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Hemothorax Pathophysiology

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Hemothorax Pathophysiology

 Blood pooling in the pleural space  Pleural space can hold 30% to 40% of

patient’s blood volume

 Blood may collapse the lung on the injured

side

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Hemothorax Pre‐Hospital Presentation

 MOI  Tachypnea and dyspnea  Diminished or absent breath sounds

• Affected lung

 Tracheal deviation to the unaffected lung

• Rare

 Hypovolemia  Cyanosis

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Hemothorax Management

 High flow oxygen

• Possible intubation and BVM

 Fluid resuscitation  Definitive care requires tubal thoracostomy

• Posterior and superior for blood

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Tubal Thoracostomy

 Indications

• Definitive care for pneumothorax, hemothorax,

and tension pneumothorax

 Insertion

• 5th ICS MAL
• REMEMBER with maximum expiration the

diaphragm can reach the 4th ICS anteriorly, the 6th laterally, and the 8th posteriorly

 Multiple tubes may be necessary or position

patient to desired angle for best relief

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Tubal Thoracostomy Procedure

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Tubal Thoracostomy

 With a hemothorax, if the chest tube only

evacuates a small amount of blood and the patient remains in shock, you should suspect an abdominal injury

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Pathophysiology, Pre‐Hospital Presentation, and Management of Myocardial Contusion

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Myocardial Contusion Pathophysiology

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Myocardial Contusion Pathophysiology

 Most common cardiac injury due to blunt

trauma

 Deformed steering wheel, column, or

dashboard, alerts to cardiac contusion

 Blast injury  Reported in approximately 20% of patients

with severe blunt chest trauma

• Rarely fatal

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Myocardial Contusion Pre‐Hospital Presentation

 Chest pain and dyspnea  Abnormal chest wall movement

• Flail segment

 Contusions or abrasions of the chest wall  Tenderness to the touch  Subcutaneous emphysema

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Myocardial Contusion Pre‐Hospital Presentation

 Tachycardia out of proportion to other

findings

 Tachypnea  Dysrhythmias

• PVCs, atrial fibrillation, and/or conduction

abnormalities

 Decrease cardiac output

• Heart failure

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Myocardial Contusion Management

 Supplemental oxygen  Pain control  12 lead EKG  Drug therapy for dysrhythmias  Cardiac ultrasound

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Pathophysiology, Pre‐Hospital Presentation, and Management of Pericardial Tamponade

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Pericardial Tamponade Pathophysiology

 Blunt or penetrating trauma disrupts heart

wall(s) and/or vessels causing blood to leak into pericardial space

 Up to 300 ml of blood enters the

pericardial space causing the tamponade to develop

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Pericardial Tamponade Pathophysiology

 Fluid in the pericardial space increases

pericardial pressure and does not allow heart to expand fully

 Decrease in stroke volume and cardiac

• utput

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Pericardial Tamponade Pre‐Hospital Presentation (Beck’s Triad)

 Hypotension

• Narrowing pulse pressure

 Muffled heart sounds

• Due to pericardial sac being filled with blood

 Jugular vein distention (JVD)

• Due to a decrease ventricular filling

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Pulse Pressure

 Pulsus paradoxus

• Systolic blood pressure that drops more than

10 mm Hg upon inspiration compared with expiration

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Echocardiography of a Pericardial Effusion

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Large Pericardial Effusion

Echocardiogram (Parasternal Long Axis)

LA LV Large Pericardial Effusion RV

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Large Pericardial Effusion

Same Patient in Short Axis Views

RV LV Large Pericardial Effusion

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Pericardial Tamponade Pre‐Hospital Presentation

 Electrical alternans on EKG

• Alternating high and low‐voltage QRS

complexes as the hearts swings toward and then away from the EKG leads on the chest wall with each contraction

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Electrical Alternans

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Electrical Alternans

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Pericardial Tamponade Pre‐Hospital Presentation

 Question

• How does the Pre‐Hospital presentation of

pericardial tamponade differ from a tension pneumothorax?

 Answer

• Tension pneumothorax should have no breath

sounds on one side, hyperessonance and maybe tracheal deviation

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Pericardial Tamponade Management

 Oxygen administration  EKG monitoring  Fluid resuscitation  Pericardiocentisis

• Better be right!
• May need to be done repeatedly

 Thoracotomy

• Surgical exploration and repair

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Pericardiocentesis Sites

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Pericardiocentesis/Ultrasound

 Ultrasound is extremely useful in the

diagnosis and management of pericardial tamponade

 If ultrasound is available, use it to guide

your pericardiocentesis

 If ultrasound is not available and the

patient has cardiac or hemodynamic compromise, the blind approach for pericardiocentesis can be used

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Pericardiocentesis Procedure

 Insert 3 to 10 inch 16 gauge needle attached

to a 20 to 50 ml syringe below xiphoid process at 45 degrees towards the left MCL

 Aspirate every 1 to 2 mm as needle is

advanced

 Advance the needle carefully until

• Ultrasound shows correct placement
• Blood is obtained
• Cardiac pulsations are felt
• EKG changes

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Pericardiocentesis Procedure (cont)

 Aspirate blood from pericardial sac

• Percardial blood is often clotted
• May only be able to aspirate a few milliliters

without manipulating the needle

• If 20 ml can be easily and rapidly aspirated you

are probably in the right ventricle

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Pericardiocentesis Procedure

NARROWED PULSE PRESSURE JVD MUFFLED HEART TONES

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Pathophysiology, Pre‐Hospital Presentation, and Management of Aortic Rupture

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Aortic Rupture Pathophysiology

 Result of shear force injury  Descending aorta

• Tightly fixed to the thoracic vertebrae
• Ligamentum arteriosum

 Heart and aortic arch suddenly move

anteriorly or laterally

 80% to 90% exsanguinate into left pleural

space within first hour

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Aortic Rupture Pre‐Hospital Presentation

 Difficult to diagnose  MOI and scene survey of the magnitude of

trauma

 Unexplained shock from a frontal or lateral

impact

 Blood pressure and pulse variations

• Marked variation in BP from right to left arm
• Decreased femoral and pedal pulses

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Aortic Rupture Radiograph

Slide 125

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Aortic Rupture Management

 High flow oxygen  Airway support as needed  Immediate transport

• Requires surgical repair

 Careful fluid resuscitation

• May increase tearing of remaining aortic wall

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Pathophysiology, Pre‐Hospital Presentation, and Management of Diaphragmatic Rupture

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Diaphragmatic Rupture Pathophysiology

Slide 128

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Diaphragmatic Rupture Pathophysiology

 Can occur in both high pressure blunt

thoracoabdominal trauma as well as in penetrating trauma

 Equally common on the left and right side

• Some right sided injuries may be undiagnosed

due to the liver preventing the herniation of abdominal contents into the chest

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Diaphragmatic Rupture Pre‐Hospital Presentation

 Similar to a tension pneumothorax or

hemothorax

 Patient will present with history of blunt or

penetrating trauma

 Upon IAPP of chest you hear bowel sounds  Abdomen may appear to be hollow  CXR may reveal the nasogastric tube going

into the abdomen then back into the chest

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Diaphragmatic Rupture Radiograph

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Diaphragmatic Rupture Management

 Prompt surgical repair

• Laparotomy is necessary to repair the

diaphragm

 Treat associated injuries

• Check lung fields
• Listen for bowel sounds in the chest

Slide 132

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Class Discussion of a Thoracic Trauma Patient Scenario

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Slide 135

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Case Scenario

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Slide 136 JSOMTC, SWMG(A)

Case Scenario Objectives

• By eliciting feedback

from your facilitator

• Assess your patient (10

minutes)

• Obtain your findings
• Come to a diagnosis

and develop a treatment plan (10 minutes)

In 20 minutes each small group will present their case to the class

Slide 137 JSOMTC, SWMG(A)

Group 1

Assessment

Slide 138 JSOMTC, SWMG(A)

Group 1 Assessment

• Airway Inspection
• Coughing (hemoptysis)
• Audible wheezing
• Chest Inspection
• No visible external trauma
• Chest Auscultation
• Abnormal crackling sound in

chest (rales)

• Chest Palpation
• No crepitus or grimace
• Chest Percussion
• Normal resonance
• Skin Inspection
• Cyanosis
• Capillary Refill
• Delayed
• Pulse
• Tachycardia
• Head Inspection
• Tympanic membrane

perforation

• Pulse Oximetry
• <90%
• Arterial Blood Gas
• PaO2 59 mm Hg (hypoxemia)
• PCO2 50 mm Hg
• Chest X‐ray
• All explosion victims should

get one!

• Ultrasound
• CT

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Slide 139 JSOMTC, SWMG(A)

Group 1 Assessment Continued

Normal CXR Group 1 CXR

Slide 140

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Group 1

Diagnosis

Slide 141

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Group 1 Diagnosis Blast Lung

• Blast lung should be suspected for anyone with

dyspnea, cough, hemoptysis, or chest pain following blast exposure

• Most common fatal primary blast injury among

initial survivors

• Almost always affects air‐filled structures such as the

lungs, ears, and gastrointestinal (GI) tract

• Signs are usually present at the time of initial

evaluation, but they have been reported as late as 48 hours after the explosion

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Group 1 Diagnosis Blast Lung

Slide 143 JSOMTC, SWMG(A)

Group 1 Blast Lung

Management

Slide 144

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Group 1 Blast Lung Management

• Supplemental high flow oxygen to prevent

hypoxemia

• Monitor closely for respiratory deterioration for

at least 6 hours post‐blast

• If ventilatory failure is imminent or occurs,

patients should be intubated;

• however, caution should be used as mechanical

ventilation and positive end pressure may increase the risk of alveolar rupture and air embolism

• If air embolism is suspected, the patient should

be placed in prone, semi‐left lateral, or left lateral positions

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Slide 145 JSOMTC, SWMG(A)

Group 2

Assessment

Slide 146 JSOMTC, SWMG(A)

Group 2 Assessment

• Airway Inspection
• Dyspnea
• Tachypnea
• Chest Inspection
• Penetrating sucking wound
• Unilateral chest rise
• Chest Auscultation
• Diminished breath sounds on

the affected side

• Displaced apex beat (heart)
• Chest Palpation
• Subcutaneous Emphysema
• Chest Percussion
• Hyper resonance
• Skin Inspection
• Cyanosis
• Capillary Refill
• Delayed
• Pulse
• Tachycardia
• Neck Inspection
• JVD
• Tracheal Deviation
• Pulse Oximetry
• <90%
• Chest X‐ray
• All explosion victims should

get one!

• Arterial Blood Gas
• PaO2 59 mm Hg (hypoxemia)
• PCO2 50 mm Hg
• Ultrasound
• CT

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Group 2 Assessment Continued

Sucking Entrance Wound Exit Wound

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Slide 148 JSOMTC, SWMG(A)

Group 2 Assessment Continued

Normal CXR Group 2 CXR

Slide 149 JSOMTC, SWMG(A)

Group 2

Diagnosis

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Group 2 Diagnosis Tension Pneumothorax

• Tension Pneumothorax should be should be

suspected for anyone with dyspnea and penetrating wounds from the mandible to the umbilicus

• During negative pressure

inspiration air is sucked in between the parietal and visceral pleura

• Air enters thoracic cavity

via “one way valve” type defect and cannot exit the pleural space

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Slide 151 JSOMTC, SWMG(A)

Group 2 Tension Pneumothorax

Management

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Group 2 Tension Pneumothorax Management

• Close the defect quickly
• every hole between the chin and

the navel gets an occlusive dressing (chest seal)

• Apply a vented chest seal

preferably

• If not available use a non‐vented

chest seal

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Group 2 Tension Pneumothorax Management Continued

• Supplemental high flow
• xygen to maintain an
• xygen saturation >90%
• Burp the chest seal
• Needle thoracentesis

(decompression)

• Continuously monitor for

redeveloping tension pneumothorax

• Definitive treatment is a

tubal thoracostomy (chest tube)

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Slide 154 JSOMTC, SWMG(A)

Group 3

Assessment

Slide 155 JSOMTC, SWMG(A)

Group 3 Assessment

• Airway Inspection
• Dyspnea
• Tachypnea
• Chest Inspection
• No visible external trauma
• Chest Auscultation
• Diminished breath sounds left

side

• Bowel sounds left side
• Chest Palpation
• No crepitus or grimace
• Chest Percussion
• Normal resonance
• Skin Inspection
• Cyanosis
• Capillary Refill
• Delayed
• Pulse
• Tachycardia
• Head Inspection
• Tympanic membrane

perforation

• Abdomen Inspection
• Hollow appearance
• Pulse Oximetry
• <90%
• Chest X‐ray
• All explosion victims should

get one!

• Arterial Blood Gas
• PaO2 59 mm Hg (hypoxemia)
• PCO2 50 mm Hg
• Ultrasound
• CT

Slide 156 JSOMTC, SWMG(A)

Group 3 Assessment Continued

Normal CXR Group 3 CXR

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Slide 157 JSOMTC, SWMG(A)

Group 3

Diagnosis

Slide 158

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Group 3 Diagnosis Diaphragmatic Rupture

• Diaphragmatic injuries are caused most frequently

by penetrating trauma of the lower chest or upper

• abdomen. Rupture due to blunt trauma is much less

frequent and occurs in <5% of patients

• Right‐sided injuries may

be undiagnosed, owing to the liver preventing the herniation of abdominal contents into the chest.

Slide 159 JSOMTC, SWMG(A)

Group 3 Diaphragmatic Rupture

Management

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Group 3 Diaphragmatic Rupture Management

• Treat associated injuries
• >80% of diaphragmatic ruptures are associated with
• ther severe injuries
• Evacuation for prompt surgical repair
• Laparotomy is necessary to repair the diaphragm

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Agenda

 Identify the causes of thoracic trauma  Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of blast lung

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of tracheobronchial injuries

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of rib fractures

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Agenda

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Flail Chest

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Pulmonary Contusion

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Open Pneumothorax

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Agenda

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Closed/Tension Pneumothorax

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Hemothorax

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Myocardial Contusion

Slide 164

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Agenda

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Pericardial Tamponade

 Identify the Pathophysiology, Pre‐Hospital

presentation, and Management of Aortic Rupture

 Identify the Pathophysiology, Pre‐Hospital

Presentation, and Management of Diaphragmatic Rupture

Slide 165

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Agenda

 Participate in a class discussion of a

Thoracic Trauma Patient Scenario

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References

 Needle Versus Tube Thoracostomy in a

Swine Model of Tension Hemopneumothorax: Prehospital Emergency Care, January/March 2009, volume 13, number 1

 Chest Wall Thickness in Military Personnel:

Implications for Needle Thoracentesis in tension Pneumothorax Military Medicine, Volume 172, Dec 2007, pg. 1260

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References

 Ant. Vs Lat. Needle Decompression of

Tension Pneumothorax: Comparison by Computed Tomography Chest Wall Measurement ACADEMIC EMERGENCY MEDICINE 2011; 18:1022–1026 ª 2011 by the Society for Academic Emergency Medicine

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References

 Are needle decompressions for tension

pneumothoracentesis being performed appropriately for appropriate indications? American Journal of Emergency Medicine (2008) 26, 597–602 Received 1 June 2007; revised 14 August 2007; accepted 15 August 2007

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Terminal Learning Objective

 Action: Communicate knowledge of

thoracic trauma

 Condition: Given a lecture in a classroom

environment

 Standard: Received a minimum score of

75% on the written exam IAW course standards

Slide 170 JSOMTC, SWMG(A)

Thoracic Trauma PFN: SOMEML1D

Hours: 3.0 Instructor: