chest trauma

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Thoracic TraumaThoracic Trauma

Bisatyo MardjikoenBisatyo MardjikoenUniversitas Islam Negeri Syarif Universitas Islam Negeri Syarif

HidayatullahHidayatullahFakultas Kedokteran & Ilmu Fakultas Kedokteran & Ilmu

KesehatanKesehatanProgram Studi Ilmu KedokteranProgram Studi Ilmu Kedokteran

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Chest TraumaChest Trauma

Second leading cause of trauma Second leading cause of trauma deaths after head injurydeaths after head injury

About 20% of all trauma deathsAbout 20% of all trauma deaths

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AnatomyAnatomy

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Type of Chest InjuriesType of Chest Injuries

PenetratingPenetrating the forces are distributed over a small

area

Blunt Blunt the forces are distributed over a larger

area occur from compression or shearing occur from compression or shearing

forceforce

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Assessment Assessment

Signs and symptoms of chest trauma: Shortness of breath

Tachypnea

Chest pain

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Chest Injuries: Physical Examination

LOOK : bruises, lacerations, distended neck veins,tracheal deviation, open chest wounds, lack of symmetrical chest rise, paradoxical chest movement, cyanosis.

FEEL : tenderness, bony crepitus, subcutaneous emphysema and an unstable chest wall segment

LISTEN : presence or absence of breath sounds, and bilateral symmetry of air movement

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Chest TraumaChest Trauma

Initial exam directed toward:Initial exam directed toward: Open pneumothoraxOpen pneumothorax Flail chestFlail chest Tension pneumothoraxTension pneumothorax Massive hemothoraxMassive hemothorax Cardiac tamponadeCardiac tamponade

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Rib FractureRib Fracture

Most common chest injuryMost common chest injury More common in adults than More common in adults than

childrenchildren Especially common in elderlyEspecially common in elderly Ribs form ringsRibs form rings

Consider possibility of break in two Consider possibility of break in two placesplaces

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Most commonly 5th to 9th ribsMost commonly 5th to 9th ribs Poor protectionPoor protection Associated injuries:

pulmonary contusion laceration of the intercostals artery

an/or vein with resulting hemothorax & pneumothorax

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Fractures of 1st, 2nd ribs require high Fractures of 1st, 2nd ribs require high forceforce

Frequently have injury to aorta or bronchiFrequently have injury to aorta or bronchi 30% will die30% will die

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Fractures of 8th to 12th ribs can damage Fractures of 8th to 12th ribs can damage underlying abdominal solid organs:underlying abdominal solid organs: LiverLiver SpleenSpleen KidneysKidneys

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Signs and SymptomsSigns and Symptoms Localized pain, tendernessLocalized pain, tenderness Increases when patient:Increases when patient:

CoughsCoughs MovesMoves Breathes deeplyBreathes deeply

Chest wall instabilityChest wall instability Associated pneumo or hemothoraxAssociated pneumo or hemothorax

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ManagementManagement Oxygenation, if necessaryOxygenation, if necessary Encourage patient to breath deeplyEncourage patient to breath deeply

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Flail ChestFlail Chest

Two or more adjacent ribs broken in Two or more adjacent ribs broken in two or more places two or more places

Produces free-floating chest wall Produces free-floating chest wall segmentsegment

Usually secondary to blunt traumaUsually secondary to blunt trauma More common in older patientsMore common in older patients

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Signs and SymptomsSigns and Symptoms Paradoxical movementParadoxical movement

May May NOTNOT be present initially due to be present initially due to intercostal muscle spasmsintercostal muscle spasms

Be suspicious in any patient with Be suspicious in any patient with chest wall:chest wall:

TendernessTenderness CrepitusCrepitus

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ConsequencesConsequences Pain, leading to decreased ventilationPain, leading to decreased ventilation Increased work of breathingIncreased work of breathing Contusion of lungContusion of lung

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ManagementManagement Establish airwayEstablish airway Suspect spinal injuriesSuspect spinal injuries OxygenationOxygenation

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Simple PneumothoraxSimple Pneumothorax

Air in pleural space Air in pleural space Partial or complete lung Partial or complete lung

collapse occurscollapse occurs

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CausesCauses Chest wall penetrationChest wall penetration Fractured rib lacerating lungFractured rib lacerating lung Paper bag effectPaper bag effect May occur spontaneously following:May occur spontaneously following:

ExertionExertion CoughingCoughing Air TravelAir Travel

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Signs and SymptomsSigns and Symptoms Pain on inhalationPain on inhalation Difficulty breathingDifficulty breathing TachypneaTachypnea Decreased or absent breath soundsDecreased or absent breath sounds

Severity of symptoms depends on size of pneumothorax, speed of lung collapse,

and patient’s health status

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ManagementManagement Establish airwayEstablish airway Suspect spinal injury based on Suspect spinal injury based on

mechanismmechanism High concentration OHigh concentration O22 Monitor for tension pneumothoraxMonitor for tension pneumothorax

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Open PneumothoraxOpen Pneumothorax

Hole in chest wall Hole in chest wall Allows air to enter pleural space Allows air to enter pleural space Larger hole = Greater chance air Larger hole = Greater chance air

will enter there than through will enter there than through trachea trachea

“Sucking Chest Wound”

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Sucking Chest Wound: First Aid

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Open PneumothoraxOpen Pneumothorax

ManagementManagement Close hole with occlusive dressingClose hole with occlusive dressing High concentration OHigh concentration O22

Assist ventilationsAssist ventilations Consider transport on injured sideConsider transport on injured side Monitor for tension pneumothoraxMonitor for tension pneumothorax

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Tension PneumothoraxTension Pneumothorax

One-way valve forms in lung or chest One-way valve forms in lung or chest wall wall

Air enters pleural space; cannot Air enters pleural space; cannot leaveleave

Air is trapped in pleural spaceAir is trapped in pleural space Pressure risesPressure rises Pressure collapses lungPressure collapses lung

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Trapped air pushes heart, lungs Trapped air pushes heart, lungs awayaway from injured sidefrom injured side

Vena cavae become kinkedVena cavae become kinked Blood cannot return to heartBlood cannot return to heart Cardiac output fallsCardiac output falls

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Signs and SymptomsSigns and Symptoms Extreme dyspneaExtreme dyspnea Restlessness, anxiety, Restlessness, anxiety,

agitationagitation Decreased breath Decreased breath

soundssounds Hyperresonance to Hyperresonance to

percussion percussion CyanosisCyanosis Subcutaneous Subcutaneous

emphysemaemphysema

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Signs and SymptomsSigns and Symptoms Rapid, weak pulseRapid, weak pulse Decreased BPDecreased BP Tracheal shift Tracheal shift awayaway from injured side from injured side Jugular vein distensionJugular vein distension

Early dyspnea/hypoxia - Late shock

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ManagementManagement Secure airwaySecure airway High concentration OHigh concentration O22 If available, request ALS intercept for If available, request ALS intercept for

pleural decompressionpleural decompression

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HemothoraxHemothorax

Blood in pleural spaceBlood in pleural space Most common result of major chest Most common result of major chest

wall traumawall trauma Present in 70 to 80% of penetrating, Present in 70 to 80% of penetrating,

major non-penetrating chest traumamajor non-penetrating chest trauma

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Signs and Signs and SymptomsSymptoms Rapid, weak pulseRapid, weak pulse Cool, clammy skinCool, clammy skin Restlessness, Restlessness,

anxietyanxiety ThirstThirst ChillsChills HypotensionHypotension Collapsed neck Collapsed neck

veinsveins

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Signs and SymptomsSigns and Symptoms Decreased breath soundsDecreased breath sounds Dullness to percussionDullness to percussion DyspneaDyspnea Ventilatory failureVentilatory failure

Shock precedes ventilatory failure

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ManagementManagement Secure airwaySecure airway Assist breathing with high Assist breathing with high

concentration Oconcentration O22

Rapid transportRapid transport

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Traumatic AsphyxiaTraumatic Asphyxia

Blunt force to chest causes Blunt force to chest causes Increased intrathoracic pressureIncreased intrathoracic pressure Backward flow of blood out of heart into Backward flow of blood out of heart into

vessels of upper chest, neck, headvessels of upper chest, neck, head

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Signs and SymptomsSigns and Symptoms Possible sternal fracture or central flail chestPossible sternal fracture or central flail chest ShockShock Purplish-red discoloration of:Purplish-red discoloration of:

HeadHead NeckNeck ShouldersShoulders

Blood shot, protruding eyesBlood shot, protruding eyes Swollen, cyanotic lipsSwollen, cyanotic lips

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Name given because patients looked Name given because patients looked like they had been strangled or hangedlike they had been strangled or hanged

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ManagementManagement Airway with C-spine controlAirway with C-spine control Assist ventilations with high Assist ventilations with high

concentration Oconcentration O22

Spinal stabilizationSpinal stabilization Rapid transportRapid transport

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Cardiovascular Cardiovascular TraumaTrauma

Any patient with significant blunt or Any patient with significant blunt or penetrating trauma to chest has penetrating trauma to chest has

heart/great vessel injury until proven heart/great vessel injury until proven otherwiseotherwise

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Myocardial ContusionMyocardial Contusion

Bruise of heart muscleBruise of heart muscle Most common blunt cardiac injuryMost common blunt cardiac injury Usually due to steering wheel Usually due to steering wheel

impactimpact

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Behaves like acute MIBehaves like acute MI May produce arrhythmiasMay produce arrhythmias May cause cardiogenic shock, May cause cardiogenic shock,

hypotensionhypotension

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Signs and SymptomsSigns and Symptoms Cardiac arrhythmias after blunt chest Cardiac arrhythmias after blunt chest

traumatrauma Angina-like pain unresponsive to Angina-like pain unresponsive to

nitroglycerinnitroglycerin Chest pain independent of respiratory Chest pain independent of respiratory

movementmovementSuspect in all blunt chest trauma

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ManagementManagement High concentration OHigh concentration O2 2

TransportTransport Consider ALS interceptConsider ALS intercept

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Cardiac TamponadeCardiac Tamponade

Rapid accumulation of blood in Rapid accumulation of blood in space between heart, pericardiumspace between heart, pericardium

Heart compressed Heart compressed Blood entering heart decreasesBlood entering heart decreases Cardiac output fallsCardiac output falls

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Signs and SymptomsSigns and Symptoms Hypotension unresponsive to Hypotension unresponsive to

treatmenttreatment Increased central venous pressure Increased central venous pressure

(distended neck/arm veins in (distended neck/arm veins in presence of decreased arterial BP)presence of decreased arterial BP)

Small quiet heart (decreased heart Small quiet heart (decreased heart sounds)sounds)

Beck’s Triad

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Signs and SymptomsSigns and Symptoms Narrowing pulse pressureNarrowing pulse pressure Pulsus paradoxicusPulsus paradoxicus

Radial pulse becomes weak or disappears Radial pulse becomes weak or disappears when patient inhaleswhen patient inhales

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ManagementManagement Secure airwaySecure airway High concentration OHigh concentration O22

Rapid transportRapid transport Definitive treatment is Definitive treatment is

pericardiocentesis followed by pericardiocentesis followed by surgerysurgery

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Traumatic Aortic Traumatic Aortic AneurysmAneurysm

Caused by sudden decelerations, Caused by sudden decelerations, massive blunt force:massive blunt force: Vehicle collisionsVehicle collisions Falls from heightsFalls from heights Crushing chest traumaCrushing chest trauma Blunt chest traumaBlunt chest trauma Animal kicksAnimal kicks

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Rupture usually occurs just beyond Rupture usually occurs just beyond left subclavian arteryleft subclavian artery

Attachment of aorta to pulmonary Attachment of aorta to pulmonary artery at this point produces artery at this point produces shearing force on aortic archshearing force on aortic arch

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Traumatic Aortic Traumatic Aortic Aneurysm Aneurysm

Signs and SymptomsSigns and Symptoms Increased BP in arms in absence of head Increased BP in arms in absence of head

injuryinjury Decreased femoral pulses with full arm Decreased femoral pulses with full arm

pulsespulses Respiratory distressRespiratory distress Ache in chest, shoulders, lower back, Ache in chest, shoulders, lower back,

abdomen. (Only 25% of patients)abdomen. (Only 25% of patients)Detection requires high index of suspicion

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ManagementManagement High concentration High concentration

oxygenoxygen Assist ventilationAssist ventilation Suspect spinal Suspect spinal

injuryinjury Rapid transportRapid transport

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Associated Abdominal Associated Abdominal TraumaTrauma

Diaphragm forms dome that extends Diaphragm forms dome that extends up into rib cageup into rib cage

Trauma to chest below 4th rib = Trauma to chest below 4th rib = Abdominal injury until proven Abdominal injury until proven otherwiseotherwise

chest trauma

Documents

flail chest signs

chest wall air

symptoms of chest trauma

common chest injury

chest wall instability

flail chest consequencespain

tension pneumothorax

open chest wounds