Thoracic Trauma

Chest injuries cause one in every four trauma deaths in North America.
Many of these patients die after reaching the hospital, and many of these deaths could be prevented with prompt diagnosis and treatment.


Hypoxia: results from inadequate delivery of oxygen to the tissues
Hypovolemia: Inadequate intravascular volume, i.e.. Blood loss
Pulmonary ventilation/ perfusion mismatch- e.g. contusion, hematoma, alveolar collapse
Changes in intrathoracic pressure relationships- tension pneumothorax, open pneumothorax
Respiratory acidosis, Hypercarbia (increased CO2) most often results from inadequate ventilation caused by changes in intrathoracic pressure relationships and depressed level of consciousness
Metabolic acidosis can be caused by hypoperfusion of the tissues (shock).

Initial Assessment and Management
1. Primary survey
2. Resuscitation of vital functions
3. Detailed secondary survey
4. Definitive care

*  Because hypoxia is the most serious feature of chest injury, early interventions are     designed to prevent or correct hypoxia.
*  Immediately life-threatening injuries are treated as quickly and as simply as possible.
*  Most life-threatening thoracic injuries are treated by airway control or an appropriately placed chest tube or needle.
*  The secondary survey is influenced by mechanism of injury and high index of suspicion.

Primary Survey: 
Take body substance isolation precautions
Determine the scene is safe
Determine mechanism of injury
Number of patients
Need for additional help
Stabilization of spine & Airway management

*  Major injuries affecting the airway should be recognized and addressed during the primary survey.
*  Airway patency and air exchange should be assessed by listening for air movement at nose, mouth and lung fields.
*  Inspect the oropharynx for foreign body obstruction.
*  Observe for intercostal and supraclavicular muscle retractions.
* Laryngeal injury may accompany major thoracic trauma. Clinical presentation may be subtle but life threatening.
* Recognition of this injury is by upper airway obstruction ( stridor), a marked change in expected voice quality (if pt. can talk), obvious injury at the base of the neck with palpable defect and many times crepitus.

* Establishing a patent airway by jaw thrust, suctioning, oral/nasal airway use as appropriate.
*Evaluate need for  endotracheal intubation
*Rapid transport

Expose the patients chest and neck to allow assessment of breathing and the neck veins.  
Respiratory movement and quality for respirations are assessed by observing, palpating and listening.  Look for signs of trauma, feel for excursion, subcutaneous air, bony crepitance, listen for quality of breath sounds as well as abnormal sounds

Signs of hypoxia include: 
* Increased respiratory rate and change in breathing pattern (each breath becomes more shallow)
* Anxious Behavior
* Poor air movement
* Diaphoresis
* Dilated pupils
* Cyanosis is a late sign of hypoxia

Major Injuries Affecting Breathing, Usually Found on Primary Asessment

Tension Pneumothorax:
*  Develops when a “one-way valve” air leak occurs either from the lung or through the chest wall.
* Air is forced into the thoracic cavity without any means of escape. Causing a collapse of the affected lung, displacement of mediastinum to opposite side, decrease in venous return, and compression of the opposite lung.

Causes of Tension Pneumothorax
1. Mechanical ventilation with positive pressure ventilation in the the patient with visceral injury
2. Simple pneumothorax following a penetrating or blunt chest trauma in which lung injury has failed to seal
3. Misguided attempt at subclavian or internal jugular venous catheter insertion
4. Incorrectly covered chest wall injury with occlusive dressing
5. Markedly displaced thoracic spine fractures

Signs and Symptoms
Chest pain
Air hunger
Respiratory distress
Tracheal deviation
Unilateral absence of breath sounds
Neck vein distention

Immediate Decompression, Rapidly inserting a large-bore needle into the 2nd intercostal space , midclavicular line of the affected side, Converts tension pneumothorax into a simple pneumothorax.
Definitive treatment is chest tube therefore, rapid transport to appropriate facility.

Open Pneumothorax
An open/sucking chest wound allows free passage of air into and out of the pleural space.
If opening in chest is two-thirds the diameter of the trachea, air passes through chest defect with each respiratory effort, because air tends to follow the path of least resistance through the chest wall defect.
Effective ventilation is impaired leading to hypoxia and hypercarbia.

Signs and Symptoms

Chest pain
Penetrating wound to the chest
Hyperresonance of the affected hemithorax
Decreased or absent breath sounds on affected side
Sucking sound on inspiration

Promptly closing the defect with a sterile occlusive dressing, large enough to overlap the wound’s edges, that is taped securely on three sides.
If tension pneumothorax develops immediately remove dressing.
Definitive treatment is chest tube therefore, rapid transport to appropriate facility.

Tracheobronchial Injuries
Occurs as air dissects through the tear into the pleural space or the mediastinum
Air in the pleural space produces a pneumothorax
Air in the mediastinum causes mediastinal emphysema
Signs and Symptoms
Respiratory distress
Subcutaneous or mediastinal emphysema in the neck, face, suprasternal area
Decreased or absent breath sounds
Hamman’s Sign- Crunching sound in the anterior chest synchronized with pt heart beat
Immediate placement of ETT with placement distal to the level of the injury
Bilateral needle decompression may be needed
Two chest tubes inserted on injured side
Monitor for signs of tension pneumothorax
Surgical intervention is necessary

Flail Chest 
A segment of the chest wall that does not have continuity with the rest of the thoracic cage.
Two or more ribs fractured in two or more places
The major difficulty in flail chest stems from the injury to the underlying lung (pulmonary contusion).
Signs and Symptoms
Chest pain
Paradoxical chest wall movement (asymmetrical and uncoordinated)
Poor air movement
Palpation of abnormal respiratory motion
Crepitus of ribs

Adequate ventilation- high flow O2, intubation
Administration of humidified O2
Fluid resuscitation
In absence of hypotension give fluid judiciously to prevent overhydration 
Pain management with medical control permission 

Major Injuries Affecting Circulation

Circulation Assessment
Patient’s pulse should be assessed for quality, rate, and regularity.
In hypovolemic patients, radial and pedal pulses may be absent due to volume depletion.
Blood pressure and pulse pressure should be measured and peripheral pulses should be assessed by observing and palpating the skin for color and temperature.
REMEMBER, neck veins may not be distended in the hypovolemic pt with tension pneumothorax, cardiac tamponade, or diaphragmatic injury.

Massive Hemothorax 
results from the rapid accumulation of more than 1500 ml of blood in the chest cavity.
penetrating wound that disrupts the systemic or hilar vessels
Blunt trauma( deceleration injury)
Signs and Symptoms
Chest pain
Dullness on the affected hemithorax
Decreased breath sounds on affected side
Tracheal shift
Aggressive crystalloid infusion
Type specific blood transfusion
Decompression of chest cavity
Chest tube. REMEMBER that chest tube can cause an avenue for exsanguination by eliminating any tamponade effect of the closed chest injury. >1000cc out at once, consider clamping the chest tube.

Cardiac Tamponade
Blood accumulates in the pericardium, exerting pressure on the heart and limiting cardiac filling.
Cardiac tamponade may occur in patients with either penetrating or blunt chest trauma.

Signs and Symptoms
Evidence of penetrating chest wound
Fracture of the left 3rd –5th ribs
Pulsus paradoxus
Beck’s triad: Muffled heart sounds, JVD, Decreased BP
Rapid intravenous fluid administration- this helps to improve cardiac output while preparing for pericardiocentesis.

Traumatic Aortic Rupture / Great Vessel Injuries
Rupture of the aorta is usually the result of an abrupt deceleration or compression injury.
Often rapidly fatal, only approximately 10% of victims survive to reach the hospital. Of that number only 20% survive > 1 hour.
Long term survival rate low.
Early identification of the tear and aggressive intervention offer the best chance for patient survival.
Signs and Symptoms
Hypovolemic shock
Chest wall ecchymosis
Marked variation in BP from right to left arm
Decreased femoral/pedal pulses
Loud murmur in the parascapular region
Widened mediastinum on chest x-ray
Fractures of the 1st and 2nd  & 3rd ribs especially on the left

If complete rupture occurs during transport there is nothing the medical crew can do to prevent death
Rapid Transport for operative repair


Life-Threatening Chest Injuries Most Likely to be found in the Secondary Survey 

Simple Pneumothorax

Results from air entering the potential space between the visceral and parietal pleura.
Causing a loss of negative pressure which causes a partial or total collapse of the lung.
Signs and Symptoms
Hyperresonance of the affected hemithorax
Decreased or absent breath sounds of the affected hemithorax
Dyspnea (SOB)
Sudden onset of pain with radiation to the shoulder

High Flow O2
Rapid Transport for Chest tube insertion

The accumulation of blood within the pleural space. 
In majority of cases bleeding is self-limiting.
Signs and Symptoms
Chest pain
Dullness on the affected hemithorax
Decreased breath sounds
Rapid transport to definitive care for  chest tube  placement and possibly operative repair.
A Needle thoracostomy can be performed (Inserted in the 4th or 5th intercostal space, midaxillary line on the injured side.)  Effectiveness is controversial, follow local protocol.

Pulmonary Contusion
* Damage to the lung parenchyma which may cause leakage of blood and fluid into the interstitial spaces of the lung.
* Pulmonary contusion can occur with or without a laceration of the lung tissue.
* The largest percentage of patients who suffer pulmonary contusions are those who experience a rapid deceleration injury (high speed MVA’s, falls, other blunt trauma).
Signs and Symptoms
There are few clinical findings to document the presence of pulmonary contusion.
Chest wall contusions or abrasions
Increased respiratory rate
Bloody sputum
Cautious fluid administration
Ventilatory support

Myocardial Contusion
Difficult to diagnosis in trauma patients, but should be suspected following any blunt trauma to the chest.
Diagnosed with associated history of injury
Signs and Symptoms
Chest pain similar to the pattern seen with myocardial infarction 
Chest wall ecchymosis
Auscultation of rales and/or S3 gallop rhythm ( signs of heart failure)
Close monitoring
Treatment of dysrhythmias
Analgesic administration

Diaphragmatic Rupture
Herniation of the abdominal viscera into the chest occurs when there is a traumatic defect in the diaphragm produced by blunt or penetrating trauma to the upper abdomen or lower thorax.
Majority of diaphragmatic ruptures occur on the left side, because the liver protects the right hemidiaphragm

Signs and Symptoms
Sharp shoulder pain
Bowel sounds in the lower to middle chest
Decreased breath sounds
Maintain adequate oxygenation with endotracheal tube placement and mechanical ventilation
NG to decompress the stomach
Immediate surgical repair is needed

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