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ATLS - Ch 4

Thoracic Trauma

Eight potentially life-threatening chest injuries 1-simple pneumothorax 2-hemothorax 3-pulmonary contusion 4-tracheobroncial tree injury 5-blunt cardiac injury 6-traumatic aortic disruption 7-traumatic diaphragmatic injury 8-blunt esophageal disruption
Three manifestations of chest injury 1-subcutaneous emphysema 2-crushing injury (traumatic asphyxia) 3-rib, sternum, and scapular fractures
Percent of injury to chest requiring thoracotomy Blunt <10% Penetrating 15 to 30%
Often result from chest injury (3) 1-hypoxia 2-hypercarbia 3-acidosis
Tissue hypoxia in chest injury results from (3) 1-hypovolemia 2-ventilation/perfusion mismatch 3-altered intrathoracic pressure relationship
Hypercarbia in chest trauma results from inadequate ventilation
Inadequate ventilation in chest trauma results from (2) 1-altered intrathoracic pressure relationships 2-depressed level of consciousness
Metabolic acidosis in chest trauma caused by shock (hypoperfusion of the tissues)
Most serious feature of chest trauma is hypoxia
Most life-threatening thoracic injuries treated by (3) 1-airway control 2-chest tube 3-needle decompression
Major thoracic problems corrected when? as they are identified
Airway patency assessed by (3) 1-listening for air movement at nose, mouth, lung fields 2-inspecting oropharynx for FB 3-observing for intercostal and supraclavicular muscle retractions
Posterior clavicular dislocation can cause upper airway obstruction
How to identify posterior clavicular dislocation (2) 1-stridor (upper airway obstruction) 2-change in voice quality
Posterior clavicular dislocation reduced by (2) 1-extension of shoulders 2-pointed clamp
Early signs of hypoxia with thoracic trauma(2) 1-increased RR 2-change in breathing (shallow)
Late sign of hypoxia with thoracic trauma cyanosis
Absence of cyanosis does/does not indicate does not indicate adequate tissue oxygenation or adequate airway
Major thoracic injuries affecting airway (5) 1-tension pneumothorax 2-open pneumothorax 3-flail chest 4-pulmonary contusion 5-massive hemothorax
Tension pneumothorax involves ____ ____ one-way
Three things that happen with tension pneumothorax 1-mediastinum displaces to opposite side 2-venous return decreases 3-opposite lung compresses
Most common cause of tension pneumothorax mechanical ventilation
T/F Wait for x-ray confirmation to treat tension pneumothorax. False
Characteristics of tension pneumothorax 1-chest pain 2-air hunger 3-respiratory distress 4-tachycardia 5-hypotension 6-tracheal deviation 7-unilateral absence of breath sounds 8-neck vein distension 9-cyanosis (late)
Tension pneumothorax may be confused with cardiac tamponade
Differentiate tension pneumothorax with cardiac tamponade 1-hyperresonant note on percussion 2-absence of breath sounds
Needle decompression size and location large bore in 2nd intercostal space in midclavicular line
Needle decompression converts tension pneumothorax to simple pneumothorax
Definitive treatment of tension pneumothorax chest tube in 5th IC space at nipple level just anterior to midaxillary line
Size of open pneumothorax >2/3 diameter of trachea
Initial management of open pneumothorax sterile occlusive dressing taped on 3 sides (flutter valve)
Definitive management of open pneumothorax remote chest tube, then surgical closure
Flail chest occurs when chest wall segment lacks bony continuity
Flail chest often involves multiple rib fractures
Major problem with flail chest pulmonary contusion
In flail chest, movement of chest wall is (2) 1-asymmetrical 2-uncoordinated
Aids in diagnosis of flail chest (4) 1-abnormal respiratory motion 2-crepitation of rib fracture or cartilage fracture 3-chest xray 4-ABG with hypoxia
Treatment of flail chest (5) 1-adequate ventilation 2-humidified O2 3-fluids (careful) 4-analgesia (IV or local) 5-intubation (maybe)
Percussion difference between tension pneumothorax and massive hemothorax TP: hyperresonance MHT: dullness
Pulse is checked for (3) 1-quality 2-rate 3-regularity
Which pulses may be absent in hypovolemia? radial and dorsalis pedis
Myocardial trauma may lead to dysrhythmias
Define PEA ECG rhythm with no pulse
PEA may be found with what injuries? (4) 1-cardiac tamponade 2-tension pneumothorax 3-profound hypovolemia 4-cardiac rupture
Major chest injuries associated that affect circulation (2) 1-massive hemothorax 2-cardiac tamponade
Amount of blood with massive hemothorax 1500 mL (1/3 or more of blood volume)
Causes of massive hemothorax (2) 1-penetrating (most common) 2-blunt
Three major ways to identify massive hemothorax 1-shock 2-absence of breath sounds 3-dullness to percussion
Initial management of massive hemothorax 1-restore blood volume (IV fluid and blood) 2-decompress chest cavity
Blood from chest tube in massive hemothorax may be used for autotransfusion
Persistent need for blood transfusion with massive hemothorax indicator for thoracotomy
Color of blood from massive hemothorax poor indicator for thoracotomy
Only do thoracotomy if qualified surgeion is present
Injury causes of cardiac tamponade (2) 1-penetrating (most common) 2-blunt
Beck's Triad for Cardiac Tamponade 1-venous pressure elevation 2-decline in arterial pressure 3-muffled heart tones
May mimic cardiac tamponade tension pneumothorax
Distended neck veins may be absent due to hypovolemia
Kussmaul's sign in cardiac tamponade rise in venous pressure during inspiration with spontaneous respiration
How do you diagnose cardiac tamponade? (3) 1-echocardiogram 2-FAST 3-pericardial window
Accurace of FAST in cardiac tamponade 90%
Definitive treatment for cardiac tamponade surgery
Diagnosis/therapy for cardiac tamponade pericardiocentesis
Urgent priority in cardiac tamponade remove blood from pericardial sac
Facilitates accurate needle placement in cardiac tamponade FAST
Pericardiocentesis may not be diagnostic nor therapeutic if blood in pericardial sac is clotted
Candidate for immediate resuscitative thoracotomy (3) 1-penetrating injury 2-PEA 3-qualified surgeon
Signs of life (3) 1-reactive pupils 2-spontaneous movement 3-organized ECG activity
Therapeutic maneuvers of thoracotomy 1-evacuation of pericardial blood in cardiac tamponade 2-direct control of intrathoracic hemorrhage 3-open cardiac massage 4-cross clamping of aorta
Effectiveness of thoracotomy in blunt trauma and cardiac arrest rare
Indicates severe force to chest and underlying tissues (2) 1-multiple rib fractures 2-fracture of 1st or 2nd rib(s)
Pneumothorax results from air entering potential space between visceral and parietal pleura
Common cause of pneumothorax in blunt trauma lung laceration
Lung is held to chest wall by surface tension between pleural surfaces (viseral and parietal)
Chest tube is connected to underwater seal apparatus
Avoid in pneumothorax patients without chest tube (3) 1-general anesthesia 2-positive pressure ventilation 3-air ambulance
Primary causes of hemothorax (2) 1-lung laceration 2-intercostal vessel laceration
Characteristic of bleeding with hemothorax usually self-limiting
Treatment of hemothorax chest tube
Exploratory surgery for hemothorax when (3) 1-1500 mL blood in chest tube 2->200 mL/hr blood for 2-4 hours 3-blood transfusion required
Most common potentially lethal chest injury: pulmonary contusion
Characteristics of blunt trauma causing tracheobronchial tree injury (3) 1-within 1 in of carina 2-most die at scene of injury 3-surgical consultatino required
Presentation of TBT injury (2) 1-hemoptysis 2-subcutaneous emphysema 3-tension pneumothorax with mediastinum shift
How do you confirm TBT injury? bronchoscopy
Treatment of TBT injury (2) 1-more than one chest tube 2-temporary intubation of opposite mainstem bronchus
Blunt cardiac injury can result in (5) 1-muscle contusion 2-cardiac chamber rupture 3-coronary artery dissection 4-coronary artery thrombosis 5-valvular disruption
Facilitates diagnosis of BCI FAST
Sequelae of BCI contusion (3) 1-hypotension 2-dysrhythmia 3-wall motion abnormalities (2-D echo)
ECG findings with cardiac contusion (5) 1-multiple PVC's 2-unexplained sinus tachycardia 3-atrial fibrillation 4-BBB (R) 5-ST segment changes
Cardiac enzymes in BCI no role
Risk for dysrhythmias in BCI decreases after 24 hours
Common causes of traumatic aortic disruption (TAD) 1-automobile collision 2-fall from great height
Anatomic problem with TAD incomplete laceration of ligamentum arteriosum
Survivors of TAD have a retained hematoma
Treatment of TAD (2) 1-primary repair or resection of torn segment 2-replacement with interposition graft
If you suspect TAD transfer the patient
More common side of traumatic diaphragmatic injury (TDI)? left, because of liver
TDI with blunt trauma radial tears with herniation
TDI with penetrating trauma may be years until herniation
Diagnose TDI with (3) 1-NG tube in chest 2-UGI contrast 3-peritoneal lavage fluid in chest tube
Elevated right hemidiaphragm suggest traumatic diaphragmatic injury
Treatment of TDI? direct repair
Characteristics of esophageal trauma most commonly penetrating and rare
Flow of blund esophageal injury blow to upper abdomen --> gastric contents into esophagus --> linear tear --> leakage to mediastinum --> empyema
Esophageal injury to be considered when (5) 1-left pneumothorax or hemothorax without rib fracture 2-blow to abdomen 3-pain or shock out of proportion 4-particulate matter in chest tube 5-mediastinal air
Treatment of BER (2) 1-drainage of pleural space 2-direct repair
Subcutaneous emphysema can result from (3) 1-airway injury 2-lung injury 3-blast injury
Crushing injury to chest can show (3) 1-plethora with petechiae 2-massive swelling 3-cerebral edema
Created by: tcrouch2000



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