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