chest trauma management

Chest Trauma ManagementChest Trauma Management
&&
Various Chest IncisionsVarious Chest Incisions
Dr sumer yadavDr sumer yadav

Organs of the ThoraxOrgans of the Thorax
 TracheaTrachea
 BronchiBronchi
 LungsLungs
 MediastinumMediastinum

Anatomy of chestAnatomy of chest

 Chest injuries may result from:Chest injuries may result from:
Gunshot wounds (GSW)Gunshot wounds (GSW)
ExplosionsExplosions
Motor vehicle crashes (MVC)Motor vehicle crashes (MVC)
FallsFalls
Crush injuriesCrush injuries
Stab woundsStab wounds
GeneralGeneral

Chest TraumaChest Trauma
ManagementManagement
COMBAT MEDIC ADVANCED SKILLS TRAINING (CMAST)

 Penetrating trauma.Penetrating trauma.
– GSW or stab woundsGSW or stab wounds
– Concentrates forces overConcentrates forces over
smaller areasmaller area
– Bullet trajectoriesBullet trajectories
unpredictableunpredictable
Determine the MOIDetermine the MOI

Determine the MOI cont.Determine the MOI cont.
 Blunt trauma.Blunt trauma.
– Force distributed over largerForce distributed over larger
areaarea
– Visceral injuries occur from:Visceral injuries occur from:
• DecelerationDeceleration
• CompressionCompression
• Sheering forcesSheering forces

Assess the CasualtyAssess the Casualty
 Identify signs and symptoms:Identify signs and symptoms:
Assess mental status (AVPU)Assess mental status (AVPU)
Assess the airwayAssess the airway
Assess the breathingAssess the breathing
Assess the circulationAssess the circulation

Signs Indicative of Chest InjurySigns Indicative of Chest Injury
 Shock.Shock.
 Cyanosis.Cyanosis.
 Hemoptysis.Hemoptysis.
 Chest wallChest wall
contusion..contusion..
 Flail chest.Flail chest.
 Open wounds.Open wounds.
 Jugular veinJugular vein
distention (JVD).distention (JVD).
 TrachealTracheal
deviationdeviation

Assess RespirationsAssess Respirations
 Respiratory rate and effort:Respiratory rate and effort:
TachypneaTachypnea
BradypneaBradypnea
LaboredLabored
RetractionsRetractions
Progressive respiratory distressProgressive respiratory distress

Assess the NeckAssess the Neck
 Position of trachea.Position of trachea.
 SubcutaneousSubcutaneous
emphysema.emphysema.
 JVP.JVP.

Assess the Chest WallAssess the Chest Wall
 Contusions.Contusions.
 Tenderness.Tenderness.
 Asymmetry.Asymmetry.
 Open wounds orOpen wounds or
impaled objects.impaled objects.
 Crepitation.Crepitation.
 Paradoxical movement.Paradoxical movement.

 Lung sounds:Lung sounds:
Absent or decreasedAbsent or decreased
UnilateralUnilateral
BilateralBilateral
LocationLocation
Bowel sounds inBowel sounds in
chest?chest?

 Lung sounds – Percussion.Lung sounds – Percussion.
HyperresonanceHyperresonance
PneumothoraxPneumothorax
Tension pneumothoraxTension pneumothorax
Hyporesonance (hemothorax)Hyporesonance (hemothorax)

 Compare bothCompare both
sides of thesides of the
chest at thechest at the
same time whensame time when
assessing forassessing for
asymmetry.asymmetry.

Chest PhysiologyChest Physiology
 Chest normally has negative pressure.Chest normally has negative pressure.
 Penetrating wound creates a positivePenetrating wound creates a positive
pressure in chest cavity.pressure in chest cavity.
 Air will enter the easiest route. If aAir will enter the easiest route. If a
hole in the chest is smaller than 2/3hole in the chest is smaller than 2/3
the size of the trachea, air will enterthe size of the trachea, air will enter
through the trachea preferentially andthrough the trachea preferentially and
not through the hole in the chest.not through the hole in the chest.

Injuries of chestInjuries of chest
Rib FractureRib Fracture
Flail ChestFlail Chest
Simple/Closed PneumothoraxSimple/Closed Pneumothorax
Open PneumothoraxOpen Pneumothorax
Tension PneumothoraxTension Pneumothorax

injuries of chest contd.injuries of chest contd.
HaemothoraxHaemothorax
Cardiac TamponadeCardiac Tamponade
Traumatic Aortic RuptureTraumatic Aortic Rupture
Traumatic AsphyxiaTraumatic Asphyxia
Diaphragmatic RuptureDiaphragmatic Rupture

Rib FractureRib Fracture
11.. Most common chest wall injury fromMost common chest wall injury from
direct traumadirect trauma
2.More common in adults than2.More common in adults than
childrenchildren
3.Especially common in elderly3.Especially common in elderly
4.Most commonly 5th - 9th ribs4.Most commonly 5th - 9th ribs

 Rib Fracture Fractures of 1st and 2ndRib Fracture Fractures of 1st and 2nd
second require high forcesecond require high force
 Frequently have injury to aorta orFrequently have injury to aorta or
bronchibronchi
 Occur in 90% of patients withOccur in 90% of patients with
tracheobronchial rupturetracheobronchial rupture


 Rib Fracture Fractures of 10 to 12thRib Fracture Fractures of 10 to 12th
ribs can cause damage to underlyingribs can cause damage to underlying
abdominal solid organs:-abdominal solid organs:-
1 Liver1 Liver
2.Spleen2.Spleen
3.Kidneys3.Kidneys

Assessment Findings:-Assessment Findings:-
1.Localized pain, tenderness1.Localized pain, tenderness
2.Increases on palpation or when2.Increases on palpation or when
patient:patient:
Coughs ,Moves , Breathes deeplyCoughs ,Moves , Breathes deeply
3.Splinted Respirations3.Splinted Respirations

Rib FractureRib Fracture ManagementManagement

High concentration O2High concentration O2
 Positive pressure ventilationPositive pressure ventilation
 Encourage pt to breath deeplyEncourage pt to breath deeply
 Analgesics for isolated traumaAnalgesics for isolated trauma
 Non-circumferential splintingNon-circumferential splinting

Flail ChestFlail Chest
The breaking of 2The breaking of 2
or more ribs in 2or more ribs in 2
or more placesor more places

S/S of Flail ChestS/S of Flail Chest
 Shortness of BreathShortness of Breath
 Paradoxical MovementParadoxical Movement
 Bruising/SwellingBruising/Swelling
 Crepitus( Grinding of bone ends onCrepitus( Grinding of bone ends on
palpationpalpation

Treatment of Flail ChestTreatment of Flail Chest
 ABC’s with c-spine control asABC’s with c-spine control as
indicatedindicated
 High Flow oxygenHigh Flow oxygen
 Monitor Patient for signs ofMonitor Patient for signs of
Pneumothorax or TensionPneumothorax or Tension
 Use Gloved hand as splint till bulkyUse Gloved hand as splint till bulky
dressing can be put on patientdressing can be put on patient

Bulky Dressing for splint of FlailBulky Dressing for splint of Flail
ChestChest
Use Trauma bandageUse Trauma bandage
and Triangularand Triangular
Bandages to splint ribs.Bandages to splint ribs.

Simple/Closed PneumothoraxSimple/Closed Pneumothorax
 Opening in lungOpening in lung
tissue that leaks airtissue that leaks air
into chest cavityinto chest cavity
 Blunt trauma isBlunt trauma is
main causemain cause
 May beMay be
spontaneousspontaneous
 Usually selfUsually self
correctingcorrecting

S/S of Simple/Closed PneumothoraxS/S of Simple/Closed Pneumothorax
 Chest PainChest Pain
 DyspneaDyspnea
 TachypneaTachypnea
 Decreased Breath Sounds onDecreased Breath Sounds on
Affected SideAffected Side

Treatment for Simple/ClosedTreatment for Simple/Closed
ABC’s with C-spine controlABC’s with C-spine control
Airway Assistance as neededAirway Assistance as needed
If not contraindicated transportIf not contraindicated transport
in semi-sitting positionin semi-sitting position
Provide supportive careProvide supportive care

Open PneumothoraxOpen Pneumothorax
 Opening in chestOpening in chest
cavity that allowscavity that allows
air to enter pleuralair to enter pleural
cavitycavity
 Causes the lung toCauses the lung to
collapse due tocollapse due to
increased pressureincreased pressure
in pleural cavityin pleural cavity

Inhale

Exhale

Open PnuemothoraxOpen Pnuemothorax
Inhale

S/S of Open PneumothoraxS/S of Open Pneumothorax
 DyspneaDyspnea
 Sudden sharp painSudden sharp pain
 Subcutaneous EmphysemaSubcutaneous Emphysema
 Decreased lung sounds on affectedDecreased lung sounds on affected
sideside
 Red Bubbles on Exhalation fromRed Bubbles on Exhalation from
woundwound

Subcutaneous EmphysemaSubcutaneous Emphysema
 Air collects in subcutaneous fatAir collects in subcutaneous fat
from pressure of air in pleuralfrom pressure of air in pleural
cavitycavity
 Feels like rice crispies or bubbleFeels like rice crispies or bubble
wrapwrap
 Can be seen from neck to groinCan be seen from neck to groin
areaarea

Sucking Chest WoundSucking Chest Wound

Open PneumothoraxOpen Pneumothorax Management:Management:
 Ensure an open airwayEnsure an open airway
 Close the chest wall defect, bothClose the chest wall defect, both
entrance and exit with an occlusiveentrance and exit with an occlusive
dressing, petrolatum gauze or Ashermandressing, petrolatum gauze or Asherman
Chest SealChest Seal®®
 Place the casualty in the sitting positionPlace the casualty in the sitting position
 Monitor respirations after an occlusiveMonitor respirations after an occlusive
dressing is applieddressing is applied

 Petroleum Gauze can also be used to sealPetroleum Gauze can also be used to seal
a sucking chest wound.a sucking chest wound.

"Asherman Chest Seal"Asherman Chest Seal®®""

Tension PneumothoraxTension Pneumothorax
Air builds in pleural space withAir builds in pleural space with
no where for the air to escapeno where for the air to escape
Results in collapse of lung onResults in collapse of lung on
affected side that results inaffected side that results in
pressure on mediastium,thepressure on mediastium,the
other lung, and great vesselsother lung, and great vessels

Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

Heart is being
compressed
The trachea is
pushed to
the good side

S/S of Tension PneumothoraxS/S of Tension Pneumothorax
 Anxiety/RestlessnessAnxiety/Restlessness
 Severe DyspneaSevere Dyspnea
 Absent Breath sounds on affectedAbsent Breath sounds on affected
sideside
 TachycardiaTachycardia
 Poor ColorPoor Color

S/S of Tension Pneumothorax cont.S/S of Tension Pneumothorax cont.
 Accessory Muscle UseAccessory Muscle Use
 JVDJVD
 Narrowing Pulse PressuresNarrowing Pulse Pressures
 HypotensionHypotension
 Tracheal DeviationTracheal Deviation
(late if seen at all)(late if seen at all)

Air pushes over heart
and collapses lung
Heart compressed not able
to pump well
Air
outside
lung from
wound

 Management:Management:
Ensure an open airwayEnsure an open airway
Decompress the affected sideDecompress the affected side
Indications:Indications:
– Penetrating chest wound withPenetrating chest wound with
progressive respiratory distressprogressive respiratory distress

Needle Chest DecompressionNeedle Chest Decompression
 Procedure:Procedure:
 Identify the second ICS on theIdentify the second ICS on the
anterior chest wall, MCL:anterior chest wall, MCL:

 If a tension pneumothorax is present,If a tension pneumothorax is present,
a" hiss of air” may bea" hiss of air” may be
heard escaping from theheard escaping from the
chest cavity.chest cavity.
 Remove the needle, leave the catheterRemove the needle, leave the catheter
in place.in place.

Insert a 14 ga. Catheter atInsert a 14 ga. Catheter at
aa
9090°° angle over the topangle over the top
ofof
the 3the 3rdrd
rib, into the 2rib, into the 2ndnd
ICSICS
at the MCL.at the MCL.
 Needle should be longNeedle should be long
enough to enter theenough to enter the

HemothoraxHemothorax
 Occurs when pleural space fillsOccurs when pleural space fills
with blood .Usually occurs due towith blood .Usually occurs due to
lacerated blood vessel in thoraxlacerated blood vessel in thorax
 As blood increases, it puts pressureAs blood increases, it puts pressure
on heart and other vessels in cheston heart and other vessels in chest
cavitycavity
 Each Lung can hold 1.5 liters ofEach Lung can hold 1.5 liters of
bloodblood

May put pressure on the heart

Lots of blood vessels
Where does the blood come
from.

S/S of HemothoraxS/S of Hemothorax
 Anxiety/RestlessnessAnxiety/Restlessness
 Signs of ShockSigns of Shock
 Frothy, Bloody SputumFrothy, Bloody Sputum
 Diminished Breath Sounds onDiminished Breath Sounds on
Affected SideAffected Side
 TachycardiaTachycardia

Treatment of HaemothoraxTreatment of Haemothorax
Establish airway HighEstablish airway High
concentration O2concentration O2
Drainage by chest tubeDrainage by chest tube
ThoracotomyThoracotomy

Chest Drainage tube IndicationsChest Drainage tube Indications
Traumatic haemothoraxTraumatic haemothorax
Traumatic pneumothoraxTraumatic pneumothorax
Drainage of empyemaDrainage of empyema
Following thoracotomyFollowing thoracotomy

Chest Drainage tubeChest Drainage tube

Complications of Chest DrainageComplications of Chest Drainage
tubetube
HemorrhageHemorrhage
Damage to intercostal vesselsDamage to intercostal vessels
and nervesand nerves
Lung and mediastinal injuryLung and mediastinal injury
InfectionInfection

Indications of thoracotomyIndications of thoracotomy
In pneumothoraxIn pneumothorax
1.continuing air leak for more1.continuing air leak for more
than 7 daysthan 7 days
2.massive air leak suggesting2.massive air leak suggesting
major air -way injurymajor air -way injury
3.associated lung contusions3.associated lung contusions

Indications of thoracotomyIndications of thoracotomy
In haemothoraxIn haemothorax
1. massive bleeding more than 11. massive bleeding more than 1
Ltr.statLtr.stat
2. continuing bleeding more2. continuing bleeding more
than 200 Ml/hr over 3 hrsthan 200 Ml/hr over 3 hrs
3.brisk bleeding more than 1003.brisk bleeding more than 100
Ml every 15 min for 1 hrMl every 15 min for 1 hr

Pericardial TamponadePericardial Tamponade
Blood and fluidsBlood and fluids
leak into theleak into the
pericardial sacpericardial sac
which surroundswhich surrounds
the heart.the heart.
As the pericardialAs the pericardial
sac fills, it causessac fills, it causes
the sac to expandthe sac to expand
until it cannotuntil it cannot
expand anymore
pericardial sac

Once the pericardialOnce the pericardial
sac can’t expandsac can’t expand
anymore, the fluidanymore, the fluid
starts puttingstarts putting
pressure on the heartpressure on the heart
Now the heart can’tNow the heart can’t
fully expand and can’tfully expand and can’t
pump effectively.pump effectively.

S/S of Pericardial TamponadeS/S of Pericardial Tamponade
Distended Neck VeinsDistended Neck Veins
Increased Heart RateIncreased Heart Rate
Respiratory Rate increasesRespiratory Rate increases
Poor skin colorPoor skin color
Narrowing Pulse PressuresNarrowing Pulse Pressures
HypotensionHypotension
 DeathDeath

ManagementManagement
 Secure airwaySecure airway
 High concentration O2High concentration O2
 Definite treatment is pericardiocentesisDefinite treatment is pericardiocentesis
followed by surgeryfollowed by surgery

PericardiocentesisPericardiocentesis
 Using aseptic technique, Insert at leastUsing aseptic technique, Insert at least
3” needle at the angle of the Xiphoid3” needle at the angle of the Xiphoid
Cartilage at the 7Cartilage at the 7thth
ribrib
 Advance needle at 45 degree towardsAdvance needle at 45 degree towards
the clavicle while aspirating syringe tillthe clavicle while aspirating syringe till
blood return is seenblood return is seen
 Continue to Aspirate till syringe is fullContinue to Aspirate till syringe is full
then discard blood and attempt againthen discard blood and attempt again
till signs of no more bloodtill signs of no more blood

Traumatic Aortic RuptureTraumatic Aortic Rupture
The heart, more or less, just
hangs from the aortic arch
Much like a big pendulum.
If enough motion is placed on
the heart (i.e.. Deceleration
From a motor vehicle
accident, striking a tree while
skiing etc) the heart may tear
away from the aorta.

Traumatic Aortic RuptureTraumatic Aortic Rupture
The chances of survival are
very slim and are based on the
degree of the tear.
If there is just a small tear then
the patient may survive. If the
aorta is completely transected
then the patient will die
instantaneously

S/S Of Traumatic Aortic RuptureS/S Of Traumatic Aortic Rupture
 Burning or Tearing Sensation inBurning or Tearing Sensation in
chest or shoulder bladeschest or shoulder blades
 Rapidly dropping Blood PressureRapidly dropping Blood Pressure
 Pulse Rapidly IncreasingPulse Rapidly Increasing
 Decreased or loss of pulse or b/pDecreased or loss of pulse or b/p
on left side compared to right sideon left side compared to right side
 Rapid Loss of ConsciousnessRapid Loss of Consciousness

Treatment of Traumatic AorticTreatment of Traumatic Aortic
RuptureRupture
 ABC’s with c-spine control asABC’s with c-spine control as
indicatedindicated
 High Flow oxygenHigh Flow oxygen
 Treatment for ShockTreatment for Shock
 RAPID TRANSPORTRAPID TRANSPORT
 Contact Hospital and ALS Unit AsContact Hospital and ALS Unit As
soon as possiblesoon as possible

Traumatic AsphyxiaTraumatic Asphyxia
Results from suddenResults from sudden
compression injury to chestcompression injury to chest
cavitycavity
Can cause massive rupture ofCan cause massive rupture of
Vessels and organs of chestVessels and organs of chest
cavitycavity
Ultimately DeathUltimately Death

S/S of Traumatic AsphyxiaS/S of Traumatic Asphyxia
 Severe DyspneaSevere Dyspnea
 Distended Neck VeinsDistended Neck Veins
 Bulging, Blood shot eyesBulging, Blood shot eyes
 Swollen Tounge with cyanotic lipsSwollen Tounge with cyanotic lips
 Reddish-purple discoloration ofReddish-purple discoloration of
face and neckface and neck
 PetechiaePetechiae

Treatment for Traumatic AsphyxiaTreatment for Traumatic Asphyxia
ABC’s with c-spine control asABC’s with c-spine control as
indicatedindicated
High Flow oxygenHigh Flow oxygen
Treat for shockTreat for shock
Care for associated injuriesCare for associated injuries

Diaphragmatic RuptureDiaphragmatic Rupture
 A tear in the Diaphragm thatA tear in the Diaphragm that
allows the abdominal organs enterallows the abdominal organs enter
the chest cavitythe chest cavity
 More common on Left side due toMore common on Left side due to
liver helps protect the right side ofliver helps protect the right side of
diaphragmdiaphragm
 Associated with multiple injuryAssociated with multiple injury
patientspatients

Diaphragm RuptureDiaphragm Rupture

S/S of Diaphragmatic RuptureS/S of Diaphragmatic Rupture
Abdominal PainAbdominal Pain
Shortness of AirShortness of Air
Decreased Breath Sounds onDecreased Breath Sounds on
side of ruptureside of rupture
Bowel Sounds heard in chestBowel Sounds heard in chest
cavitycavity

Treatment of DiaphragmaticTreatment of Diaphragmatic
RuptureRupture
ABC’s with c-spine control asABC’s with c-spine control as
indicatedindicated
High Flow oxygenHigh Flow oxygen
Treat Associated InjuriesTreat Associated Injuries
Definitive treatment is surgeryDefinitive treatment is surgery

Various chest incisionsVarious chest incisions
Commonly used chest incisionsCommonly used chest incisions
1.Median sternotomy1.Median sternotomy
2.posterolateral thoracotomy2.posterolateral thoracotomy
3.Anterior thoracotomy3.Anterior thoracotomy
4.thoracoabdominal4.thoracoabdominal

Indications ofIndications of mmedianedian
sternotomysternotomy
Surgery forSurgery for
1.thymus1.thymus
2.heart and great vessels2.heart and great vessels
3.both pleural sac3.both pleural sac

mmedian sternotomyedian sternotomy

Posterolateral thoracotomyPosterolateral thoracotomy
An incision is made in the bedAn incision is made in the bed
of the 5th rib (5th intercostalsof the 5th rib (5th intercostals
space).space).
Used mainly for hilum and lungUsed mainly for hilum and lung
surgery eg.pneumonectomysurgery eg.pneumonectomy

Posterolateral thoracotomyPosterolateral thoracotomy

ThoracoabdominalThoracoabdominal
Used in surgery of lowerUsed in surgery of lower
oesophagus,gastric cardiaoesophagus,gastric cardia
,stomach,pancreas,diaphragm,stomach,pancreas,diaphragm

chest trauma management

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