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Chest Trauma - Mike Noonan

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Amit Maini
Amit Maini

Chest trauma is common, with the most life-threatening injuries including tension pneumothorax, massive haemothorax, and cardiac tamponade. Simple injuries are typically diagnosed and treated with clinical exams, imaging, chest decompression, analgesia and physiotherapy. Severe chest trauma may require advanced life support like emergency thoracotomy or transfer to the operating room.

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Chest TraumaChest Trauma Dr Mike NoonanDr Mike Noonan
Overview Introduction: •Epidemiology Pathophysiology of Chest Injuries: •Hypoventilation •Impaired Gas Exchange •Shock Management Principles: •Chest Decompression •Analgesia, Physiotherapy, Mobility and Nutrition •Ventilatory Support •Resuscitative Thoracotomy 2
Epidemiology and Classification Chest Injury: •Common: – Major chest trauma is 10th most common injury via DRG classification for all trauma admissions. – 58 patients 2010-2011 •Primary cause of mortality in 20-25% of deaths •Contribute to death in a further 25% of deaths Classification: •Blunt •Penetrating •Alfred: Major Trauma- 3.6% penetrating 3
Trauma Service Audit 2010-11 4 Injury Profile by AIS body region – major trauma 0 500 1000 1500 2000 2500 Head Legs Chest Spine Face Arms Abdomen External Neck injuries 2009/10 2010/11
Pathophysiology Pathophysiologic consequences of chest trauma: •Hypoventilation – Mechanical failure of ventilatory mechanism •Hypoxia – Secondary to hypoventilation – Impaired gas exchange •Shock – Hypovolemia – Pump (cardiogenic) failure – Neurogenic shock due to spinal cord injury 5 Decreased tissue oxygenation Decreased tissue perfusion Decreased tissue oxygenation Decreased tissue perfusion
Spectrum of Injuries • Rib fracture(s) • Simple pneumothorax • Simple haemothorax • Tension pneumothorax • Open pneumothorax • Massive haemothorax • Cardiac tamponade • Flail chest • Pulmonary contusion • Ruptured diaphragm • Aortic Injury • Oesophageal injury 6
Scenario 1 51yo male. Fall against table while intoxicated. PHx: •Alcohol abuse •Poorly controlled Insulin-requiring Type II DM •HPT •Smoker (20/day; 30 pkt year history) On arrival: •A: Speaking in full sentences. Cx collar applied •B: RR 28. Satn 90% high flow oxygen. Complaining of right chest pain and ‘unable to catch breath’. Decreased breath sounds on right with subcutaneous emphysema. •C: HR 95. BP 178/94. FAST negative. •D: Agitated E4 V4 M6=14 7
Scenario 1 8
Scenario 1 Initial Management: •O2 via Hudson mask, high flow. •Set up for right ICC •Intravenous access: warmed crystalloid. 8/24 Adjuncts to Primary Survey: •CXR PXR •ABGs: – Type 1 or Type 2 respiratory failure – CO2 retention •Venous blood: Hb/U&E/LFTs/Clotting/EtOH/Glucose 9
Scenario 1 10
Scenario 1 ABG: •pH 7.40 •pCO2 55 •pO2 110 •HCO3- 32 11 Management Priorities?
Scenario 1 • Drainage of blood and pneumothorax to maximise ventilation: ICC • Analgesia – CALL APS – Systemic – Local – Regional Patient needs to be able to deep breath and cough • Position and mobility: – Spine clearance so that the patient can be sat up • Physiotherapy: chest as well as general mobility • Optimisation of comorbidities: – Diabetes – EtOH withdrawal – Nutrition • ? ICU admission 12
Scenario 2 19yo male. HSP MVA into tree. At scene: A: Grunting, obvious facial fractures. Cx collar applied B: Decreased air entry right chest. Seat belt bruising right upper chest wall. RR 26. C: HR 135 with thready pulse. SBP 80/. D: GCS E1 V2 M4=7 Initial Treatment: •Cx collar. RSI. •Right pneumocath. •Iv access with 1.0 l Nsaline commenced. Pelvic binder applied. 13
Scenario 2 14
Scenario 2 On arrival (45 minutes post-accident): •A: Intubated. Cx collar in situ. •B: Absent air entry right chest. Satn 87% on 100% FIO2. Trachea midline. •C: HR 145. SBP 89 after 1.5 litres crystalloid. Cool, clammy, shut down. Plethoric face(?). Deformed right femur. •D: GCS E1 VT M1 15
Scenario 2 16
Scenario 2 Progress: •Post ICC insertion: – Improved air entry right chest – HR 95 BP 115/62 – 200ml blood from right ICC •FAST negative, PXR normal •Femur reduced and splinted •Further 1000ml Nsaline Key Points: •Tension Pneumothorax is a cause of shock- easy to treat! •Do not need tracheal deviation 17
Scenario 3 35 year old depressed man: •Penetrating chest wound just above and medial to the left nipple •Self presented to triage On arrival: •A: Speaking in short sentences, very agitated. •B: Tachypnoeic with RR 34, Sat 89% •C: HR 130, thready. SBP 90 18
Scenario 3 Treatment: • Supplemental Oxygen • iv access: 500ml Nsaline Progress: • Became less agitated though drowsy. Airway maintained. • B: RR 26. Sat 87%. Air-entry equal bilaterally. • C: HR 140, thready. SBP80. • Plethoric face and distended neck veins noted 19
Scenario 3 20
Scenario 3 21 HaemopericardiumHaemopericardium Right VentricleRight Ventricle
Scenario 3 22 What does this patient need? Where will this be performed?
Scenario 3 23 •Identification of immediately life-threatening situation (tamponade) via systematic attention to A, B and C. •Transfer of the patient to theatre in a timely fashion, or •Perform emergency room thoracotomy if SBP remains <70 mmHg despite iv resuscitation NB: ATLS Guidelines 8th edition: Treatment of Cardiac Tamponade
Questions? 24
Summary • Chest trauma is common • Most injuries are diagnosed with simple clinical and imaging techniques • Most life-threatening injuries can be managed with simple procedures and attention to analgesia, physiotherapy and nutrition • Severe chest trauma requires more advanced life support 25

More Related Content

Chest Trauma - Mike Noonan

  • 1. Chest TraumaChest Trauma Dr Mike NoonanDr Mike Noonan
  • 2. Overview Introduction: •Epidemiology Pathophysiology of Chest Injuries: •Hypoventilation •Impaired Gas Exchange •Shock Management Principles: •Chest Decompression •Analgesia, Physiotherapy, Mobility and Nutrition •Ventilatory Support •Resuscitative Thoracotomy 2
  • 3. Epidemiology and Classification Chest Injury: •Common: – Major chest trauma is 10th most common injury via DRG classification for all trauma admissions. – 58 patients 2010-2011 •Primary cause of mortality in 20-25% of deaths •Contribute to death in a further 25% of deaths Classification: •Blunt •Penetrating •Alfred: Major Trauma- 3.6% penetrating 3
  • 4. Trauma Service Audit 2010-11 4 Injury Profile by AIS body region – major trauma 0 500 1000 1500 2000 2500 Head Legs Chest Spine Face Arms Abdomen External Neck injuries 2009/10 2010/11
  • 5. Pathophysiology Pathophysiologic consequences of chest trauma: •Hypoventilation – Mechanical failure of ventilatory mechanism •Hypoxia – Secondary to hypoventilation – Impaired gas exchange •Shock – Hypovolemia – Pump (cardiogenic) failure – Neurogenic shock due to spinal cord injury 5 Decreased tissue oxygenation Decreased tissue perfusion Decreased tissue oxygenation Decreased tissue perfusion
  • 6. Spectrum of Injuries • Rib fracture(s) • Simple pneumothorax • Simple haemothorax • Tension pneumothorax • Open pneumothorax • Massive haemothorax • Cardiac tamponade • Flail chest • Pulmonary contusion • Ruptured diaphragm • Aortic Injury • Oesophageal injury 6
  • 7. Scenario 1 51yo male. Fall against table while intoxicated. PHx: •Alcohol abuse •Poorly controlled Insulin-requiring Type II DM •HPT •Smoker (20/day; 30 pkt year history) On arrival: •A: Speaking in full sentences. Cx collar applied •B: RR 28. Satn 90% high flow oxygen. Complaining of right chest pain and ‘unable to catch breath’. Decreased breath sounds on right with subcutaneous emphysema. •C: HR 95. BP 178/94. FAST negative. •D: Agitated E4 V4 M6=14 7
  • 9. Scenario 1 Initial Management: •O2 via Hudson mask, high flow. •Set up for right ICC •Intravenous access: warmed crystalloid. 8/24 Adjuncts to Primary Survey: •CXR PXR •ABGs: – Type 1 or Type 2 respiratory failure – CO2 retention •Venous blood: Hb/U&E/LFTs/Clotting/EtOH/Glucose 9
  • 11. Scenario 1 ABG: •pH 7.40 •pCO2 55 •pO2 110 •HCO3- 32 11 Management Priorities?
  • 12. Scenario 1 • Drainage of blood and pneumothorax to maximise ventilation: ICC • Analgesia – CALL APS – Systemic – Local – Regional Patient needs to be able to deep breath and cough • Position and mobility: – Spine clearance so that the patient can be sat up • Physiotherapy: chest as well as general mobility • Optimisation of comorbidities: – Diabetes – EtOH withdrawal – Nutrition • ? ICU admission 12
  • 13. Scenario 2 19yo male. HSP MVA into tree. At scene: A: Grunting, obvious facial fractures. Cx collar applied B: Decreased air entry right chest. Seat belt bruising right upper chest wall. RR 26. C: HR 135 with thready pulse. SBP 80/. D: GCS E1 V2 M4=7 Initial Treatment: •Cx collar. RSI. •Right pneumocath. •Iv access with 1.0 l Nsaline commenced. Pelvic binder applied. 13
  • 15. Scenario 2 On arrival (45 minutes post-accident): •A: Intubated. Cx collar in situ. •B: Absent air entry right chest. Satn 87% on 100% FIO2. Trachea midline. •C: HR 145. SBP 89 after 1.5 litres crystalloid. Cool, clammy, shut down. Plethoric face(?). Deformed right femur. •D: GCS E1 VT M1 15
  • 17. Scenario 2 Progress: •Post ICC insertion: – Improved air entry right chest – HR 95 BP 115/62 – 200ml blood from right ICC •FAST negative, PXR normal •Femur reduced and splinted •Further 1000ml Nsaline Key Points: •Tension Pneumothorax is a cause of shock- easy to treat! •Do not need tracheal deviation 17
  • 18. Scenario 3 35 year old depressed man: •Penetrating chest wound just above and medial to the left nipple •Self presented to triage On arrival: •A: Speaking in short sentences, very agitated. •B: Tachypnoeic with RR 34, Sat 89% •C: HR 130, thready. SBP 90 18
  • 19. Scenario 3 Treatment: • Supplemental Oxygen • iv access: 500ml Nsaline Progress: • Became less agitated though drowsy. Airway maintained. • B: RR 26. Sat 87%. Air-entry equal bilaterally. • C: HR 140, thready. SBP80. • Plethoric face and distended neck veins noted 19
  • 22. Scenario 3 22 What does this patient need? Where will this be performed?
  • 23. Scenario 3 23 •Identification of immediately life-threatening situation (tamponade) via systematic attention to A, B and C. •Transfer of the patient to theatre in a timely fashion, or •Perform emergency room thoracotomy if SBP remains <70 mmHg despite iv resuscitation NB: ATLS Guidelines 8th edition: Treatment of Cardiac Tamponade
  • 25. Summary • Chest trauma is common • Most injuries are diagnosed with simple clinical and imaging techniques • Most life-threatening injuries can be managed with simple procedures and attention to analgesia, physiotherapy and nutrition • Severe chest trauma requires more advanced life support 25