Professional Documents
Culture Documents
• Most thoracic injuries (90% of blunt trauma and 70% to 85% of penetrating
trauma) can be managed without surgery.
Definition
• Chest injury is any form of physical injury to the chest including the
ribs, heart, and lungs.
ventilation-
perfusion Inadequate oxygen
mismatch delivery to tissues
changes in
intrathoracic
pressure TISSUE
relationships HYPOXIA
Pathophysiology of Chest Trauma
• Tissue hypoxia
• Hypercarbia
• Respiratory acidosis - inadequate ventilation
• Metabolic acidosis - tissue hypoperfusion (e.g., shock)
Chest Trauma
Initial Evaluation
• Life-threatening injuries should be identified and treated
immediately.
• Injuries may develop over time and become life-threatening during
the course of a resuscitation.
• Re-assessment and evaluation is therefore extremely important,
especially if the patient's condition deteriorates.
Chest Trauma - Initial Evaluation
Mechanism of Injury
• Primary survey
• Resuscitation of vital functions
• Detailed secondary survey
• Definitive care
Initial assessment and management
•Airway
•Breathing
•Circulation
Chest Trauma – Initial Evaluation
Physical examination
• Physical examination is the primary tool for diagnosis of acute
thoracic trauma.
• However, in the noisy ER or in the pre-hospital arena, an adequate physical
examination may be very difficult.
• Percuss
• Percuss both sides of the chest looking for dullness or resonance (more
difficult to appreciate in the trauma room).
Chest Trauma – Initial Evaluation
Classic PE findings
• The size of the injury, and position of the patient will affect the clinical
findings.
• For example, a small hemothorax may have no clinical signs at all.
• This leads to collapse of the right upper lobe and shift of the trachea to the right.
• The left chest appears hyperesonant compared to the left, and breath sounds may be difficult
to determine.
• End-tidal carbon dioxide monitoring (ETCO2) should be used in all intubated trauma patients.
• ETCO2 is the only definitive method of confirming placement of a tracheal tube.
• Other methods, such as watching for chest wall movement and listening to breath sounds or
for air in the stomach are inaccurate, especially in the setting of the trauma resuscitation
room.
• ETCO2 also allows for the estimation of the arterial PaCO2 level, and for its continuous
montioring.
• This is important for all mechanically ventilated patients and vital for patients with traumatic
brain injury.
Chest Trauma – Initial Evaluation
• Chest X-ray
• The plain antero-posterior chest radiograph remains the standard initial
evaluation for the evaluation of chest trauma.
• Although the indications and techniques are slightly different for blunt and
penetrating trauma.
Chest Trauma – Initial Evaluation
• Blunt trauma
• All blunt trauma patients should have a portable chest X-ray performed in the trauma
resuscitation room.
• The chest X-ray is a rapid screening examination that will identify significant thoracic
problems requiring intervention.
Chest Trauma – Initial Evaluation
• Blunt trauma
• Chest radiographs in blunt trauma patients are taken in the supine position,
as unstable spinal fractures have not been ruled out at this stage.
• Chest films should be slightly over-penetrated to allow better visualization of
the thoracic spine, paraspinal lines and aortic outline.
Chest Trauma – Initial Evaluation
• Penetrating trauma
• Patients with a stab wound that may have violated the thoracic cavity or
mediastinum should have a chest X-ray.
• In practice, this means all patients with stab wounds between the neck and
the umbilicus (front or back!).
Chest Trauma – Initial Evaluation
• Penetrating trauma
• For gunshot wounds, all patients with wounds between the neck and the
pelvis/buttock area should have a chest film.
• This is especially true if the bullet track is unclear, there is a missing bullet or
an odd number of entry/exit wounds.
Chest Trauma – Initial Evaluation
• Penetrating trauma
• The chest-X-ray in penetrating trauma should be taken with the patient sitting
upright if possible.
• This will increase the sensitivity for detecting a small hemothorax,
pneumothorax or diaphragm injury.
Chest Trauma – Initial Evaluation
• FAST examination
• Focused abdominal sonography for trauma (FAST) is a rapid ultrasound
examination performed in the trauma resuscitation room looking specifically
from blood - in the peritoneum, pericardium, or hemithorax.
• Currently, FAST is indicated for all hemodynamically unstable blunt trauma
patients. It may also have a role in some patients with penetrating trauma.
Chest Trauma – Initial Evaluation
• As part of the secondary survey the chest is fully examined, front and
back.
• Special attention is paid to identifying any missed injuries or
progression of previously identified injuries.
• The examination is also directed by findings on the chest X-ray or by
information from monitoring adjuncts.
Chest Trauma – Initial Evaluation
Insert the needle just above the third rib to avoid the nerve, artery,
and vein that lie just beneath each rib.
Tension pneumothorax
• Tension pneumothorax is not an x-ray diagnosis - it MUST be
recognized clinically
• Treatment is decompression
- needle into 2nd intercostal
space of mid-clavicular line -
followed by thoracotomy
tube
Tension pneumothorax
• The classic signs of a tension pneumothorax are deviation of the
trachea away from the side with the tension, a hyper-expanded chest,
an increased percussion note and a hyper-expanded chest that moves
little with respiration.