Thoracic Trauma Christopher McPeak, MD Department of Emergency Medicine Albany Medical Center

Thoracic TraumaThoracic TraumaChristopher McPeak, Christopher McPeak,

MDMDDepartment of Emergency Department of Emergency

MedicineMedicine

Albany Medical CenterAlbany Medical Center

Thoracic TraumaThoracic Trauma

Second leading cause of trauma Second leading cause of trauma deaths after head injurydeaths after head injury

Cause of about 10-20% of all trauma Cause of about 10-20% of all trauma deathsdeaths

Many deaths due to thoracic trauma Many deaths due to thoracic trauma are preventableare preventable


Prevention StrategiesPrevention Strategies Gun Safety EducationGun Safety Education Sports Training & Protective EquipmentSports Training & Protective Equipment Seat Belt & Air Bag UseSeat Belt & Air Bag Use


Mechanisms of InjuryMechanisms of Injury Blunt InjuryBlunt Injury

DecelerationDeceleration CompressionCompression

Penetrating InjuryPenetrating Injury


Anatomical InjuriesAnatomical Injuries Thoracic Cage (Skeletal)Thoracic Cage (Skeletal) CardiovascularCardiovascular Pleural and PulmonaryPleural and Pulmonary MediastinalMediastinal DiaphragmaticDiaphragmatic EsophagealEsophageal Penetrating CardiacPenetrating Cardiac

Thoracic TraumaThoracic Trauma Often result in:Often result in:

HypoxiaHypoxia

HypercarbiaHypercarbia

Acidosis Acidosis hypoperfusion of tissues (metabolic)hypoperfusion of tissues (metabolic)

Thoracic Trauma--CardiacThoracic Trauma--Cardiac

Impairments to cardiac outputImpairments to cardiac output blood lossblood loss increased intrapleural pressuresincreased intrapleural pressures blood in pericardial sacblood in pericardial sac myocardial valve damagemyocardial valve damage vascular disruptionvascular disruption

Thoracic Trauma--Thoracic Trauma--RespiratoryRespiratory

Impairments in ventilatory efficiencyImpairments in ventilatory efficiency chest excursion compromisechest excursion compromise

painpain air in pleural spaceair in pleural space asymmetrical movementasymmetrical movement

bleeding in pleural spacebleeding in pleural space ineffective diaphragm contractionineffective diaphragm contraction

Thoracic Trauma--Thoracic Trauma--RespiratoryRespiratory

Impairments in gas exchangeImpairments in gas exchange atelectasisatelectasis pulmonary contusionpulmonary contusion respiratory tract disruptionrespiratory tract disruption

Thoracic Trauma--ExamThoracic Trauma--Exam Initial exam directed toward life Initial exam directed toward life

threatening:threatening: InjuriesInjuries

Open pneumothoraxOpen pneumothorax Flail chestFlail chest Tension pneumothoraxTension pneumothorax Massive hemothoraxMassive hemothorax Cardiac tamponadeCardiac tamponade

ConditionsConditions ApneaApnea Respiratory DistressRespiratory Distress

Thoracic Trauma--ExamThoracic Trauma--Exam

Assessment FindingsAssessment Findings Mental Status (decreased)Mental Status (decreased) Pulse (absent, tachy or brady)Pulse (absent, tachy or brady) BP (narrow PP, hyper- or hypotension, BP (narrow PP, hyper- or hypotension,

pulsus paradoxus)pulsus paradoxus) Ventilatory rate & effort (tachy- or Ventilatory rate & effort (tachy- or

bradypnea, labored, retractions)bradypnea, labored, retractions) Skin (diaphoresis, pallor, cyanosis, open Skin (diaphoresis, pallor, cyanosis, open

injury, ecchymosis)injury, ecchymosis)


Assessment FindingsAssessment Findings Neck (tracheal position, SQ emphysema, Neck (tracheal position, SQ emphysema,

JVD, open injury)JVD, open injury) Chest (contusions, tenderness, asymmetry, Chest (contusions, tenderness, asymmetry,

absent or decreased lung sounds, bowel absent or decreased lung sounds, bowel sounds, abnormal percussion, open injury, sounds, abnormal percussion, open injury, impaled object, crepitus, hemoptysis)impaled object, crepitus, hemoptysis)

Heart Sounds (muffled, distant, regurgitant Heart Sounds (muffled, distant, regurgitant murmur)murmur)

Upper abdomen (contusion, open injury)Upper abdomen (contusion, open injury)


Assessment FindingsAssessment Findings ECG (ST segment abnormalities, ECG (ST segment abnormalities,

dysrhythmias)dysrhythmias) HistoryHistory

DyspneaDyspnea PainPain Past hx of cardiorespiratory diseasePast hx of cardiorespiratory disease Restraint devices usedRestraint devices used Item/Weapon involved in injuryItem/Weapon involved in injury

Thoracic Thoracic TraumaTraumaSpecific InjuriesSpecific Injuries

Rib FractureRib Fracture

Most common chest wall injury Most common chest wall injury from direct traumafrom direct trauma

More common in adults than More common in adults than childrenchildren

Especially common in elderlyEspecially common in elderly Ribs form ringsRibs form rings

Possibility of break in two placesPossibility of break in two places Most commonly 5th - 9th ribsMost commonly 5th - 9th ribs

Poor protectionPoor protection


Fractures of 1st and 2nd second Fractures of 1st and 2nd second require high forcerequire high force Frequently have injury to aorta or bronchiFrequently have injury to aorta or bronchi Occur in 90% of patients with tracheo-Occur in 90% of patients with tracheo-

bronchial rupturebronchial rupture May injure subclavian artery/veinMay injure subclavian artery/vein May result in pneumothoraxMay result in pneumothorax

30% will die30% will die


Fractures of 10 to 12th ribs can cause Fractures of 10 to 12th ribs can cause damage to underlying abdominal solid damage to underlying abdominal solid organs:organs: LiverLiver SpleenSpleen KidneysKidneys

Rib FractureRib Fracture Assessment FindingsAssessment Findings

Localized pain, tendernessLocalized pain, tenderness Increases on palpation or when patient:Increases on palpation or when patient:

CoughsCoughs MovesMoves Breathes deeplyBreathes deeply

““Splinted” RespirationsSplinted” Respirations Instability in chest wall, CrepitusInstability in chest wall, Crepitus Deformity and discolorationDeformity and discoloration Associated pneumo or hemothoraxAssociated pneumo or hemothorax

Rib FractureRib Fracture ManagementManagement

High concentration OHigh concentration O22

Positive pressure ventilation as neededPositive pressure ventilation as needed Splint using pillow or swathesSplint using pillow or swathes Encourage pt to breath deeplyEncourage pt to breath deeply

Helps prevent atelectasisHelps prevent atelectasis Analgesics for isolated traumaAnalgesics for isolated trauma Non-circumferential splintingNon-circumferential splinting

Rib FractureRib Fracture ManagementManagement

Monitor elderly and COPD patients closelyMonitor elderly and COPD patients closely Broken ribs can cause Broken ribs can cause

decompensationdecompensation Patients will fail to breathe deeply Patients will fail to breathe deeply

and cough, resulting in poor and cough, resulting in poor clearance of secretionsclearance of secretions

Usually Non-Emergent TransportUsually Non-Emergent Transport

Sternal FractureSternal Fracture

Uncommon, 5-8% in blunt chest traumaUncommon, 5-8% in blunt chest trauma Large traumatic forceLarge traumatic force Direct blow to front of chest byDirect blow to front of chest by

DecelerationDeceleration steering wheelsteering wheel dashboarddashboard

Other objectOther object

Sternal FractureSternal Fracture 25 - 45% mortality due to associated trauma:25 - 45% mortality due to associated trauma:

Disruption of thoracic aortaDisruption of thoracic aorta Tracheal or bronchial tearTracheal or bronchial tear Diaphragm ruptureDiaphragm rupture Flail chestFlail chest Myocardial traumaMyocardial trauma

High incidence of myocardial contusion, High incidence of myocardial contusion, cardiac tamponade or pulmonary contusioncardiac tamponade or pulmonary contusion

Sternal FractureSternal Fracture

Assessment FindingsAssessment Findings Localized painLocalized pain Tenderness over sternumTenderness over sternum CrepitusCrepitus Tachypnea, DyspneaTachypnea, Dyspnea ECG changes with associated ECG changes with associated

myocardial contusionmyocardial contusion Hx/Mechanism of blunt chest traumaHx/Mechanism of blunt chest trauma

Sternal FractureSternal Fracture ManagementManagement

Establish airwayEstablish airway High concentration oxygenHigh concentration oxygen Assist ventilations with BVM as neededAssist ventilations with BVM as needed IV NS/LRIV NS/LR Emergent TransportEmergent Transport

Trauma centerTrauma center

Flail ChestFlail Chest

Two or more adjacent ribs Two or more adjacent ribs fractured in two or more fractured in two or more places producing a free places producing a free

floating segment of the chest floating segment of the chest wallwall

Flail ChestFlail Chest Usually secondary to Usually secondary to

blunt traumablunt trauma Most commonly in MVCMost commonly in MVC Also results fromAlso results from

falls from heightsfalls from heights industrial accidentsindustrial accidents assaultassault birth traumabirth trauma

More common in More common in older patientsolder patients


Mortality rates 20-40% due to Mortality rates 20-40% due to associated injuriesassociated injuries

Mortality increased withMortality increased with advanced ageadvanced age seven or more rib fracturesseven or more rib fractures three or more associated injuriesthree or more associated injuries shockshock head injurieshead injuries

Flail ChestFlail Chest Consequences of flail chestConsequences of flail chest

Respiratory failure due toRespiratory failure due to pulmonary contusionpulmonary contusion intrathoracic injuryintrathoracic injury inadequate diaphragm movementinadequate diaphragm movement

Paradoxical movement of the chestParadoxical movement of the chest must be large to compromise ventilationmust be large to compromise ventilation Increased work of breathingIncreased work of breathing

Pain, decreased chest expansionPain, decreased chest expansion leading decreased ventilationleading decreased ventilation


Consequences of flail chestConsequences of flail chest Contusion of lungContusion of lung

decreased lung compliancedecreased lung compliance intra alveolar-capillary hemorrhageintra alveolar-capillary hemorrhage

Decreased ventilationDecreased ventilation HypercapneaHypercapnea HypoxiaHypoxia


Assessment FindingsAssessment Findings Chest wall contusionChest wall contusion Respiratory distressRespiratory distress Pleuritic chest painPleuritic chest pain Splinting of affected sideSplinting of affected side CrepitusCrepitus Tachypnea, TachycardiaTachypnea, Tachycardia Paradoxical movement (possible)Paradoxical movement (possible)

Flail ChestFlail Chest ManagementManagement

Suspect spinal injuriesSuspect spinal injuries Establish airwayEstablish airway High concentration oxygenHigh concentration oxygen Assist ventilation with BVMAssist ventilation with BVM

Treat hypoxia from underlying contusionTreat hypoxia from underlying contusion Promote full lung expansionPromote full lung expansion

Consider need for intubation and PEEPConsider need for intubation and PEEP Mechanically stabilize chest wallMechanically stabilize chest wall

questionable valuequestionable value

Flail ChestFlail Chest ManagementManagement

IV of LR/NSIV of LR/NS Avoid rapid replacement in Avoid rapid replacement in

hemodynamically stable patienthemodynamically stable patient Contused lung cannot handle fluid loadContused lung cannot handle fluid load

Monitor EKGMonitor EKG Chest trauma can cause dysrhythmiasChest trauma can cause dysrhythmias

Emergent TransportEmergent Transport Trauma centerTrauma center

Simple PneumothoraxSimple Pneumothorax IncidenceIncidence

10-30% in blunt chest 10-30% in blunt chest traumatrauma

almost 100% with almost 100% with penetrating chest penetrating chest traumatrauma

Morbidity & Mortality Morbidity & Mortality dependent ondependent on

extent of atelectasisextent of atelectasis associated injuriesassociated injuries

Simple PneumothoraxSimple Pneumothorax CausesCauses

Commonly a fx rib lacerates lungCommonly a fx rib lacerates lung May occur spontaneously in tall, thin May occur spontaneously in tall, thin

young males following:young males following: ExertionExertion CoughingCoughing Air TravelAir Travel

Simple PneumothoraxSimple Pneumothorax PathophysiologyPathophysiology

Air enters pleural space causing partial lung Air enters pleural space causing partial lung collapsecollapse

small tears self-sealsmall tears self-seal larger tears may progresslarger tears may progress

Usually well-tolerated in the young & healthyUsually well-tolerated in the young & healthy Severe compromise can occur in the elderly Severe compromise can occur in the elderly

or patients with pulmonary diseaseor patients with pulmonary disease Degree of distress depends on amount and Degree of distress depends on amount and

speed of collapsespeed of collapse

Simple PneumothoraxSimple Pneumothorax Assessment FindingsAssessment Findings

Tachypnea, TachycardiaTachypnea, Tachycardia Difficulty breathing or respiratory distressDifficulty breathing or respiratory distress Pleuritic painPleuritic pain

may be referred to shoulder or arm on affected may be referred to shoulder or arm on affected sideside

Decreased or absent breath soundsDecreased or absent breath sounds not always reliablenot always reliable

if patient standing, assess apices first if patient standing, assess apices first if supine, assess anteriorlyif supine, assess anteriorly

patients with multiple ribs fractures may patients with multiple ribs fractures may splint injured side by not breathing deeplysplint injured side by not breathing deeply

Simple PneumothoraxSimple Pneumothorax ManagementManagement

Establish airwayEstablish airway High concentration OHigh concentration O22 with NRB with NRB Assist with BVMAssist with BVM IV of LR/NSIV of LR/NS Monitor for progressionMonitor for progression Monitor ECGMonitor ECG Usually Non-emergent transportUsually Non-emergent transport

Open Open PneumothoraxPneumothoraxHole in chest wall that allows air to Hole in chest wall that allows air to

enter pleural space. enter pleural space.

Larger the hole the more likely air Larger the hole the more likely air will enter there than through the will enter there than through the

trachea. trachea.

Open PneumothoraxOpen Pneumothorax

If the trauma If the trauma patient does not patient does not ventilate well with ventilate well with an open airway, an open airway, look for a holelook for a hole May be subtleMay be subtle Abrasion with deep Abrasion with deep

puncturespunctures


PathophysiologyPathophysiology Result of penetrating traumaResult of penetrating trauma Profound hypoventilation may occurProfound hypoventilation may occur Allows communication between pleural Allows communication between pleural

space and atmospherespace and atmosphere Prevents development of negative Prevents development of negative

intrapleural pressureintrapleural pressure Results in ipsilateral lung collapseResults in ipsilateral lung collapse

inability to ventilate affected lunginability to ventilate affected lung

Open PneumothoraxOpen Pneumothorax PathophysiologyPathophysiology

V/Q MismatchV/Q Mismatch shuntingshunting hypoventilationhypoventilation hypoxiahypoxia large functional dead spacelarge functional dead space

Pressure may build within pleural spacePressure may build within pleural space Return from Vena cava may be impairedReturn from Vena cava may be impaired


Assessment FindingsAssessment Findings Opening in the chest wallOpening in the chest wall Sucking sound on inhalationSucking sound on inhalation TachycardiaTachycardia TachypneaTachypnea Respiratory distressRespiratory distress SQ EmphysemaSQ Emphysema Decreased lung sounds on affected sideDecreased lung sounds on affected side

Open PneumothoraxOpen Pneumothorax ManagementManagement

Cover chest opening with occlusive dressingCover chest opening with occlusive dressing High concentration OHigh concentration O22

Assist with positive pressure ventilations prnAssist with positive pressure ventilations prn Monitor for progression to tension Monitor for progression to tension

pneumothoraxpneumothorax IV with LR/NSIV with LR/NS Monitor ECGMonitor ECG Emergent TransportEmergent Transport

Trauma CenterTrauma Center

Tension PneumothoraxTension Pneumothorax IncidenceIncidence

Penetrating TraumaPenetrating Trauma Blunt TraumaBlunt Trauma

Morbidity/MortalityMorbidity/Mortality Severe hypoventilationSevere hypoventilation Immediate life-threat if not managed earlyImmediate life-threat if not managed early

Tension PneumothoraxTension Pneumothorax PathophysiologyPathophysiology

One-way valve forms in lung or chest wall One-way valve forms in lung or chest wall Air enters pleural space, but cannot leaveAir enters pleural space, but cannot leave

Air is trapped in pleural spaceAir is trapped in pleural space Pressure collapses lung on affected sidePressure collapses lung on affected side Mediastinal shift to contralateral sideMediastinal shift to contralateral side

Reduction in cardiac outputReduction in cardiac output Increased intrathoracic pressureIncreased intrathoracic pressure deformed vena cava reducing preloaddeformed vena cava reducing preload

Tension PneumothoraxTension Pneumothorax Assessment Findings - Most LikelyAssessment Findings - Most Likely

Severe dyspnea Severe dyspnea extreme resp distress extreme resp distress Restlessness, anxiety, agitationRestlessness, anxiety, agitation Decreased/absent breath soundsDecreased/absent breath sounds Worsening or Severe Shock / Worsening or Severe Shock /

Cardiovascular collapseCardiovascular collapse TachycardiaTachycardia Weak pulseWeak pulse HypotensionHypotension Narrow pulse pressureNarrow pulse pressure

Tension PneumothoraxTension Pneumothorax Assessment Findings - Less LikelyAssessment Findings - Less Likely

Jugular Vein DistensionJugular Vein Distension absent if also hypovolemicabsent if also hypovolemic

Hyperresonance to percussion Hyperresonance to percussion Subcutaneous emphysemaSubcutaneous emphysema Tracheal shift Tracheal shift awayaway from injured side (late) from injured side (late) Cyanosis (late)Cyanosis (late)

Tension PneumothoraxTension Pneumothorax ManagementManagement

Recognize & Manage Recognize & Manage earlyearly

Establish airwayEstablish airway High concentration OHigh concentration O22 Positive pressure Positive pressure

ventilations w/BVM prnventilations w/BVM prn Needle thoracostomyNeedle thoracostomy IV of LR/NSIV of LR/NS Monitor ECGMonitor ECG Emergent TransportEmergent Transport

Consider need to Consider need to intubateintubate

Trauma Center preferredTrauma Center preferred

Tension PneumothoraxTension Pneumothorax ManagementManagement

Needle Thoracostomy ReviewNeedle Thoracostomy Review Decompress with 14g (lg bore), 2-inch Decompress with 14g (lg bore), 2-inch

needleneedle Midclavicular line: 2nd intercostal Midclavicular line: 2nd intercostal

spacespace Midaxillary line: 4-5th intercostal spaceMidaxillary line: 4-5th intercostal space Go over superior margin of rib to avoid Go over superior margin of rib to avoid

blood vesselsblood vessels Be careful not to kink or bend needle Be careful not to kink or bend needle

or catheteror catheter If available, attach a one-way valveIf available, attach a one-way valve

HemothoraxHemothorax PathophysiologyPathophysiology

Blood in the pleural Blood in the pleural spacespace

Most common result of Most common result of major trauma to the major trauma to the chest wallchest wall

Present in 70 - 80% of Present in 70 - 80% of penetrating and major penetrating and major non-penetrating trauma non-penetrating trauma casescases

Associated with Associated with pneumothoraxpneumothorax

Rib fractures are Rib fractures are frequent causefrequent cause


Each can hold up to 3000 cc of bloodEach can hold up to 3000 cc of blood Life-threatening often requiring chest tube Life-threatening often requiring chest tube

and/or surgeryand/or surgery If assoc. with great vessel or cardiac injuryIf assoc. with great vessel or cardiac injury

50% die immediately50% die immediately 25% live five to ten minutes25% live five to ten minutes 25% may live 30 minutes or longer 25% may live 30 minutes or longer

Blood loss results inBlood loss results in HypovolemiaHypovolemia Decreased ventilation of affected lungDecreased ventilation of affected lung


Accumulation of blood in pleural spaceAccumulation of blood in pleural space penetrating or blunt lung injurypenetrating or blunt lung injury chest wall vesselschest wall vessels intercostal vesselsintercostal vessels myocardiummyocardium

Massive hemothorax indicates great vessel Massive hemothorax indicates great vessel or cardiac injuryor cardiac injury

Intercostal artery can bleed 50 cc/minIntercostal artery can bleed 50 cc/min Results in collapse of lungResults in collapse of lung


Accumulated blood can eventually produce Accumulated blood can eventually produce a tension hemothorax a tension hemothorax

Shifting the mediastinum producingShifting the mediastinum producing ventilatory impairmentventilatory impairment cardiovascular collapsecardiovascular collapse

HemothoraxHemothorax Assessment FindingsAssessment Findings

Tachypnea or respiratory distressTachypnea or respiratory distress ShockShock

Rapid, weak pulseRapid, weak pulse Hypotension, narrow pulse pressureHypotension, narrow pulse pressure Restlessness, anxietyRestlessness, anxiety Cool, pale, clammy skinCool, pale, clammy skin ThirstThirst

Pleuritic chest painPleuritic chest pain Decreased lung soundsDecreased lung sounds Collapsed neck veinsCollapsed neck veins Dullness on percussionDullness on percussion

HemothoraxHemothorax ManagementManagement

Establish airwayEstablish airway High concentration OHigh concentration O22

Assist Ventilations w/BVM prnAssist Ventilations w/BVM prn Needle thoracostomy if tension & unable to Needle thoracostomy if tension & unable to

differentiate from Tension Pneumothoraxdifferentiate from Tension Pneumothorax IVs x 2 with LR/NSIVs x 2 with LR/NS Monitor ECGMonitor ECG Emergent transport to Trauma CenterEmergent transport to Trauma Center

Pulmonary ContusionPulmonary Contusion PathophysiologyPathophysiology

Blunt trauma to the chestBlunt trauma to the chest Rapid deceleration forces cause lung to Rapid deceleration forces cause lung to

strike chest wallstrike chest wall high energy shock wave from explosionhigh energy shock wave from explosion high velocity missile woundhigh velocity missile wound low velocity as with ice picklow velocity as with ice pick

Most common injury from blunt thoracic Most common injury from blunt thoracic traumatrauma

30-75% of blunt trauma30-75% of blunt trauma mortality 14-20%mortality 14-20%

Pulmonary ContusionPulmonary Contusion PathophysiologyPathophysiology

Rib Fx in many but not Rib Fx in many but not all casesall cases

Alveolar rupture with Alveolar rupture with hemorrhage and edemahemorrhage and edema

increased capillary increased capillary membrane membrane permeabilitypermeability

Large vascular Large vascular shunts developshunts develop

Pulmonary ContusionPulmonary Contusion Assessment FindingsAssessment Findings

Tachypnea or respiratory distressTachypnea or respiratory distress TachycardiaTachycardia Evidence of blunt chest traumaEvidence of blunt chest trauma Cough and/or HemoptysisCough and/or Hemoptysis ApprehensionApprehension CyanosisCyanosis

Pulmonary ContusionPulmonary Contusion ManagementManagement

Supportive therapySupportive therapy Early use of positive Early use of positive

pressure ventilation pressure ventilation reduces ventilator reduces ventilator therapy durationtherapy duration

Avoid aggressive Avoid aggressive crystalloid infusioncrystalloid infusion

Severe cases may Severe cases may require ventilator require ventilator therapytherapy

Emergent TransportEmergent Transport Trauma CenterTrauma Center

Cardiovascular Cardiovascular TraumaTrauma

Any patient with significant Any patient with significant blunt or penetrating trauma blunt or penetrating trauma

to chest has heart/great to chest has heart/great vessel injury until proven vessel injury until proven

otherwiseotherwise

Myocardial ContusionMyocardial Contusion

Most common blunt injury to heartMost common blunt injury to heart Usually due to steering wheelUsually due to steering wheel Significant cause of morbidity and Significant cause of morbidity and

mortality in the blunt trauma patientmortality in the blunt trauma patient

Myocardial ContusionMyocardial Contusion PathophysiologyPathophysiology

Behaves like acute MIBehaves like acute MI Hemorrhage with edemaHemorrhage with edema

Cellular injuryCellular injury vascular damage may occurvascular damage may occur

Hemopericardium may occur from Hemopericardium may occur from lacerated epicardium or endocardiumlacerated epicardium or endocardium

May produce arrhythmiasMay produce arrhythmias May cause hypotension unresponsive to May cause hypotension unresponsive to

fluid or drug therapyfluid or drug therapy

Myocardial ContusionMyocardial Contusion Assessment FindingsAssessment Findings

Cardiac arrhythmias following blunt chest Cardiac arrhythmias following blunt chest traumatrauma

Angina-like pain unresponsive to Angina-like pain unresponsive to nitroglycerinnitroglycerin

Precordial discomfort independent of Precordial discomfort independent of respiratory movementrespiratory movement

Pericardial friction rub (late)Pericardial friction rub (late)

Myocardial ContusionMyocardial Contusion Assessment FindingsAssessment Findings

ECG ChangesECG Changes Persistent tachycardiaPersistent tachycardia ST elevation, T wave inversionST elevation, T wave inversion RBBBRBBB Atrial flutter, Atrial fibrillationAtrial flutter, Atrial fibrillation PVCsPVCs PACsPACs

Myocardial ContusionMyocardial Contusion ManagementManagement

Establish airwayEstablish airway High concentration OHigh concentration O2 2

IV LR/NSIV LR/NS Cautious fluid administration due to injured Cautious fluid administration due to injured

myocardiummyocardium ECGECG

Standard drug therapy for arrhythmiasStandard drug therapy for arrhythmias 12 Lead ECG if time permits12 Lead ECG if time permits

Consider vasopressors for hypotensionConsider vasopressors for hypotension Emergent TransportEmergent Transport

Trauma CenterTrauma Center

Pericardial TamponadePericardial Tamponade IncidenceIncidence

Usually associated with penetrating Usually associated with penetrating traumatrauma

Rare in blunt traumaRare in blunt trauma Occurs in < 2% of chest traumaOccurs in < 2% of chest trauma GSW wounds have higher mortality GSW wounds have higher mortality

than stab woundsthan stab wounds Lower mortality rate if isolated Lower mortality rate if isolated

tamponadetamponade

Pericardial TamponadePericardial Tamponade PathophysiologyPathophysiology

Space normally filled with 30-50 ml of Space normally filled with 30-50 ml of straw-colored fluidstraw-colored fluid

lubricationlubrication lymphatic dischargelymphatic discharge immunologic protection for the heartimmunologic protection for the heart

Rapid accumulation of blood in the inelastic Rapid accumulation of blood in the inelastic pericardiumpericardium

Pericardial TamponadePericardial Tamponade PathophysiologyPathophysiology

Heart is compressed decreasing blood Heart is compressed decreasing blood entering heartentering heart

Decreased diastolic expansion and fillingDecreased diastolic expansion and filling Hindered venous return (preload)Hindered venous return (preload)

Myocardial perfusion decreased due toMyocardial perfusion decreased due to pressure effects on walls of heartpressure effects on walls of heart decreased diastolic pressuresdecreased diastolic pressures

Ischemic dysfunction may result in injuryIschemic dysfunction may result in injury Removal of as little as 20 ml of blood may Removal of as little as 20 ml of blood may

drastically improve cardiac outputdrastically improve cardiac output

Pericardial TamponadePericardial Tamponade Signs and SymptomsSigns and Symptoms

Beck’s TriadBeck’s Triad Resistant hypotensionResistant hypotension Increased central venous Increased central venous pressure (distended neck/arm pressure (distended neck/arm veins in presence of decreased veins in presence of decreased arterial BP)arterial BP)

Small quiet heart (decreased Small quiet heart (decreased heart sounds)heart sounds)

Pericardial TamponadePericardial Tamponade

Signs and SymptomsSigns and Symptoms Narrowing pulse pressureNarrowing pulse pressure Pulsus paradoxicusPulsus paradoxicus

Radial pulse becomes weak or Radial pulse becomes weak or disappears when patient inhalesdisappears when patient inhales

Increased intrathoracic Increased intrathoracic pressure on inhalation causes pressure on inhalation causes blood to be trapped in lungs blood to be trapped in lungs temporarilytemporarily

Pericardial TamponadePericardial Tamponade ManagementManagement

Secure airwaySecure airway High concentration OHigh concentration O22

PericardiocentesisPericardiocentesis Out of hospital, primarily reserved for Out of hospital, primarily reserved for

cardiac arrestcardiac arrest Rapid transportRapid transport

Trauma CenterTrauma Center IVs of LR/NSIVs of LR/NS

Pericardial TamponadePericardial Tamponade ManagementManagement

Definite treatment is pericardiocentesis Definite treatment is pericardiocentesis followed by surgeryfollowed by surgery

Pericardial WindowPericardial Window Tamponade is hard to diagnosisTamponade is hard to diagnosis

Hypotension is common in chest traumaHypotension is common in chest trauma Heart sounds are difficult to hearHeart sounds are difficult to hear Bulging neck veins may be absent if Bulging neck veins may be absent if

hypovolemia is presenthypovolemia is present High index of suspicion is requiredHigh index of suspicion is required

Traumatic Aortic Traumatic Aortic Dissection/RuptureDissection/Rupture

Caused By:Caused By: Motor Vehicle Motor Vehicle

CollisionsCollisions Falls from heightsFalls from heights Crushing chest traumaCrushing chest trauma Animal KicksAnimal Kicks Blunt chest traumaBlunt chest trauma

15% of all blunt 15% of all blunt trauma deathstrauma deaths


1 of 6 persons dying in MVC’s has 1 of 6 persons dying in MVC’s has aortic ruptureaortic rupture 85% die instantaneously85% die instantaneously 10-15% survive to hospital10-15% survive to hospital

1/3 die within six hours1/3 die within six hours 1/3 die within 24 hours1/3 die within 24 hours 1/3 survive 3 days or longer1/3 survive 3 days or longer

MustMust have high index of suspicion have high index of suspicion


Separation of the aortic intima and mediaSeparation of the aortic intima and media Tear 2° high speed deceleration at points of relative Tear 2° high speed deceleration at points of relative

fixationfixation Blood enters media through a small intima Blood enters media through a small intima

teartear Thinned layer may ruptureThinned layer may rupture

Descending aorta at the isthmus distal to left Descending aorta at the isthmus distal to left subclavian artery most common site of subclavian artery most common site of rupturerupture ligamentum arteriosomligamentum arteriosom

Traumatic Aortic Traumatic Aortic Dissection/Rupture Dissection/Rupture

Assessment FindingsAssessment Findings Retrosternal or interscapular painRetrosternal or interscapular pain Pain in lower back or one legPain in lower back or one leg Respiratory distressRespiratory distress Asymmetrical arm BPsAsymmetrical arm BPs Upper extremity hypertension withUpper extremity hypertension with

Decreased femoral pulses, ORDecreased femoral pulses, OR Absent femoral pulses Absent femoral pulses

DysphagiaDysphagia

Traumatic Aortic Traumatic Aortic Dissection/Rupture Dissection/Rupture

ManagementManagement Establish airwayEstablish airway High concentration oxygenHigh concentration oxygen Maintain minimal BP in dissectionMaintain minimal BP in dissection

IV LR/NS TKOIV LR/NS TKO minimize fluid administrationminimize fluid administration

Avoid PASGAvoid PASG Emergent TransportEmergent Transport

Trauma CenterTrauma Center Vascular Surgery capabilityVascular Surgery capability

Diaphragmatic RuptureDiaphragmatic Rupture Usually due to blunt trauma but may Usually due to blunt trauma but may

occur with penetrating traumaoccur with penetrating trauma Usually life-threateningUsually life-threatening Likely to be associated with other Likely to be associated with other

severe injuriessevere injuries

Diaphragmatic RuptureDiaphragmatic Rupture PathophysiologyPathophysiology

Compression to abdomen resulting in Compression to abdomen resulting in increased intra-abdominal pressureincreased intra-abdominal pressure

abdominal contents rupture through abdominal contents rupture through diaphragm into chestdiaphragm into chest

bowel obstruction and strangulationbowel obstruction and strangulation restriction of lung expansionrestriction of lung expansion mediastinal shiftmediastinal shift

90% occur on left side due to protection of 90% occur on left side due to protection of right side by liverright side by liver

Diaphragmatic RuptureDiaphragmatic Rupture

Assessment FindingsAssessment Findings Decreased breath soundsDecreased breath sounds

Usually unilateralUsually unilateral Dullness to percussionDullness to percussion

Dyspnea or Respiratory DistressDyspnea or Respiratory Distress Scaphoid Abdomen (hollow appearance)Scaphoid Abdomen (hollow appearance) Usually impossible to hear bowel soundsUsually impossible to hear bowel sounds

Diaphragmatic RuptureDiaphragmatic Rupture ManagementManagement

Establish airwayEstablish airway Assist ventilations with high concentration OAssist ventilations with high concentration O2 2

IV of LRIV of LR Monitor EKGMonitor EKG NG tube if possibleNG tube if possible AvoidAvoid

MASTMAST Trendelenburg positionTrendelenburg position

Diaphragmatic Diaphragmatic PenetrationPenetration

Suspect intra-abdominal trauma Suspect intra-abdominal trauma with any injury below 4th ICSwith any injury below 4th ICS

Suspect intrathoracic trauma with Suspect intrathoracic trauma with any abdominal injury above any abdominal injury above umbilicusumbilicus

Esophageal InjuryEsophageal Injury Penetrating Injury most frequent causePenetrating Injury most frequent cause

Rare in blunt traumaRare in blunt trauma Can perforate spontaneouslyCan perforate spontaneously

violent emesisviolent emesis carcinomacarcinoma

Esophageal InjuryEsophageal Injury Assessment FindingsAssessment Findings

Pain, local tendernessPain, local tenderness Hoarseness, DysphagiaHoarseness, Dysphagia Respiratory distressRespiratory distress Resistance of neck on passive motionResistance of neck on passive motion Mediastinal esophageal perforationMediastinal esophageal perforation

mediastinal emphysema / mediastinal crunchmediastinal emphysema / mediastinal crunch mediastinitismediastinitis SQ EmphysemaSQ Emphysema splinting of chest wallsplinting of chest wall

ShockShock

Esophageal InjuryEsophageal Injury ManagementManagement

Establish AirwayEstablish Airway Consider early intubation if possibleConsider early intubation if possible IV LR/NS titrated to BP 90-100 mm HgIV LR/NS titrated to BP 90-100 mm Hg Emergent TransportEmergent Transport

Trauma CenterTrauma Center Surgical capabilitySurgical capability

Tracheobronchial Tracheobronchial RuptureRupture

Uncommon injury Uncommon injury less than 3% of chest traumaless than 3% of chest trauma

Occurs with penetrating or blunt Occurs with penetrating or blunt chest traumachest traumaHigh mortality rate (>30%)High mortality rate (>30%)May involve fracture of upper 3 May involve fracture of upper 3 ribsribs

Tracheobronchial Tracheobronchial RuptureRupture

PathophysiologyPathophysiology Majority (80%) occur at or near carinaMajority (80%) occur at or near carina rapid movement of air into pleural spacerapid movement of air into pleural space Tension pneumothorax refractory to needle Tension pneumothorax refractory to needle

decompressiondecompression continuous flow of air from needle of continuous flow of air from needle of

decompressed chestdecompressed chest

Tracheobronchial Tracheobronchial RuptureRupture Assessment FindingsAssessment Findings

Respiratory DistressRespiratory Distress DyspneaDyspnea TachypneaTachypnea

Obvious SQ emphysemaObvious SQ emphysema HemoptysisHemoptysis

Especially of bright red bloodEspecially of bright red blood Signs of tension pneumothorax Signs of tension pneumothorax

unresponsive to needle decompressionunresponsive to needle decompression

Tracheobronchial Tracheobronchial RuptureRupture ManagementManagement

Establish airway and ventilationsEstablish airway and ventilations Consider early intubationConsider early intubation

intubating right or left mainstem may be intubating right or left mainstem may be life savinglife saving

Emergent TransportEmergent Transport Trauma CenterTrauma Center

Pitfalls to AvoidPitfalls to Avoid

Elderly do not tolerate relatively minor Elderly do not tolerate relatively minor chest injurieschest injuries Anticipate progression to acute respiratory Anticipate progression to acute respiratory

insufficiencyinsufficiency Children may sustain significant Children may sustain significant

intrathoracic injury w/o evidence of intrathoracic injury w/o evidence of thoracic skeletal traumathoracic skeletal trauma Maintain a high index of suspicionMaintain a high index of suspicion

Pitfalls to AvoidPitfalls to Avoid

Don’t overlook the Obvious!Don’t overlook the Obvious! Be suspicious of the non-obvious!Be suspicious of the non-obvious!

Documents

Thoracic Trauma Christopher McPeak, MD Department of Emergency Medicine Albany Medical Center