Thoracic Trauma

Question 1

True or false: Most life threatening thoracic injuries can be treated with airway control or decompression of the chest with a needle, finger or tube.

Answer 1

True!

Question 2

What are clinical signs and symptoms of tracheobronchial tree injury?

Answer 2

1. Hemoptysis
2. Cervical subcuteneous emphysema
3. Tension pneumothorax
4. Cyaynosis
5. Incomplete expansion of the lung and continued large air leak after placement of a chest tube

Question 3

What is the most common cause of tension pneumothorax?

-other causes?

Answer 3

Most common cause of tension pneumothorax = mechanical positive pressure ventilation in patients with visceral pleural injury

Other causes:

1. Penetrating or blunt chest trauma in which a parenchymal lung injury fails to seal
2. Iatrogenic from subclavian or IJ venous catheter insertion
3. Traumatic defects in the chest wall that have occlusive dressings placed on them or the defect itself has a flap-valve mechanism
4. Markedly displaced thoracic spine fractures (rare)

Question 4

Fill in the blank: Patients with tension pneumothorax who are spontaneously breathing often manifest ____ and ____ whereas patients who are mechanically ventilated manifest ____

Answer 4

Spontaneously breathing: manifest air hunger and extreme tachypnea

Mechanically ventilated: manifest hemodynamic collapse

Question 5

What is the ideal length of needle for needle decompression in tension pneumothorax?
-what is the recent evidence for placement of needle for needle decompression?

Answer 5

5 cm over the needle catheter will reach the pleural space >50% of the time whereas an 8 cm over the needle catheter will reach the pleural space > 90% of the time
-recent evidence supports placing the large needle at the fifth interspace slightly anterior to the midaxillary line

Question 6

True or false: Tube thoracostomy is mandatory after needle or finger decompression of the chest.

Answer 6

True

Question 7

You attempt needle decompression with no success of treating a tension pneumothorax. What is your next move?

Answer 7

Finger decompression may be necessary as you prepare to insert a chest tube

Question 8

What is an open pneumothorax?

Answer 8

Large injuries to the chest wall that remain open can result in an open pneumothorax - equilibration between intrathoracic pessure and atmospheric pressure is immediate
-since air follows the path of least resistance, when the opening of the chest wall is approximately 2/3s the diameter of the trachea or greater, air passes preferentially through the chest wall defect with each inspiration

Question 9

How do you manage an open pneumothorax?

Answer 9

Promptly close the defect with a sterile dressing large enough to overlap the wound’s edges

• tape it securely with occlusive dressing ONLY on three sides to provide a flutter valve effect
• as the patient breathes in, the dressing occludes the wound so air cannot enter the chest wall. As the patient breathes out, the open end of the dressing allows air to escape from the pleural space
• ***DO NOT TAPE ALL 4 EDGES OF THE DRESSING DOWN OR YOU MIGHT WORSEN THE PNEUMOTHORAX BY ALLOWING AIR TO ACCUMULATE IN THE THORACIC CAVITY UNLESS A CHEST TUBE IS PLACED
• definitive management: place chest tube remove from the wound as soon as possible and get surgical closure of the wound

Question 10

You have a trauma patient presenting with PEA. What are the three most common causes? (4)

Answer 10

1. Tension pneumothorax
2. Cardiac tamponade
3. Profound hypovolema
4. Blunt cardiac injury with resulting blunt rupture of the atria or ventricles

Other causes:

1. Hypoxia
2. Hypovolemia
3. Hydrogen ion (acidosis)
4. Hypothermia
5. Toxins
6. Thrombosis

Question 11

What are the Hs and Ts of PEA/asystole?

Answer 11

1. Hydrogen Ion
2. Hyperkalemia
3. Hypoxia
4. Hypothermia
5. Hypovolemia
6. Toxins
7. Tamponade
8. Tension pneumothorax
9. Thrombosis

Question 12

What is the definition of a massive hemothorax?

-most common cause?

Answer 12

Rapid accumulation of > 1500 ml of blood or 1/3 or more of patient’s blood volume in the chest cavity
-most commonly caused by a penetrating injury that disrupts the systemic or hilar vessels but can also result from blunt trauma

Question 13

What is the management of a massive hemothorax?

Answer 13

1. Restore blood volume
2. Decompress the chest cavity with a chest tube

**When appropriate, blood from chest tube can be collected in a device suitable for autotransfusion

Question 14

What chest tube output is an indication for urgent thoractomy?
-what if there is continued blood loss: what rate of blood loss is an indication for thoractomy?

Answer 14

Immediate return of 1500 ml of blood or more in the chest tube

• basically if they meet criteria for a massive hemothorax!!!
• patients who have an initial output of < 1500 ml but continue to bleed may also require thoractomy
• base this decision on the rate of continuing blood loss (200 ml/hr x 2-4 hours) in addition to patient’s hemodynamic status
• persistent need for blood transfusion in an indication for thoracotomy

Question 15

Name 3 indications for urgent chest thoracotomy in a hemothorax.

Answer 15

1. Initial blood loss of 1500 ml or more through a chest tube
2. Initial blood loss < 1500 ml but continuous blood loss at a rate of > 200 ml x 2-4 hours
3. Persistent need for blood transfusion

Question 16

What anatomical location should you be most concerned about in penetrating thoracic trauma that would indicate a need for thoractomy most likely?

Answer 16

A penetrating thoracic injury in the mediastinal box: penetrating anterior chest wounds medial to the nipple line and posterior wounds medial to the scapula
-high potential for damage to the great vessels, hilar structures, heart with associated potential for cardiac tamponade

Question 17

What is Kussmaul’s sign?

Answer 17

A rise in venous pressure with inspiration when breathing spontaneously - indicates cardiac tamponade or tension pneumothorax

Question 18

On clinical exam, what is the easiest way to differentiate between cardiac tamponade and tension pneumothorax since both can give shock and distended neck veins?

Answer 18

Tension pneumothorax: unilateral decreased breath sounds and hyperresonance on percussion of affected side

Cardiac tamponade: presence of bilateral breath sounds

Question 19

What is the definitive management for cardiac tamponade?

Answer 19

Emergency thoracotomy or sternotomy by a qualified surgeon as soon as possible
-pericardiocentesis is only temporizing measure and should be used as a lifesaving measure of last resort in a setting where no qualified surgeon is available to perform a sternotomy or thoracotomy and whenever possible use ultrasound guidance

Question 20

What is the survival rate for patients in traumatic circulatory arrest?

Answer 20

1. 9% if closed CPR and appropriate resuscitation is performed
   - in centers proficient with restorative thoracotomy, 10% survival and higher has been reported

Question 21

What is the management algorithm for traumatic circulatory arrest?

Answer 21

1. Start closed CPR simultaneously with ABC management. Secure a definitive airway with orotracheal intubation, administer mechanical ventilation with 100% oxygen. Administer rapid fluid resuscitation through large bore IV lines or IO needles Administer epinephrine 1 mg (0.01 mg/kg in kids) or if V fib is present, follow PALS algorithm
2. If no ROSC: to alleviate a potential tension pneumothorax, perform bilateral finger or tube thoracostomies
3. If no ROSC: consider resuscitative thoracotomy (anterolateral or clamshell thoracotomy) if a surgeon is available.
4. If cardiac tamponade is diagnosed and no surgeon is available, do decompressive needle pericardiocentesis
5. After thoracotomy reveals thorax/abdomen:
   - if bleeding is identified from pulmonary pedicle, mediastainal vessel, clamp for hemostasis
   - if bleeding is in abdomen, clamp on descending aorta
6. If still no ROSC, consider cardiac massage and/or internal electric shock

***Death after 30 minutes of resuscitation and temp > 33 degrees celcius

Question 22

What are the immediate life-threatening thoracic injuries that you should identify on your primary survey?

Answer 22

Primary survey immediate life-threatening thoracic injuries:

1. Cardiac tamponade
2. Tension pneumothorax
3. Open pneumothorax
4. Massive hemothorax
5. Airway obstruction
6. Tracheobronchial tree injury

Question 23

What are potentially life threatening thoracic injuries that you should identify on your secondary survey?

Answer 23

Secondary survey potentially life-threatening thoracic injuries:

1. Simple pneumothorax
2. Hemothorax
3. Flail chest
4. Pulmonary contusion
5. Blunt cardiac injury
6. Traumatic aortic disruption
7. Traumatic diaphragmatic injury
8. Blunt esophageal rupture

Question 24

Where is the air in a pneumothorax?

Answer 24

Air is trapped in between the visceral and parietal pleura

Question 25

Where should you place a chest tube?

Answer 25

4-5th intercostal space just anterior to the midaxillary line

Question 26

What is the difference in definition between a hemothorax and a massive hemothorax?

Answer 26

Hemothorax: accumulated blood in pleural cavity < 1500 ml Massive hemothorax: accumulated blood in pleural cavity 1500 ml or more

Question 27

What injured structures can create a hemothorax?

Answer 27

1. Lacerated lung 2. Intercostal vessels 3. Great vessels 4. Internal mammary artery

Question 28

What is the definition of a flail chest?

Answer 28

When a segment of the chest wall does not have bony continuity with the rest of the thoracic cage -usually results from trauma associated with multiple rib fractures (ie. two or more adjacent ribs fractured in 2 or more places) but it can also occur when there is a costochondral separation of a single rib from the thorax

Question 29

What is the most concerning complication for patients with flail chest or pulmonary contusions?

Answer 29

Respiratory failure due to inadequate ventilation and oxygenation - restricted chest wall movement associated with pain and underlying lung contusion can cause severe hypoxia ***Do NOT underestimate the effect of a pulmonary contusion!!! Monitor ABG, end tidal CO2, monitor breathing, intubate when necessary and BE CAREFUL WITH CRYSTALLOID FLUID INFUSION

Question 30

What is the management for flail chest and pulmonary contusions?

Answer 30

1. Humidified oxygen 2. Pain control 3. Cautious fluid resuscitation - in the absence of systemic hypotension, the administration of crystalloid IV solutions should be carefully controlled to prevent volume overload which can further compromise the patient's respiratory status

Question 31

What are the options for analgesia in flail chest/pulmonary contusion?

Answer 31

1. IV or PO opioids 2. Local anesthetics: intermittent intercostal nerve blocks, transcutaneous intrapleural, extrapleural, epidural anesthesia

Question 32

What are possible consequences on the heart of a blunt cardiac injury?

Answer 32

1. Cardiac chamber rupture 2. Valvular disruption 3. Coronary artery dissection/thrombosis 4. Myocardial muscle contusion

Question 33

How does cardiac rupture typically present?

Answer 33

Presents as cardiac tamponade with bleeding into the pericardial sac

Question 34

What are possible clinical features of blunt cardiac injury? | -how useful is troponin in blunt cardiac injury?

Answer 34

1. Hypotension 2. Dysrhythmias 3. ECG changes: can see frank MI, PVCs, unexplained sinus tachycardia, A fib, bundle branch block, ST segment changes, etc. 4. Elevated central venous pressure with no obvious cause can indicate RV dysfunction secondary to contusion Trops are of limited value and offer no additional info beyond what is available via ECG

Question 35

How long should you monitor a patient with suspected blunt cardiac injury?

Answer 35

- if the patient has an abnormal ECG (ie. conduction abnormalities), need to be monitored x at least 24 hours since they are at risk for sudden dysrhythmias - if the patient has a normal ECG, do not need to do further monitoring

Question 36

What is a common cause of sudden death after a vehicle collision or fall from a great height?

Answer 36

Traumatic aortic disruption - causes immediate exsanguination and death -those patients with the best possibility of surviving tend to have an incomplete laceration near the ligamentum arteriosum of the aorta with an intact adventitial layer or a contained mediastinal hematoma,

Question 37

What is one characteristic shared by ALL survivors of traumatic aortic dissection?

Answer 37

They all have a CONTAINED mediastinal hematoma -persistent or recurrent hypotension in these patients is usually due to a separate, unidentified bleeding site because if it was the traumatic aortic disruption that was still bleeding, the patient would be dead

Question 38

What are the radiographic signs of blunt aortic injury? (12) - good luck remembering these... :D

Answer 38

1. Widened mediastinum 2. Obliteration of the aortic knob 3. Deviation of the trachea to the right 4. Depression of the left mainstem bronchus 5. Elevation of the right mainstem bronchus 6. Obliteration of the space between the pulmonary artery and the aorta (obscuration of the aortopulmonary window) 7. Deviation of the esophagus to the right 8. Widened paratracheal stripe 9. Widened paraspinal interfaaces 10. Left hemothorax 11. Fractures of the first or second rib or scapula

Question 39

What is the ideal test to screen for blunt aortic injury? | -what is the gold standard test?

Answer 39

CT chest - should be performed liberally because the findings on CXR are very unreliable - If CT is equivocal, aortography should be performed - if CT is negative for mediastinal hematoma and aortic rupture, then no further diagnostic imaging of the aorta is likely necessary but the surgeon will be the final decision maker on that - another helpful test: TEE

Question 40

What is the management for blunt aortic injury to decrease the likelihood of rupture?

Answer 40

Heart rate and blood pressure control 1. Adequate analgesia to control pain (and thus blood pressure) 2. If no contraindications, can obtain heart rate control with a short acting beta blocker to a goal HR of 80 or less and BP control with a goal MAP of 60-70 - can use esmolol - if esmolol use is not possible, can use calcium channel blocker instead - overall: a qualified surgeon should treat patients with blunt traumatic aortic injury and should assist in the diagnosis - open repair involves resection and repair of the torn segment - can do this or endovascular repair

Question 41

Why are traumatic diaphragmatic ruptures more commonly diagnosed on the left side?

Answer 41

Because the liver obliterates the defect or protects it on the right side whereas the appearance of displaced bowel, stomach or NG tube is more easily detected in the left chest

Question 42

What is the difference between the traumatic diaphragmatic ruptures caused by blunt trauma vs penetrating trauma?

Answer 42

Blunt traumatic diaphragmatic ruptures: usually large radial tears that lead to herniation of intraabdominal content into thoracic cavity Penetrating traumatic diaphragmatic ruptures: usually small perforations that can remain asymptomatic for years

Question 43

How do you diagnose a left sided traumatic diaphragmatic injury?

Answer 43

Insert an NG and if the NG appears in the thoracic cavity on the CXR, this is your diagnosis Can also diagnose with an upper GI contrast study Can also undergo minimally invasive endoscopic procedures (laparoscopy and thoracoscopy) to look at the diaphragm ****overall: be careful when placing a chest tube in a patient with a suspected diaphragm injury so you don't injury the abdominal contents that have become displaced in the chest cavity

Question 44

What are two complications that can occur from blunt esophageal rupture? -management?

Answer 44

1. Mediastinitis 2. Empyema when there is rupture of esophageal contents into the pleural space Management: wide drainage of the pleural space and mediastinum with direct repair of the injury

Question 45

What is traumatic asphyxia? | -clinical features

Answer 45

Crushing injury to the chest - clinical features: 1. Upper torso/facial/arm plethora 2. Petechiae secondary to acute temporary compression of the SCV 3. Massive swelling of chest 4. Cerebral edema

Question 46

What are two potential complications of rib fractures?

Answer 46

1. Atelectasis | 2. Pneumonia