Chapter 4_ Thoracic Trauma.pptx ATLS.....
- 1. 4 Thoracic Trauma Tenth Edition
- 2. 2 of 27 Thoracic Trauma 4 Thoracic injury is common in polytrauma patients and can be life- threatening, especially if not promptly identified and treated during the primary survey.
- 3. 3 of 27 Thoracic Trauma 4 Objectives By the end of this interactive discussion, you will be able to: 1. Apply the ATLS principles to the management of a patient with thoracic trauma. 2. Recognize the important life-threatening injuries in a patient with thoracic trauma. 3. Evaluate the case scenario of a patient with thoracic trauma to identify immediate life-threatening injuries. 4. Discuss the clinical findings and adjunctive studies that may be useful during the secondary survey in a patient with thoracic trauma.
- 4. 4 of 27 Thoracic Trauma 4 Case Scenario 27-year-old male unrestrained driver in high-speed, frontal-impact MVC Airway patent, obvious respiratory distress BP 90/50; HR 110; RR 36; and GCS 14 None reported M I S T
- 5. 5 of 27 Thoracic Trauma 4 Discussion Questions: 1. What life-threatening injuries might one discover in the primary survey that could account for the patient’s clinical status? 2. What are the next steps in the evaluation and treatment of this patient? Case Details M 27-year-old male unrestrained driver in high-speed, frontal- impact MVC Airway patent, obvious respiratory distress BP 90/50; HR 110; RR 36; and GCS 14 None reported I S T
- 6. 6 of 27 Thoracic Trauma 4 Discussion Questions: 1. What are the immediately life- threatening thoracic injuries involving: • Airway • Breathing • Circulation Case Details M 27-year-old male unrestrained driver in high-speed, frontal- impact MVC Airway patent, obvious respiratory distress BP 90/50; HR 110; RR 36; and GCS 14 None reported I S T
- 7. 7 of 27 Thoracic Trauma 4 Case Scenario Progression On arrival to ED: • Patient complains of profound shortness of breath, asking to sit up • O2 sat 89%. • Cervical collar in place • Trachea deviated to left • Breath sounds absent on left • Heart sounds normal • Left chest wall crepitus
- 8. 8 of 27 Thoracic Trauma 4 Discussion Questions: 1. What is this patient’s most likely diagnosis? 2. What is the appropriate technique to alleviate this patient’s condition? • Patient complains of profound shortness of breath, asking to sit up • O2 sat 89%. • Cervical collar in place • Trachea deviated to left • Breath sounds absent on left • Heart sounds normal • Left chest wall crepitus Case Details
- 9. 9 of 27 Thoracic Trauma 4 Case Scenario Progression • Needle decompression performed, no rush of air • Vital signs unchanged
- 10. 10 of 27 Thoracic Trauma 4 Discussion Question: What alternative management strategy can you use? Case Details • Needle decompression performed, no rush of air • Vital signs unchanged
- 11. 11 of 27 Thoracic Trauma 4 Discussion Question: What are the differences in clinical presentation between a tension pneumothorax and an open pneumothorax?
- 12. 12 of 27 Thoracic Trauma 4 Case Scenario Progression • Finger thoracostomy performed • Vital signs: RR 28; HR 110; BP 100/60 • Thoracostomy tube placed, 600 mL dark blood drained • Two large-bore IV lines established, isotonic fluid given • Type and crossmatch requested • Chest x-ray shows: o obscured L diaphragm o multiple L rib fractures o wide mediastinum o pulmonary contusion
- 13. 13 of 27 Thoracic Trauma 4 Discussion Questions: 1. What are the indications for operation in a patient with traumatic hemothorax? 2. What resuscitative measures should be undertaken in a patient with massive hemothorax?
- 14. 14 of 27 Thoracic Trauma 4 Discussion Questions: 3. What other potential life threats might exist in a patient with this mechanism? For each, what would the clinical presentation/findings and the appropriate treatment be? 4. What test would you perform to make the diagnosis during the secondary survey? • Finger thoracostomy performed • Vital signs: RR 28; HR 110; BP 100/60 • Thoracostomy tube placed, 600 mL dark blood drained • Two large-bore IV lines established, isotonic fluid given • Type and crossmatch requested • Chest x-ray shows: • obscured L diaphragm • multiple L rib fractures • wide mediastinum • pulmonary contusion Case Details
- 15. 15 of 27 Thoracic Trauma 4 Potential Life Threat Clinical Presentation/Findings Treatment Pitfalls Simple Pneumothorax +/- shortness of breath No hypotension Diagnosis by chest x-ray Chest tube drainage Could become tension pneumothorax if untreated Hemothorax Dullness to percussion Diagnosis by chest x-ray Chest tube drainage Could become massive hemothorax Flail Chest and Pulmonary Contusion May see paradoxical movement of chest wall More commonly presents with pain and poor respiratory excursions Oxygen Analgesia Intubation if necessary Progressive respiratory failure Blunt Cardiac Injury ECG changes Cardiac monitoring Therapy based on clinical status At risk for clinically significant dysrhythmias Traumatic Aortic Disruption May be asymptomatic Multiple possible radiographic findings Endovascular or open surgical repair Blood pressure control important prior to definitive therapy Traumatic Diaphragm Injury Respiratory distress Obscured left diaphragm border Evidence of abdominal viscera in chest Operative repair Concomitant pulmonary contusion may mask diaphragm injury Esophageal injury Chest pain; mediastinal air on imaging; crepitus delayed fever Operative repair Delayed diagnosis
- 16. 16 of 27 Thoracic Trauma 4 Case Scenario Progression • 250 mL of IV fluids given • Vital signs: BP 110/70; HR 110; RR 18 • O2 sat 91% on nonrebreather mask
- 17. 17 of 27 Thoracic Trauma 4 Discussion Question: Which of the following treatments is best for pulmonary contusion/flail chest? A. Beta blockers B. Massive fluid resuscitation C. Immediate nebulizer treatment D. Supplemental oxygen, pain control, and recognition of the potential for respiratory failure
- 18. 18 of 27 Thoracic Trauma 4 Case Scenario Conclusion Your institution has the capability to care for this patient, and you order a CT scan for further evaluation.
- 19. 19 of 27 Thoracic Trauma 4 Case Scenario #2 25-year-old male, high-speed MVC Awake and responds to questions, complaining of chest pain and shortness of breath, gurgling sounds L lung base. BP 102/76; HR 134; O2 sat 93% on oxygen by face mask Chest x-ray M I S T
- 20. 20 of 27 Thoracic Trauma 4 Discussion Questions: 1. What abnormalities do you note on the chest film?
- 21. 21 of 27 Thoracic Trauma 4 Discussion Questions: 2. What is the treatment for a traumatic diaphragm injury? 3. Aside from the tracheal deviation to the right seen on the chest film, what other signs and x-ray findings might one see in a patient with traumatic aortic disruption? Case Details M 25-year-old male, high-speed MVC Awake and responds to questions, complaining of chest pain and shortness of breath, gurgling sounds L lung base. BP 102/76; HR 134; O2 sat 93% on oxygen by face mask Chest x-ray I S T
- 22. 22 of 27 Thoracic Trauma 4 Case Scenario Progression CT scan shows blunt aortic injury
- 23. 23 of 27 Thoracic Trauma 4 Discussion Questions: 1. What is the expected hemodynamic impact of a contained aortic disruption from blunt trauma? 2. If a patient with a known contained aortic disruption from blunt trauma becomes hypotensive, what should you consider? 3. What therapeutic steps should a clinician consider when managing a traumatic aortic disruption? Case Details • CT scan shows blunt aortic injury
- 24. 24 of 27 Thoracic Trauma 4 Case Scenario Conclusion • Discussion with anesthesiology re: management of the patient’s aortic injury • Patient undergoes repair of his diaphragmatic injury via laparotomy • The following day, he undergoes endovascular repair of his aortic injury • He does well after 2 weeks in the ICU and is discharged home
- 25. 25 of 27 Thoracic Trauma 4 Any Questions? ?
- 26. 26 of 27 Thoracic Trauma 4 Review Objectives By the end of this interactive discussion, you will be able to: 1. Apply the ATLS principles to the management of a patient with thoracic trauma. 2. Recognize the important life-threatening injuries in a patient with thoracic trauma. 3. Evaluate the case scenario of a patient with thoracic trauma to identify immediate life-threatening injuries. 4. Discuss the clinical findings and adjunctive studies that may be useful during the secondary survey in a patient with thoracic trauma.
- 27. 27 of 27 Thoracic Trauma 4 Key Learning Points 1. It is important to recognize thoracic life-threatening problems in polytrauma patients. 2. Most immediate thoracic life-threatening problems can be recognized without special testing and may be treated with: • airway control • decompression and/or • fluid resuscitation 3. Potential life-threatening problems can become immediate life- threatening problems if untreated (e.g., a simple pneumothorax can become a tension pneumothorax).
Editor's Notes
- #2: The instructor needs to establish: 1. Content of the interactive discussion: Thoracic Trauma 2. Aim of the interactive discussion: a. To allow participants to apply the ATLS knowledge they have gained from reading the Student Manual chapter. b. Session will be run as an interactive discussion guided by an unfolding case with stimulus questions. c. Participants are required to engage with the discussion and respond to questions. d. This is a supportive learning environment in which we learn from each other. People need to be supportive of one another’s input. If you are unsure how to respond to a question, feel free to request help from a fellow participant (i.e., work together).
- #3: Read each of the learning objectives so that the participants understand the key learning outcomes for this discussion. In addition, explain the common language that ATLS teaches and its importance. Discuss the roles of trauma team members. This interactive discussion must cover the Key Points for this chapter: Key Learning Points: 1. It is important to recognize thoracic life-threatening problems in polytrauma patients. Most immediate thoracic life-threatening problems can be recognized without special testing and may be treated with: - airway control - decompression and/or - fluid resuscitation 3. Potential life-threatening problems can become immediate life-threatening problems if untreated (e.g., a simple pneumothorax can become a tension pneumothorax).
- #5: The participants’ responses should include the following information: 1. Because the patient’s airway is patent, laryngeal and proximal tracheobronchial injuries are less likely. Breathing and circulatory life threats must be considered (RR is 36 and the patient is in obvious distress, with tachycardia, and hypotension), such as tension pneumothorax, open pneumothorax, massive hemothorax, and cardiac tamponade. An assessment should be performed of the patient’s breath and cardiac sounds, while simultaneously applying supplemental oxygen and obtaining information about the patient’s oxygen saturation (with pulse oximetry and/or ABGs) and ventilation (with EtCO2 and/or ABG). Intravenous and/or intraosseous access should be obtained and resuscitation initiated. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself. For example: - What other injuries may the patient have? (if they don’t cover the entire list) - What type of pneumothorax? (if they just say pneumothorax). - What other therapies might be appropriate? (What about oxygen? How will you know if the patient is responding to supplemental oxygen?)
- #6: These are the responses that you are expecting from the participants. Prompt if not immediately forthcoming (e.g., Anything else? What about the type of pneumothorax?). Airway Problems - Laryngeal injuries - Proximal tracheobronchial injuries note these injuries may present with tension pneumothorax and extensive subcutaneous emphysema. Treatment with a single chest tube may not fully re-expand the lung Note: These injuries require prompt establishment of a definitive airway and may require advanced airway skills (e.g., fiberoptic intubation). Breathing Problems - Open pneumothorax - Tension pneumothorax Note: This is often classified as a breathing problem, but mortality is due to obstructive shock caused by decreased venous return associated with mediastinal shift. Circulation Problems - Massive hemothorax - Cardiac tamponade
- #8: The participants’ responses should include the following information: 1. The patient most likely has a tension pneumothorax. His heart tones are clear and not muffled, and he has absent breath sounds on the left side. Cardiac tamponade does not result in a deviated trachea. 2. Chest decompression is warranted. Acceptable techniques are needle decompression in the fifth intercostal space, anterior axillary line (higher likelihood of success); the second interspace midclavicular line; or a finger thoracostomy, followed by chest tube in the anterior axillary line. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #10: The participants’ responses should include the following information: The students should describe the technique of finger decompression. You may also discuss needle decompression. Particularly discuss the possibility that needle could not reach the thoracic cavity if the patients very obese or muscular or if the needle is not of adequate length. The students should indicate that this should be followed by placement of a chest tube using full barrier precautions. Add to the discussion the fact that needle decompression will not decompress blood, so it would not help if the patient has a hemothorax. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #11: The participants’ responses should include the following information: Both types of pneumothoraces present with respiratory distress, but an open pneumothorax is usually accompanied by noisy air movement through the injury due to the size of the hole in the chest wall. Unlike a tension pneumothorax, an open pneumothorax will not improve with needle or finger decompression. It should initially be treated with an occlusive dressing taped on three sides, followed by a chest tube inserted remote from the injury. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself. For example: - Can you treat an open pneumothorax with needle/finger decompression? (if the students are unable to describe treatment) - Emphasize that the injury should NOT be used as the insertion site. - Try to elicit from the students the fact that some of these injuries require operative address (e.g., What are the options for definitive treatment of the wound if it is very large?)
- #13: The participants’ responses should include the following information: 1. A “massive hemothorax” is defined as 1500 ml initial output from the chest tube or ongoing bleeding of 200 mL/hr for 2 to 4 hours. Students should indicate that this is an indication for thoracotomy. 2. Blood loss should be replaced with either standard transfusion or autotransfusion, if possible. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #14: The participants’ responses should include the following information: 3. The students should list several potential life threats, as seen below. Time permitting, you can ask students to describe the clinical findings when they identify a potential life threat. Prompt for missing life threats if not identified, rather than providing them yourself. Time permitting, discuss the potential pitfalls. Simple pneumothorax Simple hemothorax Blunt aortic injury Blunt cardiac injury Cardiac tamponade Esophageal injury Diaphragmatic injury Flail chest Rib fractures 4. CT scan in hemodynamically stable patients is useful to characterize hemothoraces, but chest x-ray is usually sufficient. Traumatic aortic injury requires spiral CT scan or angiography. Diaphragm injuries not seen on plain x-ray are often seen with CT scan with fine cuts. Pulmonary contusions may be better visualized on CT scan as well. Bronchoscopy may be needed to diagnose tracheobronchial injuries. Esophagoscopy or GI contrast study may be needed to diagnose esophageal injury. Echocardiography, 12 lead EKG and continuous monitoring for blunt cardiac injury. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #15: These are the responses that you are expecting from the participants. Prompt if not immediately forthcoming (e.g., Anything else? What about hemothorax?).
- #17: The participants’ responses should include the following information: The correct answer is D. Pulmonary contusion/flail chest is best treated with supplemental oxygen, pain control, and recognition of the potential for respiratory failure. There is no role for beta blockers in this scenario, and fluids should be limited with this injury. Nebulizer treatment may help if there is an underlying lung disorder. Pulmonary contusion should be treated with supportive therapy, including oxygen, adequate pain control, and close observation to recognize if the patient is unable to ventilate properly. Some patients require mechanical ventilation. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #20: The participants’ responses should include the following information: 1. There is evidence of gastric bubble in the left hemithorax, which represents a traumatic diaphragm injury. In the chest, the trachea is deviated slightly to the right, and the mediastinum is wide, with poor contour. These findings are concerning for a traumatic aortic disruption. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #21: The participants’ responses should include the following information: 2. The treatment for traumatic diaphragm injury is laparotomy. 3. Other findings or signs of possible traumatic aortic disruption include asymmetric upper extremity pulses, deviation of a nasogastric tube downward, apical capping, loss of aortic knob, and widened mediastinum. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #23: The participants’ responses should include the following information: 1. Patients with contained aortic disruption from blunt trauma do not usually have hemodynamic instability from the injury; although they have lost blood, it is not enough to cause hemorrhagic shock. Should the aorta rupture freely, the outcome is almost universally fatal. Therefore, it is important to carefully manage the blood pressure in a patient with traumatic aortic disruption. 2. If a patient becomes hypotensive with a known traumatic aortic disruption, consider a worsening or undiagnosed solid organ injury or some other source of bleeding. (If necessary, help the students discover the answers by asking, What other types of injuries might one see in a patient with polytrauma that could cause hypotension?) 3. If possible, it is important to try to manage the patient’s blood pressure carefully. The patient may require a short-acting beta blocker such as Esmolol to control blood pressure and heart rate. If the participants do not provide the information, ask additional questions to elicit the information from the participants, rather than providing it yourself.
- #26: Specifically state how each of the learning objectives was achieved during the interactive discussion. Encourage participants to: 1. Reflect on these learning objectives and on their confidence in completion of the objectives. 2. Review the ATLS Student Manual chapter to reinforce ATLS principles and material not specifically discussed in this session.
- #27: Summarize for the participants the Key Points from this interactive discussion.