Thoracic Trauma Overview

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Questions and Answers

What percentage of traumatic deaths is thoracic trauma directly responsible for?

15%

30%

25%

20% (correct)

Which type of trauma has a higher percentage of being managed without surgical intervention?

Heart trauma

Skeletal trauma

Blunt trauma (correct)

Penetrating trauma

What is a primary characteristic of blunt thoracic injuries?

Immediate need for surgical intervention

Forces distributed over a large area (correct)

Forces concentrated in a small area

Localized damage to organs

Which classification of chest injuries includes damage to the diaphragm?

Diaphragmatic injury Signup and view all the answers

What mechanism is commonly associated with penetrating thoracic injuries?

Focused forces along a path of penetration Signup and view all the answers

How many deaths do chest injuries account for annually in the United States?

16,000 deaths Signup and view all the answers

Which type of injury leads the statistics in thoracic trauma as the second leading cause of trauma deaths?

Blunt thoracic injuries Signup and view all the answers

What is the main purpose of ventilation in the respiratory system?

To mechanically move air into and out of the lungs Signup and view all the answers

Which of the following conditions is NOT a result of impairments in cardiac output?

Increased lung capacity Signup and view all the answers

What is a classic symptom of clavicular fractures?

Evident deformity at the site of injury Signup and view all the answers

In assessing a patient with potential pleural injury, which finding would indicate significant respiratory distress?

Absence of lung sounds on one side Signup and view all the answers

Which physiological process involves the exchange of oxygen and carbon dioxide?

Respiration Signup and view all the answers

What is a common cause of rib fractures in elderly patients?

Falls from standing height Signup and view all the answers

What is indicated by the presence of narrowed pulse pressure in a patient?

Hypovolemic shock Signup and view all the answers

Which of the following assessment findings may suggest a mediastinal injury?

Asymmetry of lung sounds Signup and view all the answers

What management strategy is often used for significant airway obstruction?

Needle cricothyrotomy Signup and view all the answers

What is a primary consequence of mediastinal shift in tension pneumothorax?

Compression of the uninjured lung Signup and view all the answers

Which of the following is considered a late sign of tension pneumothorax?

Tracheal deviation Signup and view all the answers

What is the most critical step in managing tension pneumothorax?

Reduce pressure in the pleural space Signup and view all the answers

Which of the following findings is NOT typically associated with tension pneumothorax?

Increased lung expansion Signup and view all the answers

When should pleural decompression be performed in a patient suspected of tension pneumothorax?

Only if significant dyspnea and distinct signs are present Signup and view all the answers

What is one of the critical assessment findings of an open pneumothorax?

To-and-fro air motion out of the defect Signup and view all the answers

In the management of an open pneumothorax, which step is crucial to ensure proper airway and ventilation?

Provide high-concentration oxygen Signup and view all the answers

How does tension pneumothorax primarily occur?

From air entering the pleural space without a means of exit Signup and view all the answers

What is a common complication that can arise if a tension pneumothorax is not treated immediately?

Mediastinal shift Signup and view all the answers

Which of the following symptoms is directly associated with a tension pneumothorax?

Profound hypoventilation Signup and view all the answers

What should be monitored during the management of a patient with an open pneumothorax?

Development of a tension pneumothorax Signup and view all the answers

Which injury mechanism is associated with tension pneumothorax?

Blunt trauma and rib fractures Signup and view all the answers

Why is it vital to apply an occlusive dressing in the management of an open pneumothorax?

To seal the wound and prevent air entry Signup and view all the answers

What does the presence of tachycardia indicate in a patient with an open pneumothorax?

Compensatory response to hypoxemia Signup and view all the answers

What should be established before positive-pressure ventilation in managing open pneumothorax?

Airway patency and positioning Signup and view all the answers

What is a common cause of pneumothorax related to rib fractures?

Fractured rib penetrating the lung Signup and view all the answers

What is the management strategy for circulation in cases where pulmonary contusion is suspected?

Restrict fluids Signup and view all the answers

What physiological mechanism primarily causes a closed pneumothorax?

Presence of air in the pleural space Signup and view all the answers

Which of the following is NOT a part of the management for sternal fractures?

Immediate surgery for stabilization Signup and view all the answers

In adult blunt chest trauma, the incidence of closed pneumothorax is approximately:

10% to 30% Signup and view all the answers

What should be monitored if a patient exhibits signs of pneumothorax?

Ventilation/perfusion mismatch Signup and view all the answers

What is the expected outcome for small tears in the lung associated with pneumothorax?

Self-seal and reexpand Signup and view all the answers

What is the primary effect of the 'paper-bag effect' during a closed pneumothorax scenario?

Increased airway pressure leading to ruptured alveoli Signup and view all the answers

Which strategy is crucial for psychological support during the management of thoracic injuries?

Effective communication strategies Signup and view all the answers

What respiratory complication can result from a closed pneumothorax?

Atelectasis due to collapsed alveoli Signup and view all the answers

Study Notes

Thoracic Trauma

Thoracic trauma is responsible for over 20% of all traumatic deaths, regardless of mechanism.
Approximately 16,000 deaths occur annually in the United States due to chest injuries.
Chest injuries are the second leading cause of trauma deaths each year.
Most thoracic injuries (90% of blunt and 70-85% of penetrating trauma) are manageable without surgery.

Classifications of Chest Injuries

Skeletal injury: Damage to bones of the chest.
Pulmonary injury: Damage to the lungs (e.g., collapsed lung).
Heart and great vessel injury: Damage to the heart or major blood vessels.
Diaphragmatic injury: Damage to the diaphragm.

Mechanism of Injury

Blunt thoracic injuries: Forces distributed over a large area, including deceleration and compression.
Penetrating thoracic injuries: Forces concentrated over a small area, along the path of the penetrating object.

Injury patterns

Open injuries: Injuries with a break in the skin.
Closed injuries: Injuries without a break in the skin.

Injury Patterns-Specific Types

Cardiovascular
Pleural and pulmonary
Mediastinal
Diaphragmatic
Esophageal
Penetrating cardiac trauma
Blast injury
Confined spaces
Shock wave
Thoracic cage

Thoracic Anatomy

Skin, muscles
Respiratory muscles: (phrenic and intercostal nerves)
Bones: Thoracic cage, sternum, thoracic spine
Trachea
Bronchi
Lungs

Vascular Anatomy

Heart: Ventricles, atria, valves and pericardium.
Arteries: Aorta, carotid, subclavian, intercostal
Veins: Superior vena cava, inferior vena cava, subclavian, internal jugular
Pulmonary: Arteries & Veins

Mediastinum

The area between the lungs
Contains the heart, trachea, venae cavae, pulmonary arteries, aorta, esophagus, and lymph nodes.

Thoracic Physiology

Ventilation: Mechanical process of moving air into and out of the lungs.
Respiration: Exchange of oxygen and carbon dioxide between the outside atmosphere and the body's cells.

Pathophysiology of Thoracic Trauma-Cardiac Output

Impairments in cardiac output: Blood loss, increased intrapleural pressures, blood in the pericardial sac, myocardial valve damage, or vascular disruption.

Pathophysiology of Thoracic Trauma-Gas Exchange

Impairments in gas exchange: Atelectasis, contused lung tissue, disruption of the respiratory tract.

Assessment Findings - Pulse

Pulse deficit: Reduced pulse strength
Tachycardia: Increased heart rate
Bradycardia: Decreased heart rate

Assessment Findings - Blood Pressure

Narrowed pulse pressure: Reduced difference between systolic and diastolic pressures
Hypertension: Elevated blood pressure
Hypotension: Low blood pressure
Pulsus paradoxus: Decrease in systolic blood pressure during inspiration

Assessment Findings - Respiratory Rate

Tachypnea: Increased respiratory rate
Bradypnea: Decreased respiratory rate
Labored breathing: Increased respiratory effort
Retractions: Visible inward movement of the chest during breathing
Other respiratory distress: Additional signs of respiratory difficulty

Assessment Findings - Skin

Diaphoresis: Excessive sweating
Pallor: Paleness
Cyanosis: Bluish discoloration of the skin
Open wounds: Visible breaks in the skin
Ecchymosis: Bruising
Other evidence of trauma: Additional signs of injury

Assessment Findings - Neck

Trachea position: Check for displacement.
Subcutaneous emphysema: Presence of air in the tissues under the skin.
Jugular venous distension: Swelling in the neck veins
Penetrating wounds: Open injuries to the neck.

Assessment Findings - Chest

Contusions: Bruises on chest wall
Tenderness: Pain when touched
Asymmetry: Unequal sides
Lung sounds: Check for presence, quality, and location of breath sounds.
Absent or decreased breath sounds: Reduced or missing breath sounds.
Bilateral breath sounds: Normal breath sounds on both sides.
Bowel sounds in hemothorax: Unusual bowel sounds in the chest cavity.
Abnormal percussion findings: Checking for unusual sounds/qualities. (e.g. hyperresonance-air, hyporesonance-fluid)

Assessment Findings - ECG

ST/T wave elevation or depression
Conduction disturbances
Rhythm disturbances

History

Dyspnea
Chest pain
Associated symptoms
Symptoms before incident
Past cardiac/respiratory disease
Motor vehicle crash restraint use

Thoracic Trauma Treatment-Airway and Ventilation

High-concentration oxygen.
Positive-pressure ventilation.
Endotracheal intubation
Needle cricothyrotomy
Surgical cricothyrotomy
Pleural decompression
Occlude open wounds
Stabilize chest wall

Thoracic Trauma Treatment-Circulation

Manage cardiac dysrhythmias.
Intravenous access
Supportive Measures

Thoracic Trauma Treatment-Pharmacological and Nonpharmacological

Analgesics
Antidysrhythmics
Stabilize chest wall
Needle thoracostomy
Tube thoracostomy (in-hospital management)
Pericardiocentesis (in-hospital management)

Clavicular Fractures

Common causes: Falling, contact sports.
Signs and symptoms: Pain, point tenderness, deformity
Treatment: Sling and swathe or strap immobilisation
Complications: Injury to subclavian vein/artery, hematoma, or venous thrombosis.

Rib Fractures

Incidence: Less common in adults, more often in elderly. Significant force needed to fracture ribs.
Common reasons: Fall, impact trauma to the chest.
Pathophysiology: Blunt trauma - bowing. Respiratory restriction from pain and splinting. Intercostal nerve/vascular damage important. Associated complications include rupture of the aorta, tracheal/bronchial tree injury or vascular trauma.
Morbidity/Mortality: Can lead to associated pulmonary or cardiovascular injury if severe or multiple fractures.
Management: Airway and ventilation (high oxygen, positive pressure ventilation). Encourage coughing. Pharmacological: Analgesics. Nonpharmacological: Splinting.

Multiple Rib Fractures-Assessment Findings

Localized pain
Pain aggravated by movement, breathing, coughing
Point tenderness
Pointing to affected area on chest (palpated)
Crepitus/audible crunch
Splinting during respiration

Multiple Rib Fractures-Causes of Complications

Atelectasis: Blockage from trauma, reduced breathing causing part of lungs to collapse
Hypoventilation: Inadequate breathing/lower airflow
Inadequate cough: Reduced capacity to cough/remove secretions
Pneumonia: Infection of the lung tissue

Rib Fractures - Management

Airway and ventilation: high concentration oxygen and positive pressure ventilation may be necessary
Encourage coughing and deep breathing
Pharmacological: analgesics; avoid broad spectrum antibiotics in this scenario.
Nonpharmacological: Splinting
Consider transport mode, facility

Flail Chest

Incidence: Multiple rib fractures that result in a free-floating chest wall segment. High-speed impacts common cause.
Most common causes: vehicular crashes; falls from heights; industrial accidents; or assault. Birth trauma is less frequent.
Morbidity/Mortality: 20% to 40% of associated injuries can result in death if in an advanced age with or when other significant and severe injuries are present. Mortality increased with advanced age, seven or more fractured ribs, three or more associated injuries, shock, or head injury or brain damage.
Pathophysiology: Two or more adjacent ribs fractured in two or more places. Direct impact typically causes the fracture. Disruption will result in reduced lung function as a result of respiratory inadequacy. Intra-thoracic, internal thoracic injury typically causes compression of the uninjured lung.
Assessment Findings: Pleuritic chest pain; pain/splinting on affected side; tachypnea; respiratory distress; chest wall contusion; paradoxical chest wall movement; crepitus (cracking/grating sound when palpating and breathing); tachycardia; possible bundle branch block on ECG.
Management: Airway and ventilation (high-concentration oxygen and positive-pressure ventilation may be necessary to reverse the paradoxical chest wall movement, restore tidal volume, and assist breathing if necessary); Monitor closely for pneumothorax, and possible intubation if needed.

Sternal Fractures

Incidence: 5-8% of blunt chest trauma patients. High-force trauma typically involved in causing this.
Common causes: Deceleration injuries, steering wheel, dashboard impacts; direct blows, massive crush injuries; and severe hyperflexion of the thoracic cage.
Morbidity/Mortality: High association with associated myocardial or lung injury, may be substantial. 25-45% mortality risk dependent on degree of injury.
Pathophysiology: Associated injuries including pulmonary and myocardial contusion; flail chest.
Management: Airway and ventilation (high concentration oxygen and positive pressure ventilation may be needed). Circulation (restrict fluids if pulmonary contusion suspected). Nonpharmacologic (allowing chest wall splinting).

Pulmonary Injury (Pneumothorax)

Incidence: 10-30% in blunt chest trauma; almost 100% in penetrating chest trauma
Pathophysiology: Air enters pleural space (between lung and chest wall), resulting in collapse or reduced lung expansion (often caused by fractured rib).
Assessment Findings: Tachypnea, respiratory distress, absent or decreased breath sounds on the affected side, hyperresonance, decreased chest wall movement, dyspnea, chest pain(referred), slight pleuritic chest pain.
Closed pneumothorax: May occur in absences of rib fractures, result of sudden increase in intrathoracic pressure, (e.g., "paper bag effect"); small tear self-seal but larger may progress), trachea shifted towards affected side
Open pneumothorax: Usually a penetrating injury to the chest wall. Air can enter/leave pleural space.
Management: (Closed) Airway/ventilation, high concentration oxygen; (Closed):positive-pressure ventilation if respiration rate is <12 or > 28 breaths per minute; Ventilation assistance(bag-valve mask if needed); Non-pharmacological: Needle thoracostomy. If possible, transport in the position of comfort. Transport considerations mode/facility
Morbidity/Mortality: Severity directly related to wound size and potentially life-threatening if hypoventilation results in hypoxemia.

Tension Pneumothorax

Associated Injuries: Penetrating injury to chest, blunt trauma; penetration from a fractured rib. Many other causes.
Morbidity/Mortality: Life-threatening. Associated with profound hypoventilation, immediate threatening chest injury. Death related to delayed management if emergency intervention is delayed.
Pathophysiology: Air leaks into the interpleural space (between lung and chest wall), increasing pressure in the chest. This compression can shift the mediastinum and impair cardiac output.
Assessment Findings: Extreme anxiety, cyanosis, diminished/absent breath sounds on affected side, tracheal deviation, tachycardia, hypotension, increasing dyspnea; difficult ventilation while being assisted; unequal chest expansion; bulging intercostal muscles, subcutaneous emphysema; jugular distension, hyperresonance percussions.
Management: Emergency care to reduce pressure in the pleural space. High-concentration oxygen. Potential need for positive pressure ventilation. May need intubation. Perform needle thoracostomy. Monitor for and treat/address life-threatening complications.

Hemothorax

Incidence: Associated with pneumothorax (hemopneumothorax). Typically caused by blunt or penetrating trauma, often rib fractures.
Morbidity/Mortality: Life threatening injury requiring urgent chest tube placement or surgery. 50% mortality if immediate (or with minimal) treatment is unavailable.
Pathophysiology: Blood accumulates in pleural space between lung and chest wall. Compromises cardiovascular function, reduces lung function, decreases blood pressure. Hypovolemia results as blood accumulates in the pleural space.
Assessment Findings: Tachypnea, dyspnea, cyanosis (typically not evident in shock); diminished or decreased breath sounds on the affected side, hyporesonance on affected side, hypotension, narrowed pulse pressure; tracheal deviation to unaffected side, pale, cool, moist skin.
Management: Airway and ventilation, high-concentration oxygen/positive pressure ventilation if necessary; circulation (volume expansion, correcting hypovolemia); pharmacologic/non-pharmacologic (tube thoracostomy for managing/treating/removing blood, blood transfusions).

Hemopneumothorax

Pathophysiology: Combination of pneumothorax and hemothorax.
Assessment: Assessment/findings & management is the same as for hemothorax.
Management: Management is the same as for Hemothorax.

Pulmonary Contusion

Incidence: High incidence of blunt chest trauma (30-75% of blunt trauma patients have this). Commonly associated with rib fractures.
Morbidity/Mortality: Potentially lethal; may be missed due to high incidence of associated injuries. Mortality: 14-20%.
Pathophysiology: Blunt trauma to the chest can damage lung tissue resulting in bruising and leakage of blood inside the lung tissue that can affect gas exchange.
Assessment Findings: Tachypnea, tachycardia, respiratory distress, dyspnea, cough, hemoptysis, evidence of blunt chest trauma, apprehension, cyanosis.
Management: Airway and ventilation (high-concentration oxygen; may consider positive pressure ventilation). Circulation (restricting IV fluids if patient not low/hypovolemic).

Traumatic Asphyxia

Incidence: Caused by a severe crushing injury to the chest (and abdomen). Causes include steering wheel injuries, conveyor belt/strap injury or a severe compression injury by a heavy object of some type.
Pathophysiology: Results from a sudden increase in intrathoracic pressure. This pressure increase pushes blood from the right side of the heart into the veins of the upper thorax, neck, & face. The result is jugular vein engorgement and capillary rupture.
Assessment Findings: Reddish/purple discoloration of the face and neck, (skin below the face and neck will remain pink). Jugular distension, swelling of the lips/tongue, head/neck, or hemorrhage of the conjunctiva. (subconjunctival petechiae may appear). When pressure is released hypotension may be present.
Management: Airway and ventilation-ensure an open airway, provide adequate ventilation; circulation-IV access, expect hypotension & shock release of compression; Transport-Appropriate mode/facility.

Heart and Great Vessel Injury

Incidence: Myocardial contusion is the most common cardiac injury after blunt chest trauma. (16-76% of patients with blunt trauma). Often a result of motor-vehicle collisions. Sternal and multiple rib fractures common.
Morbidity/Mortality: Significant cause of morbidity and mortality in blunt trauma patients. Subclinical in assessment.
Pathophysiology: Blunt force to the chest, often resulting from motor vehicle collisions or high deceleration impacts that result in an internal thoracic injury or heart/vessels injury that is easily overlooked.
Assessment Findings: Retrosternal chest pain, ECG changes (persistent tachycardia, ST elevation/T wave inversion, right bundle branch block, atrial flutter/fibrillation, premature ventricular/atrial contractions). New cardiac murmurs, pericardial friction rub (late). Hypotension; chest wall contusion/ecchymosis.
Management: Airway and ventilation-high concentration oxygen/possible positive pressure ventilation if necessary. Circulation-IV access and possible consideration/administration of anti-dysrhythmics/vasopressors if life threatening. Transport considerations-Appropriate mode/facility.

Pericardial Tamponade

Incidence: Rare, less than 2% of all chest traumas. Rare in blunt trauma, more frequent in penetrating trauma/wounds.
Morbidity/Mortality: Gunshot wounds have higher mortality. Lower mortality if isolated tamponade.
Pathophysiology: Fluid (typically blood) accumulates in the pericardial sac, which compresses the heart resulting in decreased cardiac output.
Assessment Findings: Tachycardia, respiratory distress, narrowed pulse pressure (with hypotension); cyanosis of head, neck, & extremities; Beck's triad (narrowing pulse pressure, neck-vein distension, muffled heart sounds), Kussmaul's sign (rise in venous pressure with inspiration).
Management: Airway and ventilation; circulation (IV fluid challenge/treatment for shock/dehydration and hypotension). Non-pharmacological, pericardiocentesis; Transport considerations-Appropriate mode/facility; Psychological support.

Traumatic Aortic Rupture

Incidence: 15% of all blunt trauma deaths. Trauma results from high speed impacts (e.g., motor vehicle collision), falls from significant heights, crushing injuries.
Morbidity/Mortality: Significant cause of morbidity and mortality. 80-90% die at accident scene; 10-20% surviving the immediate hour. Often not obvious during initial assessment but high mortality due to associated injuries.
Pathophysiology: Blunt force to the chest. Bleeding can be quickly tamponaded by the surrounding tissue.
Assessment Findings: Upper extremity hypertension with decreased/absent femoral pulses; generalized hypertension secondary to increased sympathetic discharge; harsh systolic murmur over the pericardium or interscapular/chest wall area; paraplegia with a normal cervical/thoracic spine (rare); retrosternal or interscapular pain; dyspnea and dysphagia; and ischemic pain of extremities.
Management: Airway and ventilation (high-concentration oxygen; ventilatory support with spinal precautions). Circulation (limited fluid replacement for normotensive patients; prevent increased pressure in remaining aortic wall tissue). Transport considerations-Appropriate mode/facility/communication.

Diaphragmatic Rupture

Incidence: 1%- 8% of all blunt injuries. 90% of injuries are associated with high speed motor vehicle crashes.
Pathophysiology: Blunt or penetrating trauma typically breaks the diaphragm. Intra-abdominal organs may move into the thoracic cavity, placing pressure on the lung resulting in poor venous return. Reduced venous/cardiac output/lung function. These are signs of severe/significant injury.
Assessment Findings: Tachypnea, tachycardia, respiratory distress; dullness to percussion; bowel sounds in the affected hemithorax(abnormal); scaphoid abdomen (hollow or empty appearance); decreased breath sounds on the affected side; possible chest or abdominal pain.
Management: Airway and ventilation (high-concentration oxygen; positive-pressure ventilation if necessary, caution as positive pressure can worsen the injury); Circulation (IV access); Non-pharmacological (avoiding Trendelenburg positioning. Transport, etc).

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Test your knowledge on thoracic trauma with this comprehensive quiz. Questions cover classifications, characteristics, management approaches, and the physiological impacts associated with various chest injuries. Ideal for medical students and healthcare professionals seeking to reinforce their understanding of thoracic injuries.