Thoracic Trauma PDF

THORACIC TRAUMA Topics  Introduction to Thoracic Trauma  Thoracic Anatomy  Pathophysiology of Thoracic Trauma  Assessment of Thoracic Trauma  Management of Thoracic Trauma Introduction to Chest Injuries * I 61 a 20...

THORACIC TRAUMA Topics  Introduction to Thoracic Trauma  Thoracic Anatomy  Pathophysiology of Thoracic Trauma  Assessment of Thoracic Trauma  Management of Thoracic Trauma Introduction to Chest Injuries * I 61 a 20 3 A  Directly responsible for more than 20% of all TWI 6 if It Iis traumatic deaths (regardless of mechanism)  Account for about 16,000 deaths per year in the United States Statistics * DE  Chest injuries are the second leading cause of trauma deaths each year.  Most thoracic injuries (90% of blunt trauma and 70% to 85% of penetrating trauma) can be managed without surgery. Mentiall Classifications of Chest Injuries due I Skeletal injury 2 Pulmonary injury   Heart and great vessel injury 3  Diaphragmatic injury 4 whatClassification is Mechanism of Injury 7* Type of 066  Blunt thoracic injuries: 1 6145 Forces distributed over a large area mimosa 1  Deceleration WE  Compression 2 Is 9 of Penetrating thoracic injuries gg iAoj.EmW 2   Forces are usually distributed over a small area.  Organs injured are usually those that lie along the path of the penetrating object. foment 401b Injury Patterns (1weof 2)have I  General types  Open injuriesPenterating  Closed injuries Blur  Injury tow mud Patterns (2 ofhave we 2) 2  Cardiovascular  Pleural and pulmonary 3 4 Mediastinal  Diaphragmatic 5 6 Esophageal  Penetrating cardiac trauma 7  Blast injury 8  Confined spaces 9  Shock wave 10  Thoracic cage  V6 in Anatomy (1 of 3) Is MAY 1 Skin, muscles 7  The respiratory muscles contract in response to stimulation of the phrenic and intercostal nerves 3 Bones diaphragm  Thoracic cage  Sternum  Thoracic spine 4 Trachea  Bronchi 5 6  Lungs  Vascular Anatomy (2 of 3) T6Is in WITH what is 7 contents  Heartthe  Ventricles  Atria 3 Valves  Pericardium 4 what isthe j  Arteries (Aorta, Carotid, Subclavian, Intercostal)  Veins (Superior vena cava, Inferior vena cava, Subclavian, Internal jugular)  Pulmonary (Arteries, Veins)  Ñ6Is 1w Anatomy (3 of 3) WITH gutatisthe  Mediastinum  The area between the lungs contain what I Heart 2 Trachea 3 Vena cavae 4 Pulmonary artery 9 Aorta 6 Esophagus 7 Lymph nodes  What is the main stocess of respiratory Physiology system 1 Ventilation—the mechanical process of moving air into and out of the lungs 2 Respiration—the exchange of oxygen and carbon dioxide between the outside atmosphere and the cells of the body  It 511 441 Pathophysiology (1 of 2) * 1 t.b 1 t.SI ive  Impairments in cardiac output causes: I  Blood loss Z  Increased intrapleural pressures 3  Blood in the pericardial sac  Myocardial valve damage  Vascular disruption 1 41  Pathophysiology (2 of 2) * Impairments in gas exchange causes: 6  Atelectasis collapse of Alvali ñ 11 17  Contusedlung tissue 8  Disruption of the respiratory tract OF Mention the Assessment Findings *(1 of 3) 1 Pulse it I  Deficit 2  Tachycardia mu Nbij lajiow 3 Bradycardia if bé Iw 2 Blood pressure fggfjygggysqyg.gg I  Narrowedpulse pressure  Hypertension p.gg ggggj  Hypotension 4  Pulsus paradoxus 2 OPD 3 pericarditis Assessment Findings *(2 of 3) i Respiratory rate and effort  Tachypnea muster  Bradypnea a IX 26 August 3  Labored y  Retractions www i  Other evidence of respiratory distress 5  Assessment Findings *(3 of 3) 4  Skin I  Diaphoresis b 2 Pallor I  Cyanosis 3  Openwounds y 5  Ecchymosis we 541 6  Other evidence of trauma  5 Assessment (Neck)* I  Position of trachea 2 Subcutaneous emphysema 6115513  Jugular venous 267 distention THE 3 y  Penetrating wounds  6 Assessment (Chest)*  Contusions AS 7 2  Tenderness IT 3  Asymmetry unequal Tart  Lung sounds: y I  Absent or decreased 7  Unilateral thinking 3  Bilateral iv 1 3  Location y 5  Bowel sounds in hemothorax 441 1,1 5  Abnormal Percussion Finding: I  Hyper resonance–Air Id's 2  Hypo resonance–Fluid 4819 1  7 Assessment ECG* I ST/T wave elevation or depression Was disturbancesto9inST  Conduction heattIsihemiaiiutrac bothinT 2 si 2 1disturbances  Rhythm ischemia Teletrolyte Glatase imbalance Af  8 History* I Dyspnea 7  Chest pain 3 Associated symptoms I  Other areas of pain or discomfort 2 Symptoms before incident  Past history of cardiorespiratory disease  Use of restraint in motor vehicle crash How weManagement can be I  Airway and ventilation: 1  High-concentration oxygen 2 Positive-pressure ventilation 3  Endotracheal intubation y  Needle cricothyrotomy 5  Surgical cricothyrotomy  Pleural decompression  Occlude open wounds 8  Stabilize chest wall 7 Circulation: 3 Manage cardiac dysrhythmias  Intravenous access y Management  Pharmacological:  Analgesics  Antidysrhythmics  Stabilize chest wall  Nonpharmacological:  Needle thoracostomy  Tube thoracostomy—in-hospital management  Pericardiocentesis—in-hospital management  Transport Considerations:  Appropriate mode  Appropriate facility  Skeletal Injury* Jul Is 3st Clavicular fractures: whatis  Claviclethe most commonly fractured bone 2dB it d is  Isolated fracture of the clavicle seldom a significant injury is the it what  Common causes: 7 7  Children who fall on their shoulders or outstretched arms 3  Athletes involved in contact sports  Clavicular Fractures* what  kSigns and symptoms 2 Jan to above waltible fada Pain is called 1 a 2  Point tenderness 3  Evident deformity waitTreatment  7  Usually accomplished with a sling and swathe or a clavicular strap that immobilizes the affected shoulder and arm  Usually heals well within 4 to 6 weeks whistle  Complications  Injury to the subclavian vein or artery from bony fragment penetration, producing a hematoma or venous thrombosis (rare)  Rib Fractures*  Incidence tell  Infrequent until adult life ijtihad  Significant force required Common teason falldown  Most often elderly patients α 1 3084 protected more 3 8 4 7 themost Soated Rib Fractures I 7 Morbidity/Mortality* Blooding Hempfix M  Can lead to serious consequences. such  Older ribs are more brittle and rigid.  There may be associated underlying pulmonary or cardiovascular injury.  Rib Fractures Pathophysiology* whitish  Most often caused by blunt trauma—bowing effect with midshaft fracture why  Ribs 3 to 8 are fractured most often (they are thin and poorly where uos protected)  Respiratory restriction as a result of pain and splinting  Intercostal vessel injurymusclesbetweentide is the  Associated complications why  First and second ribs are injured by severe trauma I  Rupture of the aorta 3 Tracheobronchial tree injury Vascular injury y  morethan 3 ribs Multiple Rib Fractures *(1 of 2)fractured is the n what Assessment findings of ILocalized pain  2  Pain that worsens with movement, deep breathing, coughing  Point tenderness 3 am  Most patients can localize the fracture by pointing to the area (confirmed by palpation). y  Crepitus or audible crunch  Splinting on respiration 5 is on them Multiple Rib Fractures *(2 of 2) IIII 208 16 dueto trauma collapse for one too 6 Atelectasis Blockage  Hypoventilation a seen  Inadequate cough ask.FI dudfoexcosute  Pneumonia fh Rib Fractures Complications*  t Splinting, which leads to atelectasis and ventilation- perfusion mismatch (ventilated alveoli that are not perfused or perfused alveoli that are not collapse ventilated) 481 If G it  Rib Fractures car oethManagement* an I Airway and ventilation Take care 1 High-concentration oxygen 2  Positive-pressure ventilation 3 Encourage coughing and deep breathingwhit six 7 Pharmacological 18H24 ws iedimwI  Analgesics a.EE Ej Nonpharmacological 3  Non-circumferential splinting 4  Transport Considerations: And IE a ithoibsoa  Appropriate mode & Appropriate facility  Flail Chest* Incidence means til fracture morethan 3 t.GS thsid  y Most whatisthe Most common cause: vehicular crash 1  Falls from heights 2  Industrial accidents coat 3  Assault 191rad 4  Birth trauma rare  Flail Chest Morbidity/Mortality*  Significant chest trauma whatis the Mortality rates 20% to 40% due to associated injuries  Mortality increased with:  Advanced age I 2  Seven or more rib fractures 3  Three or more associated injuries  Shock  Head injuries  Flail Chest Mfm - Pathophysiology ok *(1 of 2) I  Two or more adjacent ribs fractured in two or more places producing a free-floating segment of chest wall Flail chest usually results from direct impact.  Flail Chest -ok*(2 of 2) Mm Pathophysiology 2  Respiratory failure due to:  Underlying pulmonary contusion The blunt force of the injury typically produces an 3  of underlying pulmonary contusion. -  Associated intrathoracic injury 2 Inadequate bellows action of the chest  Flail Chest offAssessment Findings* of I  Pleuritic chest pain 2 Pain and splinting of affected side 3  Tachypnea y  Respiratory distress 5  Chest wall contusion 6  Paradoxical chest wall movement 7  Crepitus 8  Tachycardia 9  Possible bundle branch block on ECG  Flail Chest 4 theManagement*65 I  Airway and ventilation High-concentration oxygen. 1 while 2 Positive-pressure ventilation may be needed: read Reverses the mechanism of paradoxical chest wall movement Restores the tidal volume Reduces the pain of chest wall movement y Assess for the development of a pneumothorax very  Evaluate the need for endotracheal intubation. y  Stabilize the flail segment (controversial). 9  Fast ultrasound Sternal Fractures*  Incidence  Occurs in 5% to 8% of all patients with blunt chest off trauma I  A deceleration compression injury 2  Steering wheel w.mil Dashboard MI MOI gid 3  Y  A blow to the chest; massive crush injury  Severe hyperflexion of the thoracic cage 5  is the association of a whatSternal Fractures Morbidity/Mortality*  25% to 45% mortality rate  High association with myocardial or lung injury  Myocardial contusion I 2  Myocardial rupture 3  Cardiac tamponade IN y  Pulmonary contusion whatis the accoliated injury that cures morbidity Mortality Sternal Fractures Pathophysiology*  Associated injuries cause morbidity and mortality. I  Pulmonary and myocardial contusion 2  Flail chest  Seriously displaced sternal fractures may produce a flail chest.  Vascular disruption of thoracic vessels  Intra-abdominal injuries  Heart injuries howcan eSternal Fractures me Management*  Airway and ventilation I  High-concentration oxygen I 2  Circulation—restrict fluids if pulmonary contusion suspected 3  Pharmacological—analgesics y  Nonpharmacological—allow chest wall self-splinting Transport considerations 5   Appropriate mode  Appropriate facility 6  Psychological support/communication strategies  Pulmonary such Injury* At how adf.is 4H Abi's I  Closed (simple) pneumothorax  Incidence 10% to 30% in blunt chest trauma Almost 100% with penetrating chest trauma  Morbidity/mortality ate Extent of atelectasis Associated injuries How Pathophysiology Caused by the presence of air in the pleural space what isthe A common cause of pneumothorax is a fractured rib that penetrates the underlying lung.  Closed (Simple) Pneumothorax*  May occur in the absence of rib fractures from: 2 A sudden increase in intrathoracic pressure generated when the chest wall is compressed against a closed glottis (the what c paper-bag effect) Results in an increase in airway pressure and ruptured alveoli, which lead to a pneumothorax  Small tears self-seal; larger ones may progress. 3  The trachea may tug toward the affected side. Sings  Ventilation/perfusion mismatch. what Closed Pneumothorax stressAssessment Findings* 1  Tachypnea MOI 151 Tachycardia 2  Respiratory distress ABC 3 Absent or decreased breath sounds on the affected side y   Hyperresonance Air 5 6 Decreased chest wall movement 7 Dyspnea 8 Chest pain referred to the shoulder or arm on the affected side 9 Slight pleuritic chest pain  Closed Pneumothorax For the Management*of(1 of92) ABC 1  Airway and ventilation I  High-concentrationoxygen. 7  Positive-pressure ventilation if necessary.28  If respiration rate is 28 per minute, ventilatory 3 assistance with a bag-valve mask may be indicated.  Closed Pneumothorax Management* (2 of 2) IN 7  Nonpharmacological:  Needle thoracostomy ? Absent soud DVD  Transport considerations: 3  Positionof comfort (usually partially sitting) unless contraindicated by possible spine injury  Appropriate mode  Appropriate facility 2 Open Pneumothorax* why  Incidence  Usually the result of penetrating trauma Suchas Gunshot wounds I Knife wounds Impaled objects Motor vehicle collisions y Falls 5  Open Pneumothorax Morbidity/Mortality*  Severity is directly proportional to the size of the wound. sings  Profound hypoventilation can be the result.  Death is related to delayed management. why  Open Pneumothorax when Pathophysiology*a (1 of 2) An open defect in the chest wall (>3 cm) Read   If the chest wound opening is greater than two-thirds the diameter of the trachea, air follows the path of least resistance through the chest wall with each inspiration.  As the air accumulates in the pleural space, the lung on the injured side collapses and begins to shift toward the uninjured side.  Open Pneumothorax Pathophysiology* (2 of 2) Red  Very little air enters the tracheobronchial tree to be exchanged with intrapulmonary air on the affected side, which results in decreased alveolar ventilation and decreased perfusion. The normal side also is adversely affected because expired 3 air may enter the lung on the collapsed side, only to be rebreathed into the functioning lung with the next ventilation. y May result in severe ventilatory dysfunction, hypoxemia, and death unless rapidly recognized and corrected.  Open Pneumothorax whim Assessment Findings* I  To-and-fro air motion out of the defect ? 2 A defect in the chest wall 3 A penetrating injury to the chest that does not seal itself 4 A sucking sound on inhalation 5 Tachycardia 6 Tachypnea 7 Respiratory distress 8 Subcutaneous emphysema a Decreased breath sounds on the affected side ow Open Pneumothorax BethManagement* (1 of 2)  Nonpharmacological  Occlude the open wound— apply an occlusive petroleum gauze dressing (covered with sterile dressings) and secure it with tape, keep one angle open. how Open Pneumothorax can In Management* (2 of 2) I  Airway and ventilation: High-concentration oxygen. 1 7 Positive-pressure ventilation if necessary. 3 Assist ventilations with a bag-valve device and intubation as necessary.  Monitor for the development of a tension pneumothorax.  Circulation—treat for shock with crystalloid infusion.  what is 3 Tension Pneumothorax*  Associated Injuries I A penetrating injury to the chest 7  Blunt trauma 3  Penetration by a rib fracture y  Many other mechanisms of injury Tension Pneumothorax Morbidity/Mortality*why Same  Profound hypoventilation can result.  An immediate, life-threatening chest injury.  Death is related to delayed management.  Tension Pneumothorax Pathophysiology *(1 of 2) Reed can occur How I Occurs when air enters the pleural space from a lung injury or through the chest wall without a means of exit. 7  Results in death if it is not immediately recognized and treated. IT  When air is allowed to leak into the pleural space during inspiration and becomes trapped during exhalation, an increase in the pleural pressure results.  Tension Pneumothorax Pathophysiology Reed *(2 of 2) what hardwhy Increased pleural pressure produces mediastinal y shift. MA 681 I when  Mediastinal shift results in: g  Compression of the uninjured lung  Kinking of the superior and inferior vena cava, decreasing venous return to the heart, and subsequently decreasing cardiac output whomTension Pneumothorax Assessment Findings* (1 of 3) I Extreme anxiety 2  Cyanosis 3 Diminished or absent breath sounds on the injured side y  Tracheal deviation (a late sign) 5 1 to  Tachycardia if 5 b  Hypotension Identification is the most difficult aspect of field care in a tension pneumothorax.  Tension Pneumothorax Assessment Findings* (2 of 3) 7 Increasing dyspnea 8  Difficult ventilations while being assisted 9  Tachypnea 10 Respiratory distress  Tension Pneumothorax Assessment Findings* (3 of 3) mi of the intercostal muscles  Bulging 12  Subcutaneous emphysema WHEN at s 13 Jugular venous distention (unless hypovolemic)  Unequal expansion of the chest (tension does not fall with respiration)  Hyperresonnace to percussion  Tension Pneumothorax him Physical Findings fowcombey Tension Pneumothorax Management* (1 of 5) I Emergency care is directed at reducing the pressure in the pleural space. 2  Airway and ventilation:  High-concentration oxygen  Positive pressure ventilation if necessary  Circulation—relieve the tension pneumothorax to improve cardiac output. Tension Pneumothorax Management* (2 of 5) y  Nonpharmacological l  Occlude open wound (3 ways occlusive dressing) 7  Needle thoracostomy 3  Tube thoracostomy—in-hospital management Pleural decompression should only be employed if the patient demonstrates significant dyspnea and distinct signs and symptoms of tension pneumothorax.  Tension Pneumothorax Management (3 of 5) How  Needle thoracostomy CLAY whatis Tension Pneumothorax Management* (4 of 5) I  Tension pneumothorax associated with penetrating trauma  May occur when an open pneumothorax has been sealed completely with an occlusive dressing.  Pressure may be relieved by momentarily removing the dressing (air escapes with an audible release of air). After the pressure is released, the wound should be resealed. Tension Pneumothorax Management*(5 of 5) Tension pneumothorax associated with closed trauma 2  I  If the patient demonstrates significant dyspnea and distinct signs and symptoms of tension pneumothorax: Provide thoracic decompression with either a large-bore needle or commercially available thoracic decompression kit. Insert a 2-inch 14- or 16-gauge hollow needle or catheter into the affected pleural space. Usually the second intercostal space in the midclavicular line Insert the needle just above the third rib to avoid the nerve, artery, and vein that lie just beneath each rib.  Hemothorax* IBdood Accoriated whithwhat Play.gl  Incidence  Associated with pneumothorax. (If this condition is associated with pneumothorax, it is called a hemopneumothorax). use  Blunt or penetrating trauma.  Rib fractures are frequent cause. 2  Hemothorax Morbidity/Mortality*  A life-threatening injury that frequently requires urgent chest tube placement and/or surgery  Associated with great vessel or cardiac injury 3  50% of these patients will die immediately.  25% of these patients live 5 to 10 minutes.  25% of these patients may live 30 minutes or longer. on Hemothorax happen can pleural II Blood Pathophysiology* spare  Accumulation of blood in the pleural space caused by bleeding from I  Penetrating or blunt lung injury 2  Chestwall, Intercostal vessels 3  Myocardium or great vessels what Hypovolemia results as blood accumulates in the pleural space.  Hemothorax whod s Assessment Findings* (1 of 2) The 1  Tachypnea  Dyspnea Tachycardia 3 Cyanosis  Often not evident in hemorrhagic shock y  Diminished or decreased breath sounds on the affected side  Hemothorax whod s TheAssessment Findings* (2 of 2) IN Hyporesonance (dullness on percussion) on the 4 affected side  5  Hypotension 6  Narrowed pulse pressure 7  Tracheal deviation to the unaffected side (rare) 8  Pale, cool, moist skin 41 Hemothorax Physical Findings ow Hemothorax of Management* the I  Airway and ventilation 1High-concentration oxygen a Positive-pressure ventilation if necessary: 3 Ventilatory support with bag-valve mask, intubation, or both  Circulation 7 17 I Am  Administer volume-expanding fluids to correct hypovolemia 2Nonpharmacological—tube thoracostomy (in-hospital management)  Transport considerations Appropriate mode i Appropriate facility  h 1 Hemopneumothorax*  Pathophysiology—pneumothorax with bleeding in the pleural space  Assessment—findings and management are the same Adam as for hemothorax.  Management—management is the same as for hemothorax. wht Pulmonary Contusion* the wdl.at  A pulmonary contusion is the most commonwhat potentially lethal chest injury. INGE Incidence well Blunt trauma to the chest cause's I The most common injury from blunt thoracic trauma. 30% to 75% of patients with blunt chest trauma have pulmonary contusion. 2 Commonly associated with rib fracture High-energy shock waves from explosion 3 High-velocity missile wounds y Rapid deceleration 5 A high incidence of extra thoracic injuries 6 7 Low velocity—i.e. ice pick CHINA  Pulmonary Contusion Morbidity/Mortality* find the  May be missed due to the high incidence of other associated injuries Mortality—between 14% and 20% hat sale Pulmonary Contusion Assessment Findings* I  Tachypnea 2 Tachycardia  Respiratory distress 2  Dyspnea  Cough Hemoptysis cough ith bleeding 6  7  Evidence of blunt chest trauma 8 Apprehension in d  Cyanosis is 9 How Pulmonary Contusion Ye Management*Bed In imit mi I  Airway and ventilation: mob  High-concentration oxygen IN as I µW 31 49  Positive-pressure ventilation if necessary Him 111 HWIS.is  Circulation—restrict IV fluids (use caution restricting fluids in hypovolemic patients). www.fio.at 3  Transport considerations. 8181 Ies IWhwfiww.ws www.t.sisojkixgg j j 5 right 4  Traumatic Asphyxia* 9.11 1  Incidence cause A severe crushing injury to the chest and abdomen iÉ 64 Steeringwheel injury ids is or belt injury Convey 0b Compression of the chest under a heavy object it I It imbedded ai w.ii in.it 1imi Traumatic Asphyxia Pathophysiology*  A sudden compressional force squeezes the chest.results Html ftp.wliki d  An increase in intrathoracic pressure forces blood from the right side of the heart into the veins of the upper1thorax, neck, and face. I d.tl 01  Jugular veins engorge and capillaries rupture. whatTraumatic Asphyxia i ith Assessment* I  Reddish-purple discoloration of the face and neck (the skin below the face and neck remains pink). 2 Jugular vein distention. 3  Swelling of the lips and tongue.  Swelling of the head and neck.  Swelling or hemorrhage of the conjunctiva (subconjunctival petechiae may appear). f mm euthen mod in  Hypotension results once the pressure is released. low Traumatic Asphyxia canbeManagement* I  Airway and ventilation  Ensure an open airway.  Provide adequate ventilation. 2 Circulation  IV access.  Expect hypotension and shock once the compression is released. 3 Transport considerations  Appropriate mode. 41 Is.im  Appropriate facility. the HI  Heart and Great Vessel Injury* It  Myocardial contusion (blunt myocardial injury)  Incidence x̅ The chest most common cardiac injury after a blunt trauma to the Occurs in 16% to 76% of blunt chest traumas Usually results from motor vehicle collisions as the chest wall strikes the dashboard or steering column Sternal and multiple rib fractures common Heart and Great Vessel Injury Morbidity/Mortality*  A significant cause of morbidity and mortality in the itmm dhwdi.LI blunt trauma patient 55 11 4  sinks Clinical findings are subtle and frequently missed due is to: feeding I Multiple injuries that direct attention elsewhere Little evidence of thoracic injury Lack of signs of cardiac injury on initial examination  Heart and Great Vessel Injury entir alue Assessment Findings* (1 of 2) attain chest pain Retrosternal 1 2  ECG changes I  Persistent tachycardia 2  STelevation, T wave inversion 7 Right bundle branch block  Atrial flutter, fibrillation  Premature ventricular contractions 6 Premature atrial contractions  Heart and Great Vessel Injury Assessment Findings* (2 of 2) 1901.2.6 New cardiac murmur a 3 81T ms hosidifs 4 Pericardial friction rub (late) 16061 XD.tt 5  Hypotension Cows.IN.im wtbdiW1n 5WIf Chest wall contusion and ecchymosis in f  ask.im d MY adl js did 9 681 A I tow Heart and Great Vessel Injury Management* I Airway and ventilation—high-concentration oxygen 7 Circulation—IV access 3 Pharmacological  Antidysrhythmics (if life threatening)  Vasopressors Wahl it if 4 Transport considerations Edit  Appropriate mode int  Appropriate facility Psychological support/communication strategies 5   Pericardium Pericardial Tamponade* 1 055 ed  Incidence 4b II t.tw  Rare in blunt trauma  Penetrating trauma  Occurs in less than 2% of all chest traumas cobPericardial Tamponade Morbidity/Mortality* Gunshot wounds carry higher mortality than stab I wounds.  Lower mortality rate if isolated tamponade is 2 present.  Pericardial Tamponade Anatomy and Physiology whatis  Pericardium A tough fibrous sac that encloses heart  Attaches to the great vessels at the base of the heart  Two layers: The visceral layer forms the epicardium. The parietal layer is regarded as the sac itself.  Pericardial Tamponade can be Pathophysiology* (1 of 2) 1A blunt or penetrating trauma may cause tears in the heart chamber walls, allowing blood to leak from the heart.  If the pericardium has been torn sufficiently, blood leaks into the thoracic cavity. How with me If 150 to 200 mL of blood enters the pericardial space acutely, pericardial tamponade develops.  Pericardial Tamponade Pathophysiology* (2 of 2) 2  Increased intrapericardial pressure: Resulting  Does not allow the heart to expand and refill with blood I 7 Results in a decrease in stroke volume and cardiac output 3  Myocardial perfusion decreases due to pressure effects on the walls of the heart and decreased diastolic pressures. y Ischemic dysfunction may result in infarction. 9 Removal of as little as 20 mL of blood may drastically improve cardiac output. we Pericardial Tamponade Assessment Findings* (1 of 3) I Tachycardia 2 Respiratory distress 3 Narrowed pulse pressure with hypotension y Cyanosis of the head, neck, and upper extremities Pulsel systoleil Lafadors j.ws Admit Diastolition we Pericardial Tamponade Assessment Findings* (2 of 3) Beck’s triad 5  I  Narrowing pulse pressure emoth 511  Neck vein distention IN bowl 3  Muffled heart sounds bwt I.TT  Pericardial Tamponade Assessment Findings* (3 of 3) 6  Kussmaul’s sign—a rise in venous pressure with inspiration when spontaneously breathing 7 ECG changes why Pericardial Tamponade Physical Findings Muffled for car Pericardial Tamponade Management* 09 I Airway and ventilation Circulation—IV fluid challenge 2 3  Nonpharmacological—pericardiocentesis (in-hospital management) y  Transport considerations l Appropriate mode  Appropriate facility 3 Psychological support/communication strategies wtfTraumatic Aortic Rupture* 1441105  Incidence  Blunt trauma Rapid deceleration in high-speed motor vehicle crashes Falls from great heights Crushing injuries 15% of all blunt trauma deaths  Traumatic Aortic Rupture ton Morbidity/Mortality*of many the 9  80% to 90% of these patients die at the scene as a result of massive hemorrhage.  About 10% to 20% of these patients survive the first hour. Bleeding is tamponaded by surrounding adventitia of the aorta and intact visceral pleura. Of these, 30% have rupture within 6 hours. indeed edia iii it whatTraumatic Aortic Rupture Assessment Findings* (1 of 2) I Upper-extremity hypertension with absent or decreased amplitude of femoral pulses  Thought to result from compression of the aorta by the expanding hematoma 2  Generalized hypertension www.dkbli  Secondary to increased sympathetic discharge 3  About 25% have6501 a harsh systolic murmur over the pericardium or interscapular region Whitsitt UA HIewd Paraplegia with a normal cervical and thoracic spine iI imH 4  (rare)  Retrosternal or interscapular pain  Traumatic Aortic Rupture Assessment Findings* (2 of 2) 6  Dyspnea 7  Dysphagia I m d  Ischemic pain of the extremities α  Chest wall contusion Tachycardia poor Traumatic Aortic Rupture Management* case(1 of 2) I  Airway and ventilation:  High-concentration oxygen  Ventilatory support with spinal precautions 2  Circulation—do not over-hydrate. mask g idol's JE www.glwtdniikfibsle IMp.ws How Traumatic Aortic Rupture Management* use (2 of 2) its Hot add imp  Patients who are normotensive should have limited 3 replacement fluids to prevent an increase in i pressure in the remaining aortic wall tissue. imlik  Transport considerations µs Appropriate mode msn. Gn Appropriate facility Psychological support/communication strategies whyDiaphragmatic Rupture*  Incidence  Penetrating trauma  Blunt trauma:  Injuries to the diaphragm account for 1% to 8% of all blunt injuries. 90% of injuries to the diaphragm are associated with high- myuses speed motor vehicle crashes. whyDiaphragmaticRupture Anatomy Review  The diaphragm is a voluntary muscle that separates the abdominal cavity from the thoracic cavity.  The anterior portion attaches to the inferior portion of the sternum and the costal margin.  Attaches to the 11th and 12th ribs posteriorly.  The central portion is attached to the pericardium.  Innervated via the phrenic nerve. IFFY 6315 160Diaphragmatic Rupture* case  Rupture can allow intra-abdominal organs to enter the thoracic cavity, which may cause the following: I  Compression of the lung with reduced ventilation 2  Decreased venous return 3  Decreased cardiac output  Shock y  Diaphragmatic Rupture Pathophysiology* what is  Can produce very subtle signs and symptoms 7  Gift Bowel obstruction and strangulation 2 Restriction ofw̅lung 45 expansion  Hypoventilation result 1  Hypoxia of 3 Mediastinal shift Result  Cardiac compromise in 1 IF 2 Respiratory compromise whatDiaphragmatic Rupture Assessment is allFindings* 7 I  Tachypnea 2  Tachycardia  Respiratory distress 7  Dullness to percussion ?  Bowel sounds in the affected hemithorax 6  Scaphoid abdomen (hollow or empty appearance) If.I  If a large quantity of the abdominal contents are displaced into the 46 chest www.wfiwsf 7  Decreased breath sounds on the affected side Possible chest or abdominal pain 8  how can we Diaphragmatic Rupture Management* 1 Airway and ventilation IHigh-concentration oxygen  Positive-pressure ventilation if necessary  Caution: positive pressure may worsen the injury Circulation—IV access   Nonpharmacological—do not place patient in Trendelenburg position M  Transport considerations Appropriate mode  4  Appropriate facility Y. f ffme Ñd