Pathophysiology of Chest Trauma

Blunt trauma.
Force distributed over larger area
Visceral injuries occur from:
Deceleration
Compression
Sheering forces
Bursting
Age Factors
Pediatric Thorax: More cartilage = Absorbs forces
Geriatric Thorax: Calcification & osteoporosis= More fractures

Pathophysiology of Chest Trauma

Penetrating Trauma
Low Energy
Arrows, knives, handguns
Injury caused by direct contact
and cavitation
High Energy
Military, hunting rifles & high
powered hand guns
Extensive injury due to high
pressure cavitation

Trauma.org

Injuries Associated with Chest Trauma

Closed pneumothorax
Open pneumothorax (including
sucking chest wound)
Tension pneumothorax
Pneumomediastinum
Hemothorax
Hemopneumothorax
Laceration of vascular structures
Traumatic Asphyxia

Tracheobronchial tree lacerations

Esophageal lacerations
Penetrating cardiac injuries
Pericardial tamponade
Skeletal injuries
Flail Chest
Diaphragm trauma
Intra-abdominal penetration with
associated organ injury

Sternal Fracture & Dislocation

Associated with severe blunt anterior
trauma
Direct Blow (i.e. Steering wheel,
das board)
Incidence: 5-8%
Mortality: 25-45%
Myocardial contusion
Pericardial tamponade
Cardiac rupture
Pulmonary contusion
Dislocation uncommon.
Tracheal depression if posterior

Rib Fractures
>50% of significant chest trauma cases due to blunt trauma
Compressional forces flex and fracture ribs at weakest points
Ribs 1-3 requires great force to fracture
Possible underlying lung injury
Ribs 4-9 are most commonly fractured
Ribs 10-12 less likely to be fractured
Transmit energy of trauma to internal organs
If fractured, suspect liver and spleen injury
Hypoventilation is COMMON due to PAIN

Flail Chest
Two or more ribs are broken in two or more
places that causes a free floating section.
Serious chest wall injury with underlying
pulmonary injury
Reduces volume of respiration
Adds to increased mortality
Paradoxical flail segment movement
Positive pressure ventilation can restore
tidal volume

Signs and symptoms of Flail Chest

Shortness of Breath
Paradoxical Movement
Bruising/Swelling
Crepitus( Grinding of bone ends on palpation)

Management of Skeletal Injuries

ABCs with c-spine control as indicated (may include intubation)

Establish IV access
High Flow oxygen that may include bag valve mask (BVM)
Monitor Cardiac Rhythm
Monitor Patient for signs of pneumothorax or tension pneumothorax
If Tension develops, needle decompress affected side
You may need a splint
Medical emergency

Bulky Dressing for splint of Flail

Chest

Use Trauma bandage and

Triangular Bandages to splint
ribs.
Can also place a bag of D5W
on area and tape down. (The
only good use of D5W I can
find)

Pulmonary Contusion

Soft tissue contusion of the lung

30-75% of patients with significant blunt chest trauma
Frequently associated with rib fracture
Typical mode of impact
Deceleration
Chest impact on steering wheel
Bullet Cavitation
High velocity ammunition
Microhemorrhage may account for 1- 1 L of blood loss in alveolar
tissue
Progressive deterioration of ventilatory status
Hemoptysis typically present

Signs and Symptoms of Pulmonary

Contusion
Most Common result of blunt injury
Signs & Symptoms
Erythema
Ecchymosis
Dyspnea
HYPOVENTILATION
BIGGEST CONCERN = HURTS TO BREATHE

Pulmonary Contusion
Admission CXR

Pulmonary Contusion
24 Hours

Simple/Closed Pneumothorax
Occurs when lung tissue is disrupted and air leaks into the pleural space
It is a non-expanding collection of air around the lung.
Progressive Pathology
Air accumulates in pleural space
Lung collapses
Alveoli collapse (atelectasis)
Reduced oxygen and carbon dioxide exchange
Ventilation/Perfusion Mismatch
Increased ventilation but no alveolar perfusion
Reduced respiratory efficiency results in HYPOXIA
It may progress to Tension Pneumothorax

Signs and Symptoms of Simple/Closed

Pneumothorax

Chest Pain
Dyspnea
Tachypnea
Decreased Breath Sounds on Affected Side

Open Pneumothorax

Free passage of air between

atmosphere and pleural space
Causes the lung to collapse due
to increased pressure in pleural
cavity
Mediastinum shifts to uninjured
side
Can be life threatening and can
deteriorate rapidly

Signs and Symptoms of Open

Pneumothorax

Dyspnea
Sudden sharp pain
Subcutaneous Emphysema
Decreased lung sounds on affected side
Red Bubbles on Exhalation from wound ( a.k.a. Sucking chest wound)
Hypovolemia

Open Pneumothorax

Open Pneumothorax

Inhale

Open Pneumothorax

Exhale

Open Pneumothorax

Inhale

Open Pneumothorax

Exhale

Open Pneumothoarx

Inhale

Open Pnuemothorax
Inhale

Subcutaneous Emphysema

Air collects in subcutaneous fat from pressure of air in pleural cavity

Feels like rice crispies or bubble wrap

Can be seen from neck to groin area

Sucking Chest Wound

Hole in the chest wall that extends into the pleural space
allowing are to move in and out of the pleural space interfering
with breathing.

Occlusive Dressing

Asherman Chest Seal

Tension Pneumothorax

Buildup of air under pressure in the thorax.

Excessive pressure reduces effectiveness of respiration
Air is unable to escape from inside the pleural space
Progression of Simple or Open Pneumothorax

Left tension pneumothorax

Bilateral tension pneumothoraces

Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

Tension Pneumothorax
Each time we inhale,
the lung collapses further. There
is no place for the air to
escape..

Tension Pneumothorax
The trachea is
pushed to
the good side

Heart is being
compressed

Signs & Symptoms of Tension

Pneumothorax

Dyspnea
Tachypnea at first
Progressive ventilation/perfusion
mismatch
Atelectasis on uninjured side
Hypoxemia
Hyperinflation of injured side of
chest
Hyperresonance of injured side of
chest

Diminished then absent breath

sounds on injured side
Cyanosis
Diaphoresis
JVD
Hypotension
Hypovolemia
Tracheal Shifting

Needle Decompression

Locate 2-3 Intercostal space midclavicular line

Cleanse area using aseptic technique

Insert catheter ( 14g or larger) at least 3 in length over the top of the
3rd rib( nerve, artery, vein lie along bottom of rib)

Remove Stylette and listen for rush of air

Place Flutter valve over catheter

Reassess for Improvement

Needle Decompression

Flutter Valve

Asherman Chest Seal makes

good Flutter Valve .
Also can use a Finger from a
Latex Glove
Or A Condom works also

Hemothorax
Accumulation of blood in the pleural space
Serious hemorrhage may accumulate 1,500 mL of blood
Mortality rate of 75%
Each side of thorax may hold up to 3,000 mL
Blood loss in thorax causes a decrease in tidal volume
Ventilation/Perfusion Mismatch & Shock
Typically accompanies pneumothorax
Hemopneumothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

Hemothorax

May put pressure on the heart

Hemothorax
Where does the blood come
from.

Lots of blood vessels

X-ray differrence between Hemothorax

and Hemopneumothorax
When a haemothorax is visible on the erect chest X-ray, the presence of a
FLAT MENISCUS laterally indicates the presence of an associated
pneumothorax.

Meniscus of haemothorax

Meniscus of haemopneumothorax

Signs & Symptoms of Hemothorax

Shock
Dyspnea
Tachycardia
Tachypnea
Diaphoresis
Hypotension
Dull to percussion over injured side (stony dull)
Frothy , bloody sputum
Flat Neck Veins

Management of Pneumothorax

ABCs with c-spine as indicated

Establish IV access and Draw Blood Samples
High Flow oxygen including BVM
Monitor Cardiac Rhythm
Treat for S/S of Shock
Needle Decompression of Affected Side
Chest draining
Consider Left Lateral Recumbent position if not contraindicated

Summary of Physical Findings in

Pulmonary Injury
Tension
Pneumothorax
Simple
Pneumothorax

Trachea

Expansion

Away

Decreased.
Chest may be
fixed in hyperexpansion

Midline

Decreased

Breath Sounds

Percussion

Diminshed or
Hyper-resonant
absent
May be
diminished

May be hyperresonant.
Usually normal

Diminished if
Dull, especially
large. Normal if
posteriorly
small

Haemothorax

Midline

Decreased

Pulmonary
Contusion

Midline

Normal

Normal. May
have crackles

Normal

Lung collapse

Towards

Decreased

May be reduced

Normal