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Lower Resp Trauma

This document discusses lower respiratory tract trauma. It covers the incidence, pathophysiology, immediate life threats (airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest), potential life threats (lung contusion, heart contusion, aorta rupture), and common injuries (subcutaneous emphysema, traumatic asphyxia, pneumothorax, hemothorax, rib fractures) from chest trauma. It describes the primary survey process of assessing the patient's airway, breathing, and circulation and provides treatment approaches for specific injuries.

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A Rezki Chairamsyah
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58 views62 pages

Lower Resp Trauma

This document discusses lower respiratory tract trauma. It covers the incidence, pathophysiology, immediate life threats (airway obstruction, tension pneumothorax, open pneumothorax, massive hemothorax, flail chest), potential life threats (lung contusion, heart contusion, aorta rupture), and common injuries (subcutaneous emphysema, traumatic asphyxia, pneumothorax, hemothorax, rib fractures) from chest trauma. It describes the primary survey process of assessing the patient's airway, breathing, and circulation and provides treatment approaches for specific injuries.

Uploaded by

A Rezki Chairamsyah
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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Lower resp

tract Trauma
Dr.Amran S, SpB
Incidence of Chest Trauma

1/4 American trauma deaths


Contributes to another 1 of 4
Many die after reaching hospital -
preventable if recognized
<10% blunt needs surgery
~1/3 penetrating needs surgery
Most life-saving procedures do NOT
require thoracic surgeon
Pathophysiology of Chest
Trauma
hypovolemia

ventilation-
perfusion Inadequate oxygen
mismatch delivery to tissues

changes in
intrathoracic TISSUE
pressure HYPOXIA
relationships
Pathophysiology of Chest
Trauma

Tissue hypoxia
Hypercarbia
Respiratory acidosis: inadequate
ventilation
Metabolic acidosis: tissue
hypoperfusion (e.g., shock)
6 Immediate Life Threats

Airway obstruction
Tension
pneumothorax
Open pneumothorax
sucking chest
wound
Massive hemothorax
Flail chest

6 Potential Life Threats

Lung contusion
Heart contusion
Aorta rupture
Diaphragm rupture
Tracheobronchial tree
injury - larynx, trachea,
bronchus
Esophagus trauma
6 Other Frequent Injuries

Subcutaneous
emphysema
Traumatic asphyxia
Simple
pneumothorax
Hemothorax
Scapula fracture
Rib fractures
Primary Survey

Airway

Breathing

Circulatio
n
A = Airway

Assess for airway patency and air


exchange - listen at nose & mouth
Assess for intercostal and
supraclavicular muscle retractions
Assess oropharynx for foreign body
obstruction
B = Breathing

Assess respiratory movements and


quality of respirations look, listen,
feel
Shallow respirations are early
indicator of distress cyanosis is late
C = Circulation

Assess pulses for quality, rate,


regularity
Assess blood pressure and pulse
pressure
Skin - look and feel for color,
temperature, capillary refill
Look at neck veins - flat vs.
distended
Cardiac monitor
Where can adults hide blood
and go into shock?

Chest: listen, do chest x-ray


Abdomen: do DPL or CT or US
Retroperitoneum: do CT
Thigh: physical examination
Street: ask paramedic
...and in children, add
Head
Initial assessment and
management

Primary survey
Resuscitation of vital functions
Detailed secondary survey
Definitive care
Initial assessment and
management

Hypoxia most serious problem: early


interventions aimed at reversing
Immediate life-threatening injuries
treated quickly and simply, usually
with tube or a needle
Secondary survey guided by high
suspicion for specific injuries
6 Immediate Life Threats

Airway obstruction
Tension
pneumothorax
Open pneumothorax
sucking chest
wound
Massive hemothorax
Flail chest

Airway Obstruction

Airway obstruction at alveolar level:


assessed and managed during 2o
survey
Upper airway obstruction
immediate life threat which must be
dealt with in primary survey
Most common cause: patients
tongue
Airway Obstruction

Chin-lift:
fingers under
mandible, lift
forward so
chin is
anterior
Airway Obstruction
Airway Obstruction

Jaw thrust: grasp angles of mandible


and bring jaw forward
Airway Obstruction

Oropharyngeal
airway: insert into
mouth behind
tongue
DO NOT push
tongue further
back
Airway Obstruction

Nasopharynge
al airway:
gently insert
well-lubricated
trumpet
through nostril
Airway Obstruction

Definitive Airway
Management:
tube in trachea
through vocal
cords with
balloon inflated
Airway Obstruction

Orotracheal intubation
Nasotracheal intubation: in breathing
patient without major facial trauma
Surgical airways
jet insufflation
retrograde
cricothyrotomy
tracheostomy
Tension pneumothorax
Air leak through lung or chest wall
One-way valve lung collapse
Mediastinum shifts to opposite side
Inferior vena cava kinks on
diaphragm decreased venous
return cardiovascular collapse
Inferior vena cava
Tension pneumothorax

Tension pneumothorax is not an


x-ray diagnosis it MUST be
recognized clinically
Treatment is decompression needle
into 2nd intercostal space of mid-
clavicular line - followed by
thoracotomy tube
Insert needle here
Open pneumothorax

Sucking Chest Wound


Normal ventilation requires negative
intra-thoracic pressure
Large open chest-wall defect
immediate equilibration of intra-
thoracic and atmospheric pressures
If hole >2/3 tracheal diameter, air
prefers chest defect
Open pneumothorax
Open pneumothorax

Initial treatment: seal defect and


secure on three sides (total occlusion
may lead to tension pneumothorax
Definitive repair of defect in O.R.
Massive hemothorax

Rapid accumulation of >1500 cc


blood in chest cavity
Hypovolemia & hypoxemia
Neck veins may be:
Flat: from hypovolemia
Distended: intrathoracic blood
Absent breath sounds, DULL to
percussion
Massive hemothorax: treatment

Large-bore (32 to 36 F) tube to drain


blood
If moderate sized (500 to 1500 ml)
and stops bleeding, closed drainage
usually sufficient
If initial drainage >1500 ml OR
continuous bleeding >200 ml / hr,
OPEN THORACOTOMY indicated
Chest
tube
Flail chest

Free-floating chest
segment, usually from
multiple ribs fractures
Pain and restricted
movement paradoxical
movement of chest
wall with respiration
Flail chest
Flail treatment (old)
Flail treatment (old)
Flail treatment

Ventilate well
Humidify oxygen
Resuscitate with
fluids
Manage pain (!!)
Stabilize chest
Internal ventilator
External sand bags
(rare)
6 Potential Life Threats

Pulmonary contusion
Myocardial contusion
Traumatic aortic rupture (TAR)
Traumatic diaphragmatic rupture
Tracheobronchial tree injury: larynx,
trachea, bronchus
Esophageal trauma
Pulmonary contusion

Potentially life-threatening condition


with insidious onset
Parenchymal injury without
laceration
More than 50% will develop
pneumonia, even with treatment
Up to 50% have only hemoptysis as
presenting symptom
Pulmonary contusion

Patients with pre-existing conditions


(emphysema, renal failure) need
early intubation
Treatment needs
to occur over time
as symptoms develop
Tracheobronchial tree injury

Larynx - rare
Hoarseness
Subcutaneous emphysema
Palpable crepitus
Intubation may be difficult:
tracheostomy (not
cricothyroidotomy) is treatment of
choice
Tracheobronchial tree injury

Trachea
Blunt or
penetrating
Esophagus, carotid
artery and jugular
vein may be
involved
Noisy breathing
partial airway
Tracheobronchial tree injury

Bronchus
1.5% blunt
chest trauma
80% due to
BLUNT trauma
within one inch
of carina
(tethered)
6 Other Frequent Injuries

Subcutaneous emphysema
Traumatic asphyxia
Simple pneumothorax
Hemothorax
Scapula fracture
Rib fractures
Traumatic asphyxia

Purple face from


extravasation of
blood (Masque
ecchymotique)
Major damage is to
underlying
structures
Purple face fades
over time in
Simple pneumothorax

Air enters potential space between


visceral and parietal pleura
Breath sounds down on affected side
Percussion hyper-resonance
Treatment: chest tube in 4th or 5th
intercostal space anterior to mid-
axillary line
Medial
pneumothorax
Pocket shooter
Hemothorax

Lacerated lung OR disrupted


intercostal artery or internal
mammary artery
Most are self-limiting
Surgical consultation if
initial drainage of >20 cc/kg (~1500
cc)
continued flow of >200 cc/hr
thanks

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