Chest Trauma Em

Front 1

Chest Trauma: EM

Back 1

Chest Trauma: EM

Front 2

Define Flail chest:

Back 2

Flapping chest wall; 3 or more consecutive ribs on same side fractured in 2 places, resulting in instability of chest wall, paradoxic resp, movements of injured segment, and loss of resp efficiency

Front 3

Define Subcutaneous emphysema:

Back 3

The presence of air or gas in the subcutaneous tissues

Front 4

Define Thoracotomy:

Back 4

Incision into the chest wall.

Front 5

Define Thoracostomy:

Back 5

Establishment of an opening into the chest cavity, as for the drainage of an empyema.

Front 6

Define Thoracentesis:

Back 6

Placing a needle in the chest cavity to remove fluid

Front 7

Define Pendelluft:

Back 7

A ventilatory phenomenon referring to movement of air back and forth between the injured and uninjured lungs with each breath. Tintinalli pg 1601

Front 8

Define Air embolism:

Back 8

Embolism occuring when air enters blood vessel usually vein, as result of trauma, surgery, or deliberate injection; a large air embolism can cause lethal derangement of cardiac function

Front 9

Define Fat embolism:

Back 9

occurrence of fat globules in circulation following fractures of long bone, burns, parturition, and association with fatty degeneration of liver; most commonly block pulmonary or cerebral vessels.

Front 10

Define Tamponade:

Back 10

pathologic compression of a joint or organ

Front 11

Differentiate the significance or cause of a patient with little or no effort to breathe

Back 11

CNS dysfunction due to head trauma, drugs, or spinal cord injury is the most likely problem.

Front 12

Differentiate the significance or cause of a patient attempting to breathe but moving little or no air

Back 12

upper airway obstruction should be suspected.

Front 13

Differentiat the significance or cause of a patient attempting to breathe and upper airway appears intact but breathe sounds poor

Back 13

thoracic problems such as: flail chest, hemopneumothorax, diaphragmatic injury, or parenchymal lung damage are more likely

Front 14

Compare the survival rates of a patient with a penetrating chest wound. Understand why.

Back 14

injuries that don't violate pleura manage as simple laceration or puncture. injuries that violate pleura typically result in pneumothorax. With exception of very small pneumothoraces, tube thoracostomy indicated and nearly always sufficient therapy. If trajectory appears to traverse diaphragm, suspicion of intra-abdominal injury prompts laparotomy or at laparoscopy.

Front 15

Compare the survival rates of a patient with blunt trauma to the chest with a patient with a penetrating wound. Understand why.

Back 15

MOI: compression (organ rupture), direct trauma (e.g. fracture) & acceleration/ deceleration forces (vessel shear/tear). severity of injury predicts clinical course & outcome. may or may not require thoracostomy to drain hemopneumothorax, but many require intubation & mechanical vent & will sustain complications of injury & therapy such as pneumonia. generally, penetrating injuries survive smoother, shorter courses than blunt injuries.

Front 16

Understand how intubation can contribute to cardiac arrest or pneumothorax.

Back 16

If pt has poor venous return due to hypovolemia vent with excessive pressure can further reduce venous return & cause cardiac arrest. Hypovolemic pts should be vent with tidal volumes of 5-8 ml/kg at 10-14 min until venous return improved. If lung injury or fragile subpleural blebs, overzealous insufflation can cause tension pneumothorax, further reducing venous return

Front 17

Be able to make an initial survey to detect the immediate life threatening condition of: Airway obstruction

Back 17

Auscultation of the neck to detect abnormal or absent air movement can be diagnostic

Front 18

Be able to make an initial survey to detect the immediate life threatening condition of: Massive hemothorax

Back 18

The quick bedside ultrasound can reveal a layer of fluid between the chest wall and the lung.

Front 19

Be able to make an initial survey to detect the immediate life threatening condition of: Tension pneumothorax

Back 19

Should be suspected when presentation includes dyspnea, hypoperfusion, distended neck veins, diminished or absent breathe sounds on the affected side, and tracheal deviation to the opposite side.

Front 20

Be able to make an initial survey to detect the immediate life threatening condition of: Pericardial tamponade

Back 20

Presents similar to tension pneumothorax; with hypoperfusion and distended neck veins, but may also muffled heart tones. Breathe sounds should be audible bilaterally and the trachea should be midline.

Front 21

Be able to make an initial survey to detect the immediate life threatening condition of: Shock

Back 21

(not listed in book, but would think vital signs, usual signs)

Front 22

Be able to make an initial survey to detect the immediate life threatening condition of: Cardiac arrest

Back 22

(not listed in book, but I would think an EKG and labs would be most diagnostic)

Front 23

Be able to make an initial survey to detect the immediate life threatening condition of: Open pneumothorax

Back 23

An open communication between the outer chest wall and the pleural space. Sometimes referred to as a “sucking chest would” because of the sound produced as air moves through the wound.

Front 24

Be able to make an initial survey to detect the immediate life threatening condition of: Flail chest

Back 24

characterized by a paradoxical inward movement of the involved portion of the chest wall during spontaneous inspiration and outward movement during expiration.

Front 25

Explain when early ventilatory support is needed and the use of pulse oximeter.

Back 25

pts with chest trauma, impaired vent that persist in spite measures to open airway, relief of chest wall pain, & drainage of hemopneumothorax is indication for vent support. strongly consider if pt in shock, has had multiple injuries, comatose, require multiple transfusions, elderly, or preexisting pulmonary disease. All trauma pts should be monitored by pulse oximetry

Front 26

Describe how the therapeutic measures listed may be needed early to prevent death: Fluid resuscitation:

Back 26

Failure to correct hypotension within 15 to 30 mins greatly increases the mortality rate. In previously healthy pts requiring massive transfusions but having hypotension for less than 30mins, the mortality rate average is about 10%, but if the hypotension is present for more than 30mins the mortality is almost 50%.

Front 27

Describe how the therapeutic measures listed may be needed early to prevent death: Chest tube:

Back 27

A large hemothorax or hemopneumothorax can seriously interfere with ventilation and venous return; consequently; it should be evacuated as rapidly as possible.

Front 28

Describe how the therapeutic measures listed may be needed early to prevent death: External massage:

Back 28

In pts with cardiac arrest due to chest trauma, external cardiac massage is generally of no value and may in fact be harmful. In addition, forced ventilation and external cardiac compression may result in air emboli in the coronary arteries.

Front 29

Describe how the therapeutic measures listed may be needed early to prevent death: Thoracotomy & open cardiac massage

Back 29

Resuscitative thoracotomy can be helpful in carefully selected pts. Pts with blunt thoracic injuries who arrive in the ED without SOL should be declared dead. Pts with penetrating wounds have a significantly better chance of surviving with benefit of thoracotomy.

Front 30

Describe how the therapeutic measures listed may be needed early to prevent death: Thoracentesis:

Back 30

A large hemothorax or hemopneumothorax can seriously interfere with ventilation and venous return; consequently; it should be evacuated as rapidly as possible.

Front 31

Identify the unique physical finding to look for in inspecting the neck, thorax and abdomen in a patient with thoracic trauma.

Back 31

Distended neck veins,
chest wall for contusion, abrasions, and other signs of trauma like seat belt sign, paradoxical segments (flail chest), intrathoracic bleeding, and open (sucking) chest wounds. Excessive abd movement during breathing

Front 32

Explain the pathophysiology of a sucking chest wound.

Back 32

Small open chest wounds can act as one-way valves, allowing air to enter during inspiration, but doesn't leave during expiration, causing an expanding pneumothorax.

Front 33

Explain how to recognize and treat a sucking chest wound.

Back 33

Cover immediately with a sterile petrolatum gauze, and a chest tube should be inserted simultaneously at a separate site to relieve the consequent pneumothorax.

Front 34

Explain what to avoid in a sucking chest wound.

Back 34

A chest tube should not be inserted through the trauma wound, because it is then likely to follow the missile or knife tract into the lung or diaphragm.

Front 35

Understand the significance of subcutaneous emphysema.

Back 35

Pts with subcutaneous emphysema should be presumed to have an underlying pneumothorax, even if it is not visible on the chest x-ray

Front 36

Understand the potential complications of a clavicle fracture.

Back 36

fx's caused by blunt trauma usually uncomplicated. direct trauma produces sharp fragments that may injure subclavian vein producing moderately large hematoma or venous thrombosis.

Front 37

Know how to recognize rib fractures and possible complications.

Back 37

Rib fractures should be assumed to be present in any patient who has localized pain and tenderness over one or more ribs after chest trauma.

Front 38

What significant complications can occur with rib fractures

Back 38

hemopneumothorax, pulmonary contusion, or major vascular injury.

Front 39

What treatments should be avoided in rib fractures.

Back 39

Strapping the chest with adhesive tape or a rib belt is more likely to predispose to atelectasis and pneumonia and is not recommended

Front 40

What percent of rib fractures are missed initially on plain x-rays.

Back 40

Up to 50% of rib fractures (especially those involving the anterior and lateral portions of the first five ribs) may not be apparent on x-ray, particularly for the first few days after injury.

Front 41

Understand the complications associated with multiple rib fractures or fractures of 9th, 10th and 11th ribs.

Back 41

If pt becomes hypotensive & does't have lg hemothorax or tension pneumothorax, intra-abdominal bleeding from liver or spleen should be suspected. Aspiration pneumonitis & fat embolism often not apparent clinically or on chest x-ray for at least 24 to 28 hours

Front 42

Explain the special significance of 1st and 2nd rib fractures.

Back 42

With exception of direct trauma, like a hammer blow, it takes great force to fracture 1st & 2nd ribs. frequently associated with significant injuries like blunt myocardial injury, bronchial tears, or major vascular injury

Front 43

Be able to recognize flail chest

Back 43

paradoxical inward movement of involved chest wall during spontaneous inspiration and outward movement during expiration.

Front 44

Describe treatment of a flail chest

Back 44

Preferred intervention is analgesia adequate to allow the pt to fully expand the underlying lung, with a goal of improving ventilation and pulmonary toilet.

Front 45

Define cyclic pattern or significance of a flail chest

Back 45

paradoxical movement during breathing increases the work to breath but with decreased efficiency of ventilation causing pt to fatigue rapidly and leading to respiratory arrest

Front 46

Define the indication for early ventilatory support of pts with flail chest

Back 46

shock, 3+ associated injuries, severe head injury, comorbid pulmonary disease, fracture of 8+ ribs, or age greater than 65 years.

Front 47

Discuss sternal fracture and how to recognize and treat it.

Back 47

Accumulating evidence suggests that sternal fracture is not an indicator of significant blunt myocardial injury.

Front 48

Discuss blunt cardiac injury (BMI), the incidence and how to recognize and treat it.

Back 48

blunt chest trauma without sternal fracture whose VS and ECG are normal require no further consideration of SMI. Pts with normal VS and ECG with sternal fractures should repeat ECG in 6 hrs. If unchanged, no further work-up for BMI is required

Front 49

Explain the domino effect of a lung contusion and how to recognize and treat it.

Back 49

opacification on CXR within 6 h of blunt trauma are considered as pulmonary contusion. Giving fluid to unilateral pulmonary contusion causes extravasation of fluid into contralateral lung.

Front 50

Describe the history and physical findings in hemothorax. Know the special x-ray views that can aid in diagnosis. Know the indications for tube thoracostomy.

Back 50

Hemothorax should be suspected following trauma if breath sounds are reduced and chest is dull to percussion on the involved side.

Front 51

Know the special x-ray views in hemothorax that can aid in diagnosis.

Back 51

Fluids collections greater than 200 to 300 ml, can usually be seen on a good upright or decubitus CXR.

Front 52

Know the indications for tube thoracostomy in hemothorax.

Back 52

If there is more than 300 to 500 ml of blood in the pleural cavity, it should be removed as completely and rapidly as possible.

Front 53

Be able to recognize a pneumothorax.

Back 53

not likely to cause severe symptoms unless it is 1) a tension pneumothorax, 2) occupies more than 40% of one hemithorax, or 3) occurs in a pt with shock or preexisting cardiopulmonary disease.

Front 54

Recognize the criteria for a chest tube in a pneumothorax

Back 54

One should assume a tension pneumothorax is present and begin treatment without waiting for CXR if pt has 1) severe respiratory distress, 2) decreased breath sounds and hyperresonance on one side of the chest, 3) distended neck veins, and 4) deviation of the trachea away from the involved side.

Front 55

Understand the possible complications of a pneumothorax

Back 55

If a combination of a pneumothorax and continued air leak is allowed to exist for more than 24 to 48 h, the incidence of empyema and bronchopleural fistula is greatly increased.

Front 56

Know when to suspect systemic air emboli.

Back 56

In a pt with penetrating chest wound, and especially those with hemoptysis, air leaking from an injured bronchus into an adjacent injured vessel. This can produce symptoms of severe dysrhythmias or CNS changes.

Front 57

Understand when a patient is considered to have a cardiac injury until proven otherwise.

Back 57

Every pt with penetrating chest injury anywhere near heart and shock should be considered as having a cardiac injury until proven otherwise. Penetrating wounds of heart are usually rapidly fatal, generally because of massive hemorrhage.

Front 58

Describe the causes of cardiac tamponade

Back 58

Anything that causes bleeding into the cardiac sac around the heart, either from penetrating trauma, or from blunt trauma to the chest wall.

Front 59

Describe the physiology that contributes to the presentation of cardiac tamponade.

Back 59

Sometimes the pericardial tamponade may prolong life by reducing the initial blood loss; the tamponade itself can be fatal by interfering with diastolic filling of the heart.

Front 60

Explain the treatment for cardiac tamponade.

Back 60

Pericardiocentesis, removal of as little as 5 to 10 ml of blood from the pericardial sac may increase stroke volume by 25 to 50%, with a dramatic improvement in cardiac output and blood pressure. Thoracotomy may be necessary. Fluid replacement is always needed.

Front 61

Understand Beck’s triad as well as what it may indicate.

Back 61

Beck’s triad is distended neck veins, hypotension, and muffled heart tones.

Front 62

Understand what Beck's triad may indicate

Back 62

Beck’s triad may be present in pericardial tamponade, tension pneumothorax, myocardial dysfunction, and systemic air embolism.

Front 63

Describe pulsus paradoxus and the cause

Back 63

a drop in systolic blood pressure of more than 10 to 15 mm Hg during normal spontaneous inspiration. The amount of paradox may be further increased by hypovolemia. This is caused by cardiac tamponade

Front 64

Describe the type of injury that can result from blunt trauma to the chest.

Back 64

1) rupture chamber wall 2) septal rupture 3) valvular injuries (aortic valve is most common) 4) direct myocardial injury (contusion) 5) laceration or thrombosis of coronary arteries 6) pericardial injury

Front 65

Explain why a knife should be left in place until the patient gets to the OR.

Back 65

If the knife stays in place, it may temporarily seal the involved vessel. No - I say pull it out...

Front 66

Compare MOI of stab wounds and gun shot wounds to the chest•

Back 66

The size of a knife, its length, and the angle of penetration may suggest the vessels or organs most likely to be injured.

Front 67

Compare rates of survival with stab wounds and gun shot wounds to the chest.

Back 67

survival rate with stab wounds is generally much higher than with gunshot wounds. Small knife wounds are often rapidly sealed off by surrounding tissue, especially vascular adventitia

Front 68

Describe the trauma mechanism suggestive of aortic artery injury.

Back 68

High-speed deceleration injury or side impact, multiple rib fractures or flail chest

Front 69

Describe the physical findings suggestive of an aortic artery injury.

Back 69

1)an acute onset of upper extremity hypertension, 2) difference in pulse amplitude between the upper and lower extremities, and 3) the presence of a harsh systolic murmur over the precordium or posterior interscapular area.