BODY CAVITY TRAUMA

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					BODY CAVITY TRAUMA
     Leaugeay Webre
 BS, CCEMT-P, NREMT-P
Body Cavities
 Thoracic
   1) respiratory
   2) cardiovascular
 Abominopelvic
   1) digestive
   2) urinary
   3) reproductive
Thoracic Cavity
 Chest wall and diaphram
 Serous membranes
    1) parietal- surrounds body cavity
    2) visceral- surrounds organs
    3) potential space
 Contains heart and lungs
    1) mediastinum
    2) pericardial cavity
    3) pleural cavity
Chest Wall
 Elastic structure supported by 12 pairs of ribs
 Intercostal muscles
     Costal groove
      – Inferior rib surface
      – Midclavicular, superior & superior
     Intercostal vein, artery, nerve (most inferior)
    Function
 Supports and protects heart and lungs
 Facilitates ventilation


 Take out a piece of paper!
 Describe the mechanics of ventilation
 What nerve innervates the diaphragm
      Where does it originate from
 Describe the primary respiratory control system
Respiratory System
 Trachea
 Bronchi
 Bronchioles
 Alveoli
Lungs
 Each lung occupies a pleural cavitty
 R lung 3 lobes
 L lung 2 lobes
Assignment
 Take out a piece of paper
 Explain the mechanics of respiration
 Discuss respiratory control system
Respiration
 Diaphram and IC muscles CONTRACT
 Expansion of rib cage
 INCREASED thoracic volume
 DECREASED intrathoracic pressure
 Causes air to enter lungs
Con’t
 RELAXATION of IC muscles and diaphragm
 Decreased thoracic volume
 INCREASED intrathoracic pressure
 Forces air out
Innervation
   Diaphragm                 Intercostal muscles


 Right and left phrenic    Intercostal nerves
  nerve
 Originate C3- C5
 Respiratory Regulation
 Medulla
 Microscopic Stretch Receptors
 Chemoreceptors
 Hypoxic Drive
Respiratory Regulation:
Nervous Impulses-Medulla
 Primary respiratory center (Inhalation)
 Increase in impulses=increase in respirations
 Connected to respiratory muscles via CN-X
  (Vagus)
 Medulla Fails
     Pons (Apneustic Center) takes control
Respiratory Regulation: Pons

  Within Medulla
     Shut off switch to inspiration
      – Apneustic Center
     Primary Exhalation
      – Pneumotaxic Center
Respiratory Regulation:
Stretch Receptors
   During Inspiration
       Stretch Increases: lungs distend
        – Activation of Stretch Receptors
              Increase stretch = increased firing
              Impulses go to Medulla
              Medulla stops/decreases inspiratory stimulation
       Stretch Decreases
        – Stretch receptors stop firing
              Medulla is triggered to increase rate
   Hering-Breuer Reflex:
       Prevents over-expansion
Respiratory Regulation:
Chemoreceptors
   Involuntary Control
       Medulla
        – Central Chemoreceptors
       Carotid Bodies & Arch of Aorta
        – Peripheral Chemoreceptors
   Stimulated by
       Decreased PaO2
       Increased PaCO2
       Decreased pH in CSF
        – Lower pH = Greater Acidity/Lesser Alkalinity
        – Higher pH = Greater Alkalinity/Lesser Acidity
Respiratory Regulation:
Chemoreceptors
   CSF pH is primary control of respiratory
    stimulation
       Increase in CSF pH reduces respirations & Vice-
       versa)
   Arterial PCO2 is inversely related to pH
       PaCO2 =  in pH  RESPIRATORY ACIDOSIS
       PaCO2 =  in pH  RESPIRATORY ALKALOSIS
        Arterial PaCO2 stimulates peripheral chemoreceptors
        – Impulse to Medulla to  Respirations

       Vice-Versa for slowing respirations
Respiratory Regulation:
Hypoxic Drive
   Hypoxemia
      Decreased PaO2 in blood (<80-100 torr)
   COPD-ers
      Retain CO2 and have elevated PaCO2
   Chemorecptors become acclimated to increased
    PaCO2
      CNS ceases dependence on PaCO2 for respiratory
      control thru chemoreceptors
      Respiratory Stimulation
       –  respirations with  O2
       –  respirations with  O2
   Lungs
 Occupy right and left pleural space
     Chest wall lined with?
     Outer lungs surrounded by?
 Potential space
     Fluid between pleuras
     Lubrication
      – Keep lung adhered to chest wall
      – High surface tension between visceral and parietal pleuras
 Either pleural cavity potential of 3L blood/ air
 TV- tidal volume = 500 ml
     Volume of air in/exhaled in one breath
 MV- minute volume
     TV x RR = 7,000 ml
     Amount of air exchanged by the lung in 1 minute
 Physiologic dead space
     Amount of air not exchanged = 150 ml
Chest Trauma
 Rapid shallow breaths
 TV = 200 ml
 100 ml to alveoli
 < if injury to lung
Air Movement
 Tidal volume
 Dead space
 Inspiratory reserve
 Expiratory reserve
 Total lung capacity
 Work Of Breathing
 Compliance
     Measure of distensibility of the lung volume
    produced by a unit pressure change.
 Surfactant
     Lipoproteins that reduce the surface tension of
    pulmonary fluids, allowing the exchange of gases in
    the alveoli of the lungs and contributing to the
    elasticity of pulmonary tissue.
AIRWAY RESISTANCE
 Structural changes in lungs or thorax
     Trauma or disease
      – Increases work of breathing
     Requires accessory muscles
      – Scalenes
      – Sternocleidomastoid
      – Posterior neck and back muscles
      – Abdominal muscles
Measuring Oxygen &
Carbon Dioxide Levels
 Partial Pressure
    Pressure exerted by each component of a gas
    mixture
    Calculated by:
      – Multiplying percentage of atmospheric gas by
        atmospheric pressure at sea level
      – i.e.: Oxygen = 21%
           0.21 x 760 torr = 159.6 torr
      – Pressure at sea level is 760 torr (14.7 psi)
Normal Arterial Values
& Pressures
 pH: 7.35-7.45
 Oxygen (PaO2)
    100 Torr
        – Avg 80-100
    FiO2
        – Concentration of oxygen in inspired air
 Carbon Dioxide (PaCO2)
    40 Torr
        – Avg 35-45
 Diffusion
 Diffusion
     The movement of a gas or solute from an area of
    higher concentration (partial pressure) to an area of
    lesser concentration (partial pressure.)

 Lungs     Blood
 Blood     Peripheral Tissues
 98% O2 carried on hemoglobin
 2% dissolved in plasma
Factors Affecting PaO2
   Decreased hemoglobin concentration
   Inadequate Alveolar Ventilation
   Decreased Diffusion Across Pulmonary
    Membrane
   Ventilation/Perfusion Mismatch
      Atelectasis
       – Collapse of alveoli
      Pulmonary Embolism
       – Blood clot or other thrombus in the pulmonary
         circulation.
Carbon Dioxide
Concentrations in the Blood
 CO2 transported mainly in the form of
  bicarbonate (HCO3)
     ~70% as bicarbonate
     ~20% combined with hemoglobin
     >7% dissolved in plasma
 Hyperventilation
     Lowers CO2 and can increase rate and depth of R’s
Factors Affecting PaCO2
 Increased CO2            Decreased CO2
  Production               Elimination
    Fever                     Airway Obstruction
    Shivering                 Respiratory Depression
    Muscle Exertion           Muscular Impairment
    Metabolic Processed       Obstructive Disease
    with Increased Acid

    HYPERCARBIA
Pathophysiology of Thoracic
Trauma
   Blunt Trauma
       Results from kinetic energy forces
       Subdivision Mechanisms
        – Blast
               Pressure wave causes tissue disruption
               Tear blood vessels & disrupt alveolar tissue
               Disruption of tracheobronchial tree
               Traumatic diaphragm rupture

                                                               (continued)
Pathophysiology of Thoracic
Trauma
    – Crush (Compression)
         Body is compressed between an object and a hard surface
         Direct injury of chest wall and internal structures
    – Deceleration
         Body in motion strikes a fixed object
         Blunt trauma to chest wall
         Internal structures continue in motion
               Ligamentum Arteriosum shears aorta
    Age Factors
    – Pediatric Thorax: More cartilage = Absorbs forces
    – Geriatric Thorax: Calcification & osteoporosis = More fractures
    Pathophysiology of Thoracic
    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
       Shotgun
        – Injury severity based upon the distance between the victim and shotgun & caliber of shot
        – Type I: >7 meters from the weapon
             Soft tissue injury
        – Type II: 3-7 meters from weapon
             Penetration into deep fascia and some internal organs
        – Type III: <3 meters from weapon
             Massive tissue destruction
Thoracic Trauma
 Rib fractures
 Great vessel injury
 Cardiac contusion
    sternal Fx
 Pulmonary contusion
    scapular Fx
 Traumatic asphyxia
alveolus
 Most basic unit of lung
     Surfactant resists collapse (atelectasis)
     Decreased surface tension
     CO2/ O2 exchange
 Perfusion is directed toward lung area that is
  well ventilated
 Ventilation- perfusion matching
SURFACTANT
   Lowers the surface tension and prevents the collapse of
    alveolus at end of exhalation.
   Decrease in surfactant requires higher pressures to expand
    lung.
   Causes of decreased surfactant
       Pneumonia
       Drowning
       ARDS
       Pulmonary Edema
   Premature infants often lack surfactant and have respiratory
    distress.
V/Q Mismatch
 Blood enters systemic circulation without being
  adequately oxygenated
 Trauma patients
     Shock
     Tension pneumothorax
     Massive hemothorax
 O2/ CO2 diffuse at different rates between alveoli and
  bloodstream due to chemical properties
 CO2 diffuses rapidly from blood to alveoli
 (CO2) in blood dependent on alveolar ventilation
 Increased alveolar ventilation: decreased blood CO2
 O2 diffuses from alveoli to bloodstream more slowly
 Therefore delivery of O2 dependent on open alveoli
 Max surface area
Right to Left Shunt
 Blood/ fluid in alveoli
     Hemothorax
     Pulmonary edema
     Toxic inhalation, injury, contusion
     Near drowning
 Blood flows to alveoli that is not ventilated
     Rib fractures
      – atelectesis
     Flail chest
     Compression
Opposite Pathophysiology
 Sufficient blood does not pass through
  adequately ventilated alveoli
     Shock
     Injury to pulmonary vasculature
     Inadequate gas exchange
     Hypoxemia
     Hypercarbia
Improve Oxygenation
 Increase (O2) inspired
 Increase number open alveoli
 Adequate pain control
     Adequate lung expansion
 PEEP
     >10-15 cm H2)
     Decreased venous return (preload): CO
     Increased pulmonary pressure
Mediastinum
 Thymus
 Trachea
 Esophagus
 Major vessels
 Pericardial cavity
 Paired vagus & phrenic N.
Pericardial Cavity
 Heart
    pericardium
    epicardium
 great veins & arteries attached at base
 apex formed by the ventricles
Anatomy
 R & L atrium
 R & L ventricles
 Divided vertically by septum
 Divided horizontally by
    1) L- tricuspid valve
    2) R- bicuspid valve (mitral)
    3) chordae tendonae & papillary muscle
Heart
 Anterior aspect- RV
 Pressure ¼ of LV
 Protected by strenum
 Apex felt 5th ICS midclavicular- cardiac impulse
 CO = SV x HR = 4- 6 l/min
Posterior Mediastinum
 Firmly attached to thoracic vertebrae
 Descending aorta
 Tethered to heart by ligamentum arteriosum
Atrium
 Collect blood returning to the heart
 Deliver blood to ventricle
 Workload is similar
Ventricles
 R ventricle delivers blood to lungs
 Pulmonary arteries & veins short and wide
 Wall relatively thin, smaller
 L ventricle delivers blood to systemic circulation
 More extensive network of vessels
 Thicker, larger
Valves
 Atrioventricular prevent backflow into the atria
 Ventricle is relaxed offers no resistance
 Chodae tendonae prevent ballooning back
 Heart murmur- small amount of back flow
 Pulmonary & aortic valves prevent backflow into
  ventricles
Heart Wall
 Epicardium
   covers outer surface
 Myocardium
   muscular wall
 Endocardium
   covers inner surface of heart
Blood Supply
 Coronary circulation
    R coronary artery & L coronary artery
    Originate at base of ascending aorta
    Blood pressure highest in systemic circulation
 2 Cardiac veins carry blood away
 Drain into coronary sinus
 Flow into R atria
Assignment
 Take out a piece of paper
 Trace a drop of blood through the body
Blood Flow
 Systemic circulation- superior & inferior vena cava
 Enters R atrium through tricuspid valve
 R ventricle through pulmonary valve
 L & R pulmonary arteries
 Lungs- blood oxygenated
 L & R pulmonary veins
 L atrium through bicuspid valve (mitral)
 L ventricle through aortic valve
 Systemic circulation through ascending aorta
Pathophysiology Injuries
 Systemic hypoxia
    Most important acutely
 Hypercarbia
 Acidosis
 Injury and stress increase O2 demand
Systemic Hypoxia
 Inadequate O2 delivery secondary to hypovolemia
 Pulmonary V/Q mismatch
 Changes in intrathoracic relationships
 Direct trauma to heart
Pulmonary V/Q Mismatch
 Damage to lung tissue
 Alters ability of O2 to diffuse
 Atelectesis
 Alveoli filled with blood
   Changes in Intrathoracic
   Pressure
 Pneumothorax
    Air enters pleural space
    Adhesion by surface tension to chest wall is lost
    Adequate expansion not possible
    Ventilation compromise
 Hemothorax
    Blood/ fluid in pleural space
    Compression of lung
    Alveolar collapse
    Hypercarbia, respiratory acidosis
Great Vessel Injury
 Most patients with transection or tear
  exanguinate prehospital
 Due to rapid deceleration and shearing forces
 Most common site of injury ligamentum
  arteriosum
 Suspicion with 1st/2nd rib Fx, massive L
  hemothorax, high sternal Fx
 Aortic
rupture
Pathophysiology of Thoracic Trauma
Cardiovascular Injuries
    Traumatic Aneurysm or Aortic Rupture
        Aorta most commonly injured in severe blunt or penetrating trauma
         – 85-95% mortality
        Typically patients will survive the initial injury insult
         – 30% mortality in 6 hrs
         – 50% mortality in 24 hrs
         – 70% mortality in 1 week
        Injury may be confined to areas of aorta attachment
        Signs & Symptoms
         – Rapid and deterioration of vitals
         – Pulse deficit between right and left upper or lower extremities
    Pathophysiology of Thoracic Trauma
    Cardiovascular Injuries
    Other Vascular Injuries
        Rupture or laceration
         – Superior Vena Cava
         – Inferior Vena Cava
         – General Thoracic Vasculature
        Blood Localizing in Mediastinum
        Compression of:
         – Great vessels
         – Myocardium
         – Esophagus
        General Signs & Symptoms
         – Penetrating Trauma
         – Hypovolemia & Shock
         – Hemothorax or hemomediastinum
Chest Wall Compression
 Prevents excursion
 Prevents normal ventilation
 Pulmonary/ cardiac contusions
 Pnuemo/ hemothorax
 Traumatic asphyxia
    Pathophysiology of Thoracic Trauma
    Chest Wall Injuries
   Contusion
      Most Common result of blunt injury
      Signs & Symptoms
       –   Erythema
       –   Ecchymosis
       –   DYSPNEA
       –   PAIN on breathing
       –   Limited breath sounds
       –   HYPOVENTILATION
              BIGGEST CONCERN = “HURTS TO BREATHE”
       – Crepitus
       – Paradoxical chest wall motion
Pathophysiology of Thoracic Trauma
Chest Wall Injuries
    Sternal Fracture & Dislocation
        Associated with severe blunt anterior trauma
        Typical MOI
          – Direct Blow (i.e. Steering wheel)
        Incidence: 5-8%
        Mortality: 25-45%
          –   Myocardial contusion
          –   Pericardial tamponade
          –   Cardiac rupture
          –   Pulmonary contusion
        Dislocation uncommon but same MOI as fracture
          – Tracheal depression if posterior
Pathophysiology of Thoracic Trauma
Other Thoracic Injuries
    Traumatic Esophageal Rupture
       Rare complication of blunt thoracic trauma
       30% mortality
       Contents in esophagus/stomach may move into mediastinum
        –   Serious Infection occurs
        –   Chemical irritation
        –   Damage to mediastinal structures
        –   Air enters mediastinum
       Subcutaneous emphysema and penetrating trauma present
Pathophysiology of Thoracic Trauma
Other Thoracic Injuries
    Tracheobronchial Injury
        MOI
         – Blunt trauma
         – Penetrating trauma
        50% of patients with injury die within 1 hr of injury
        Disruption can occur anywhere in tracheobronchial tree
        Signs & Symptoms
         –   Dyspnea
         –   Cyanosis
         –   Hemoptysis
         –   Massive subcutaneous emphysema
         –   Suspect/Evaluate for other closed chest trauma
Pulmonary Contusion
 Bruising of lung parenchyma
 Rapid deceleration ruptures capillary cell walls
 Resulting in hemorrhage
 Extravasation of plasma and protein into alveolar
  and interstitial space
 Results in atelectasis and consolidation
 Leading to intrapulmonary shunting and
  hypoxemia
Assessment
 What are you looking for?
 Retractions        Excessive abdominal
 Stridor             movement
 Hoarseness         Diaphragm controlling

 Sub Q emphysema
                      ventilations
                     Respiratory effort
 Contusions
                     Respiratory rate
 Open wound
                     Respiratory pattern
 Skin color
Sx
 Dyspnea
 Rales
 Hemoptysis
 Tachypnea
 Gradual onset
 O2, IV, CM
    Pathophysiology of Thoracic Trauma
    Pulmonary Injuries
   Pulmonary Contusion
      Soft tissue contusion of the lung
      30-75% of patients with significant blunt chest trauma
      Frequently associated with rib fracture
      Typical MOI
       – Deceleration
           Chest impact on steering wheel
       – Bullet Cavitation
           High velocity ammunition
      Microhemorrhage may account for 1- 1 ½ L of blood loss in alveolar
      tissue
       – Progressive deterioration of ventilatory status
      Hemoptysis typically present
Cardiac Contusion
 Bruising of myocardium
 Rapid deceleration with strike to anterior chest
  wall
 R ventricle commonly affected due to location
 May result in CHF/ cardiogenic shock
Sx
 Chest pain
 Nonspecific EKG changes
 Atrial dysrythmias more likely with R sided
  injuries
 Ventricular dysrythmias more likely with L sided
  injuries
 Cardiac enzymes- CKMB, troponin
 O2, IV , CM, dysrythmias Tx
    Pathophysiology of Thoracic Trauma
    Cardiovascular Injuries
    Myocardial Contusion Signs & Symptoms
   Bruising of chest wall
   Tachycardia and/or irregular rhythm
   Retrosternal pain similar to MI
   Associated injuries
       Rib/Sternal fractures
   Chest pain unrelieved by oxygen
       May be relieved with rest
       THIS IS TRAUMA-RELATED PAIN
        – Similar signs and symptoms of medical chest pain
Pathophysiology of Thoracic Trauma
Cardiovascular Injuries
   Myocardial Contusion
       Occurs in 76% of patients with severe blunt chest trauma
       Right Atrium and Ventricle is commonly injured
       Injury may reduce strength of cardiac contractions
        – Reduced cardiac output
       Electrical Disturbances due to irritability of damaged myocardial cells
       Progressive Problems
        – Hematoma
        – Hemoperitoneum
        – Myocardial necrosis
        – Dysrhythmias
        – CHF & or Cardiogenic shock
Heart Trauma
 Decreased ability to provide adequate tissue
  perfusion
     Compression of heart
     Cardiac tamponade
     Tension pneumothorax
Pulsus paradoxus
 Decreased SBP > 10 mmHg with inspiration
 Increased lung volume
 Increased volume within pulmonary vessels
 RV compression will not allow filling of
  pulmonary vessels
     Decreased preload, decreased CO
Blunt & Penetrating Trauma
 Pneumothorax
 Tension pneumothorax
 Hemothorax
 Flail chest
 Cardiac tamponade
 Sucking chest wound
Rib Fractures
 No elastic recoil
 Bone edges injure underlying structures
Pathophysiology of Thoracic Trauma
Chest Wall Injuries
    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 9-12 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
Pathophysiology
 Shallow ventilations
 Hypoventilation
 Atelectesis
 pneumonia
Flail Chest
 Three or more ribs fractured in two or more
  places
 Dyspnea
 Paradoxical movement
Pathophysiology of Thoracic Trauma
Chest Wall Injuries
    Flail Chest
        Segment of the chest that becomes free to move with the
        pressure changes of respiration
        Three or more adjacent rib fracture in two or more places
        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
 Flail chest
Pathophysiology
 Paradoxical movement
 Hypoventilation
 Hypoxia
 Hypercarbia
Management of Flail Chest
 O2
 Apply gentle pressure to prevent paradoxical
  movement
 Pillow, bulky trauma pad taped in place
 Positive pressure ventilation
 IV- large bore X 2 NS/ LR
 CM
                       Tension
                       Dyspnea

Pneumothorax           Tachycardia
                       Tracheal deviation
 Simple                    LATE, PRETERMINAL
                       + JVD
 Decreased/ absent
                       Hemodynamic instability
  breath sounds to
                       Sx impaired gas exchange
  affected side
                       Decreased compliance
                       Hyperresonance
                       Cardiac impulse shift away from
                        affected
                       Pulsus paradoxus
                       Narrowed pulse pressure
Pathophysiology of Thoracic Trauma
Pulmonary Injuries
   Simple Pneumothorax
       AKA: Closed Pneumothorax
        – Progresses into Tension Pneumothorax
       Occurs when lung tissue is disrupted and air leaks into the pleural space
       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
       Typical MOI: “Paper Bag Syndrome”
 Pneumo
thorax
Sucking Chest Wound
 Penetrating trauma
 Dyspnea
 Air escape
 Defect chest wall allows air enter thoracic space
 Allows equalization of intrathoracic and
  atmospheric pressure
 Air flows thru path least resistance
 > 2/3 tracheal diameter
Pathophysiology of Thoracic Trauma
Pulmonary Injuries
   Open Pneumothorax
      Free passage of air between atmosphere and pleural space
      Air replaces lung tissue
      Mediastinum shifts to uninjured side
      Air will be drawn through wound if wound is 2/3 diameter of
      the trachea or larger
      Signs & Symptoms
       –   Penetrating chest trauma
       –   Sucking chest wound
       –   Frothy blood at wound site
       –   Severe Dyspnea
       –   Hypovolemia
Management
 O2,
 Occlusive dressing
 Taped on three sides
 IV- large bore x 2 NS/LR
 CM
    Management of the Chest Injury
    Patient
   Open Pneumothorax
      High flow O2
      Cover site with sterile occlusive
      dressing taped on three sides
      Progressive airway management if
      indicated
    Tension Pneumothorax
 Results from formation of one way valve
 Air enters pleural space
     Defect in lung
     Defect in chest wall
 Complete collapse affected lung
     Collapse of lung not immediately life threatening
 Compression mediastinum
 Compression & shift
     Decreased venous return
     Decreased CO
 Tension
pneumothorax
    Pathophysiology of Thoracic Trauma
    Pulmonary Injuries
   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
    Pathophysiology of Thoracic Trauma
    Pulmonary Injuries
    Tension Pneumothorax Signs & Symptoms
   Dyspnea                                         Diminished then absent breath sounds on
        Tachypnea at first                           injured side
   Progressive ventilation/perfusion mismatch      Cyanosis
        Atelectasis on uninjured side               Diaphoresis
   Hypoxemia                                       AMS
   Hyperinflation of injured side of chest         JVD
   Hyperresonance of injured side of chest         Hypotension
                                                    Hypovolemia
                                                    Tracheal Shifting
                                                          LATE SIGN
Common Causes
 Mechanical ventilation
 Spontaneous pneumo by rupture emphysema
  alveoli
 Blunt causes shear bronchi
     CPR
 Penetrating
    Assignment
 Take out a piece of paper
 Describe the procedure you would follow to manage a
  tension pneumothorax
 Include differentiation of a simple vs tension
  pneumothorax
 List possible complications associated with treatment.
Management of Tension
Pneumothorax
  Midclavicular                  Midaxillary
  2nd/3rd intercostal space      4th/5th intercostal space


  Insert large bore (10-14g) catheter
  Above lower rib
  90 degree angle
  Advance catheter
  Secure hub
  O2, IV, CM
    Management of the Chest Injury
    Patient
   Tension Pneumothorax
       Confirmation
        – Auscultaton & Percussion
       Pleural Decompression
        – 2nd intercostal space in mid-
          clavicular line
              TOP OF RIB
        – Consider multiple
          decompression sites if patient
          remains symptomatic




                                           (continued)
Management of the Chest Injury
Patient
 – Large over the
   needle
   catheter: 14ga
 – Create a one-
   way-valve:
   Glove tip or
   Heimlich valve
Cardiac Tamponade
 Blood enters the pericardial sac
 Does not allow for adequate filling
 Reduced cardiac output
 Results in shock
    Pathophysiology of Thoracic Trauma
    Cardiovascular Injuries
   Pericardial Tamponade
      Restriction to cardiac filling caused by blood or other fluid within the
      pericardium
      Occurs in <2% of all serious chest trauma
       – However, very high mortality
      Results from tear in the coronary artery or penetration of myocardium
       – Blood seeps into pericardium and is unable to escape
       – 200-300 ml of blood can restrict effectiveness of cardiac contractions
             Removing as little as 20 ml can provide relief
Pathophysiology of Thoracic Trauma
Cardiovascular Injuries
Pericardial Tamponade Signs & Symptoms
   Dyspnea
   Possible cyanosis
   Beck’s Triad                            Kussmaul’s sign
        JVD                                      Decrease or absence of JVD
        Distant heart tones                      during inspiration
        Hypotension or narrowing pulse      Pulsus Paradoxus
        pressure                                 Drop in SBP >10 during inspiration
   Weak, thready pulse
                                                 Due to increase in CO2 during
   Shock                                        inspiration
                                            Electrical Alterans
                                                 P, QRS, & T amplitude changes in
                                                 every other cardiac cycle
                                            PEA
 Cardiac tamponade
Sx
 BECK’S TRIAD
 Narrowing pulse pressure
 Pulsus paradoxus
 + JVD
 Muffled heart tones
 Electrical alternans
Electrical Alternans
 Highly specific marker although more common in
  chronic pericardial effusions
 Alternating amolitude of P, QRS, T waves in any
  single lead occurring every other beat
 Caused by heart swinging back and forth with
  excess fluid
 Fluid acts as insulator decerasing overall voltage
Management
 O2, IV, CM
 Aggressive fluid resuscitation
 Vasopressors
 Pericardiocentesis
    Pathophysiology of Thoracic Trauma
    Cardiovascular Injuries
   Myocardial Aneurysm or Rupture
      Occurs almost exclusively with extreme blunt thoracic trauma
      Secondary due to necrosis resulting from MI
      Signs & Symptoms
        – Severe rib or sternal fracture
        – Possible signs and symptoms of cardiac tamponade
        – If affects valves only
             Signs & symptoms of right or left heart failure
        – Absence of vital signs
  Penetrating
 Reported to arrest during/ soon after intubation
     Inadequate preoxygenation
     Esophageal intubation
     Mainstem intubation
     Vasovagal response
     Excessive respiratory acidosis
     Excessive PPV
      – Decreased venous return
      – May cause tension
          Decreased CO
Thoracotomy
 Last ditch effort
 Arrests in ER or < 10 minutes away
 Successful primarily :
     Young, healthy previously
     Penetrating chest trauma
Massive Hemothorax
 Mechanical interference with respirations
 Decreased circulating Hgb
 Each pleural space 3,000 ml
   Hemothorax
 1,500 ml pleural space
 > 300ml may form clots
 Blood in pleural space does not hinder ventilation due to
  maintained surface tension unless massive
 Requires chest tube
     4th ICS midaxillary
     Direct posteriorly
 Decompressing effect may increase hemorrhage
     > 1,500 clamp and autotransfuse
Sx
 Hemodynamic instability
 Hyporessonance
 Dull precussion
 Hemorrhagic shock
   hemothorax
Management
 Airway/ ventilation support
 Hemorrhagic shock
Traumatic Asphyxia
 Sudden severe crushing of the chest
 Retrograde blood flow from right heart into veins
  of face/ neck
 Vena cava and large veins of head/ neck lack
  valves allowing capillary engorgemnet
Sx
 Bulging/ red eyes
 Cyanotic, red, purple upper body
 Edema
 Swollen tongue
 Subconjunctival hemorrhage/ petechaie
 Vascular engorgement
 Dyspnea
 Sx shock
Pathophysiology
 Venous congestion results in sluggish cranial
  blood flow
 Transient hypoxia
 Seizures
 Cerebral edema
 Small strokes
 ICH rare
Pathophysiology of Thoracic Trauma
Other Thoracic Injuries
    Traumatic Asphyxia
       Results from severe compressive forces applied to the
       thorax
       Causes backwards flow of blood from right side of heart into
       superior vena cava and the upper extremities
       Signs & Symptoms
        – Head & Neck become engorged with blood
              Skin becomes deep red, purple, or blue
              NOT RESPIRATORY RELATED
        –   JVD
        –   Hypotension, Hypoxemia, Shock
        –   Face and tongue swollen
        –   Bulging eyes with conjunctival hemorrhage
Management
 Aggressive resuscitation
 O2
 IV- large bore x 2, NS/LR , pressure infusion
 CM
 NaHCO3 if > 10 minutes
Burns
 Circumfrential:
     Inelastic eschar formation
     Tissue edema
     Decreased excursion
     Decreased TV
     Hypoventilation
     Hypoxia
     Hypercarbia
  Diaphragmatic Rupture
 Trauma to anterior chest/ abdomen
 Increased intra abdominal pressure
 Herniation of abdominal contents into thoracic cavity
 Typically L due to protection of liver
     Limits lung ability to inflate
     Respiratory compromise
    Pathophysiology of Thoracic Trauma
    Other Thoracic Injuries
    Traumatic Rupture or Perforation of the Diaphragm
         MOI
          – High pressure blunt chest trauma
          – Penetrating trauma
         Most common in patients with lower chest injury
         Most often occurs on left side
         Signs & Symptoms
          – Herniation of abdominal organs into thorax
                Restriction of ipsilateral lung
                Displacement of mediastinum
                Abdomen may appear hollow
                Bowel sounds may be noted in thorax
          – Similar to tension pneumothorax
                Dyspnea, Hypotension & JVD
          – Evaluate for other injuries
    Presentation
 PPV in intubated patients may prevent herniation even with tear
 Acute
      Injury to recovery of primary injuries
      Overshadowed by other injuries
   Latent
      Months to years following
      Complications ensue
   Obstructive
      Complications resulting from vascular compromise and strangulation of
      abd viscera
                                   Chest pain radiating to L
     Sx                             shoulder
 Acute                            Asymmetric chest wall
 Cardiovascular Sx due to
                                    movement
  mechanical effects               Dyspnea
 Mediastinal shift interfering    Cough
  with ventricular filling         Hiccough
 Decreased CO                     Abd pain
 Tachycardia                      Scaphoid abd
 Hypotension                      Cyanosis
 Dysrhythmias                     Bowel sounds in chest
 +JVD                             Ipsilateral diminished BS
Management
 Support ventilations
     PPV
 NG tube
     Decrease intra abdominal pressure
 PASG contraindicated
    Pts with immediate deterioration following
    application should be suspect
 Fluid resuscitation as needed
Management of the Chest Injury Patient
General Management
   Ensure ABC’s
       High flow O2 via NRB
       Intubate if indicated
       Consider RSI
       Consider overdrive ventilation
        – If tidal volume less than 6,000 mL
        – BVM at a rate of 12-16
             May be beneficial for chest contusion and rib fractures
             Promotes oxygen perfusion of alveoli and prevents atelectasis
   Anticipate Myocardial Compromise
   Shock Management
       Consider PASG
        – Only in blunt chest trauma with SP <60 mm Hg
       Fluid Bolus: 20 mL/kg
       AUSCULTATE! AUSCULATE! AUSCULATE!
 Management of the Chest Injury
 Patient
 Rib Fractures
    Consider analgesics for pain and to improve chest excursion
     – Valium
     – Morphine Sulfate
     – Meperidine
     – Nalbuphine
    CONTRAINDICATION
     – Nitrous Oxide
         May migrate into pleural or mediastinal space and worsen condition
Management of the Chest Injury
Patient
   Sternoclavicular Dislocation
        Supportive O2 therapy
        Evaluate for concomitant injury
   Flail Chest
        Place patient on side of injury
        – ONLY if spinal injury is NOT suspected
       Expose injury site
       Dress with bulky bandage against flail segment
        – Stabilizes fracture site
       High flow O2
        – Consider PPV or ET if decreasing respiratory status
       DO NOT USE SANDBAGS TO STABILIZE FX
Management of the Chest Injury
Patient
 Hemothorax
    High flow O2
    2 large bore IV’s
     – Maintain SBP of 90-100
     – EVALUATE BREATH SOUNDS for fluid overload
 Myocardial Contusion
    Monitor ECG
     – Alert for dysrhythmias
    IV if antidysrhythmics are needed
Management of the Chest Injury
Patient
   Pericardial Tamponade
      High flow O2
      IV therapy
      Consider pericardiocentesis if within scope and skill
   Aortic Aneurysm
      AVOID jarring or rough handling
      Initiate IV therapy enroute
       – Mild hypotension may be protective
       – Rapid fluid bolus if aneurysm ruptures
      Keep patient calm
    Management of the Chest Injury
    Patient
   Tracheobronchial Injury
       Support therapy
        – Keep airway clear
        – Administer high flow O2
            Consider intubation if unable to maintain patient airway
        – Observe for development of tension pneumothorax and SQ emphysema
   Traumatic Asphyxia
       Support airway
        – Provide O2
        – PPV with BVM to assure adequate ventilation
       2 large bore IV’s
       Evaluate and treat for concomitant injuries
       If entrapment > 20 min with chest compression
        – Consider 1mEq/kg of Sodium Bicarbonate
Abdominopelvic Cavity
 Abdominal cavity & Pelvic cavity
    lined by peritonium
    double peritonium called mesentary
        surrounds stomach
        small intestine
        portion of large intestine
Abdominal Cavity
 Liver
 Spleen
 Gallbladder
 Stomach
 Kidneys
 Pancreas
Peritoneum
 Delicate covering for abdominal organs
 Lubricating fluid
 Mesentery-tissue that provides small bowel with
  support, circulation, innervation
 Omentum-tissue that insulates anterior abdomen
  from trauma and temperature extremes
Peritoneal Cavity
 Also called the “true” abdominal cavity
 Quadrants
     Upper - right, left
     Lower - right, left
 Contents - liver, spleen, stomach, small
  intestine, colon, gallbladder, female reproductive
  organs
Pelvic Cavity
 Surrounded by the pelvic bones
 Lower part of retroperitoneal space
 Contents:
     Rectum
     Bladder
     Urethra
     Iliac vessels
     In women, internal genitalia
Retroperitoneal Space
 Potential space behind the “true” abdominal cavity
 Contents:
     Abdominal aorta
     Inferior vena cava
     Most of duodenum
     Pancreas
     Kidneys
     Ureters
     Ascending and descending colon
Abdominal Trauma
 Penetrating
 Blunt
 Evisceration
   Mechanisms of Abdominal
   Injury
 Blunt trauma
     Compression or crushing forces
     Shearing forces
     Deceleration forces
 Degree of injury is usually related to:
     Quantity and duration of force applied
     Type of abdominal structure injured (fluid filled, gas
     filled, solid, hollow
Blunt Trauma
 Solid organ injury
     Contusions, lacerations, fractures of solid organs
     Rapid hemorrhage, exsanguination possible
 Hollow organ injury
     Rupture of hollow organs with spilling of contents
     and bleeding
     Severe infection (peritonitis) possible
Blunt Trauma
 Other blunt trauma-related injuries
     Tearing of blood vessels
     Tearing of liver at ligamentum teres
     Bladder, colon, or rectum rupture
Peritonitis – Signs & Symptoms
 Pain (subjective symptom from patient)
 Tenderness (objective sign with
  percussion/palpation)
 Guarding/ rigidity
 Distention (late finding)
 Abrasions
Peritonitis – Signs & Symptoms
 Ecchymosis
 Visible wounds
 Mechanism of injury
 Unexplained shock
Penetrating Trauma
 Liver, kidneys, spleen susceptible to cavitation
  injury
 Path of projectile cannot be determined by
  entrance/ exit wounds
 O2, IV- large bore x 2 NS/LR, CM
 Stabilize any protruding object
In most cases, an impaled object
should be left in place and stabilized.
Blunt Trauma
 Solid organs
    compression, swelling, hemorrhage, failure
    fracture, peritoneal envelope may contain
  bleeding, may eventually rupture
 Hollow organs
    compression, rupture, spill contents
 O2, IV- large bore x 2 NS/LR, CM
Solid & Hollow Organs
 Solid Organs         • Hollow Organs
    Liver                –   Stomach
    Spleen               –   Intestines
    Pancreas             –   Gallbladder
    Kidneys              –   Urinary bladder
    Adrenals             –   Uterus (female)
    Ovaries (female)
Stomach
 Not commonly injured after blunt trauma because
  of its protected location in abdomen
 Penetrating trauma may cause gastric transection
  or laceration
 Patients exhibit signs of peritonitis rapidly from
  leakage of gastric contents
 Diagnosis confirmed during surgery unless
  nasogastric drainage returns blood
 Colon and Small Intestine
 Injury is usually the result of penetrating trauma
 Large and small intestine may also be injured by
  compression forces
     High-speed motor vehicle crashes
     Deceleration injuries associated with wearing personal
     restraints
 Bacterial contamination common problem with
  these injuries
  Vascular Structure Injury
 Intraabdominal arterial and venous injuries may be
  life-threatening
 Injury usually occurs from penetrating trauma
 May also occur from compression or deceleration
  forces applied to abdomen
 Usually presents as hypovolemia
 Occasionally associated with a palpable abdominal
  mass
Vascular Structure Injury
 Major vessels most frequently injured:
     Aorta
     Inferior vena cava
     Renal, mesenteric, and iliac arteries and veins
Hepatic Trauma
 Second most common injury site
 Consider with Fx R lower ribs
 RUQ pain
 Rebound tenderness
 Decreased/ absent bowel sounds
 Sx hypovolemic shock
 Avulsion of vessels
Liver
 Largest organ in the abdominal cavity
 Located in the right upper quadrant of abdomen
 Commonly injured from trauma to the:
     Eighth through twelfth ribs on right side of body
     Upper central part of abdomen
Liver
 Suspect liver injury in any patient with:
     Steering wheel injury
     Lap belt injury
     History of epigastric trauma
 After injury, blood and bile escape into peritoneal
  cavity
     Produces signs and symptoms of shock and
     peritoneal irritation, respectively
Fractured Liver
Splenic Trauma
 Most common
 Consider with L lower rib Fx
 LUQ pain radiating to shoulder (Kehr’s sign)
 Sx hypovolemic shock
 Avulsion of vessels
Spleen
 Lies in upper left quadrant of abdomen
 Rich blood supply
 Slightly protected by organs surrounding it
  medially and anteriorly and by lower portion of
  rib cage
     Most commonly injured organ from blunt trauma
     Associated intraabdominal injuries common
  Spleen
 Suspect splenic injury in:
      Motor vehicle crashes
      Falls or sport injuries in which there was an impact to
     lower left chest, flank, or upper left abdomen
 Kehr’s sign
     Left upper quadrant pain with radiation to left shoulder
     Common complaint associated with splenic injury
Retroperitoneal Organ Injury
 May occur because of blunt or penetrating
  trauma to the:
     Anterior abdomen
     Posterior abdomen (particularly the flank area) or
     Thoracic spine
Renal Trauma
 May lead to free hemorrhage, contained
  hematoma, or develpoment of an intravascular
  thrombus
 Sudden deceleration injury
 Lower rib Fx raise suspicion
 Hematuria, flank pain, flank ecchymosis
 Retroperitoneal bleeding difficult to detect
 Avulsion of vessels
Kidneys
 Located high on posterior wall of abdominal
  cavity in retroperitoneal space
     Held in place by renal fascia
     Cushioned by a generous layer of adipose tissue
     Partially enclosed and protected by lower rib cage
Kidneys
 Injuries may involve fracture and laceration
     Resulting in hemorrhage, urine extravasation, or
     both
 Contusions usually are self-limiting
     Heal with bed rest and forced fluids
 Fractures and lacerations may require surgical
  repair
Ureters
 Hollow organs
 Rarely injured in blunt trauma because of their
  flexible structure
 Injury usually occurs from penetrating abdominal
  or flank wounds (stab wounds, firearm injuries)
Pancreas
 Solid organ that lies in the peritoneal space
 Blunt injury usually occurs from a crushing injury
  of the pancreas between the spine and a
  steering wheel, handlebar, or blunt weapon
 Most pancreatic injuries are due to penetrating
  trauma
Duodenum
 Lies across the lumbar spine
 Seldom injured due to its location in the
  retroperitoneal area, near pancreas
 May be crushed or lacerated when great force of
  blunt trauma or penetrating injury occurs
     Usually associated with concurrent pancreatic
     trauma
Bladder Trauma
 Lacerated or ruptured
 Associated with pelvic Fx
 Hematuria/ absence of urine
Urinary Bladder
 Hollow organ
 May be ruptured by blunt or penetrating trauma
  or pelvic fracture
      Rupture more likely if bladder is distended at time of
     injury
 Suspect bladder injury in inebriated patients
  subjected to lower abdominal trauma
Evisceration
 Rupture or laceration of abdominal wall
 Abdominal contents escape from abdominal
  cavity
 Small bowel most common
 Obstruct wound but may result in compromised
  blood flow
 Expose organs to drying and contamination
Evisceration caused by a knife
wound.
rectal eviceration
Management
 O2, IV x 2 large bore NS/LR, CM
 Wet sterile dressing
 Occlusive dressing
Pelvic Organ Injury
 Usually results from motor vehicle crashes that
  produce pelvic fractures
 Less frequent causes:
     Penetrating trauma
     Straddle-type injuries from falls
     Pedestrian accidents
     Some sexual acts
Genitalia Injury
 Female
    Common cause-child molestation/rape
    May present with severe internal/external bleeding
    due to tearing from object forced into vagina
 Male
    Injuries more frequent than in females
    Laceration may cause large blood loss
    Blunt trauma may cause hematoma
 Pelvic Fractures
 Disruption of the pelvis may occur from:
     Motorcycle crashes
     Pedestrian-vehicle collisions
     Direct crushing injury to the pelvis
     Falls from heights greater than 12 feet
 Blunt or penetrating injury may result in:
     Fracture
     Severe hemorrhage
     Associated injury to urinary bladder and urethra
Pelvic Fx
 Complex Fx associated with high mortality
 Secondary hemorrhage
 Sepsis
 Significant force required
 Associated intraabdominal/ bladder injury
 O2, IV x 2 large bore NS/LR, CM, PASG
Pelvic Fractures
 Suspicion of pelvic injury should be based on:
     Mechanism of injury
     Presence of tenderness on palpation of iliac crests
 Force may be direct or indirect
Conclusion
 Body cavity trauma may be life threatening
 Tx must be aggressive
 Transport must be rapid
 Must be able to differentiate life threatening
  injuries and Tx appropriately

				
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