MS UNIT 5 PT.3

Thoracic Traumatic Injury

This refers to mechanical disruption, blunt force impact, or penetrating trauma to the chest wall, lungs, tracheobronchial tree, esophagus, heart, or great thoracic blood vessels.

Blunt Chest Trauma

Caused by kinetic energy transfer without breaching the skin integrity.

Blunt Chest Trauma

Common clinical presentations include rib fractures, flail chest, pulmonary contusion, and cardiac contusion.

Penetrating Chest Trauma

Caused by foreign objects entering the thoracic cavity, breaching the chest wall, parietal/visceral pleura, or mediastinum

Penetrating Chest Trauma

Common complications include open pneumothorax, hemothorax, tracheobronchial rupture, and cardiac tamponade

high-speed deceleration, steering wheel impacts, or lack of seatbelt restraints

Account for over 70% of blunt thoracic trauma cases, often due to ___

high-velocity or low-velocity penetrating wounds

Gunshot wounds (GSWs) and stabbings causing ___

Decreased bone density and chest wall compliance

____ increase susceptibility to multiple rib fractures, flail chest, and secondary pneumonia in elderly patients

High chest wall compliance

____ allows significant underlying pulmonary contusion without overt rib fractures in pediatric patients

primary lung cancer, chest wall tumors, or metastatic bone lesions

Patients with ____ have increased susceptibility to pathologic rib fractures or spontaneous pneumothorax secondary to tumor invasion

Intrapleural pressure

is the pressure inside the pleural space

subatmospheric (negative)

Normally, intrapleural pressure is ____

Pneumothorax or Hemothorax

In ____, air or blood enters the pleural space, collapsing the underlying lung parenchyma and abolishing normal negative pressure.

Tension Pneumothorax

in _____, air enters the pleural space during inspiration through a one-way valve effect but cannot escape during expiration.

severe hypotension and shock

In Tension Pneumothorax, air enters the pleural space during inspiration through a one-way valve effect but cannot escape during expiration. This rapidly increases intrapleural pressure, collapses the ipsilateral lung, shifts the mediastinum toward the unaffected side, compresses the vena cava, and impairs cardiac venous return, leading to ____

Pulmonary Contusion

Direct mechanical force damages pulmonary capillaries, leading to alveolar hemorrhage, edema, and microthrombi formation

intra-pulmonary right-to-left shunting, severe hypoxemia, and hypercapnia

Blood-filled alveoli remain perfused but unventilated, causing ____, ______.

Paradoxical Respiration (Flail Chest)

Occurs when three or more consecutive ribs are fractured in two or more places, creating a free-floating segment of the chest wall

negative intrapleural pressure

During inspiration, ____ pulls the unstable flail segment inward.

positive pressure

During expiration, ____ pushes the flail segment outward, severely compromising tidal volume

Airway clearance, endotracheal intubation

Airway Obstruction Intervention:

Tension Pneumothorax

Tracheal deviation, absent breath sounds, JVD, severe hypotension

Immediate needle decompression (2nd intercostal space, midclavicular line)

Tension Pneumothorax interventions:

Open Pneumothorax

"Sucking" chest wound, bubbling blood at wound site

Sterile 3-sided occlusive dressing

Open Pneumothorax intervention:

Massive Hemothorax

Dullness to percussion, absent breath sounds, hemorrhagic shock

large-bore chest tube insertion (>1500 mL initial drainage)

Massive Hemothorax intervention:

Flail Chest

Paradoxical chest wall motion, severe local pain

Analgesia, non-invasive or invasive mechanical ventilation

Flail Chest intervention:

Bedside Fast Exam (Focused Assessment with Sonography for Trauma

Rapidly identifies pericardial fluid (tamponade) and hemoperitoneum/hemothorax.

Extended FAST (eFAST)

it includes thoracic sliding to rule out pneumothorax

Upright CXR

identifies pneumothorax, hemothorax, rib/clavicular fractures, lung atelectasis, and tracheal displacement

Computed Tomography (CT Scan)

The gold standard for evaluating pulmonary contusions, subtle rib fractures, tracheobronchial tears, and aortic arch disruptions

Arterial Blood Gas (ABG) Analysis

Assesses PaO2, PaCO2, pH, lactate, and base deficit to quantify hypoxemia and respiratory acidosis

Continuous Electrocardiogram (ECG) & Cardiac Enzymes

Evaluates cardiac contusions (looking for ST segment changes, dysrhythmias, or elevated Troponin levels)

crepitus

a crackling feeling under the skin upon palpation

Mechanical ventilation with PEEP (Positive End-Expiratory Pressure)

it is initiated for flail chest or acute pulmonary contusions.

Isotonic crystalloids (e.g., Normal Saline or Lactated Ringer's)

they are are administered cautiously in pulmonary contusion

alveolar edema

avoid fluid overload in pulmonary contusion, as excess fluid worsens ____

1:1:1 ratio (PRBCs, FFP, Platelets)

Massive hemothorax requires immediate administration of blood products using a _____.

Aggressive pain management

____ is critical to prevent hypoventilation, atelectasis, and secondary pneumonia.

intravenous opioids, patient-controlled analgesia (PCA), intercostal nerve blocks, or epidural analgesia

Aggressive pain management is critical to prevent hypoventilation, atelectasis, and secondary pneumonia. Options include:

Tube Thoracostomy (Chest Tube Insertion)

Primary surgical treatment for simple/tension pneumothorax and hemothorax.

Tube Thoracostomy (Chest Tube Insertion)

The catheter is connected to a closed water-seal drainage system

Emergency Resuscitative Thoracotomy

Indicated in patients with penetrating thoracic trauma who suffer cardiac arrest in the emergency department, or when initial chest tube drainage exceeds 1,500 mL of blood immediately or 200 mL/hour for 2–4 consecutive hours.

cardiac arrest

Emergency Resuscitative Thoracotomy is indicated in patients with penetrating thoracic trauma who suffer ____in the emergency department, or when initial chest tube drainage exceeds 1,500 mL of blood immediately or 200 mL/hour for 2–4 consecutive hours.

1,500 mL; 200 mL/hour

Emergency Resuscitative Thoracotomy is indicated in patients with penetrating thoracic trauma who suffer cardiac arrest in the emergency department, or when initial chest tube drainage exceeds ____ of blood immediately or ____ for 2–4 consecutive hours.

Surgical Stabilization of Rib Fractures (SSRF)

Operative fixations using plates and screws for severe flail chest segments to reduce mechanical ventilation dependency

chest drainage unit

In Chest Drainage Management, keep the ___ lower than the patient's chest level at all times.

fluid level rises with inspiration, falls with expiration

Observe the water-seal chamber for normal tidaling:

persistent system air leak

Continuous, rapid bubbling in the water-seal chamber indicates a ____

acute phases

Mark the drainage level on the collection chamber every hour during ___.

100–200 mL/hour

Mark the drainage level on the collection chamber every hour during acute phases. Report sudden changes, such as blood drainage exceeding _____, immediately to the surgical team

1. collection chamber

2. water seal chamber

3. suction control chamber

Three-Chamber Pleural Drainage System:

worsening air leak or displaced chest tube

Outline the margins of crepitus on the patient's skin with a surgical marker to monitor for expansion, which could indicate a ____