trauma

initial management consists of

• 02 therapy

• endotracheal tubes and nasogastric

• placement of intercostal cathete (ICC, UWSD)

• placement of IV lines

• insertion of urinary cathetar

fractured ribs

• mechanisms

  • falls

  • road accidents

  • sports

  • pathological

• associated with other injuries

  • ribs 1-3

    • major vessel injury

    • rupture of aorta, trachea, bronchi

    • brachial plexus injury

    • phrenic nerve injury

  • ribs 4-8

    • most common rbs fractured

    • flail segement common with paradoxical movement

    • pulmonary contusion

  • 9-12

    • intrabdominal injuries

    • liver, spleen

    • kidney

    • diaphragm

• what is a flail chest

  a “floating” segment of chest wall due to two (or more) fractures in two or more consecutive ribs

  • severe pulmonary contusion

  • impaired respiratory mechanics and pump function

  • hypoxia with hypercapnia

• what is paradoxical chest wall movement due to a flail chest

  the chest wall flail segment is ‘sucked in’ during inspiration and blown out’ on expiration due to the disruption of cartilaginous/ligament rib attachments

• physiological effects of a flail segment

  • atelectasis

  • retained secretions

  • respiratory failure

• sternal fracture

  • typically managed conservatively

  • check troponins - to see if there is heart damage

  • commonly associated with a pericardial contusion

• what is pulmonary contusion

  an injury to the lung parenchyma in the absence of laceration to lung tissue or any vascular structures

  • interstitial haemorrhage and alveolar oedema leads to impaired gas exchange

• management

  • identification and risk stratification

  • mdt involvement

  • respiratory support

  • physio care - respiratory care, early mobilisation, restoring function and D/c planning

• STUMBL score in clinical practice

  • gives info on the management and d/c planning required

pneumothorax

• air in pleural space

• can be combined with blood and called a hemopneumothorax

  • clinical features of pneumothorax

    • decreased lung volumes

    • impaired gas exchange

    • shortness of breath depending on the size

    • auscultation - no breath sounds

    • chest movement decrease on that side

  • management

    • medical

      • observation

      • aspirate air

      • insertion of ICC (UWSD)

    • surgical - mainly only if failed conservative management

      • pleurectomy or pleurodesis

      • physio post-op

what is subcutaneous emphysema

air becomes trapped under the subcutaneous layer of the skin

pleural effusion

build up of fluid in the pleural space

• clinical features include

  • decreased chest movements

  • dull percussion note

  • decreased/absent breath sounds

• management

  depends on underlying cause and patient signs and symptoms

  • aspiration

  • ICC insertion

  • surgery

  • treatment for underlying cause

summary for physio Mx rib #

spinal cord injury

• effect on respiration

  • ability to breath deeply and cough forcefully is impacted

    • influenced by level of injury and completeness of SCI

  • paralysis below level of injury

  • flaccid paralysis of intercostal results in an unstable chest wall

    • paradoxical inward depression of chest wall on inspiration

  • results in ventilatory failure, long term impairment restrictive defect characterised by low lung volumes due to loss of respiratory muscle strength

• assessment of neurological level and completeness through the

  • ASIA scale

    • scaled from A-E gradings

• lung volumes

  • correlated with lesion level

  • often see reduction in vital capacity

  • TLC and FRC are also reduced

• positioning

  • position changes the respiratory function

  • differently, reduced FVC in upright position because of the length-tension relationship with the abdominal muscles and diaphragm

• treatment techniques

  • may require intubation and mechanical ventilation

  • non-invasive ventilation (NIV) to support respiration but should not delay intubation when necessary

  • in mechanically ventilated patient, PT may

    • postural drainage

    • volume augmentation with MHI/VHI

    • suction to remove secretions

  • secretion clearance

    • manual assisted coughing

    • mechanical insufflation-exsufflation

  • maximise lung volumes

    • insufflation

    • NIV

    • breath stacking

    • glassopharyngeal breathing

  • abdominal binders

  • respiratory muscle training

  • airway Mx/ weaning from mechanical ventilation

  • tracheostomy

plastic and trauma

• implications for physio

  • consider location of injury

    • UL can often still get up and move around

    • LL flaps usually RIB for 5 days , then commence dangling

    • LL SSG - RIB for 5 days , then surgical graft check

  • look out for

    • dusky flap - means blood supply is probs failing

    • slough - also not healing well

    • frequently checking flaps and SSG

abdominal trauma considerations for physio

• monitor Hb and BP for bleeding

• check post-op orders

• consider PPC risks

• ensure pain Mx is optimal

evidence on flail chest comparing operative vs mechanical ventilation management states that…

by coughlin et al 2016

• Shorter ICU LOS

• Less NIV post extubation

• reduced incidence of a pneumonia