(trauma pt 3) Chest/Thoracic trauma
Pericardial Tamponade
• Layers to recall – outside → inside: parietal pericardium → potential pericardial space → visceral pericardium (epicardium).
• Causes: infection (pericarditis, strep, viral), blunt or penetrating chest trauma, post-surgical injury, malignancy, iatrogenic (central line, pacer wires).
• Pathophysiology: fluid (blood, exudate) collects in pericardial space → intrapericardial pressure ↑ → diastolic filling ↓ → SV & CO ↓.
▪ As little as can impede venous return / CO.
▪ Up to may accumulate before pulseless electrical activity (PEA) declared.
• Classic clinical signs (Beck’s Triad – appears only of cases):
▪ Muffled or distant heart tones
▪ Jugular venous distention (JVD)
▪ Narrowing pulse pressure / hypotension.
• Additional indicators:
▪ Pulsus paradoxus = inspiratory fall in systolic BP – pulse disappears when pt inhales.
▪ Electrical alternans on 12-lead (beat-to-beat QRS height changes).
▪ Low QRS voltage, sinus tachycardia.
• Management (prehospital):
▪ Supportive – high-flow O₂, keep pt calm, rapid transport.
▪ Careful fluid bolus may transiently raise preload; avoid aggressive volumes (worsens tamponade / bleeding).
▪ Pericardiocentesis (rare in field): sub-xiphoid approach, 45° cephalad, continuous ECG lead on needle – ST elevation or PVCs = myocardium contact.
▪ Definitive = surgical pericardial window / drain.
Aortic Disruption / Transection
• Usually at aortic isthmus just distal to left subclavian; fixed by ligamentum arteriosum – deceleration tears vessel.
• MOI: high-speed MVC, fall from height, blast.
• Presentation: tearing chest/back pain, rapid hypotension, large left-side hemothorax, mediastinal widening on CXR.
• Mortality extremely high; many exsanguinate before EMS arrives.
Commotio Cordis (Cardiac Concussion)
• Sudden blunt blow to precordium during 15-30 msec vulnerable phase of ventricular repolarisation → immediate VF/VT.
• Seen in youth baseball, hockey, lacrosse, occasionally football.
• Management: instantaneous CPR & defibrillation – survival drops ≈ per minute delay.
Other Thoracic Injuries
• Tracheo-bronchial disruption: airway trauma from decel or misplaced ETT → massive air leak, subcutaneous emphysema, possible tension pneumo; definitive = surgical repair.
• Traumatic asphyxia: sudden chest compression → retrograde venous congestion → cyanotic / petechial face & upper chest, subconjunctival hemorrhage. Treat like crush injury + airway/O₂.
Hemothorax / Hemopneumothorax Scenario (case in transcript)
• Findings: small posterior stab, frothy pink sputum, RR , absent L-side breath sounds, weak rapid radials, cool/diaphoretic.
• Initial care sequence:
▪ Glove, direct pressure, occlusive dressing (three-sided if sucking chest).
▪ Rapid ABC → consider needle decompression if tension suspected (burp dressing first).
▪ Suction airway → OPA/NPA → BVM + PEEP 5–10 cmH₂O; if resistance ↑ reassess for pneumo.
▪ Large-bore IVs (≥18 G) or EJ/IO, warm fluid challenge.
▪ Monitor ETCO₂, SpO₂; keep on-scene time <.
Trauma Assessment Algorithms
• “Rapid” (unresponsive, multi-system): 60-90 sec head-to-toe, then vital signs, SAMPLE if caregivers present.
• “Focused” (isolated alert pt).
• Verbalise Plan between B & C: “Need rapid trauma, c-spine maintained, partner obtains vitals/O₂, prepare long board…”
• On trauma practical & registry exams examiners expect:
▪ Airway → Breathing → Circulation → Disability → Expose (ABCDE).
▪ Life-threatening interventions as they are found, not after survey.
▪ Package & depart ≤ min (load-and-go).
Shock Review (Exam Hot-Spot)
• Compensated vs decompensated vs irreversible; recognise by mental status, pulse pressure, skin, etc.
• Hemorrhagic shock – triad of death: acidosis, coagulopathy, hypothermia; core temp ↓ increases mortality ≈ → cover pt, turn heat on, warm fluids.
• Cardiogenic, distributive (neurogenic, septic, anaphylactic), obstructive, hypovolemic – know patho & treatment priorities.
Hemorrhage Classes (know volumes & vitals)
• Class I: <15\% blood loss ((≤750\;mL)). • Class II: ((750!–!1500\;mL)); tachycardia, narrow PP. • Class III: ((1500!–!2000\;mL)); hypotension, AMS. • Class IV: > (>(2000\;mL)); pre-terminal.
• Charts in instructor slide deck – will appear on quiz.
Blood Product Compatibility
• Whole blood / packed RBC universal donor = O- negative.
• Universal plasma donor = AB (antibodies absent).
• Universal recipient (RBC) = AB positive.
Mechanisms of Injury (MOI) Patterns
• MVC:
▪ Up-and-over (face/chest, aortic tear).
▪ Down-and-under (knees, femur, pelvis).
▪ Lateral (splenic/liver, aorta).
▪ Rear-end (whiplash/brain shear, airway).
• Motorcycle – lower extremity, degloving, head/neck.
• Pedestrian struck:
▪ Adult – bumper → legs, hood → torso, ground → head.
▪ Child (Waddell triad): femur #, chest/abd injury, head injury.
Blast Injuries
• Primary – barotrauma (TM rupture, lung blast).
• Secondary – shrapnel penetration.
• Tertiary – body displacement vs object.
• Quaternary – burns, asphyxia, tox gases.
• Quinary – biological/chemical contaminants causing hyper-inflammatory state.
Ballistics & Cavitation
• Low-velocity (<): knives, handguns – laceration/track.
• Medium (rifle), High (military) – temporary cavitation expands tissues → wider damage than bullet diameter.
• Exam buzzword: “cavitation visualised in ballistic gel”.
Pelvic Injuries
• Unstable pelvis can hide >!3\,000\;mL blood.
• Binder at greater trochanters ASAP; minimal log-rolling.
• Consider proximal tibial IO if IV access poor; Trendelenburg / external jugular tricks (stethoscope loop around neck lightly occludes jugular to distend vein).
Thoracic Needle Decompression Key Points
• Indications: penetrating trauma + hypotension + unilateral absent sounds + progressive dyspnea.
• Site: 2nd ICS mid-clavicular or 5th ICS anterior-axillary; 14 G / 3.25 in.
• “Burping” three-sided dressing first may release initial tension.
Exam-Specific Study Reminders (from instructor)
• Falls in geriatrics – fragility fractures, head bleeds, anticoagulants.
• Trauma center field triage criteria – last 2 slides of PPT.
• Impalement management – stabilise object, cut away if too long.
• Know Class I–IV hemorrhage table, MOI pictures, blast ladders.
• Practice rapid vs focused trauma sheet; memorise “verbalise plan” step.
• Expect ~ question exam; many thoracic scenario stems; mix of multiple-choice & “select-all” (intervention cards).