The ABC s of Chest Trauma J Bradley Pickhardt MD, FACS Providence St Patrick Hospital What s the Problem? 2/3 of trauma patients have chest trauma Responsible for 25% of all trauma deaths Most injuries can be managed with simple maneuvers Less than 10% require definitive operative repair Immediate Priorities in Management of Chest Trauma Airway Breathing Circulation 1
Case #1 40 year old male has fallen from a scaffold, landing on a pile of wooden pallets What are your initial thoughts about possible injuries? How are you going to determine his injuries? How likely are you to miss injuries if you don t expose and palpate the patient s chest? What factors complicate chest assessment? What assessment findings would alert you that this patient is in acute distress? What Injuries are Possible? Always Look at the Back!! 2
Rib Fractures What complications might this patient suffer? How does pre-morbid status affect onset and severity of complications? What can we do to prevent these complications from occurring, or at least lessen their severity? Life Threatening Injuries Tension Pneumothorax Flail Chest w/ pulmonary contusion Open chest wounds Massive Pneumo/Hemothorax Tracheo-bronchial disruption Cardiac Tamponade Tension Pneumothorax Common with both blunt an penetrating trauma Diminished breath sounds (listen laterally) Subcutaneous emphysema Hypotension 3
Subcutaneous Emphysema Treatment Needle Thoracostomy 14 to 16 gauge needle Mid-clavicular Anterior axillary Pitfalls of Needle Thoracostomy May not decompress the tension Bleeding/lung laceration May kink Mandates that patient gets a chest tube 4
Case #2 22 year old male stabbed in left chest just lateral to the nipple BP 120/78, O2 sat 95% CXR shows 50% pneumothorax Open Chest Wounds Loss of chest wall support Direct pulmonary injury Magnitude of blood loss may be underappreciated 5
Treatment for open chest wounds Direct pressure to control bleeding Semi-occlusive dressing Chest tube Early intubation to support ventilation There is no organ in the chest or abdomen that has not been injured by a chest tube. Pitfalls of Chest Tube Placement Damage to heart/lung/vessels Intra-abdominal placement with injury to spleen and/or liver Subcutaneous placement Last hole not in the thoracic cavity Pain from the tube being in too far 6
Case #2 continued Heart rate now 130 s, BP upper 90 s Chest tube output 500cc/2 hours CXR shows some opacity over the left lung field Indications for Thoracotomy Greater than 1000-1500 cc initial output 200-250 cc bleeding over 2-4 hours Hemodynamic instability 7
Case #3 78 year old male driver of vehicle that struck a tree head on Paradoxical chest wall movement easily seen Multiple rib fractures seen on CT 8
Flail chest/pulmonary Contusion 3 or more ribs fractured in two or more places Increased mechanical work of breathing Impaired gas exchange due to underlying pulmonary contusion Brad video, scroll over and click play Treatment: Flail chest May require early intubation, mechanical ventilation Pain control for rib fractures Oxygenation will worsen over first 24 to 48 hours Rib plating External binding is not beneficial 9
What Does He Need? Intubation/ventilation support CVP/A-line Euvolemia Pain control Tracheostomy PEG DVT prophylaxis Consider transfer to higher level of care Diaphragmatic Rupture Most commonly presents on the left side Often a delay in diagnosis if ventilated Instability usually due to abdominal injury Blunt Aortic Injury Free rupture dies prior to the hospital Most alive on admission are contained hematomas Operative repair can be delayed with blood pressure control 10
Blunt Cardiac Injury (AKA Cardiac Contusion) Signs and Symptoms Chest pain and tenderness Broken Steering Column Arrhythmias Diagnosis Treatment- expectant, monitor for 24-48 hr Cardiac Tamponade Most commonly due to penetrating trauma Early signs may be subtle muffled heart tones Jugular Venous Distension hypotension Requires a high index of suspicion Case # 4 26 y/o male with GSW to R upper arm and multiple defensive stab wounds Pt had significant bleeding from GSW site. HR 81, BP 89/48, RR 20, O2 sats 92%, GCS 15 Actions? 11
What injuries are possible? Tracheobronchial Injuries Penetrating or blunt injures Often present with tension pneumothorax Persistent, massive air leak May be difficult to ventilate due to loss of tidal volume Often require several chest tubes What Next? Blood, fluids Chest tube Intubation CT if stable OR if unstable Bronch Upper endoscopy 12
Case #4 80 y/o male fell off skateboard Sustained left rib fx 4-12 Admitted at outside facility 7 days--discharged home Chest x-ray and CT done Repeat chest x-ray for 2 days then DC x-ray Discharge on day 7 Case #4 continued Bounce back to ED a few hours later following DC with difficulty breathing, extreme chest pain and fever Chest x-ray and CT; What are these going to show? 13
Trauma Center ICU He was admitted to ICU Thoracic Injury management Protocol ordered Worked up for Sepsis Pigtail drain placed by interventional radiology No epidural placed Implementation of Thoracic Injury Management Protocol July 2018 started Protocol Education to respiratory therapy, nursing, trauma advanced practice providers Inclusion is 3 or more rib fractures Thoracic Injury Management Protocol Inclusion Criteria (Extubated or recently extubated) GCS 13-15 ( 14 years of age) +Rib or Sternal fracture (Absence of high spinal cord injury) ICU and Med Surg Floors Provider On admission order: Nursing Communication order "pt on Thoracic Injury Protocol" RT evaluate and treat consult order for Thoracic Injury Protocol Document recent PIC scores in notes Pulmonary Hygiene - IS, cough & DB Q1 hour WA Minimize IVF Mobilize at least TID if not contraindicated HOB 30 degrees if not contraindicated Pain medication plan Give patient instruction at discharge RT to assess patient within an hour of consult: Measure initial IS volumes Set goal range (male 2500-3500, female 2000-3000, peds 500-2500, ex; 11 yo 1500ml) Routine clinical care: IS monitoring Q6 & PRN (RT responsible for IS at 0800, 1400, 2000, & 0200) Chart PIC score, pain & IS Q6 hour in Epic and on score board Incorporate PIC score, I/S volumes and IS goal in daily rounds **Notify RN when total PIC score 4 and /or a score of 1 point in any category after intervention Nursing Notify RT of pt admission Place PIC score board in visible place in the room Instruct pt and family on PIC scoring methods and rationale Provide pt and family PIC educational handout Routine clinical care: Proper IS method and cough & DB Q1 hour WA Educate and encourage use of splinting Elevate HOB 30 degrees if not contraindicated Mobilize at least TID if not contraindicated Incorporate PIC score, I/S volumes, and goal in daily rounds **Notify provider if total PIC score 4 and or a score of 1 point in any category after interventions 14
First PICC Score: Pain: 2 - moderate Inspiration: 3 Goal to alert volume Cough: 2 weak Total Score: 7 How will this information guide care? What if his PICC score was this: Pain: 1-severe Inspiration: 2 below alert level Cough: 2 weak Total score: 5 15
Last PICC Score done day 3 of 8 transferred to floor Pain: 3-controlled Inspiration: 4-above goal volume Cough: 2-weak Total: 9 CXR 6/25 PIC Statistics Improvements in Care Incentive spirometer consistently in patients room on day one of initiation of PIC protocol Increased patient education on need for IS, use of IS, deep breath, and cough ICU readmit d/t respiratory failure decrease Pain control improved (epidurals placed earlier in care process) PIC Statistics Improvements in Care 350 Total Patients Seen July-December 331 Trends Noticed Since Implementation of PIC Protocol 300 250 274 % OF PATIENTS RE-ADMIT TO ICU 0.0% 5.0% 10.0% 15.0% 20.0% 25.0% 9.4% 200 5.1% 150 19.3% 100 % OF PATIENTS W/ 3 OR MORE RIB FX 23.9% 50 0 2017 2018 2017 2018 16
Summary Common Mechanism of injury important Course often very prolonged Elderly and/or those with co-morbidities do poorly Knowledge of natural history essential to anticipate/prevent complications as course evolves 17