1.Chest Injuries First Aid and Treatment Options Anas Bahnassi PhD 5

2. Anas Bahnassi PhD CDM CDE 2 3. External trauma to the chest: Blunt Penetrating Possible damage to underlying organs: Heart Lungs Possible spinal injury. Chest injuries are responsible for 25% of trauma related deaths. Introduction 4. Tri-modal peak of Mortality 1st peak: Non- survivable severe CNS or CVS injuries Location of death: Pre- hospital environment 2nd peak: First few hours after injury, most often due to hypoxia and hypovolemic shock Usually can be saved 3rd peak: Within 6 weeks of injury Cause: Multisystem failure and sepsis 5. The Golden Hour Treat the greatest threat to life first Treat despite lack of a definitive diagnosis Treat despite complete history 6. The Golden Hour A = Airway with c-spine protection B = Breathing C = Circulation, stop the bleeding D = Disability/Neurological status E = Exposure and Environment 7. Three Stage Approach 1. Primary Survey: ABCDE sequential yet actually simultaneous includes resuscitation efforts normalization of vital signs 2. Secondary Survey: AMPLE history head-to-toe and x-rays 3. Definitive Care: Specialist treatment of identified injuries 8. Primary Assessment ABCDE Injury Resuscitation Re-evaluation Secondary Survey Head-to-toe + X-Ray Re-evaluation Transfer Definitive Care 9. Initial Assessment Starting with the ABCDE A.Airway B.Breathing C.Circulation D.Disability E.Exposure and Environment 10. Airway: Preventable Deaths Failure to recognize need Inability to establish Incorrectly placed airway Displacement Failure to ventilate Aspiration 11. Airway: Problem Recognition Objective Signs Airway Obstruction: agitation, cyanosis = hypoxia obtundation = hypercarbia abnormal sounds tracheal location external trauma 12. Airway: Problem Recognition Altered Levels of Consciousness closed head injury intoxication Maxillofacial Trauma hemorrhage dislodged teeth mandible fracture 13. Airway: Problem Recognition Penetrating Neck Trauma laceration of trachea hemorrhage with tracheal deviation/ obstruction patient may initially maintain airway prophylactic intubation? 14. Airway: Problem Recognition Blunt Neck Trauma hemorrhage with tracheal deviation/ obstruction disruption of the larynx hoarseness subcutaneous emphysema palpable fracture prophylactic intubation? 15. Airway: Management Always Assume This. So Do This. C-Spine Stabilization 16. Airway: Management Airway Maintenance Techniques: chin lift jaw thrust oral airway nasal trumpet Definitive Airway: orotracheal or nasotracheal intubation surgical airway 17. Airway: Cricothyroidotomy Vertical skin incision make it longer than you think you need. 18. Circulation: Preventable Deaths Address: Immediately Life-Threatening Chest Injuries: Tension Pneumothorax Open Pneumothorax (sucking chest wound) Flail Chest Disruption of Tracheo-Brochial tree Potentially Life-Threatening Chest Injuries: Pulmonary contusion Diaphragmatic rupture esophageal rupture 19. Check: 1. Vital signs 2. ECG 3. Pulse oximetry 4. End-Tidal Carbon Dioxide 5. Arterial Blood Gas 6. Urinary output 7. Urethral Catheterization 8. Nasogastric tube 9. Chest X-Ray 10.Pelvic X-Ray 20. Breathing: Problem Recognition Look Listen Feel Assess: Look Respiratory rate Shallow, gasping or labored breathing: Respiratory failure? Cyanosis: Hypoxia Paradoxical Respiration: Pendulum breathing with asynchronisation of chest and abdomen: Respiratory failure or Structural damage. Unequal chest inflation: Pneumothorax or Flail chest Bruising or contusion: Seat-Belt sign. Penetrating chest injury Distended neck veins: venous return-Tension pneumothorax or cardiac tamponade 21. Breathing: Problem Recognition Look Listen Feel Assess: LISTEN Absent breath sounds: Apnoea or tension pneumothorax Noisy breathing/ Crepitations/ Stridor/ Wheeze: Partially obstructed airway Reduced air entry: Pneumothorax, Haemothorax, Heamo-pnemothorax, flail chest 22. Breathing: Problem Recognition Look Listen Feel Assess: FEEL Tracheal deviation: Mediastinal shift Tenderness: Chest wall contusion and/ rib fracture Crepitus / Instabilty: Underlying rib fracture Surgical emphysema: Bubble-wrap sign 23. Breathing: Management The patients hemodynamic status dictates imaging and management. Chest tube, chest tube, chest tube Occlusive dressing Ventilatory support Thoracotomy? 24. Indications for thoracotomy 1. Internal cardiac massage 2. Control of haemorrhage from injury to the heart 3. Control of haemorrhage from injury to the lungs/intrapleural haemorrhage 4. Cardiac tamponade 5. Ruptured oesophagus 6. Aortic transection 7. Control of massive air leak 8. Traumatic diaphragmatic tear 25. Circulation: Preventable Deaths Hypotension = Hemorrhage Assess: level of consciousness pulse / skin color Address: external bleeding massive hemothorax cardiac tamponade massive hemoperitoneum unstable pelvic fracture 26. Circulation: Classes of Shock 27. Circulation: Classes of Shock Example: 1 year old falls off the stairway (10 kg) lost cup of blood blood volume = 70cc/kg x 10kg EBL = cup=6 oz=180cc 180cc / 700cc = 25%blood loss Class II/III shock 28. Circulation: Causes of Shock Hypovolemic = Hemorrhage: 5 spaces = chest, abdomen, pelvis, long-bones, street Fractures: rib = 100-200 cc tibia = 300-500 cc femur = 800-1200 cc pelvis = 1500 and up 29. Circulation: Causes of Shock Neurogenic: spinal cord injury Septic Cardiogenic: tension Pnemothorax cardiac tamponade or contusion air embolism primary cardiac disease 30. 30 Fractured Ribs: Problem Recognition Pain at site which increases with movement or touch Pain at site when breathing in Difficulty breathing, Rapid shallow breathing Rapid pulse Bruising Deformity Bloody sputum Guarding of the injury 31. Fractured Ribs: Management Primary survey - ABCDE Position of comfort (often sitting position with the injured side downwards). Stabilize the fracture site - Put the arm on the injured side in a collar and cuff or a sling. Seek medical aid Provide supplemental oxygen if available Observe for respiratory compromise 31 32. Fractured Ribs: Management Reduction of pain with 2 week follow up Analgesics : Opiods NSAIDs Intercostal Blocks Strapping of chest: relieves pain by immobilizing the ribs Breathing exercises 33. Pneumothorax (collapsed lung) Air enters the between the lungs and the inside of the chest wall (pleural space). The air takes up space, causing a section of the lung to collapse. If air continues to enter - tension pneumothorax. 33 34. 34 Pneumothorax: Problem Recognition Severe chest pain Breathing distress (Rapid, shallow breathing) Rapid pulse Bluish skin color (cyanosis) Possible altered conscious state Possible deviated windpipe (trachea) Distended neck veins 35. 35 Pneumothorax: Management Seek immediate medical aid, Primary Survey Oxygen provision Resuscitation if required 36. 36 Flail Segment When ribs and/or the breastbone are fractured in a number of places and result in a free-floating section of bone. 37. 37 Flail Segment: Problem Recognition As for fractured rib but more severe Paradoxical breathing Mediastinal Flutter Pendular Movement of air Associated injuries: Pulmonary Contusion! Hypoventilation 38. Flail Segment: Management Primary Survey Urgent medical assistance Position of comfort. (This is often a sitting position with the injured side downwards). Stabilize the fracture site as for a fractured rib Provide supplemental oxygen 38 39. Open Chest Wound: Problem Recognition Open wound to chest Severe breathing difficulty Rapid pulse Sound of air being sucked in through wound 39 40. Open Chest Wound: Management Urgent medical assistance Position the victim in a sitting position with the injured side downwards Cover the wound site with some air tight material (e.g. polythene). This dressing needs to be taped on three sides with the bottom edge left free. This will stop air being sucked in but will allow trapped air to escape Provide supplemental oxygen if able Continuously monitor and reassure the victim If the victim becomes unconscious, conduct a Primary Survey and take appropriate action 40 41. Clinical Pharmacy VI: First Aid abahnassi@gmail.com http://www.twitter.com/abpharm http://www.facebook.com/pharmaprof http://www.linkedin.com/in/abahnassi Anas Bahnassi PhD CDM CDE