trauma by : consaltant surgon ezz abdul-salam
TRANSCRIPT
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TRAUMA BY : CONSALTANT SURGON EZZ ABDUL-SALAM
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CATEGORIES OF CHEST WOUNDS
• OPEN
– Tension pneumothorax
– Sucking chest wound
– Hemothorax
– Impaled object
• CLOSED
– Tension pneumothorax
– Hemothorax
– Flail chest
– Rib fractures
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TENSION PNEUMOTHORAX
• 33% of preventable combat deaths
• Injured chest or lung acts as one-way valve
• Air becomes trapped between the lung and chest wall causing the lung to collapse
• The heart is pushed to the other side causing blood vessels to kink
• Death will result if not quickly recognized and treated with needle decompression
• May occur in open and closed chest wounds
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TENSION PNEUMOTHORAX
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Tension Pneumothorax
Air collapses lung and pushes heart to other side
Blood return to heart restricted by kinked vessels, heart unable to pump
Air between lung and chest wall
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TACTICAL FIELD CARE: TENSION PNEUMOTHORAX
• Progressive severe respiratory distress in setting of unilateral penetrating chest trauma
• Do not rely on typical signs as breath sounds, tracheal shift, and hyperresonance on percussion
• Decompress immediately with 14-gauge catheter
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OTHER SIGNS AND SYMPTOMS OF TENSION PNEUMOTHORAX
• Difficulty breathing
• Chest pain
• Unilateral decreased/absent breath sounds
• Anxiety or agitation
• Increased pulse
• Tracheal deviation
• Jugular venous distention (JVD)
• Cyanosis
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TRACHEAL DEVIATION AND JVD
• The trachea is shifted away from the collapsed lung
• The jugular veins become engorged from restricted blood return to heart
• LATE SIGNS!
JVD
TrachealDeviation
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NEEDLE CHEST DECOMPRESSION
• Locate 2d intercostal space at midclavicular line
• Insert 14-gauge catheter-over-needle into chest cavity over superior edge of rib
• Listen for gush of air and observe for improvement of symptoms
• Tape catheter in place with cap or valve in place to prevent re-entry of air
• May also place Asherman chest seal over catheter
• Dress open chest wound if present
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NEEDLE CHEST DECOMPRESSION
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NEEDLE CHEST DECOMPRESSION
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NEEDLE CHEST DECOMPRESSION
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SUCKING CHEST WOUND (OPEN PNEUMOTHORAX)
• Open chest wound allows air entry into chest and escape
• Although lung is collapsed (pneumothorax), pressure is relieved by air escape and tension pneumothorax is avoided
• Tension pneumothorax may develop later
• Continually reassess the casualty for signs and symptoms of tension pneumothorax
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OPEN CHEST WOUND
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SUCKING CHEST WOUND
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SIGNS AND SYMPTOMS OF SUCKING CHEST WOUND
• Penetrating chest wound
• A “sucking” or “hissing” sound with inhaling
• Difficulty breathing
• Impaled object in chest
• Froth or bubbles around injury
• Coughing up blood or blood-tinged sputum
• Pain in chest or shoulder
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MANAGEMENT OF SUCKING CHEST WOUND
• Expose the wound
• Check for exit wound
• Seal the wounds with airtight material, covering the larger wound first
• Cover wound completely and tape down 3 sides to provide flutter-type valve for air escape
• May use Asherman chest seal
• NOTE: Treat ALL penetrating chest wounds in this manner
• Continually reassess for tension pneumothorax and shock
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SUCKING CHEST WOUND
• Upon exhaling, air in the chest escapes
through the flutter-type valve created by taping
3 sides only
• With inhaling, the patch should suck against the skin,
preventing air entry
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HEMOTHORAX
• Blood accumulation in chest cavity
• May occur slowly or rapidly depending on size of disrupted blood vessel
• May occur due to penetrating or blunt trauma
• In massive hemothorax, blood loss is complicated by low oxygen levels in blood (hypoxia)
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SIGNS AND SYMPTOMS OF HEMOTHORAX
• Usually open chest wound
• Chest pain and tightness
• Shock
• Cyanosis
• Dullness to percussion
• Coughing up frothy red blood
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TREATMENT OF HEMOTHORAX
• Cover and dress open chest wounds
• Tension pneumothorax may also be present, therefore treat with needle chest decompression if suspected
• If massive hemothorax, must be treated with IV fluids for shock
• Immediate evacuation to surgical assets
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FLAIL CHEST
• Three or more ribs fractured in two or more places or a fractured sternum
• Severe pain at site
• Rapid shallow breathing
• Paradoxical respirations (may be difficult to detect initially)
• Pneumothorax may be present
• Possible underlying contusion to lung could lead to hypoxia
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FLAIL CHEST
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PARADOXICAL RESPIRATIONS
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MANAGEMENT OF FLAIL CHEST AND FRACTURED RIBS
• Stabilize the flail segment
–Apply manual pressure
–Tape a field jacket or poncho in place
–Place casualty on injured side
• Pain control
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THE VERY YOUNG
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THE UNLUCKY
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THE VERY CARELESS
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SCOLD BURN
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CHEMICAL BURN
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ELECTRICAL BURN
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Skin
• Largest body organ
• Functions
– Protection – (infection and trauma)
– Temperature regulation –(Hypothermia)
– Water tight seal –(Hypovolemia)
– Sensory perceptio
As ethics and phsycligcal importancse.
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Depth
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Inhalational injury
• Fires
• Closed space
• Singed nasal hair
•
• Carbonaceous material in nose & mouth
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INHALATIONAL INJURY
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Extent of Burn Wounds
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Extent of Burn Wounds
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Lund and Browder Charts
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Fluid Therapy
• Objective
– HR < 110/minute
– Normal sensorium (awake, alert, oriented)
– Urine output - 0.5-1 cc/kg/hr
• Crystalloids in the first 24 hours (R/L)
Parkland
Formula
Adults
(R/L)
Children
(G½S)
1st Day %TBSA x Wt x 4%TBSA x Wt x 3
+ Maintenance
2nd Day %TBSA x Wt x 1%TBSA x Wt x 1
+ Maintenance
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Escharotomy
• Circumferential burns and the leathery eschar that can cause a decrease in chest wall expansion or circulatory compromise in the limbs
• Non-circumferential burn does not rule out Escharotomy
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Escharotomy
• Chest: To allow respiratory movement
• Limb: To restore circulation in limb with excess swelling under rigid eschar
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Limbs: Signs of Circulatory Obstruction
• Loss of distal circulation
• pallor
• coolness
• absent pulse
• loss capillary refill
• decreased oxygen saturation
• Pain on passive extension
• Deep pain at rest
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