Thoracic Trauma

Question 1

What is the goal of the chest wall?

Answer 1

to prevent hypoxia through effective oxygenation/ventilation

Question 2

The chest creates ____________ intrathoracic pressure during inspiration and _____________ pressure during expiration. This is disrupted with a ______________.

Answer 2

negative, positive, PTX

Question 3

What are two examples of violation of the pleura?

Answer 3

PTX +/- HTX

Question 4

If a patient has little or no effort to breath consider
1
2
3

Answer 4

head trauma, intoxicantion, spinal cord injury

Question 5

Effort present > no air movement > consider ____________________

Answer 5

upper airway obstruction

Question 6

Decreased/poor or absent breath sounds, you want to consider thoracic trauma:
1.
2.
3.
4
5
6

Answer 6

PTX, HTX, rib fx, fail chest, diaphragm, lung parenchymal damage

Question 7

Apply _________ and _____________ when doing initial resuscitation

Answer 7

02, secure airway

Question 8

3. Are examples of what will kill your patient first.

Answer 8

1. hemorrhagic shock (acute blood loss)
2. obstructive shock (tension ptx, cardiac tamponade)
3. respiratory failure
   hypoxia > low SPO2 or PO2
   Hypercabia > pH 7.20 pCO2 55 PO2: 90 HCO3 24

Question 9

For which patients do you want to consider early ventilatory support?

Answer 9

shock state
poly trauma
comatose
massive transfusion
elderly
underlying pulmonary disease

Question 10

If a patient is intubuted/put on ventilator, they need a baseline then serial _______________

Answer 10

ABG

Question 11

When inspecting the chest, ensure to look in the ___________

Answer 11

axilla

Question 12

When inspecting the abdomen, you want to ensure to look for:
1.
2.

Answer 12

scaphoid abdomen- More of an inward cave to the abdomen, can see this with a diaphragm injury
2. abd movement during breathing may indicate chest wall damage

Question 13

_____________ is the first study to consider STAT in a patient with thoracic trauma.

Answer 13

CXR

Question 14

__________ is used to evaluate for intrabdominal trauma and can be used to evaluate for a PTX

Answer 14

FAST exam

Question 15

What is a normal finding for a fast exam?

Answer 15

a comet tail- will see white strands coming down inferior to the pleura

Question 16

Closed pneumothroax

Question 17

Open pneumothroax

Question 18

Tension pneumothorax

Question 19

When doing a needle decompression, you want to place the needle at the _________________

Answer 19

2nd intercostal space at the midclavicular line

Question 20

What is the first line treatment for a pneumothroax?

Answer 20

needle decompression followed by a chest tube

Question 21

What are the s/s of a tension pneumothroax?

Answer 21

Anxiety
Respiratory distress/arrest
Hypoxia
Decreased/Absent Breath Sounds
Distended neck veins
Crepitus
Tracheal Deviation
Tachypnea
Tachycardia
Chest pain
Hypotension
Ventilated patients– High airway pressures

Question 22

When placing a chest tube for a patient with a pneumothorax, you always want to reassess with ______________.

Answer 22

Always reassess with CXR after placement +/- daily CXR and CXR following transition to water seal

Question 23

What is the ideal placement for a chest tube?

Answer 23

4th 5th intercostal space at the midaxillary line.
Males- nipple line
Females- inframammary fold

Question 24

Pharmacotherapy considerations

Answer 24

local anesthesia, IV/PO narcotic analgesia

Question 25

Indications for a chest tube: 1. 2. 3. 4. 5.

Answer 25

1. PTX 2. HTX 3. H/PTX 4. PTX requiring intubation (PPV) 5. Air transport at risk for PTX

Question 26

Complications of a chest tube 1. 2. 3. 4. 5.

Answer 26

1. placement issues 2. bleeding 3. dislodgement 4. abdominal organ penetration 5. retained PTX/HTX

Question 27

What are the signs of someone with a simple traumatic pneumothorax? This patient will get serial CXRs, supplemental O2, and a pulse ox.

Answer 27

decreased breath sounds -hyperresonance -SOB -CP

Question 28

Occult ptx is only apparent on a ___________. You want to treat these patients supportively in cases of ______________. If symptomatic of PTX worsens on repeat CXR, place ___________.

Answer 28

CT scan. bunt trauma. chest tube

Question 29

What are the symptoms of an open ptx?

Answer 29

Many of same symptoms as closed ptx plus: “Sucking wound” Penny size wound Coughing up blood Frothy bleeding from wound Dyspnea Anxiety Cyanosis

Question 30

What is the initial treatment for an open pneumothorax? What is the definitive management?

Answer 30

Occlusive dressing on 3 sides definitive: Chest Tube ASAP Never through the wound Pain control Antibiotics Large defects may require closure/vac

Question 31

What is the presentation of a patient with a hemothroax? You want to be cautious with a ____________ HTX.

Answer 31

Present very similar to PTX Look at VS!! Dyspnea Hypoxia Decreased Breath Sounds Anxiety Chest pain Tachypnea Hypotension Respiratory compromise delayed, particularly those with rib fractures.

Question 32

How is a large hemothroax treated?

Answer 32

with a chest tube

Question 33

If a patient with a hemothorax has drained > _____________ or _______________ for 2-3 hours = _____________. Always confirm improvement with _____________ after chest tube placement.

Answer 33

>1500cc or >200cc/hr for 2-3 hour = Thoracotomy CXR

Question 34

Flail chest is _______ or more adjacent rib fractures in _________ or more places > creates _______________. This is an unstable chest that has a paradoxical motion. This causes significant morbidity usually from underlying contusion.

Answer 34

3, 2, floating segment.

Question 35

One of the most important things for pt education for anyone with a chest wall injury is _______________. It is done _______ an hour while awake. This can prevent them from getting pneumonia and oxygen.

Answer 35

incentive spirometry 10x

Question 36

In the management of flail chest, ____________ is key. This includes:

Answer 36

pain control PCA, IV narcotics, consider TOradol (if no other bleeding issues/Cr ok) rib blocks throacic epidural

Question 37

____________ is the most common thoracic injury

Answer 37

>2 rib fractures

Question 38

1-3rd rib fractures, increased risk of________________ injury/ _____________injury.

Answer 38

intrathoracic, vascular

Question 39

If ribs 10-12 are fractured, you want to consider an _____________ injury

Answer 39

intra abdominal

Question 40

In the treatment of a rib fracture, you want ____________ pain control. This includes: 1. 2. 3. 4. 5.

Answer 40

multimodal. 1. PCA, narcotics, nerve block 2. NSAIDs 3. Tylenol 4. topical lido 5. Gabapentin

Question 41

What is the imaging of choice for a sternal fracture?

Answer 41

CT scan

Question 42

Pulmonary contusion CXR will show: ________________ Diagnosis 1. 2. Management

Answer 42

CXR-irregular opacifications of the parenchyma Diagnosis CXR CT (not needed) Management: Pain Control Pulmonary toilet/Ambulation Maintain euvolemia Increased risk for ARDS/Pneumonia 02 prn watch for resp failure requiring Intubation

Question 43

Cardiac Tamponade= Becks Triad: 1. 2. 3.

Answer 43

1. neck vein distension 2. hypotension 3. muffled heart sound

Question 44

Cardiac tamponade is most common with ___________ trauma.

Answer 44

penetrating (cardiac box)

Question 45

What is the presentation of someone with a cardiac tamponade

Answer 45

Pale/Grey Skin Palpitations Tachypnea Weak pulse

Question 46

What is the gold standrd for what you want to do for initial tx for a cardiac tamponade

Answer 46

pericardiaocentesis

Question 47

_________________ is one of the main findings for a patient with a tracheobronchial injury. These types of patients will have continuous ___________. There's going to be reaccumulating ___________ or __________ despite the CT. The definitive dx is _____________.

Answer 47

Subcutaneous Emphysema air leak. pneumomediastinum or PTX bronchoscopy

Question 48

What are the s/s for esophageal perforation? What is the gold standard to dx it?

Answer 48

Blood in NG aspirate, Subq cervical air, neck hematoma, severe neck/back pain. barium swallow

Question 49

Diaphragm injury (L more common than R) can be hard to diagnose because it is not seen on __________ scan.

Answer 49

CT.

Question 50

What is the presentation of a patient with myocardial contusion?

Answer 50

Unexplained Tachycardia, New BBB, ST-T abnormal