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Emergency management of blunt chest trauma
emergency management o f b l u n t chest trauma Initial attention must be directed to clearing and sustaining the respiratory passages. The mouth and upper pharynx should be quickly cleared and examined. Endotracheal intubation is the preferred method of reducing dead space and guarding against aspiration of foreign material.
By George Podgorny, MD and W. Paul Wilcox, MD Winston-Salem, North Carolina Severe blunt trauma to the chest is one situation in which rapid and correct diagnosis within minutes of arrival can make the difference between survival and death. It is paramount that all ancillary personnel of the emergency department bring the case to the attention of the physician without delay, obtain vital signs and carefully prepare the patient for physical examination. The physician should then obtain a general but comprehensive evaluation of the patient. Initial Examination The initial examination should be a fast scan involving the senses of sight, touch, smell and hearing.
Sight: quality of respiration, paradoxical chest motion, evidence of obvious bleeding, salient disruptions of bony thoracic structure. Color of skin and mucous membranes, cyanosis. Touch: palpable disruptions of bones, crepitus, localized areas of pain on palpation, transmission of intrathoracic vibrations, position of trachea, carotid pulses. July/August 1972
Smell: odor of: placidyl, urea, etc.
alcohol,
beer,
Hearing: quality of heart and lung sounds, gurgling of fluid in upper respiratory tract, crepitance during respiration. General: mentation, coordination, gross motor function, condition of oro-pharynx, level of consciousness and presence of other serious injuries. During this e x a m i n a t i o n all studies deemed necessary should be ordered. These include: X-rays, electrocardiogram, laboratory studies, typing and cross matching of blood. If you feel that intravenous fluids or endotracheal intubation may be necessary, then this is the time to execute t h e m / These
measures are of no great harm to the patient and may avert an impending catastrophe.
Upper Respiratory Injuries A patient presenting with cyanosis, tachypnea, intercostal retractions, poor lung ventilation bilaterally and an intact thoracic cage may be ;~fering from numerous injuries, such as hemothorax, pneumothoraX, pulmonary contusion or ruptured bronchus.
When this cannot be performed, two other rapid accesses are available to the trachea. These are a cricothyroid stab or insertion of a large bore needle into the trachea. These are temporary measures and must soon be followed by a wellplanned tracheostomy, preferably performed semi-electively in the operating suite. Once the airway is established, a survey is made to determine if injury has occurred to the larynx, trachea or bronchial tree. Heavy emissions of frothy sanguinous material from the airway will require immediate surgical care since they point to parenchymal lung damage. Initial X-ray examination may reveal presence of a mediastinal shift, pneumothorax and/or hemothorax. These conditions may be diagnosed during physical exam by the palpable deviation of trachea, absence and decrease of breath sounds, or by an audible click on expiration, dullness to percussion and occasional audible splash sound when patient is forcibly shaken.
Lower Bronchial Tree Obstruction If these conditions are not present and pulmonary status has not improved, lower bronchial tree obstruction must be suspected. This can usually be cleared with vigorous, deep tracheal suction and es-
Journal of the American College of Emergency Physicians
Page 35
CHEST TRAUMA
tablishment of adequate continuous tracheal toilet. This could be accomplished utilizing a polyethelene or rubber suction catheter that has one or more openings near its tip. A well lubricated catheter is inserted through the nose and into the trachea. Its position is ascertained by listening to the transmission of breathing through the catheter or by submerging its free end under the water and observing air bubbles. The suction is applied and catheter withdrawn slowly and with a twisting motion. 1 To enter each mainstem bronchus selectively, turn the patient's face to the opposite side. A few milliliters of saline can be injected via the catheter to facilitate the toilet and enhance cough reflex. Positive pressure breathing with 60% oxygen should then be started cautiously, otherwise a sealed pulmonary leak can spring open. A flow rate of six liters per minute is adequate.
Chest Wall Injury An unstable or "flail" chest is easily noticed on first inspection. The salient feature is paradoxical motion or retraction of a chest wall segment with inspiration. If the area of instability is of moderate size and the patient stable, external stabilization of the chest wall should be attempted. This may be accomplished with sand bags, turning the patient with the flail segment splinted against the stretcher, applying external traction with towel clips or heavy wire sutures beneath the rib. Avoid the initial use of positive pressure breathing! We feel this may increase the severity of a tension pneumothorax that has eluded diagnosis. If the flail segment is unusually large, positive pressure breathing may afford the only means of adequate ventilation. Bilateral ventilation should be checked frequently as broken ribs and contusions may have caused damage to the pulmonary parenchyma. A tracheostomy will usually be needed for Page 36
adequate management of a serious flail chest.
Direct Pulmonary Injury High impact injuries may cause rupture and/or contusion of bronchi and lung parenchyma. Pneumothorax and hemothorax are perhaps the most common of these injuries. Auscultation and X-ray will reveal the presence of a collapsed and non-ventilating lung. If there is little doubt of pneumothorax, one may introduce into the pleural cavity a large bore needle with a large syringe attached. Infuse about 50 cc of sterile saline into the pleural space, wait a few seconds and aspirate. Return of air and no saline will indicate a pneumothorax. A small pneumothorax may be treated with close observation as air will eventually be absorbed from the pleural cavity. A large pneumothorax or hemopneumothorax will r e q u i r e placement of chest tubes to evacuate contents of the pleural space and expand the lung.
A patient with symptoms of cyanosis, dyspnea, unilateral hyperresonance of the chest and deviation of the trachea may have a tension pneumothorax. This requires immediate relief of the trapped air in the pleural space by thoracentesis or placement of chest tubes. A massive hemothorax represents significant tears in some area of the chest vasculature. Patients with tears in large vessels usually expire before arrival in the emergency department, but some patients will be encountered with rapid, continued drainage of blood from the chest tubes. This requires immediate surgical intervention and every effort should be made to replace the blood loss and stabilize the patient for an exploratory thoracotomy7
Remember that any patient with cyanosis, pallor, decreased mentation, and decreased pain reflex with stable blood pressure and pulse is hypoxic. The cause must be found and corrected quickly.
A charter member of ACEP, Dr. Podgorny is a thoracic surgeon and emergency physician at Forsyth Memorial Hospital in Winston-Salem, NC. His special interests include chest and abdominal trauma, pulmonary embolism and surgery of the esophagus. Dr. Podgorny is a Fellow of the International College of Surgeons.
Dr. Wilcox is a full-time emergency physician at Forsyth Memorial Hospital. His r e s e a r c h interests include sports medicine, gastric transplantation and detection of parathyroid adenomas in states of hyperparathyroidism.-
Journal of the American College of Emergency Physicians
July/August 1972
CHEST TRAUMA
In the absence of objective findings a severe pulmonary contusion should be suspected.
Injuries of the Heart and Pericardium A contusion of the heart can range from a small area of bruised myocardial tissue that requires no specific emergency therapy to rupture of the aortic base, rupture of the atria or ventricles and occasional valvular rupture. A minor cardiac contusion may be evidenced by chest pain and nonspecific S-T changes on the electrocardiogram. If the vital signs are stable, no immediate therapy is required.
Pericardial Tamponade Heart damage may be of serious degree with resultant pericardial tamponade. Look for a diagnostic triad of a rapid pulse, narrow pulse pressure and distant heart sounds. Other symptoms are elevated central venous pressure, neck vein distention and a globular heart on X-ray. The blood pressure may remain stable for some time, but drop precipitously as cardiac output is suddenly diminished.~ Immediate aspiration of the pericardial sac must then be performed to save the patient. Attach the chest lead of an electrocardiograph to a large bore needle and a 50 cc syringe. Advance the needle under the xyphoid process and aim towa.rd the apex of the left axilla until an electrical change is first noticed. Aspiration will then usually be from the pericardial sac and not the intracardiac contents. Usually blood obtained from inside of the heart will clot while that from the pericardial space will not. Frequently, no blood can be obtained from the pericardial space despite the presence of tamponade. This is due to formation of a coagulum inside the pericardium that envelops the heart and clogs the hole of the needle. Furthermore, whatever liquid component is present is dissipated throughout July/August 1972
a
b
c
Figure 1. a) Needle with wire going around the rib. b) Wire in place around the rib going to the traction, c) Towel clip in place holding a rib. the pericardial sac. Again immediate arrangements for thoracotomy are in order.
Other Conditions Diaphragmatic rupture will often allow bowel to enter the chest. This can embarrass cardio-respiratory function and bowel circulation. It usually happens on the left side because the liver mass beneath the right diaphragm blocks entrance to the chest. 4 Esophageal rupture may initially be a silent condition; but usually manifests as a widening of the mediastinum radiographically along with subcutaneous and mediastinal emphysema. Definitive diagnosis comes with evidence of extravasation of contrast media during a barium swallow. Both of these conditions will require early surgical intervention. A finding of isolated pneumomediastinum requires no specific emergency therapy. []
3. Steichen FM, et al: A graded approach to the management of penetrating wounds of the heart. Arch Surg 103:574, 1971. 4. H o o d M: T r a u m a t i c diaphragmatic hernia. Ann Thor Surgery 12:324, 1971.
For reprints of this article write Dr. Podgorny at 2115 Georgia Ave, Winston-Salem, NC 27104
EHSS
From Page 34
be conversant with the related legal, governmental and sociological problems which may arise. The total EMS system concept is becoming more of a reality every day. I believe we need the professional emergency health systems specialist to most effectively plan, develop and manage the elements of the overall system. []
BIBLIOGRAPHY BIBLIOGRAPHY 1. Naclerio EA: Chest trauma. Clinical Symporia 22:75, 1970.
1. The tools are there: Who's going to pick them up? Med World News April 16, 1971, 41-48.
2. Langlos.~.~J, et al: Traumatic rupture of th~'~thoracic aorta and of its branches. J of Cardiovascular Surgery 12:83, 1971.
For reprints of this article write Dr. Fortuna at 518 Rutgers St, Rockville, Md 20850.
Journal of the American College of Emergency Physicians
Page 37
By George Podgorny, MD and W. Paul Wilcox, MD Winston-Salem, North Carolina Severe blunt trauma to the chest is one situation in which rapid and correct diagnosis within minutes of arrival can make the difference between survival and death. It is paramount that all ancillary personnel of the emergency department bring the case to the attention of the physician without delay, obtain vital signs and carefully prepare the patient for physical examination. The physician should then obtain a general but comprehensive evaluation of the patient. Initial Examination The initial examination should be a fast scan involving the senses of sight, touch, smell and hearing.
Sight: quality of respiration, paradoxical chest motion, evidence of obvious bleeding, salient disruptions of bony thoracic structure. Color of skin and mucous membranes, cyanosis. Touch: palpable disruptions of bones, crepitus, localized areas of pain on palpation, transmission of intrathoracic vibrations, position of trachea, carotid pulses. July/August 1972
Smell: odor of: placidyl, urea, etc.
alcohol,
beer,
Hearing: quality of heart and lung sounds, gurgling of fluid in upper respiratory tract, crepitance during respiration. General: mentation, coordination, gross motor function, condition of oro-pharynx, level of consciousness and presence of other serious injuries. During this e x a m i n a t i o n all studies deemed necessary should be ordered. These include: X-rays, electrocardiogram, laboratory studies, typing and cross matching of blood. If you feel that intravenous fluids or endotracheal intubation may be necessary, then this is the time to execute t h e m / These
measures are of no great harm to the patient and may avert an impending catastrophe.
Upper Respiratory Injuries A patient presenting with cyanosis, tachypnea, intercostal retractions, poor lung ventilation bilaterally and an intact thoracic cage may be ;~fering from numerous injuries, such as hemothorax, pneumothoraX, pulmonary contusion or ruptured bronchus.
When this cannot be performed, two other rapid accesses are available to the trachea. These are a cricothyroid stab or insertion of a large bore needle into the trachea. These are temporary measures and must soon be followed by a wellplanned tracheostomy, preferably performed semi-electively in the operating suite. Once the airway is established, a survey is made to determine if injury has occurred to the larynx, trachea or bronchial tree. Heavy emissions of frothy sanguinous material from the airway will require immediate surgical care since they point to parenchymal lung damage. Initial X-ray examination may reveal presence of a mediastinal shift, pneumothorax and/or hemothorax. These conditions may be diagnosed during physical exam by the palpable deviation of trachea, absence and decrease of breath sounds, or by an audible click on expiration, dullness to percussion and occasional audible splash sound when patient is forcibly shaken.
Lower Bronchial Tree Obstruction If these conditions are not present and pulmonary status has not improved, lower bronchial tree obstruction must be suspected. This can usually be cleared with vigorous, deep tracheal suction and es-
Journal of the American College of Emergency Physicians
Page 35
CHEST TRAUMA
tablishment of adequate continuous tracheal toilet. This could be accomplished utilizing a polyethelene or rubber suction catheter that has one or more openings near its tip. A well lubricated catheter is inserted through the nose and into the trachea. Its position is ascertained by listening to the transmission of breathing through the catheter or by submerging its free end under the water and observing air bubbles. The suction is applied and catheter withdrawn slowly and with a twisting motion. 1 To enter each mainstem bronchus selectively, turn the patient's face to the opposite side. A few milliliters of saline can be injected via the catheter to facilitate the toilet and enhance cough reflex. Positive pressure breathing with 60% oxygen should then be started cautiously, otherwise a sealed pulmonary leak can spring open. A flow rate of six liters per minute is adequate.
Chest Wall Injury An unstable or "flail" chest is easily noticed on first inspection. The salient feature is paradoxical motion or retraction of a chest wall segment with inspiration. If the area of instability is of moderate size and the patient stable, external stabilization of the chest wall should be attempted. This may be accomplished with sand bags, turning the patient with the flail segment splinted against the stretcher, applying external traction with towel clips or heavy wire sutures beneath the rib. Avoid the initial use of positive pressure breathing! We feel this may increase the severity of a tension pneumothorax that has eluded diagnosis. If the flail segment is unusually large, positive pressure breathing may afford the only means of adequate ventilation. Bilateral ventilation should be checked frequently as broken ribs and contusions may have caused damage to the pulmonary parenchyma. A tracheostomy will usually be needed for Page 36
adequate management of a serious flail chest.
Direct Pulmonary Injury High impact injuries may cause rupture and/or contusion of bronchi and lung parenchyma. Pneumothorax and hemothorax are perhaps the most common of these injuries. Auscultation and X-ray will reveal the presence of a collapsed and non-ventilating lung. If there is little doubt of pneumothorax, one may introduce into the pleural cavity a large bore needle with a large syringe attached. Infuse about 50 cc of sterile saline into the pleural space, wait a few seconds and aspirate. Return of air and no saline will indicate a pneumothorax. A small pneumothorax may be treated with close observation as air will eventually be absorbed from the pleural cavity. A large pneumothorax or hemopneumothorax will r e q u i r e placement of chest tubes to evacuate contents of the pleural space and expand the lung.
A patient with symptoms of cyanosis, dyspnea, unilateral hyperresonance of the chest and deviation of the trachea may have a tension pneumothorax. This requires immediate relief of the trapped air in the pleural space by thoracentesis or placement of chest tubes. A massive hemothorax represents significant tears in some area of the chest vasculature. Patients with tears in large vessels usually expire before arrival in the emergency department, but some patients will be encountered with rapid, continued drainage of blood from the chest tubes. This requires immediate surgical intervention and every effort should be made to replace the blood loss and stabilize the patient for an exploratory thoracotomy7
Remember that any patient with cyanosis, pallor, decreased mentation, and decreased pain reflex with stable blood pressure and pulse is hypoxic. The cause must be found and corrected quickly.
A charter member of ACEP, Dr. Podgorny is a thoracic surgeon and emergency physician at Forsyth Memorial Hospital in Winston-Salem, NC. His special interests include chest and abdominal trauma, pulmonary embolism and surgery of the esophagus. Dr. Podgorny is a Fellow of the International College of Surgeons.
Dr. Wilcox is a full-time emergency physician at Forsyth Memorial Hospital. His r e s e a r c h interests include sports medicine, gastric transplantation and detection of parathyroid adenomas in states of hyperparathyroidism.-
Journal of the American College of Emergency Physicians
July/August 1972
CHEST TRAUMA
In the absence of objective findings a severe pulmonary contusion should be suspected.
Injuries of the Heart and Pericardium A contusion of the heart can range from a small area of bruised myocardial tissue that requires no specific emergency therapy to rupture of the aortic base, rupture of the atria or ventricles and occasional valvular rupture. A minor cardiac contusion may be evidenced by chest pain and nonspecific S-T changes on the electrocardiogram. If the vital signs are stable, no immediate therapy is required.
Pericardial Tamponade Heart damage may be of serious degree with resultant pericardial tamponade. Look for a diagnostic triad of a rapid pulse, narrow pulse pressure and distant heart sounds. Other symptoms are elevated central venous pressure, neck vein distention and a globular heart on X-ray. The blood pressure may remain stable for some time, but drop precipitously as cardiac output is suddenly diminished.~ Immediate aspiration of the pericardial sac must then be performed to save the patient. Attach the chest lead of an electrocardiograph to a large bore needle and a 50 cc syringe. Advance the needle under the xyphoid process and aim towa.rd the apex of the left axilla until an electrical change is first noticed. Aspiration will then usually be from the pericardial sac and not the intracardiac contents. Usually blood obtained from inside of the heart will clot while that from the pericardial space will not. Frequently, no blood can be obtained from the pericardial space despite the presence of tamponade. This is due to formation of a coagulum inside the pericardium that envelops the heart and clogs the hole of the needle. Furthermore, whatever liquid component is present is dissipated throughout July/August 1972
a
b
c
Figure 1. a) Needle with wire going around the rib. b) Wire in place around the rib going to the traction, c) Towel clip in place holding a rib. the pericardial sac. Again immediate arrangements for thoracotomy are in order.
Other Conditions Diaphragmatic rupture will often allow bowel to enter the chest. This can embarrass cardio-respiratory function and bowel circulation. It usually happens on the left side because the liver mass beneath the right diaphragm blocks entrance to the chest. 4 Esophageal rupture may initially be a silent condition; but usually manifests as a widening of the mediastinum radiographically along with subcutaneous and mediastinal emphysema. Definitive diagnosis comes with evidence of extravasation of contrast media during a barium swallow. Both of these conditions will require early surgical intervention. A finding of isolated pneumomediastinum requires no specific emergency therapy. []
3. Steichen FM, et al: A graded approach to the management of penetrating wounds of the heart. Arch Surg 103:574, 1971. 4. H o o d M: T r a u m a t i c diaphragmatic hernia. Ann Thor Surgery 12:324, 1971.
For reprints of this article write Dr. Podgorny at 2115 Georgia Ave, Winston-Salem, NC 27104
EHSS
From Page 34
be conversant with the related legal, governmental and sociological problems which may arise. The total EMS system concept is becoming more of a reality every day. I believe we need the professional emergency health systems specialist to most effectively plan, develop and manage the elements of the overall system. []
BIBLIOGRAPHY BIBLIOGRAPHY 1. Naclerio EA: Chest trauma. Clinical Symporia 22:75, 1970.
1. The tools are there: Who's going to pick them up? Med World News April 16, 1971, 41-48.
2. Langlos.~.~J, et al: Traumatic rupture of th~'~thoracic aorta and of its branches. J of Cardiovascular Surgery 12:83, 1971.
For reprints of this article write Dr. Fortuna at 518 Rutgers St, Rockville, Md 20850.
Journal of the American College of Emergency Physicians
Page 37