Clin Med - Thoracic Trauma

drraythe's version from 2016-03-15 12:43

Intro + Pneumothorax + Pulmonary Contusions

Question Answer
List of some possible major injuriesPneumothorax
Pulmonary contusions
Rib fractures
Flail chest
Chest wall trauma
Penetrating wounds
Tracheobronchial injury
High-rise syndrome
Diaphragmatic hernias
Cardiac contusions
What should be noted about possible presentations of thoracic trauma?COULD present NORMALLY
What’s orthopnea?Dont wanna lay down & sit - arms out, neck extended, just breathing
What is your INITIAL approach for a thoracic trauma PTx? (What should you do right away, too?)You need to give an abbreviated physical exam. You should Give O2 right away! & DONT STRESS the PTx!! Sedate if needed & be quick
What are the major emergency Parameters you are going to look at? (2 basic groups of things & what they tell you)(1) SpO2 to check oxygenation
(2) Blood gas / lactate to check for VENTILATION, as well as pCO2, pO2, HCO3, pH
What are 3 emergency Parameters you can perform? Explain them(1) T-FAST. This is a fast ultrasound which is just to look for free fluid or free gas in the chest
(2) Radiographs - IF STABLE!
(3) Thoracocentesis - This could be either for therapeutic or diagnostic reasons
(Was in a pic now sure how important) What are the 2 places you look in a T-FAST test? (4 sites!)(Ultrasound which is a quick look for free fluid/gas) There is the PCS & the CTS. PCS = pericardial site, looking for if there is there free fluid in pericardial sac L & right side (other 2 out of 4 sites for the T-fast). The CTS is the chest tube site-dorsal widest part of lung on L & right side (2 of 4 sites)
(Pic) What are 2 ways you might be able to tell something is a Pneumothorax on rads?(1) The heart is elevated far off sternum & the sternal-pericardial ligament is visible
(2) Part of the area is just black, you dont see any vessels or bronchi or anything-so just air is there (Pneumothorax)
What are 2 major characteristics of the plural space?(1) It is a POTENTIAL space
(2) Normally there is a negative intra-thoracic pressure
Blunt chest trauma can affect the alveoli how?Alveolar rupture
What is an open Pneumothorax?Pleural space communicates directly w/ atmosphere
What is a closed Pneumothorax?Air is contained w/in thorax
What is a tension Pneumothorax?Large pulmonary leak Acting as a ball valve - Air accumulates continually & puts pressure on structures in chest
Which type of Pneumothorax is the most dangerous?Tension
(Diagram/said in class:) how can a tension Pneumothorax affect the blood?The pressure of the air is pressing against the lung & other structures, including the vena cava. which czs a ↓ in venous return. (It also compresses the affected side's lung & pushes it over & compresses the opposite lung & czs mediastinal shift too)
What are some traumatic vs pathologic reasons for a Pneumothorax?TRAUMATIC - Penetrating chest wounds, Gun shot, stab wounds, HBC (blunt force trauma)
PATHOLOGIC - Rupture of a bulla/cyst (on the surface of the lung), Parasitic migration (HW dz), Migrating FB, Advanced parenchymal dz
What are some signs presented w/ Pneumothorax, related to dyspnea?DYSPNEA!! of varying degrees. Might see orthopnea, or a change in character of respiration (such as short/rapid breathing)
How might Pneumothorax present on the PE? (Which Parameters are affected?)Pale MM
↓ lung sounds (dorsally)
**How will lung sounds be affected in a Pneumothorax?↓ lung sounds (dorsally)
What kinda shock can Pneumothorax lead to?HYPOVOLEMIC shock (pressure ↓ venous return), leading to tachycardia, poor pulses, pale MM, delayed CRT
What are 2 big effects having a ↓ venous return from ↑ pressure in the thorax?Positive intra-pleural pressure (normal is neg), reduced CO
What is the SpO2 like in Pneumothorax?↓... <94%
If there is a Pneumothorax, what should you do BEFORE RADS?THORACOCENTESIS (also provide O2, like flow by nasal)
What are some supplies youd need for a thoracentesis?22-18 gauge IVC or butterfly
Syringe (35-60cc)
Extension tubing
3 way stopcock
Sterile prep
What are the landmarks you should use to do a thoracentesis in a Pneumothorax?Middle or caudal border @ 7-9th IC space (ventral portion dorsal 3rd)
*What's a glide sign, when do you see it, what does it tell you about?See during a TFAST (ultrasound). The glide sign is NORMAL & it's absence is a hint toward Pneumothorax
What are 3 indications for a chest tube in a Pneumothorax?(1) If thoracentesis is needed > 2 x’s
(2) If you fail to reach a point of negative pressure
(3) If large volumes are obtained each time
If you need to put in a chest tube, how long should it take for the leak to seal? If it doesnt, what must you do?LEAK SHOULD SEAL w/in 48 hours…..if not exploratory thoracotomy
What is the MOST common type of injury 2’ to blunt trauma? (Examples of traumas?)PULMONARY Contusion!!! (falls, Penetrating chest trauma also a cz, 17% of animals post HBC, Often associated w/ other thoracic injuries such as rib fractures, flail chest & Penetrating chest wounds)
What is the Most common cz of oxygenation / ventilation abnormalities in trauma PTx?Pulmonary contusions
What should you NEVER do if there is a pulmonary contusion? (Explain why)NEVER USE DIURETICS! They ↑ capillary hydrostatic pressure, Worsen hypovolemia, Does not prevent further hemorrhage & Does not promote reabsorption of fluid
What are 2 things you totally want to do when youre presented w/ a pulmonary contusion case?SUPPLY OXYGEN!!! & practice judicious fluid therapy
What are the pros (3) & cons of POSITIVE PRESSURE VENTILATION in the Tx of a pulmonary contusion?DO THIS ONLY IF NEEDED-it busy time, not curative. Helpful in:
(1) If persistently hypoxemic despite aggressive O2
(2) If work of breathing will lead to respiratory arrest
(3) If ventilation compromised
What is the A-a gradient & what does it tell you?A - a gradient = PAO2 - PaO2 (A = alveolar & a = arterial) → Tells you about diffusion of gases
What is the equation for PAO2? Explain the parts of the equationFIO2 (PB-PH2O) –PaCO2/R (Room air FIO2 = 21% or 0.21) (PB = 760 mmHg) (PH2O = 47 mmHg) (PaCO2 = obtain value from blood gas) (R = respiratory quotient = 0.8)
What is a NORMAL A-a gradient at room air?NORMAL gradient < 15 mmHg at room air
What are 2 possible complications of a pulmonary contusion?(1) Anemia (May require transfusion is severe & clinical)
(2) Bacterial pneumonia (uncommon... Prophylactic ABiopsy NOT recommended, bc of resistance)

Traumatic Hemothorax + Rib Fractures & Flail chest + Diaphragmatic hernia + Tracheo-bronchial injury + Penetrating injuries + High-rise Syndrome + Cardiac Contusions

Question Answer
Usually a Hemothorax is due to...Massive chest trauma (like Rib fractures
Flail chest
Pulmonary contusions can accompany injury
Penetrating chest wound/trauma)
What is presentation of PTx like in Hemothorax (might differ depending on...)(Differs depending on volume) If small volume – normal
If large volume – Respiratory distress, Restrictive breathing pattern
How much volume can the plural space accommodate?Pleural space can accommodate up to 60ml/kg volume
If you are going to perform thoracentesis on a Hemothorax PTx, what should you be cautious of?Careful not to disturb clots & cz more bleeding
What do radiographs look like when there is Hemothorax?Elevation of lung lobes – “floating”
Soft tissue opacity throughout pleural cavity
Obscures cardiac silhouette
Why do you want Minimal invasion of chest in a Hemothorax & what is the exception?Want to avoid invasion bc you want to Prevent disruption of clots & reabsorption of RBCs... However, Thoracentesis should be performed if respiratory distress!!!
When would you want to do an Emergency thoracotomy?To ligate bleeding vessels / explore for “bleeders”
Do Hemothorax PTx usually need a chest tube?Not usually
What is flail chest? (When does it happen, what does it look like?)Happens when there is fracture of 3 or more contiguous ribs & you will see a Paradoxical chest wall movement (portion moves out on expiration & in on inspiration)
What kinds of analgesia can you provide for broken ribs/flail chest?Local blocks – dorsal, ventral, caudal, or Parenteral – *caution respiratory depression
If you want to lay the PTx w/ a flail chest down, how do you position them?Place PTx Flail side down!
What sign will you see on T-FAST if there is a flail chest?Step sign (A line is way reduced & pushed down-where the flail chest is)
What czs hernias 85% of the time?Trauma
What is the most likely organ to herniate?Liver
Most hernias occur on which side??R SIDE (gas filled stomach protects L side)
What is the pathogenesis of a hernia? (Reason it herniates?)Sudden rise in intraabdominal pressure
If the hernia is of intestines, what is the main CS? Liver?Intestines = vomiting
Liver = Shock w/ splenic/hepatic necrosis
How might the resp system be affected by a hernia into the thoracic cavity?Might be Pleural effusion, hypoxemia
How will heart sounds be affected by a hernia?Dull heart sounds ventrally
Why can a hernia lead to shock?Caudal cava compression, ↓ venous return
Definitive Tx for hernia...Sx repair (STABLIAZE THEN OPERATE tho)
When is mortality greatest w/ a hernia?Mortality greatest w/in 24 hours of Sx
Potential complications of a hernia incld..Hemothorax
Reexpansion pulmonary edema
Cardiac arrhythmias
Cardiac injury
Pericardial involvement
Multiple organ failure
Tracheal rupture usually happens in who, why?Cats, 2° to intubation (traumatic)
What are some possible problems you might see that can arise from a tracheobronchial injury?SQ emphysema? Pneumomediastinum?
What are some things that can result from a penetrating chest wound? (Examples of things that cz P.C.Ws?)Hemothorax
Examples of wounds are:
Bite wounds
Gunshot wounds
High-rise Syndrome → what is this?Deceleration trauma, czd by Terminal velocity in cats reached @ > 7 stories
There will be vestibular dysfxn in High-rise syndrome when...The body position was horizontal
When is the trauma lessened?When the Impact distributes over wide surface area
What are the most common injuries you will see in High-rise syndrome?**Thorax is most common injured area (90% of feline injuries...usually Pneumothorax, contusions), then head / face, extremities
What is the survival rate in cats vs dogs for High-rise syndrome?Cats-90% survival. Dogs-poor prog
Cardiac contusions happen why? Examples?Deceleration force Acting on chest wall... such as:
Direct pressure myocardium
↑ intrathoracic pressure
Shearing force
Patchy myocyte necrosis
Transmural hemorrhage
What are 2 common complications of cardiac contusions?Ventricular dysfxn & arrhythmia
How will a cardiac contusion appear on an ECG?ST segment elevation
SVT (Septal ventricular tachycardias) can be treated w/ what 2 types of drugs?(1) Ca++ channel blockers (Diltiazem, Verapamil)
(2) B-blockers (SVT-Ca & V! ← rhymes)
Ventricular arrhythmias are usually treated w/ what drugs?Class 1a, 1b anti-arrhythmic (Vaughn-Williams) (Lidocaine, procainamide) (ventricular arrhythmia needs you to just numb that vent down)