Clin Med- Thoracic Trauma

kelseyfmeyer's version from 2015-11-30 13:44

intro+penumothorax+pulmonary contusions

Question Answer
list of some possible major injuriesPneumothorax, Pulmonary contusions, Rib fractures, Flail chest, Hemothorax, 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 and sit-- arms out, neck extended, just breathing.
what is your INITIAL approach for a thoracic trauma pt? (what should you do right away, too?)You need to give an abbreviated physical exam. you should Give O2 right away! and DONT STRESS the patient!! Sedate if needed and be quick
what are the major emergency parameters you are going to look at? (2 basic groups of things and 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 three 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 theraputic or diagnostic reasons
(was in a pic now sure how important) what are the two places you look in a T-FAST test? (4 sites!)(ultrasound which is a quick look for free fluid/gas) There is the PCS and the CTS. PCS= pericardial site, looking for if there is there free fluid in pericardial sac L and 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 and right side (2 of 4 sites)
(pic) what are two ways you might be able to tell something is a pneumothorax on rads?(1) The heart is elevatedfar off sternum, and 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 two major charateristics 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 with atmosphere
what is a closed penumothorax?air is contained within thorax
what is a tension pneumothorax?large pulmonay leak acting as a ball valve-- air accumulates continually and puts pressure on structures in chest
which type of pneumthorax 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 and other structures, including the vena cava. which causes a DEC in venous return. (it also compresses the affected side's lung, and pushes it over and compresses the opposite lung, and causes mediasteinal 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 disease
what are some signs presented with 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, cyanosis, tachypnea, orthopnea, Decreased lung sounds (dorsally)
**how will lung sounds be affected in a pneumothorax?Decreased lung sounds (dorsally)
what kinda shock can pneumothorax lead to?HYPOVOLEMIC shock (pressure dec venous return), leading to tachycardia, poor pulses, pale MM, delayed CRT
what are two big affects having a dec venous return from inc pressure in the thorax?positive intra-pleural pressure (normal is neg), reduced CO
what is the SpO2 like in pneumothorax?decreased... <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 thoracocentesis?22-18 gauge IVC or butterfly, Syringe (35-60cc), Extension tubing, 3 way stopcock, Clippers, Sterile prep
what are the landmarks you should use to do a thoracocentesis 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 and it's absence is a hint toward penumothorax
what are three indications for a chest tube in a pneumothorax?(1) If thoracocentesis 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 within 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 cause, 17% of animals post HBC, Often associated with other thoracic injuries such as rib fractures, flail chest, and Penetrating chest wounds)
what is the Most common cause of oxygenation / ventilation abnormalities in trauma patients?Pulmonary contusions
what should you NEVER do if there is a pulmonary contusion? (explain why)NEVER USE DIURETICS! they Increase capillary hydrostatic pressure, Worsen hypovolemia, Does not prevent further hemorrhage and Does not promote reabsorption of fluid
what are two things you totally want to do when youre presented with a pulmonary contusion case?SUPPLY OXYGEN!!! and practice judicious fluid therapy
what are the pros (3) and cons of POSITIVE PRESSURE VENTILATION in the treatment 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 and what does it tell you?A-a gradient = PAO2–PaO2 (A=alveolar and 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 two possible complications of a pulmonary contusion?(1) anemia (May require transfusion is severe & clinical) (2) Bacterial pneumonia (uncommon... Prophylactic antibiotics 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 pt 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 accomodate?Pleural space can accommodate up to 60ml/kg volume
If you are going to perform thoracocentesis on a hemothorax pt, what should you be cautious of?careful not to disturb clots and cause 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, and what is the exception?want to avoid invasion because you want to Prevent disruption of clots and reabsorption of RBCs...however, Thoracocentesis should be performed if respiratory distress!!!
when would you want to do a Emergency thoracotomy?to ligate bleeding vessels / explore for “bleeders”
do hemothorax patients 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, and you will see a Paradoxical chest wall movement (portion moves out on expiration and 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 patient with a flail chest down, how do you position them?Place patient Flail side down!
what sign will you see on T-FAST if there is a flail chest?step sign (A line is way reduced and pushed down-- where the flail chest is )
what causes 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 with 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, dec venous return
definitive tx for repair (STABLIAZE THEN OPERATE tho)
when is mortality greatest with a hernia?Mortality greatest within 24 hours of surgery
Potential complications of a hernia include..Hemothorax, Pneumothorax, Adhesions, Reexpansion pulmonary edema, Cardiac arrhythmias, Cardiac injury, Pericardial involvement, Multiple organ failure, death
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 pentrating chest wound? (examples of things that cause P.C.Ws?)can cause Hemothorax, pneumothorax, pyothorax, contusions.....examples of wounds are Bite wounds, Gunshot wounds, Impalement
High Rise Syndrome--> what is this?Deceleration trauma, caused by Terminal velocity in cats reached @ > 7 stories
there will be vestibular dysfunction in high rise syndrome when...the body position was horizontal
when is th trauma lessened?when the Impact distributes over wide surface area
what are the most common injuries you will see in high ise syndrome?**Thorax * most common injured area (90% of feline injuries...usualy pneumothorax, contusions)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, Increased intrathoracic pressure, Shearing force, Patchy myocyte necrosis, Transmural hemorrhage
what are two common complications of cardiac contusions?Ventricular dysfunction & arrhythmia
how will a cardiac contusion appear on a ECG?ST segment elevation
SVT (Septal ventricular tachycardias) can be treated with what two types of drugs?(1) Ca++ channel blockers (Diltiazem, Verapamil) (2) B- blockers (SVT- Ca and V! <--rhymes)
Ventricular arrhythmias are usually treated with what drugs?Class 1a, 1b anti-arrhythmics (Vaughn-Williams) (Lidocaine, procainamide) (ventricular arrythmia needs you to just numb that vent down)