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Page 1The normal chest wall consists of a flexible bone and cartilage enclosure that is covered in muscle on the exterior and lined in the interior by a lubricating parietal pleura rubbing against the visceral pleura covering the external surfaces of the lung. If any one of these structures fails to function properly, the lung will not inflate properly.Pathophysiology of all chest wall problems So, diseases of any part of the chest wall are all restrictive defects that will result in decreased lung volumes, decreased lung capacities, decreased compliance & atelectasis. At best, by decreasing the inspiratory capacity, these disorders will limit the ability to deep breath and cough so that the mucociliary transport is hampered and increased secretions can result. This can lead to atelectasis and even ‘static or passive pneumonia’ in dependent [or adjacent] areas. If there is a severe enough restriction to breathing, so that the actual Vt is decreased, there can be such profound limitation to alveolar ventilation that hypoxemic hypoxia and hypercapnea will result. As the alveolar ventilation decreases, there is decreased compliance as the critical volume inside each alveolus is lost. The patient will have s/s of increased WOB. Because the Vt is decreased, the patient will have to breathe rapidly and shallowly to keep the Ve up. Because the effective alveolar Vt is lost during this rapid shallow breathing, his Vd/Vt will rise higher than is considered acceptable. All of these problems: increased Vd/Vt, low compliance, respiratory acidosis and increased WOB, he may require mechanical ventilation. At worse, a few defects caused by illness or trauma will result in completely ineffective ventilation so that death from anoxia can result within a few minutes. These disorders should not have associated obstructive defects-- unless there is a secondary disease process such as COPD or asthma. Naturally, if the chest wall lesion was caused by trauma, the situation gets complex. There could be blood, vomitus or other debris in the upper or lower airways which acts as a partial or complete airway occlusion. EFFUSIONS: There is a normal amount of fluid [about 8 ml] in the pleural cavity that is secreted by the serous membranes of both pleura. This fluid creates lubrication for the moving lungs and it separates the pleura by 10-20 mm distance [the pleural space]. Normally this fluid leaks directly from the pleural walls into the pleural space and leaves the chest cavity via the lymphatic system. When there is excessive fluid in the chest cavity for what-ever reason, we call this a pleural effusion. Pleural effusions are categorized by both [1] substance of the fluid [2] cause of the creation of this excessive fluid. We further classify them by location i.e.: “pleural effusion in the posterior of the LLL.”
The types of fluid that constitutes an effusion consists of two types: 1. Transudates: this is fluid that leaked through the membranes of the cells. Transudate formation tends to be due to osmotic and hydrostatic imbalances in the chest. a. When analyzed in the lab, the transudate will have less than half the proteins than the blood serum has because proteins are large molecules that don’t cross the cell membranes easily. 2. Exudates: this fluid collects because cells ripped apart during inflammation, allowing not only fluid but a lot of proteins, RBC, WBC and other larger particles to enter the chest wall.
Pathophysiology of pleural effusion 1. When there is excessive pleural fluid in the chest, adjacent areas of the lung are compressed so atelectasis can result. The larger the effusion, the larger the potential area of atelectasis. 2. An effusion of as small as 300 ml might be seen on an x-ray 3. As the fluid is removed, the patient’s VC can improve by 1/3 the amount of the effusion. For example if we remove 1.5 liter of fluid we can expect the patient’s VC to increase by 500 ml. 4. The excessive fluid might cause dyspnea by irritation of stretch receptors & other irritant receptors. NOTE: The reason is clear. 5. Early in the course, before the fluid builds up to separate the two pleura, the inflammation [pleurisy] can cause pain on deep inspiration which will hamper deep breathing & coughing. 6. The effusion itself may or may not cause hypoxemia; rather the underlying cause of the effusion such as the pneumonia or chest trauma that triggered the collection of fluid into the chest decreases PA02.
How do effusions happen? If your patient is less than 60 years old, the most common cause of effusions is an infection or chest trauma, but once the patient gets older we need to r/o both congestive heart failure & lung cancer as possible causes of effusions in addition to these first two. 1. bleeding into the chest cavity is called a hemothorax and can be caused by [1] chest trauma [2] some disease states can cause bleeding into the chest [3] open thoracic surgery. 2. A disruption of the thoracic duct can result in an accumulation of lymphatic fluid in the chest. This is called chylothorax. a. lymphatic fluid is milky colored due to the microscopic fat present in the fluid--- unless the patient has been fasting, in which case, it is clearer, even blood-tinged 3. other effusions are the result of changes in fluid drainage in and out of the chest cavity a. in patients with pneumonia, the inflammation of the lung tissue on the surface of the lung facing the pleura will weep fluid into the cavity. If the effusion is found to be filled with pus, we call it empyema. Most empyemas tend to be filled with anaerobic bacteria that may have come from ruptured abscesses. b. Effusions can happen when malignant tumors near or inside the lymphatics interfere with lymphatic drainage. c. Effusions can happen when lung cancers cause inflammation in the tissues of the lung or pleura. d. bloody effusions without history of trauma suggests a malignancy 4. other causes of effusions are the result of change in the osmotic and hydrostatic pressures in the chest cavity a. Congestive Heart Failure [CHF] raises the blood volume in the capillary beds which raises their hydrostatic pressure to push more fluid than normal out of the serous membranes of the pleura into the chest cavity. When the fluid exceeds the ability of the lymphatics to drain them, it collects in the pleural cavity. b. pulmonary emboli, particularly ones near the surface of the lung can cause pleurisy and even effusions as vessel obstruction raises pulmonary blood pressure upstream from the emboli c. a person with nephritic syndrome or hypoalbuminemia can have decreased osmotic pressure in the blood vessels due to loss of proteins, so that fluid leaves the capillaries to collect in the chest cavity 5. Another cause of effusions is the collection of fluid in other parts of the body which are pulled into the pleural space due to the negative pressures of spontaneous breathing. a. end-stage liver disease creates extra fluid that fills the belly—called ascites. This fluid can leak into the right side of the chest through the lymphatics that go through the diaphragm b. Atelectasis creates a small area in which an effusion can develop c. RARELY, urinothorax in which a ruptured ureter leaks urine into the abdomen and then into the chest. 6. connective tissue disorders such as lupus and rheumatoid arthritis can both cause small effusions 7. Effusions can be caused by therapeutic procedures a. mal-placed central line can leak huge amounts of IV fluid into the chest wall b. peritoneal dialysis which fills up the abdomen can leak fluid into the chest cavity c. Open thoracic surgery can cause effusions, particularly if large amount of tissue are removed. This creates a space that will be filled by fluid d. many drugs have as side-effects the creation of effusions e. during treatment of profound hypotension, a massive influx of fluid into an IV to keep the blood pressure up can end up causing Congestive Heart Failure with effusions
Signs & symptoms of effusions: 1. On inspiration we many hear a pleural rub, and later as it compresses the adjacent lung we will auscultate absent BS over the area 2. On palpation, there will be decreased fremitus over the affected area 3. We note dullness to percussion 4. on an chest x-ray we will see X-Ray of effusions a. On an upright chest film, one sees a blunting of the costophrenic angle as the fluid creates a meniscus over the diaphragm. b. The fluid is seen as a homogenous opacity. c. IMPORTANT: this sign could be missed if the X-ray is done with a supine patient. Then, all one might see is a diffuse haziness d. a small effusion can be see by turning the patient on his side [lateral decubitus] to look for the gutter sign [fluid lining the dependent chest wall] 5. Rarely one might get such massive effusion—usually hemothorax from trauma that the mediastinal area is compressed enough to hamper the Cardiac Output. a. You might see Jugular Vein Distention [JVD] in this case as the blood is backing up the RV, into RA and into major veins. b. & the shift of the mediastinum away from the homogenous opacity. c. Like a tension pneumothorax, this ‘tension hydrothorax’ must be drained immediately. 6. We can find effusions on ultrasound, but CT-scan is the best way to find not only the effusion, but sometimes the cause 7. If it is unclear why an effusion has formed, a diagnostic thoracentesis is performed in which a needle is inserted into the pleural space to aspire the fluid so we can run several lab tests: a. CBC, gram stains, AFB and culture and sensitivity for bacterial growth b. Hematocrit of the effusion that is 50% higher than the serum is diagnostic of a hemothorax c. measurements of proteins to determine if the fluid is exudative or transudative d. triglyceride concentrations over 110mg/dL are seen with chylothorax e. cytology for the presence of cancer cells f. urinothorax has a low pH g. a leaking central line will produce fluid with high glucose levels Treatment of the effusion 1. If possible, we treat the cause of the effusion. a. For example: We give diuretics and cardiac drugs to the person in CHF. b. We give antibiotics to the patient with bacterial pneumonia 2. we support the patient’s s/s with supplementary 02,and with pain management 3. If the effusion is large enough to cause respiratory distress, we can do a therapeutic thoracentesis, a procedure in which we aspirate some of the effusion with a needle to relieve pressure on the lung. 4. a tension hydrothorax needs to be removed promptly by needle aspiration followed by chest tube placement 5. because rapid evacuation of large effusions will cause a suction in the chest that will shift structures, if the effusion is too big for needle aspiration, we will place a chest tube to drainage slowly over a day or so a. the chest tube for effusions will be placed in the axillary line on lower portion of the chest wall where we expect fluid to collect b. some effusions will form fibers and thicken to become loculated effusions that don’t move freely [locked in] but stay between two fissures or between one part of the lung & the pleura. 6. Moderate- large amount of blood needs to be removed because it can cause fibrothorax and because we need to be able to evaluate the rate of bleeding by measuring the blood in the chest tube. 7. a hemothorax can be treated by surgical repair of the damaged structures 8. In cases of persistent effusions such as those caused by cancer, sometimes the surface of the pleura is fused by a procedure called a pleurodesis. This can be done by surgical abrasion or by application of substances such as talc onto the pleura to create adhesions. 9. Another means of treating persistent effusions that fail to respond to pleurodesis is to implant a pump that sends the excessive fluid from the negative pressure of the chest into the positive pressure of the abdomen where the fluid can be absorbed into the gut. 10. CPT /PD are contraindicated in the face of effusions, but re-expansion by hyper-inflation may be needed. If the patient cannot get 10 ml/Kg IBW, consider IPPB, otherwise use Incentive Spirometry and cough and deep breathing. 11. unless there is a history or there are BBS that warrant it, mucolytics & bronchodilators aren’t necessary
PNEUMOTHORAX Air in the pleural space is called a pneumothorax, and its effect on the lung movement is quite similar to the restrictive defect caused by an effusion. Again like the effusion, the size of the pneumothorax controls the degree of symptoms and our clinical decisions regarding care. These air leaks can be tiny ones that take a long time to cause problems or massive tracheal or a bronchopleural fistula that create serious problems within minutes Air may enter the pleural space from outside the body such as during trauma or during thoracic surgery, or the lung tissue may rupture, or leak air from the alveoli or airway into the pleura. Because their management differs, we classify pneumothorax by etiology.
PATHOPHYSIOLOGY of the pneumothorax 1. The entry of air into the pleura will cause collapse of adjacent alveoli, so that atelectasis results 2. The presence of air between the lung surface & the parietal pleura will prevent the lung from following the chest wall out during inspiration so that the WOB increases 3. As atelectasis develops, the lung compliance drops & WOB increases. 4. The air in the chest is painful and splinting results in even more restrictive lung defect. 5. As alveoli collapse, there is a decreased V/Q and if it gets bad enough there is an increased physiological shunt.
Different types of pneumothorax 1. Small pneumothorax is one that is less than 10% of the lung. These are rarely symptomatic and the patient merely requires supplementary 02 to help wash out N2 in the chest wall & speed up re-absorption of the gas. He needs bed rest while the lesion heals in a day or so. We avoid IPPB, mechanical ventilation and CPT under these circumstances. If the patient gets worse, we have to place chest tubes prior to using PPV. It is important to understand that small pneumothorax in the face of positive airway pressure can become, at any moment, a tension pneumothorax and a life-threatening event. 2. Secondary spontaneous pneumothorax is a common problem that complicates exacerbations of patients with underlying air-trapping. It is quite common in the patient with bulbous emphysema and in the patient with Cystic Fibrosis 3. Idiopathic spontaneous pneumothorax happens to previously healthy very tall, thin males in their teens or twenties who have no history that hints at lung weakness. 90% of them did smoke. Oddly enough, these spontaneous pneumothoraces more often happen while the patient is supine rather than during exercise. a. This disorder is most likely due to the extreme differences in pressures between the upper & lower lobes of these tall persons. b. Or it might be due to a difference in the rate of pleura growth and chest wall size c. On CT-scan 80% these patients present with small subpleural blebs that weakened.
4. traumatic pneumothorax is caused by an event such as: a. blunt or penetrating chest trauma b. A medical procedure such as thoracentesis, biopsy during bronchoscopy, placement of central lines, or trachestomy that has resulted in a puncture of the lung. Any procedure that involves cutting or poking a sharp object into a patient’s neck or chest requires a chest x-ray to follow-up the procedure to look for a pneumothorax c. Barotrauma from any form of positive pressure mechanical ventilation—particularly in the person with air-trapping or a necrotic process. 5. Tension pneumothorax is caused by the addition of enough air into the chest that the thoracic cavity is no longer at a negative pressure but positive pressure so that the heart is compressed and the Cardiac Output drops. This is a life-threatening event that will result from death from anoxia within minutes if there is no chest decompression.
Rarely, during a tension pneumothorax the air moves into other structures in the chest: 1. Pneumomediastinum if air has moved from the pleura into the mediastinum, on the X-ray there will be two black columns of air on both sides of the heart. The compression on the heart might hamper CO. 2. Pneumopericardium if air has moved into the pericardium, there will be a black halo around the heart-which may be perfectly round from the pressure. Needless to say the CO is down
S/S of a spontaneous pneumothorax: 1. on inspection, one sees cyanosis, tachycardia and dyspnea 2. on interview, the patient may complain of chest pain over the area 3. on inspection, the chest may have asymmetric movement 4. On auscultation, there are absent breath sounds over the affected area 5. on palpation of the skin one might feel crepitus or ‘rice crispies’ of subcutaneous emphysema as air leaked just under the skin 6. On percussion there is hyper-resonance over the affected area
X-ray of pneumothorax: 1. hyperlucency, in which there is only black-no lung markings going all the way out to the pleura 2. sometimes you can see the line of the lung collapsing away from the hyperlucency 3. if atelectasis there will be opacities on the adjacent edge of the lung 4. The pneumothorax will push a fissure away from it or press down on a hemidiaphragm. 5. intercostal spaces may be farther apart over the area of pneumothorax 6. if tension pneumothorax, the mediastinum can shift away from the pneumothorax and the heart is obviously compromised
Treatment of the spontaneous pneumothorax 1. treat hypoxemia with supplementary 02 2. If great respiratory distress, we may need to do a needle aspiration to the affected area. 3. If the patient can wait, chest tube placement on the anterior chest into the 2nd intercostal space is required. 4. Care must be made that the dressing is airtight by placing petroleum jelly gauze over the hole. 5. once there is a chest tube present, the patient who needs it could now get IPPB 6. the chest tube stays until there is no more air leak 7. once the air leak is no longer seen in the water seal for 48 hours the chest tube can be removed 8. When the chest tube is removed, the patient is asked to cough so that the positive pressure in the thorax will push out any air around the hole. 9. A follow up chest film must be taken s/p removal of chest tubes to make sure the pneumothorax has not reappeared. 10. We observe the patient for another 4 hours for further problems. S/S of a tension pneumothorax are the same as a the others, but add: 1. s/s of tension pneumothorax is sudden profound hypoxemia & cyanosis that does not respond to increased Fi02, with marked respiratory distress 2. on inspection of the neck, one can see the trachea shift away from the pneumothorax & there could be JVD 3. On inspection of the chest you will see asymmetric chest excursion. if the pneumothorax was preceded by blunt or penetrating chest trauma there could be bruising or bleeding over the chest wall 4. On auscultation there are absent breath sounds over the affected area & the heart sounds shift away from the affected area 5. On palpation of the chest, the PMI [point of maximal impulse] of the heart shifts away from it normal position just to the left of the sternum. It moves away from the pneumothorax a. On palpation, the pulse will be weak & rapid as the heart attempts to keep the CO up. The systemic blood pressure will be down and will continue to drop. b. On palpation of the skin, the reduced CO will make the skin cool and clammy with poor capillary refill
Treatment of the tension pneumothorax This is a surgical emergency from which the patient will die in a few minutes if not addressed. It requires an emergency thoracentesis by needle aspiration followed by chest tube placement. Once the needle is in we should hear a rush of air out of the chest. We treat the patient the same as spontaneous pneumothorax patients. Also see our Chest Tubes Page Follow-up While we may not have to worry about the idiopathic spontaneous pneumothorax patient, anyone who has had more than one secondary spontaneous pneumothorax is watched more closely because these folks can have persistent pneumothorax. If recurrent pneumothorax is life-threatening we may need to cause adhesions by a pleurodesis procedure like with the persistent effusion Page 2Chest trauma & multiple trauma patients Chest trauma approximately 25% of all trauma deaths are related to the damage to the chest wall Penetrating chest trauma: are usually associated with attempted homicides, due to high-speed impact such as a bullet or low-speed penetration such as a knife. We get penetration wounds with shrapnel from explosions or flying glass fragments during Motor Vehicular Accidents [MVA]. Penetrating chest wounds can result in a sucking chest wound in which the patient’s efforts to breath will pull air into the chest wound rather than into the lungs especially if the chest wound is larger than the glottis. This results in a development of a bigger and bigger tension pneumothorax that collapses more and more lung tissue & can decrease the CO. Treatment of the sucking chest wound for the first responder is the application of an air-tight dressing on the wound that is taped on one end. On inspiration, the dressing is pulled toward the wound and during exhalation; gas can leave the chest via the wound. We create a one-way valve in the direction of the atmosphere. In the USA military, medics carry a Heimlich valve into battle for rapid decompression of a tension pneumothorax. This device can stay in the chest until the patient gets to where a chest tube can be placed. Go here for pictures of Heimlich valves & their placement: Heimlich Chest Drain Valve
If the pressure in the chest wall exceeds the atmosphere, so that we now have positive pressure in the chest, the heart movement becomes restricted and the Cardiac Output drops. We now have a tension pneumothorax which is a surgical emergency. 1. GSW: Gunshot wounds to the chest are frequently fatal for several reasons. The concussion from the bullet traveling through the chest wall causes damage, even if the bullet misses a structure 2. There are both entry and exit wounds that tear and lacerate as they go through & out the chest. 3. The bullet drags particulates such as fragments of clothing into the wound adding to the danger of infection. 4. The bullet can fragment on bone and do even more damage 5. The damage due to GSW to the chest is primarily due to bleeding and tension pneumothorax, but the bullet can penetrate the gastric tract and the diaphragm.
Blunt chest trauma: this trauma is associated with acceleration or deceleration compression associated with MVA [motor vehicle accidents,] explosions, a result of building collapses & falls from heights. Adults are more likely to have broken ribs than children because their boney rib cage is less elastic than the child’s, but the internal damage in a child’s chest may be just as bad. Blunt chest trauma can result in rib fractures, lung contusions, ruptured diaphragms, pneumothorax as well as hemothorax. Subcutaneous emphysema is air captured under the skin. By itself, subQ emphysema is not serious, but it could be associated with other more serious air-leaks 1. Rib fractures: rib fractures associated with blunt trauma might actually puncture the lung to cause an air leak [pneumothorax] or puncture a blood vessel to cause a hemothorax inside the chest wall or external bleeding. 2. Even if there is no damage to the lung, the pain associated with rib fractures can result in splinting and poor efforts at deep breathing and coughing. The patient with increased secretions associated with rib fractures is hard to manage because rib fractures are a contraindication for CPT, the ‘vest’ and other external vibratory means of secretion mobilization. 3. Lower rib fractures of the 9th -11th can damage abdominal structures resulting in massive internal bleeding and hypovolemic shock. These lower ribs can pierce kidneys, [23%] the liver [18%] the spleen [15%]. 4. It takes incredible force to break ribs 1st-2nd because they are supported by bones and tissues of the shoulders, so if these ribs are broken we worry about head and neck trauma and even a tracheal trauma. 5. Sternal injuries imply we may have cardiac contusion, or a major vessel or airway rupture as well as flail chest. 6. Multiple rib fractures are associated with hemothorax, [56%] with pneumothorax [39%] and lung contusions, ruptures [33%.] 7. Because rib fractures are rare in the small child, the presence of rib fractures is a serious indication of severe chest trauma 8. Flail chest In flail chest, there are multiple rib fractures [3 or more ribs broken in multiple spots] that results in a section of the chest wall becoming detached and moving into the chest during the negative pressure of a spontaneous breath. 9. This paradoxical movement of the chest wall prevents the thoracic volume from increasing, so that suction cannot be created to pull air from the atmosphere into the lungs. The patient must create very high negative pressures to get even a regular Vt
The rib fractures in flail chest can involve the sternum which is most commonly seen with steering wheel impacts or on the lateral rib cage. We once believed that this asymmetrical breathing resulted in pendelluft breathing--- which is the movement of gas from one part of the lung to the other instead of in and out of the lung. With recent research, it is shown that the failure of the thorax to move correctly is the true cause of poor alveolar ventilation rather than pendelluft breathing. Treatment of flail chest: If the increased WOB caused by flail chest leads to ventilatory failure & this patient is in severe pain, so he needs sedation, intubation, & ventilation might be needed. Traditionally we felt that we needed to stabilize the chest wall with positive pressure, but this has not been supported by research. It is now felt that the other chest injuries are causing the respiratory failure rather than the flail chest. See Our Chest Trauma Page
Diaphragm problems seen in blunt trauma 1. Ruptured diaphragms can happen with chest trauma. If the diaphragm’s rupture is big enough for abdominal contents to enter the chest, these structures will press on the lungs & cause them to collapse. Like a tension pneumothorax, this can press on the heart and cause decreased CO. Because most chest trauma patients have so many other problems, a high number of diaphragmatic ruptures go un-noticed. 2. Most diaphragmatic hernias start on the left side where there already is a natural opening for the Aorta and esophagus to go through the thorax into the belly. 3. Signs and symptoms dyspnea and pain. On auscultation, there could be bowel sounds in the chest with decreased breath sounds on the affected side. 4. The heart sounds [PMI] may be shifted away from the herniation. Jugular vein distension may be caused by a mediastinal shift. 5. On X-ray there will be bowel loops above the diaphragm. See Ruptured diaphragm X-rays & surgery for diaphragmatic rupture. See Late imaging of ruptured diaphragm 6. Treatment of diaphragmatic hernias: we need to intubate and ventilate with low Vt’s due to the high airway pressure and we need to get the patient to surgery. 7. The nurse needs to insert a gastric tube to deflate the stomach and intestines to minimize compression on the heart and lungs 8. The patient can be placed on the effected side so that we can deflate the bowels up in the chest to give the lung more room to move.
Abdominal compression syndrome The abdominal compartment syndrome is a potentially fatal condition resulting from pathologic elevation of intra-abdominal pressure above 25 cnH20 pressure. Normal pressure is 0-5 cmH20. This can happen with blunt trauma to the abdomen but also with perforation of the bowel from medical reasons Compartment Syndrome, Abdominal
1. As fluid accumulates inside the abdomen, the pressure rises, pressing on the kidneys causing kidney failure, compressing vessels and other structures in the abdomen and interfering with their function. 2. The increased fluid pressing on the diaphragm causes decreased lung compliance and the patient cannot ventilate. Abdominal compartment syndrome is a cause of multiple organ failure.
Multiple-trauma management based on 2005 AHA standards Part 10.7 As with any ER patient, the first step is A-B-C. Assessment of airway, breathing and circulation by inspection, palpation and auscultation is mandatory to assure that the patient does not require CPR or that the patient doesn’t have a condition that will hamper the ability to protect the airway, ventilate and have adequate CO. AIRWAY: upper airway occlusion from soft tissue swelling, blood, secretions, other debris, or altered LOC can result in death immediately. 1. We use the jaw thrust to open the airway in these patients 2. A second person stabilizes the neck & head during CPR, but we cannot ignore CPR for these considerations 3. We remove objects such as blood, secretions, vomitus and dental appliances, chewing gum or food that block the airway 4. Assess the patient by way of the Glasgow coma scale; if the score is 8 or less we may have a severe head injury.
5. Assess the patient’s face and neck for crushing wounds that can hamper the upper airway 6. Avoid nasotracheal intubation in trauma cases because there can be damage to the skull so that infections can tract up into the brain from the nasal cavities and the ET-tube 7. If the patient cannot be intubated, a cricothyrotomy is performed; later a tracheostomy can be done 8. Never forget that the ET-tube can be dislodged quite easily during transfer to hospital and within the facility. a. Assess the airway by auscultation of the BBS and by use of the exhaled C02 monitor to make sure the ET-tube hasn’t slipped into the esophagus. b. any sudden deterioration of a patient during manipulation must include a complete assessment of a patent airway—even if that assessment was done within the last few minutes.
BREATHING: While management of apnea is always obvious, we worry about damage to the chest wall or internal structures that render breathing difficult if not impossible. Neuromuscular difficulties such as damaged spinal cord or muscle groups may render such assessment tools as labored breathing, and retractions useless. If a patient cannot create the negative pressures required to breath, obviously he cannot create the negative pressures that result in retractions. 1. Bag if respiratory rate too low or too shallow to be effective 2. While mask bagging be aware that higher pressures can send air to esophagus and cause vomiting 3. Auscultate the chest and get X-rays to find structural changes from trauma that reduce the ability of the chest wall to function properly. 4. Remember that chest compressions and manual breaths administered to a damaged chest wall can cause a pneumothorax. Assess patient for pneumothorax with sudden deteriorations based on the following s/s: a. sudden increase in resistance to bagging that doesn’t respond to suctioning b. loss of chest excursion & BBS c. drop in Sp02 5. If tension pneumothorax is suspected, get a needle aspiration ASAP, which can be followed by insertion of a chest tube 6. Inspect the chest for sucking chest wounds and get an ‘exhalation port’ over the wound; follow with a chest tube 7. Assume the worse; give high levels of Fi02 until we know what is going on 8. Assume the worse; maintain spinal cord protection until we get a ‘cross-table’ x-ray assessment of the spinal cord to r/o spinal injuries. 9. Assume the worse; continue to exam the patient for other injuries to head, neck, chest & abdomen. CIRCULATION: Deterioration of the patient in a traumatic event can be the result of massive bleeding that decreases blood volume enough to decrease the CO. 1. Bleeding in the chest can hamper movement of both the lung and the heart; chest tube drainage of massive amounts of blood requires surgical intervention. 2. Support the CO by fluid resuscitation, but packed red cells and isotonic crystalloid are better. 3. Remember that getting the blood pressure up with IV fluids could just speed up the bleeding, so in urban areas where you are minutes away from a hospital, get them to surgery ASAP. In rural areas where you are farther away, try to maintain the systolic pressure at 90 mmHg, but get them to surgery ASAP. 4. the most common cardiac arrhythmias seen in trauma include: a. pulseless electrical arrest [PEA] that requires compressions, but will not be corrected until the traumatic event such as tension pneumothorax or bleeding is corrected. b. profound bradycardia or asystole both require compressions and correction of hypovolemia and/or severe hypoxemia that triggered these c. Ventricular fibrillation that requires compressions & defibrillation. Epinephrine may not be helpful in the face of severe hypovolemic event.
Other problems with the chest wall Boney deformities: deformities of the chest wall can be congenital, can be caused by disease, or be the result of chest trauma. Pectus excavatum Patients with this inherited [30-35% have family history] defect of the chest have a sunken chest that can involved several ribs and the sternum. Pectus excavatum results in a concave defect in which the lung and heart can be compressed. The compression on the lungs can deform the airways so that increased secretions are a problem. Based on a US Air Force study, it was found that these young men are 800 x more likely than normal folks to have recurrent pneumonia. Oddly, this defect results in a mild-moderate restrictive and obstructive defects that may not be apparent except during exercise. Pectus excavatum can also cause a restriction on free movement of the heart so that the stroke volume can be decreased & this patient may have sinus tachycardia as a baseline to keep his CO normal.&n |