Trauma Guideline Manual - SUNY Upstate Medical University

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56____________ Trauma Guideline ManualUpstate Medial University Trauma Centeri. Remember that current condition may deteriorate – intubate earlyii. If patient has a marginal airway, remember that unmonitored periods of time will bepresent – ie CT scanningiii. Intubating outside the ED or ICU is difficult, consider intubating marginal patientsprior to CT scanningb. Beware of worsening pneumothorax as pressure is applied to the airway.4. If time allows, obtain portable AP chest X-ray:a. Evaluate for possible chest injury.b. Confirm tube placement.c. In general, all transfers who have had a chest X-ray at another facility should have arepeat chest X-ray after arrival.d. Chest tubes should be placed prior to the chest X-ray if there is a hemodynamiccompromise.5. For severe anterior chest trauma, obtain an emergent EKG.6. Treat injury according to the diagnostic findings:a. Tension pneumothorax:i. Physiology: air enters the pleural space and cannot exit (“flap valve”phenomenon):a) Respiratory compromise due to increased pleural pressure.b) Hemodynamic compromise due to impaired venous return.c) Good lung is affected by mediastinal shift into its domainii.Diagnosis:a) Respiratory distress.b) Absent unilateral breath sounds.c) Asymmetric chest wall motion (hemithorax “stuck out”).d) Hypotension with distended neck veins.e) Shift of the trachea and the PMI.iii. Treatment:a) With hemodynamic compromise: needle thoracostomy followed by chest tube.b) Without hemodynamic compromise: confirm with chest X-ray and place largebore chest tube (36 Fr.).c) Obtain chest X-ray after chest tube has been placed.b. Open pneumothorax:i. Physiology:a) Open defect in chest wall allows air to enter the pleural space through thedefect rather than through the trachea.b) Mediastinum shifts as pressure gradients change across the midline.ii. Diagnosis: “sucking chest wound.”iii. Treatment:a) Intubate the patient and place on positive pressure ventilation.b) Insert large bore chest tube. Never put the tube through the wound.c) Cover the defect.d) Consider surgical closure of the defect.c. Flail chest/Pulmonary contusioni. Physiology:a) Blunt force to the chest.b) Ribs fractured in multiple places lead to unstable segment of chest wall.c) Pain!!!!!
Trauma Guideline Manual______________Upstate Medical University Trauma Center57ii.d) Pulmonary contusion in underlying area of lung with alveolar hemorrhage andedema resulting in focal compliance reduction and interference with gasexchange.Diagnosis:a) Paradoxical chest wall movement.b) Severe pain with breathing or with palpation in the affected area.c) Respiratory distress.d) Hemoptysis.e) Chest X-ray demonstrates contusion, but it may not show up for severalhours.iii. Treatment:a) Flail chest:i) Pain control: epidural, PCA, morphine drip.ii) Pulmonary toilet, monitor vital capacity.iii) Intubate for worsening compliance and respiratory distress due to theunderlying contusion or increasing pCO 2 .b) Pulmonary contusion:i) Pulmonary toilet, monitor vital capacity (patients should be able tomaintain a vital capacity of greater than 1.0 Lii)Intubate for worsening compliance, respiratory distress or hypoxemia.Maintain normovolemia, do not restrict fluids but utilize fluids judiciously.d. Massive hemothorax:i. Physiology:a) Massive bleeding into the pleural space results in hemorrhagic shock.b) After blunt trauma, source is usually bleeding from the chest wall.ii.Diagnosis:a) Hemorrhagic shock and hemothorax on chest X-ray.b) Absent breath sounds on affected side.c) Dull to percussion on affected side.iii. Treatment:a) Fluid resuscitation to correct hemorrhagic shock.b) Place large bore chest tube (36 Fr.).c) If initial drainage >1500 ml or drainage continues at >200 ml/hr (150 ml/hr forelderly patients) for more than two hours, then consider operative intervention.d) If drainage is high, may consider intubation and application of PEEP (10-20cmH 2 O) to tamponade chest wall bleeding.iv. Consider using blood salvage (autotransfuer) if available reinfusion (Note:Thisshould be done under a protocol as you may infuse activated clotting factors.Currently we do not use this at UUH. Instead we opt for the MTP as the process ismore consistent). If the patient is taken to the operating room use of a cell savershould be considered.e. Cardiac tamponade:i. Physiology:a) Traumatic injury to the atrium, ventricle, or intrapericardial vena cava results inblood loss into the pericardial sac.b) As blood accumulates in pericardial sac, then end-diastolic volume is reduced,resulting in a fall of the cardiac output.ii.Diagnosis:a) Hypotension and distended neck veins without a tension pneumothorax.b) Distant heart sounds.
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