Trauma Guideline Manual - SUNY Upstate Medical University

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58____________ Trauma Guideline ManualUpstate Medial University Trauma Centerd) “Blue facies.”e) FAST exam shows pericardial fluid ***** IMPORTANTiii. Treatment:a) Start with IV fluid bolus.b) Pericardiocentesis, orc) Pericardial window. If positive, immediately go to OR for median sternotomyor thoracotomy depending on location of injury and anticipated findingsf. Blunt cardiac injury:i. Physiology:a) Contusion of the myocardium results in conduction defects.b) Contusion may result in reduced contractility.ii. Diagnosis:a) History of severe anterior chest trauma and abnormality in EKG.i) Unexplained tachycardia.ii) Right bundle branch block.iii) Unexplained nonspecific ST-T wave changes.iv) New Q-waves.v) New arrhythmia (atrial fib/flutter, PVC’s, multifocal PAC’s).vi) With high suspicion, obtain echocardiogram (preferably TEE).vii) Serial troponins only if trying to distinguish from myocardial infarction.b) Unexplained myocardial pump failure (rule out valve injury).iii. Treatment:a) Monitor telemetry for 24 hours in the hospital - does not have to be in ICU ifno other injury warrants it.b) Treat arrhythmias according to ACLS guidelines.c) If arrhythmia or EKG changes do not resolve then do an echocardiogramd) Treat cardiac dysfunction with inotropes. Will need PA catheter if inotropesare required.g. Ruptured diaphragm:i. Physiology: tear in diaphragm allows abdominal contents to enter the chest,resulting in respiratory distress. The process is more rapid with spontaneousventilation.ii. Diagnosis:a) Left:i) Chest X-ray shows abdominal viscera in the chest.ii) Place NG tube and see if it appears in the chest.iii) If necessary, obtain barium swallow to document the location of thestomach.b) Right:i) An abnormal “hump” in the lateral diaphragm suggests laceration andprotrusion of the liver.ii) Confirm with CT or thoracoscopy.iii) Laparoscopy does not appear to be helpful since the liver often obstructsthe view of the diaphragmatic tear, although it is worth a tryiii. Treatment:a) Consider early intubation to prevent further migration of abdominal viscerainto chest.b) Operative repair through the abdomen.c) If diagnosis is delayed (greater than two weeks), may need a thoracotomy.h. Ruptured tracheobronchial tree:
Trauma Guideline Manual______________Upstate Medical University Trauma Center59i. Physiology: massive air leak into the pleural space after tear of the bronchial tree,usually near a point of fixation.ii. Diagnosis:a) Massive pneumothorax.b) Continued massive air leak after placement of the chest tube.c) Bronchoscopic diagnosis of tear.iii. Treatment:a) If massive, can try balloon occlusion of the affected bronchus.b) To the operating room for thoracotomy and operative closure.c) Avoid high pressures on the lung in the postoperative period.i. Ruptured thoracic aorta:i. Physiology:a) Aorta ruptures at point of fixation after severe deceleration events. The pointof rupture is usually just distal to the left subclavian artery or in the ascendingarch.b) Resulting hematoma is contained by adventitia or pleura.c) 85% are dead at the scene.ii.d) One half of the survivors will die in 24 hours.Diagnosis:a) History of severe deceleration impact.b. Widened mediastinum (see Guideline for evaluation of the widenedmediastinum).iii. Treatment:a) Avoid hypertension, using beta-blocker with vasodilator if necessary.b) Consult cardiothoracic surgery and prepare for operating room.j. Ruptured esophagus:i. Physiology: chest crush or penetrating injury results in rupture of the esophagus.ii.Diagnosis:a) Air in the mediastinum.b) Sputum or intestinal contents out of the chest tube.c) Confirm with esophagoscopy or gastrografin swallow (preferred)iii. Treatment:Type of repair is determined by the nature of the injury and time interval todiagnosis.a) Simple injuries, quickly diagnosed – primary repair buttressed with pleura,intercostal muscle, or omentumb) Complex injury or delay in diagnosis – may try primary repair but shouldprotect with a proximal cervical esophagostomy and G-tube.c) In all cases, the mediastinum should be widely drained with multiple chesttubes.k. Simple pneumothorax:i. Physiology: puncture of the lung with air leak into the pleural space. The air in thespace is not under excessive pressure.ii.Diagnosis:a) Absent unilateral breath sounds.b) Subcutaneous emphysema.c) Pneumothorax on chest X-ray.iii. Treatment: A tube thoracostomy is generally needed in pneumothoraces. The sizeand timing are dictated by patient stability and potential need for mechanicalventilation. Small (
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