11/10/2015 Chest and Abdominal Trauma The Saving of the President Case Studies Produced by: Frank Kavanaugh, MD NWC EMSS November 2015 Continuing Education Susan Wood, RN Paramedic Goals for Today Before going any farther… Review of: Write down one question that still remains • Different etiologies of shock specifically how it unclear for your individual practice when relates to chest & abdominal trauma encountering trauma patients, whether related • Immediate life threats surrounding pts to chest and abdominal injury or generally sustaining chest & abdominal trauma speaking. • Identify injury based on blunt vs. penetrating trauma What is so shocking? Shock…what’s the issue? Shock is classified by its primary etiology, All forms of shock are due to failure of one or even though multiple dysfunctions often more of the 3 separate but related factors occur in response to the primary insult. necessary to maintain perfusion. Pump Volume Individuals must have: – Adequate pump Container Obstruction – Circulating blood volume (with oxygen carrying capacity) – Intact vascular container 1 11/10/2015 Pump Container Deceleration injury Blunt cardiac Ruptured injury aorta Large vessel injury Obstructive shock is commonly seen Volume in association with… Chest trauma Hemothorax Jeopardy question: What other mechanism can results in obstructive shock? Pulmonary Embolus In which part of the assessment should these injuries be found? Primary • Blunt What is the B=Breathing • Penetrating mechanism? • Compression 2 11/10/2015 What is the common complaint with Unchanging Priorities any chest injury? Airway patency Breathing/gas exchange Circulation/cardiac status Respiratory Disability – neuro life threat distress Environment/expose Avoid HYPOXIC injury Deceleration injury A deceleration injury causing a ruptured large vessel quickly leads to a volume issue Vessels running through the chest are the largest in the Before EMS body is ever on These are the pts the scene that are in arrest upon EMS arrival Pump Often in trauma pts Volume cardiac monitoring is an Hemothorax after thought which is >1500 mL blood in pleural space not acceptable practice Pleural space can hold entire blood volume SOP: ITC p. 37 Conduction deficit from Permissive hypotension contusions to maintain perfusion Blunt vs. MUST be on a cardiac Penetrating monitor 3 11/10/2015 Kine-what? Trauma: “Transference of energy from some external force to the human body which exceeds the tensile force/resiliency of the body causing a structural or physiologic alteration” (Halpern, 1989). Kinematics: Both are Relationship between speed, mass, vector direction & physical injury traumatic the study of motion exclusive of the influence of but…. mass & force Case 1: Dispatched to a 2-car MVC with head on collision (posted speed 40 MPH) Case Studies • Unrestrained driver / + steering wheel deformity • A & O X 3 but restless & agitated • C / O severe chest pain & difficulty breathing Identify life threats found in Assessment A: Patent primary assessment & treat B: RR fast; labored w/ asymmetric expansion + accessory muscle use; no paradoxical movement BS absent on L, diminished on R Patent airway No open wounds; trachea midline Respiratory distress RA SpO2 86%; EtCO2 27 Perfusion status altered; no palp radial pulse C: No radial pulse; carotids fast, weak & thready + JVD D: E=spont, V=oriented, M=to command; PERL, *Mental status remains intact abrasion to L chest 4 11/10/2015 What MOI is responsible for Blunt ~70-80% of blunt chest trauma? Direct compression Fracture of solid organs MVC Blowout of hollow organs Followed by: Deceleration forces Falls Tearing of organs and blood vessels Sports related injury Crush injury • Results from energy Blunt exchange between an WHICH IS MOST LIKELY SUSPICION object & human body BASED ON PRESENTATION? • Occurs when a body area is struck by, or strikes, an object • Higher mortality Pneumothorax – Injury often hidden; evidence of injury Tension Pneumothorax very subtle or absent Why? Classic clinical findings? What information is needed Chest pain Extreme dyspnea; ↑ WOB to confirm suspicion? Anxiety, tachypnea, hypoxia ↓ BS on affected side ↑ HR; ↓ MAP; narrowed PP Resistance to BVM ventilations + JVD (- hypovolemia) Vital Signs 5 11/10/2015 Tension pneumothorax Why? How can you tell the difference between a pneumothorax & tension pneumothorax ? (both have absent breath sounds) It starts with a simple pneumothorax Simple Pneumothorax But it doesn’t stop there… Defect in chest wall acts as Collection of air one-way valve into the pleural space through an Air is allowed to enter upon injury to the inspiration, but not escape on chest wall exhalation Many underlying Each breath further deflates etiology – the lung & collapses medical and trauma *Tension PTX is often caused by care provider over/hyperventilating* Why so much pressure? Secondary Assessment VS: BP 84/60, P 116, R 24 https://www.youtube.com/watc Head to toe h?v=i-sZzZ4TMnY After identification and treatment of life threat 6 11/10/2015 Pleural needle decompression… So, what intervention should be done after identification of a life Only 3 were done in the field this threat? last year, all with proper indication Low frequency high stress situation Let’s review PBPI stats What landmarks must you find? As intrathoracic pressure ↑, it depresses the diaphragm pushing mediastinum If left Why? toward unaffected side Chain reaction: unrecognized, Mechanical obstruction ↓ preload of blood flow to R heart what is the end results in significant ↓ stroke volume result? ↓ in preload & CO ↓ CO Cardiovascular collapse is evidenced by ↓ BP hypotension Opposite lung also affected DEATH & obstructive shock This is obstructive shock! 7 11/10/2015 What should happen after the Release pressure (tension) needle Relieve acute distress penetrates the Improve ventilations pleural space? Re-establish venous return (CO, pulses, BP) What if there is no improvement? What are the risks and complications associated with procedure? Why is the mid-axillary site discouraged? • Neighbor sees pt (50 M) lying Case 2 Diaphragm can rise to 4th or 5th ICS when on cement driveway supine Dispatched for pt is supine outside home, calls EMS an adult who • Ladder on ground outside 2 story (~20 ft.) family home; fell bushes in front appear damaged • Upon arrival, EMS finds a person as stated with blood from L forehead; 10” diam of blood on ground Needle may penetrate • Moaning; localizes pain & liver or spleen appears in distress 8 11/10/2015 Assessment What is the concern? A: Gurgling sounds noted in airway w/ bloody secretions Multi-system trauma B: Breathing faster than normal, shallow and Head injury yes; but also breathing is affected labored effort (diminished BS on L side) Any add’l info does EMS obtain in 1° survey? C: + fast, reg pulse; radials are weak. Cap – Capnography (28, square) refill 3 sec – SpO2 (91%) D: Eyes open to pain, incomprehensible – Will move all extremities to command except L foot (a deformity is noted) sounds made and localizes to painful stimuli. Pupils PERRL; bG 86 Identify life What • Suction & maintain threats interventions airway have been done? • Breathing issue (↓ BS on L) The purpose of the – Determine need for oxygen 1° survey is to identify those • Alteration in injuries that are life perfusion (faint threats radial pulse) – Consider IVFs after VS The eye does not Secondary assessment Now VS: BP 94/64, P 116, R 24 see and the hand Head to toe what? does not feel what Head: airway clear w/ suctioning the mind does not Pupils: PERL, no bruising to face think of… Neck: - JVD, trachea midline Chest: abrasion & tenderness L lat area; + distress; + crepitus to palp w/paradoxical mvt Abdomen: abr. LUQ/L flank area; moans to palp Pelvis: unremarkable Ext: L LE w/deformity; otherwise + movement x 4 9 11/10/2015 True or False What ALL is going on? Individuals who sustain blunt chest trauma do • Multi-system trauma not usually have to be admitted to the hospital? • Head injury False: Accounts for 1/3 of all trauma admits Closed chest injury Often associated with multi-system injury • Flail • Assessment findings: paradoxical movement By definition, a flail consists of… Possible injury Anterior, posterior, or lateral location? Fracture of 3 or Separation of sternum from adjacent broken ribs or more adjacent costochondral joints: sternal flail Free floating ribs in 2 or more chest chest places = mobile wall segment segment palpated or observed as paradoxical movement When should a flail be recognized? Treatment? Primary assessment Assist with breathing What causes fatigue with a flail How? chest? CPAP (if pt capable of following instructions) Muscle tightening Increased effort to breathe BVM (if altered mental status) 10 11/10/2015 The significance… Flail chest, the most severe form of blunt chest wall injury with mortality rates of 10-20% Pulmonary contusion occurs in 30-75% of blunt thoracic trauma The Eastern Association of the Surgery of Trauma, 2006 EAST guidelines Flail Goal CPAP Ensure oxygenation Prevent hypercarbia “Obligatory mechanical ventilation should be https://www.youtube .com/watch?v=LU1ek avoided…and C-PAP should be considered in A-cBjY alert pts with good ventilatory effort (East, 2006) Let’s Review Contraindications Positive pressure (CPAP) “splints” lower airways & keeps alveoli open Pneumothorax Prevents alveolar collapse (atelectasis) Less energy used to Only going to be recognized through proper open them with assessment next breath MUST listen for breath sounds throughout Stops fluid movement