a case of blunt thoracic trauma author dr suen kin wing august 2013 hkcem college tutorial
TRANSCRIPT
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A case of blunt thoracic trauma
Author
DR SUEN KIN WING
August 2013
HKCEM College Tutorial
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History
▪ 78/M
▪ Riding Bicycle along the road
▪ Hit by a van of unknown speed
▪ Thrown away several meters
▪ Primary trauma diversion for decreased Glasgow Coma Scale
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Physical Examination
▪ GCS 6/15
▪ BP 105/ 43
▪ SpO2 86 % on Non-rebreather mask (NRB)
▪ Forehead hematoma with Lt ear bleeding
▪ Surgical emphysema on Lt chest wall
▪ Abrasion over lower limbs
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What are the potential causes of airway obstruction in trauma setting?
▪ Loss of upper airway muscle tone from CNS depression
▪ Foreign body such as avulsed teeth
▪ Oral bleeding
▪ Significant facial fracture
▪ Laryngeal injury
▪ Expanding neck hematoma
▪ Airway burn
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What physical signs should be looked for
during assessment of thoracic trauma?
▪ Cyanosis
▪ Distended neck vein
▪ Breath sound
▪ Surgical emphysema
▪ Bony crepitus
▪ Paradoxical chest wall movement
▪ Tracheal deviation
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WHAT ARE THE ABNORMALITIES?
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CXR findings
▪ Multiple ribs fracture on Lt side
▪ Fracture of Lt scapula
▪ Fracture of Lt clavicle
▪ Lt lung haziness
▪ Patchy consolidation suggestive of pulmonary contusion
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▪ For trauma patients, X-ray is usually taken in supine position.
▪ Look for deep sulcus sign suggestive of pneumothorax
▪ Diffuse haziness indicates the presence of haemothorax
▪ Chest x ray may also provide clues of aortic injury.
▪ Suspect aortic injury with deceleration mechanism
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What bedside investigation is useful in our patient?
eFAST-Extended Focused Assessment with Sonography in Trauma
▪ To detect fluid in pericardium and abdomen
▪ Region of examination : RUQ, LUQ, suprapubic region and subxiphoid view of pericardium
▪ Examination can be extended to detect the presence of traumatic haemothorax and
pneumothorax
http://www.youtube.com/watch?v=EVQTI7ivhFM
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Ultrasound for pneumothorax
▪ Normal lung displays pleural sliding and comet tail artifact
▪ Absence of these findings is suggestive of pneumothorax
▪ On M mode, normal pleural is displayed as seashore sign
▪ Significant surgical emphysema may make examination difficult
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Pneumothorax on USG
Sliding pleura and seashore sign on normal lung
Absence of sliding pleura and barcode sign on pneumothorax
http://www.youtube.com/watch?v=ebCbewLBNGM
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Haemothorax on USG
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Progress
▪ Patient was intubated and put on mechanical ventilation in view of unconsciousness and desaturation.
▪ X-RAY trauma series showed no abnormalities in cervical spine and pelvis while the CXR finding has been described.
▪ eFAST was negative
▪ Chest drain was inserted
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THE POSITION OF ALL DRAINS AND TUBES SHOULD BE VERIFIED ON CXR
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What are the indications for Chest drain?
▪ Tension pneumothorax
▪ Simple pneumothorax
▪ Haemothorax
▪ Patient with ribs fracture on positive pressure ventilation
▪ Minimal pneumothorax or haemothorax can be treated conservatively
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▪ The triangle of safety refers to the area surrounded by the anterior border of latissimus dorsi , the lateral border of pectoralis major muscle and the horizontal level of nipple.
What is the " triangle of safety " for chest drain insertion ?
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What are the important steps for chest drain insertion?
▪ Use blunt dissection
▪ The chest drain should be inserted just above the rib to avoid damage to the intercostal vessels and nerves
▪ Chest drain is placed apically for pneumothorax and posteriorly for haemothorax
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▪ Insertion of chest drain should be done without substantial force
▪ Use of trocar is discouraged
▪ Any functional chest drain should not be repositioned simply because of its radiological position
Chest tube insertion (NEJM)
http://www.youtube.com/watch?v=hQlt57AyQmg
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What are the potential complications of chest drain insertion?
▪ Tube malposition ▪ For example: Intraparenchymal tube placement and subcutaneous tube
placemen
▪ Nerve injury▪ For example: Horner’s syndrome and phrenic nerve injury
▪ Cardiovascular injury
▪ Intercostal artery injury
▪ Esophageal perforation
▪ Arrhythmias
▪ Emphysema
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Penetration of lung parenchyma by chest drain
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What will you consider if there is continuous air bubbling via the chest
drain and pneumothorax is unresolved after chest drain has been inserted for pneumothorax?
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A tear at right main bronchus
▪ Large tear of lung parenchyma or tracheobronchial injury may result in persistent air leakage
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Progress
▪ Whole body CT was performed
▪ Admitted ICU
▪ Continue mechanical ventilation
▪ Chest physiotherapy and antibiotic for pneumonia
▪ Opioid for pain relief
▪ Extubated and followed by prolonged course of rehabilitation
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Progress
Orange arrow : Pulmonary contusion
Blue arrow: Haemothorax
Green arrow: Surgical emphysema
Coronal view showing the extent of injury
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Pulmonary contusion
▪ Hemorrhage and alveolar edema leading to impaired gas exchange and lung compliance
▪ Avoid excessive fluid and aim at euvolemia
▪ A trial of CPAP in selected patients
▪ Independent lung ventilation for severe unilateral lung contusion
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Flail chest and ribs fracture
▪ Two or more ribs are fractured in at least two places
▪ Pathophysiology results from underlying lung contusion and splinting caused by pain
▪ For first, second rib or scapula fracture, consider the possibility of significant intrathoracic injury
▪ Fracture of lower ribs are associated intra abdominal injury
▪ Fracture of sternum is not necessarily a indicator of cardiac injury
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Consider intra-abdominal injury in thoracic trauma
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Haemothorax
▪ Each haemithorax can hold several liters of blood
▪ Bleeding from intercostal artery or thoracic vessel can results in massive haemothorax
▪ Major lung parenchyma may also bleed significantly
▪ Chest drain is both diagnostic and therapeutic
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▪ Retained haemothorax is potentially complicated by empyema and fibrothorax
▪ Indication of emergent thoracotomy:
▪ 1500ml blood on initial drainage
▪ Ongoing bleeding of > 200ml/hr for 4 hours
▪ Unstable hemodynamics secondary to thoracic bleeding
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Summary
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Immediate Life Threatening Conditions in Blunt thoracic Trauma
▪ Airway obstruction
▪ Tension pneumothorax
▪ Pericardial tamponade
▪Massive haemothorax
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Potentially life threatening conditions
• Pulmonary contusion
• Traumatic rupture of aorta
• Major tracheobronchial disruption
• Blunt cardiac injury
• Diaphragmatic tear
• Esophageal rupture ( rare )
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Five Core ED Management
▪ Airway protection
▪ Adequate oxygenation
▪Chest drain insertion
▪ Fluid resuscitation for hypovolaemia
▪ Pain relief
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Image Sources
▪ Slide 11 Occult Traumatic Pneumothorax Diagnostic Accuracy of Lung Ultrasonography in the Emergency Department Chest. 2008; 133(1):204-211
▪ Slide 12 EMresource.ORG
▪ Slide 16 BTS guidelines for the insertion of a chest drain Thorax 2003;58:ii53-ii59
▪ Slide 20 Rosen's Emergency Medicine, 7th Edition
▪ Slide 22 The CT fallen-lung sign. Eur Radiol. 2000;10(5):719-21.
▪ Slide 27 Atlas of Human Anatomy by Frank H. Netter
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Thank You