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Chest trauma
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Chest trauma
30 yo male
M: Driver in 80 kph head on collisionRestrained
I: Chest wall & sternal pain, leg injuries S: 140/80 110bpm sats 90% T: 15 mg IV morphine, Oxygen
Arrives in ED moaning, disorientated, splint on leg, hard collar on neck
High flow oxygen
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Chest trauma The key to effective trauma management is to minimize the time to
definitive management so the initial management should be focused and abbreviated
List significant differential diagnosis in chest trauma Inspection;
Retractions Symmetrical chest wall expansion Wounds, flail segments
Palpation; Chest wall tenderness crepitus Subcutaneous emphysema Position trachea
Auscultation Very difficult in ED room; low sensitivity but good specificity Determine absence / asymmetry of breath sounds
JVP (difficult to ascertain in neck collars and low in low volume states Absence of pain, tenderness and auscultatory abnormalities in the
patient with normal mental status has a NPV near 100%
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Chest trauma
Soon after arrival
100/70, PR 130, sats 92% on oxygen mask, skin dusky
What would you do and what are you looking for?
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Chest trauma
Pneumothorax
how reliable is the clinical examination?
how reliable is the trauma CXR?
how is a tension pneumothorax treated?
what do we do with occult PTx on CT?
how do we treat stab wound to the chest?
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Chest traumaPneumothorax - simple
- open- tension
Cause - Sudden increase in intra thoracic pressure - Rib fractures lacerate the lung - Deceleration injury tears the lung - Blunt force disrupts the alveoli
Examinationuniversal finding - chest pain. Respiratory distresscommon (50-7% - tachycardia, ipsilateral decreased air entryinconsistent(<25%)- low sats, tracheal dev, hypotensionrare (10%) - cyanosis, hyperresonance, drowsy
- ipsilateral; hyper-expansion, hypo-motility
Tracheal deviation is inconsistent and poorly predictive
In the ventilated patient; rapid onset drop in saturations and blood press
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Chest trauma
CXR supine misses 30 - 50% the supine AP CXR is much less sensitive (75%)than the erect CXR Air accumulates in the anteromedial recess abnormal hyperlucency in lower chest/upper abdomen as air collects
in the anterior costo-phrenic abscess Sub-pulmonary air collection or hyperlucency Deep sulcus sign; abnormally deep and lucent costophrenic angle.
Ant PTx Unusually well defined mediastinal structures because of postero-
medial air Depression of hemi-diaphragm
U/S (more sensitive than CXR >90%)
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ultrasound
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Chest trauma Tension pneumothorax
Any patient you clinically suspect of having tension PTx and in distress, is hypoxic or hypotensive decompress urgently without radiologic confirmation
(sats < 92% on O2, syst < 90, RR < 10, drowsy, cardiac arrest)mortality is 4 fold in intubated patients if thoracotomy is delayed waiting for CXR
Needle thoracotomy14# cannula in 2/3 ICS MCL. however, up to ⅓ patients have a thicker chest wall than cannula lengthcan use 4/5 ICS MAL if chest wall too thickfollow by insertion of a chest tube
Wait for CXR confirmation in stable patients (with PTx) Confirms diagnosis and may prevent unnecessary thoracostomy May reveal diaphragmatic rupture which would make thoracostomy
dangerous
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what would happen if we inserted a L sided chest tube?
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tension pneumothorax
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Chest trauma
Occult pneumothorax; diagnosed by CT in 2 – 8 % 20% will require tube thoracostomy
When do we treat occult pneumothorax?guidelines for thoracostomy 1. > 5×80mm
2. associated rib fractures 3. requiring future positive pressure ventilation 4. multiple injuries, haemorrhagic shock, brain injury
What do you do if you elect to do nothing? repeat CXR in 6 and 24 hours
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stabbing Most are clinically stable on arrival 15% require operative management ‘normal CXR’ require repeat in 6 hrs Injury to ‘cardiac box’ = clavicle-costal margin
between midclavicular lines Less than 25% make it to hospital; of which 41% present haemodynamically stable CXR; 59% widened mediastinum
27% haemothorax CT; replacing angiogram, shows trajectory
10-30% involve the abdomen; when wound is below 4th nipple
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Chest trauma
58 yo male motorbike rider hit by truck from behind
Complaining of chest pain, no LOC 120 bpm, 140/90, RR 28, sats 94% on 8L O2
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Chest trauma Haemothorax
clinical Decreased chest expansion, decreased breath sounds (dull to percussion)CXR (sens 50%, spec 90%)
moderate size: >400-500 mls blood to detect on supine CXRdiffuse non-segmental opacification through which lung markings can be
seen, large size >1500mlsground glass appearance on CXRhaemodynamic compromise from blood loss and mediastinal shift
U/S ( sens 90%, spec 95%)
tube thoracostomylung re-expansion will tamponade bleedplace ICC posteriorly unless there is a pneumothorax as well10-15% require thoracotomythoracotomy if stable and bleeds>200mls/hr or >1500ml in total
if unstable and bleeds>100mls/hr or > 100ml in total no improvement in haemothorax will require a second ICC
antibiotics prob not required if adequate drainage of haemothorax and sterile technique used
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Chest trauma – rib# Compression or shearing of the lung parenchyma leads to localized disruption
of the alveolar capillary membrane and lung interstitium. Blood leaking out into the interstitium
50% rib fractures undetectable radiologically Rib fractures cause severe pain, delayed morbidity and mortality that leads to
pneumonia Chest wall injury; ⅓ have pulmonary complications
30% pneumonia ↑rib#s → ↑mortality esp>3-4 ribs (13% mortality)
age; > 65yo mortality (8 vs 61%)(Bulger) each additional rib# increases mortalityby 19% elderly patients with rib fractures should be admitted
concurrent ≥ 2 extra-thoracic injuries ↑↑ mortality Blunt chest injury treatment;
pain control (epidural analgesia better outcome, esp if > 4 rib# and > 65yo) chest physio mobilisation Unnecessary IV fluid administration should be meticulously avoided
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Rib #
1st and 2nd rib# may indicate severe neurovasc injuries
most common in ejected MVA victims Lower rib#s may indicate -abdo injuries
diaphragmatic injuries Admit ≥ 3 rib#s, underlying resp disease, complications (pneumo,
heamo, pul contusion), pain not controlled (must be able to deep breathe and cough), unable to cope at home, elderly
Sternal fractures; ECG
troponin; not routinely required unless haemo unstable
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1. Deep sulcus
2. Widened mediastinum, obscured aortic knuckle, opacified aorto-pul window
3. R side Contusion
4. L Haemothorax
5. 7 – 10 R rib#
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Chest trauma
52 yo male Hit by car travelling at 70 kph Brief LOC, chest pain 120 bpm, 100/70, sats 90%
You are the doctor completing the primary survey
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Chest trauma Flail chest
most severe form of blunt chest trauma; mortality 10-20% Poor outcome is due to the underlying pulmonary contusion Causes long term chest wall pain and exertional dyspnoea Advances in knowledge and ICU techniques over the last 3 decades
have not impacted on mortality Management
Unnecessary IVF infusion should be avoided Obligatory mechanical ventilation should be avoided (Trinkle)
(intubate to improve gas exchange and not for mechanical correction) Optimal analgesia (epidural) Chest physio CPAP works (Tanaka, Gunduz) Surgical fixation worked in old studies not comparing new techniques
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Cardiac echo
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Blunt Cardiac Injury Sustained from rapid deceleration with direct blow to the
chest Suspect with mechanism or poor cardiovascular response to
their injury Difficult diagnosis
Chest pain or SOB Chest wall tenderness, flail, crepitus Sinus tachy, arrhythmia, pump failure
No single or combination of test reliably diagnoses it Normal ECG in stable patient with blunt chest trauma
essentially rules out significant risk of blunt myocardial injury Cardiac echo for unexplained hypotension, ECG changes or
pump failure Troponin has no important clinical value in diagnosis of BCI
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Blunt aortic injury Mainly MVA, pedestrian, falls, impact from any direction Second most common cause of death in blunt injuries; 85% die pre-hospital CXR can be used as a initial screening tool (98% NPV if normal)
Widened mediastinum most common trigger for additional workup to exclude BAI
supine 10cm, PA 8cm and mediastinal/chest ratio 0.38 (at level or aortic arch) Other signs; obscured or indistinct aortic knob
depression L main bronchusdeviation NGTopacification aorto-pul windowdisplaced L parasternal stripefracture 1st rib, apical cap
CXR may be normal in 25% Screen with CTA; 100% NPV Angiography; gold standard and may be used when CT equivocal Requires immediate repair unless there are more urgent issues requiring
laparotomy or craniectomy Endoluminal stent or surgical repair (complication; spinal cord ischaemia or renal
failure) Treat hypertension to reduce shearing forces with b -blockers
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