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28.- 31 chest trauma Flashcards

1
Q

Rib fracture

cause and clinical features. assoc condition

A

etiology: mostly blunt trauma, pathologic fractures, nonaccidental trauma (child abuse

  • Clinical features
    • Pain on inspiration
    • Focal chest wall tenderness
    • Crepitus
    • Chest wall deformity
      • assoc w/ flail chest
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2
Q

dg of rib fracture

A

Chest x-ray = gold standard (AP and lateral view): fracture lines , displaced fractures

Possible CT if complications are suspecte

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3
Q

rib fracture complications

A

Pneumothorax

Hemothorax

Especially in the elderly: pain → splinting and hypoventilation → atelectasis and/or pneumonia

Pulmonary contusion

Respiratory failure

Fracture of the lower ribs → abdominal organ injury

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4
Q

why is rib fracture rx an eneasthetists job

A

Usually no surgery necessary

Analgesia

  1. NSAIDs
  2. Opiates
  3. Local Intercostal nerve block, usually performed under the affected rib

Intubation with positive pressure ventilation in severe flail chest (bridge to surgery)

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5
Q

indications for surgery in rib fracture

A

Significant chest wall deformity

Severe flail chest

Nonunion aka Pseudarthrosis

  • Failure of bone healing caused by nonunion of long bone fragments (e.g., due to insufficient immobilization). Results in the creation of a false joint (pseudarthrosis) due to the nonunion.
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6
Q

flail chest definition

A

severe disruption of normal chest wall movement from trauma associated with multiple rib fractures-3 ribs broken in 2 or more places

occurs when a segment of the chest wall does not have bony continuity with the rest or the thoracic cage.

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7
Q

dg of flail chest

A

clinical anatomic diagnosis

noted in blunt trauma patients with paradoxical or motion of a chest wall segment while spontaneously breathing.

Arterial blood gas (ABG) measurements

show the severity of the hypoventilation created by both
the pulmonary contusion and the pain of the rib fractures, to assess the need for mechanical ventilation and to follow the patient during management.

posteroanterior (PA) chest radiography to note number of fractured ribs

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8
Q

2 types of rxx for FLAIL CHEST

A

Internal/ external pneumatic stabilization

Surgical Stabilization

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9
Q

Traumatic hemothorax DEFinition

thoracic sources of blood

A

A hemothorax is defined as the presence of blood in the pleural space.

Thoracic sources of blood

  1. lung parenchyma,
  2. chest wall including the intercostal* or *internal mammary arteries,
  3. the heart and great vessels.
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10
Q

def and etio of massive heamothotax

A

The rapid accumulation of more than 1500 ml of blood or one-third or more of the patient’s blood volume in the chest cavity

  • etio: mc by a penetrating wound that disrupts the systemic or hilar vessels;
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11
Q

sx dg of massive hemothroax

A

shock! associated with the

absence of breath sounds or dullnes to percussion on one side of the chest;

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12
Q

similar findings of

MASSIVE hemothorax and TENSION pneumothorax

A

decreased breath sounds on auscultation;

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13
Q

DX betw /tension pneum and massive hemothroax

on PHYSICAL EXAM (percussion)

A

hyperresonance confirms a pneumothorax,

whereas dullness confirms a massive hemothorax.

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14
Q

general treatment of hemothroax (ttd)

A

Tube Thoracostomy drainage

  • hemopneumothorax, placement of two chest tubes preferred,
    • with the tube draining the pneumothorax placed in a more superior and anterior position.
  • if over 1500ml evac = massive hemothorax
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15
Q

complication so hemothorax

A
  1. Empyema usually develops from superimposed infection in a retained collection of blood
  2. Fibrothorax is a late uncommon complication that can result from retained hemothorax.

Thoracotomy and decortication are required for treatment.

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16
Q

what is the deathly dozen in surgery

A
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17
Q

definition and etiology of traumatic PNEUMOthorax

A

collection of air in the pleural space 2ndary to trauma

etio= blunt/ penetrating trauma

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18
Q

what is the classification/ types of PNEUMOthorax

A

There are three subtypes of pneumothoraces:

  1. simple/closed pneumothorax,
  2. open pneumothorax,
  3. tension pneumothorax.
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19
Q

define simple pneumothroax

A

collection of air trapped in pleural space.

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20
Q

define open Pneumothorax

list it’s characteristics

A
  • Full thickness defects of the chest wall that remain open;
  • enables free comm bet/ chest wall and atmosphere leading to equilibrium:
  • intrathoracic pressure = atmospheric pressure
  • Effective ventilation is thereby impaired as air enters the pleaura with each breath
  • leading to hypoventilation, hypoxia and hypercarbia.
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21
Q

treatment of pneumothorax

A

promptly closing the defect with a sterile occlusive 3 sided dressing for a flutter-type valve effect

inspiration= the dressing occludes the wound,preventing air from entering.

exhalation= the open end of the dressing allows air to escape from the pleural space

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22
Q

define the cahracteristics of tension Pneumothorax

A
  • A tension pneumothorax develops when a tear in the lung/ chest wall causes a “one-way valve“ air leak
  • inhaled Air is forced into the pleural space without any means of escape, making the oringially negative space to become positive
  • positive presure causes complete collapse of the affected lung which displaces the mediastinum to the opposite side
  • this compresses the opposite lung decreasing it’s venous return
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23
Q

Iatrogenic cause of Tension Pneumothorax

A

Mechanical Positive Pressure ventilation

(PEEP? Positive End Expiratory Pressure)

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24
Q

how is Tension Pneumothorax diagnosed

A

clinical diagnosis based on characteristic sx, do not wait for radio confirmation!!

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25
characteristic sx and signs of tension pneumothorax
Cyanosis & Chest pain respiratory distress Tachycardia & Tracheal deviation hypotension *(1/3 of becks triad)* unilateral absence of breath sound *(1/3 of beck's triad)* neck vein distention *(1/3 of becks triad)*
26
what are the 2 DX of Tensino Pneumothorax
1. **_cardiac tamponade_** !!! * TENSION pneumothorax has a _**hyperresonant** note on percussion_ (CT is dull on percussion d/2 blood accum) and _absent breath_ sounds over the **affected hemithorax**!!! 2. **_hemothorax_** * TENSION pneumothorax has a _**hyperresonant** note on percussion_ (HEMOthorax is dull on percussion d/2 blood accum)
27
imaging dg to confirm tension pneum what is the gold standard imaging for tension pneumothorax
* U.S. - **BARCODE SIGN**: aka '*stratosphere'* shows lack of lung sliding w/ insp/exp * C.T. - **GOLD STANDARD -** Collapsed lung visualised
28
treatment of tension pneumothorax
_Initial rx:_ **_immediate decompression_** * to create an OPEN pneumothroax * rapidly inserting a large-caliber needle into the _**second** intercostal space_ in the **_midcavicular_** line of the _affected_ hemithorax for _Definitive rx: **Thoracostomy**_ * insert a chest tube into the **fifth** _intercostal space_ (usually the nipple level), just _anterior_ to the **midaxillary line.**
29
main mechanisms causing pneumothorax 2 alveioli 2 lung
(1) a _sudden increase in intrathoracic pressure_ may **rupture** **alveoli** resulting in an air leak, (2) blunt forces may directly crush and disrupt alveoli. (3) _rib fractures_ may be displaced inward and _lacerate the lung itself,_ (4) **deceleration injuries** may *_tear the lung_*, causing an air leak
30
causes of pericardial tampnade
_Acute_ 1. chest trauma- damage coronary vessels 2. **Post MI** free wall rupture (C.I of pericardiocentesis) 3. Aortic dissection( rapid accum, C.I. pericardiocentesis) _chronuc/ painless causes_ 1. uremic pericarditis 2ndary to renal failure 2. TB pericaditis 3. neoplasias of pericardium other to watch out for 1. **_post cardiac interventions_**
31
Definition of Cardiac tamponade
**life-threatening** _clinical syndrome_ where _accumulation_ of **blood** and **blood clots**, in the [_non distendable]_ **pericardial space** exerts enough pressure (**\>15mmhg**) on the cardiac muscles to in _reduced ventricular filling_ and subsequent **hemodynamic compromise**
32
PathoPhys of Cardiac Tamponade
1. Fluid accumulates (around **250-300 ml** )in the pericardial sac surrounding the heart → **reduced heart sounds** *(1/3 becks)* * onset of sx depends on speed of fluid accumulatiON (X 100) * _S L O W_ = 2 L * *FAST =* *20 ml* 2. intraventricular septum is pushed to the left side of the heart * reduced atrial compliance * venous backflor and **JVD** *(2/3 becks)* * reduces the room available for LV End Diastolic volume * this therefore reduces the SV by Frank starling law * ↓ CO and **↓ BP** *(3/3 becks)*
33
what is pulsus paradoxus
Inspiratory drop of systolic bp **over 10mmhg** or Exaggerated drop in inspiratory systolic bp over the physiological limit of 10mmhg [https://www.youtube.com/watch?v=1A7prCrz0Xc](https://www.youtube.com/watch?v=1A7prCrz0Xc)
34
normal volume of pericardial fluid in the pericardial sac
30-40 ml
35
Beck's triad for acute tamponade
1. Increased **JV pulse**/ Jugular venous distension 2ndary to increased central venous pressure * wide & sharp x descent * lost Y descent 2. **Low BP** causing _Tachycardia_ to compensate 3. **muffled heart tones**. especially apex beat 4. Pulsus paradoxus
36
dg of cardiac tamponade
clinical dg w/ beck's triad Echocardiography to confirm dg ECG = **QRS** w/ **different heights**
37
management of Cardiac Tamponade
definitive therapy: Removal of pericardial fluid by one of three methods: * Emergency **subxiphoid percutaneous** drainage * **Pericardiocentesis** (with or without echocardiographic guidance) * Percutaneous **balloon pericardiotomy**
38
when is pericardiocentesis C.I.
Post M.I Aortic dissection
39
complications of cardica tamponade
SHOCK- hypovolemic/ cardogenic pulmonary oedema d/2 venous HTN
40
most sensitivr of the becks for cardiacc tamponedae
lost y descent d/2 increased JVP
41
3 exceptions of tamponade wthout cardinal sx of tachycardia
1. myxedema( hypothyrodism) 2. uremia (heart blocks) 3. beta blockers 4. terminal stage
42
sx of tamponad
1. hemodynamic instability (becks triad assoc) 2. features of underlying caus of disease 3. features of acut pericarditis ( chest pain)
43
other causes of pulsus paradoxus
air way diseases d/2 deep breathing for compensation constrictive pericarditis but not as oftern (30%), kussmaul sign predominates ( increas in JVD w/ inspiration) massive Pulmonary embolosism severe hypovolemeic shock
44
definition of & causes Pulmonary Contusion Rx
lung **parenchymal** _hemorrhage_ with **avleolar** _distruption_ MOST LEHTAL chest injury? * etiology 1. mc: high force blunt trauma from cars ( assoc w/ **flail chest**) 2. Proejctiles 3. explosions RX = supportive
45
specific rx of pumonary contusion
_supportive_ heals on it's own * breathing= 02 therapy w/ PEEP * circulation = fluids to maintain hemodynamics * analgesics * chest physiotherapy
46
dx of pulmonary contusion
1. pulm hematoma 2. hemothorax 3. pneumothroax 4. pneumonia
47
how is pulmonary contusion diagnosed why is x ray not a great diagnosis What is goldstandard
ABG CT- **GOLD** X ray * consolidation of the lung takes 6 hours to occur * this can be obstructed incase of assoc 1. pneumothorax 2. hemothorax
48
PP of pulm contusion which age group is most susceptible in Pulmonary Contusion
* trauma causes chest wall to bend inwards on lungs * crushes lung tissure and damages cappilaries * leads to oedema and hemorrhage * severe cases= **consolidation** and **atelectasis** from collapsed alveoli children as their more flexible chest wall is more flexible
49
trachea basic anatomy - spinal level - innervation - arterial supply - venous drainage
lower border of **cricoid cartilage** (C6) to the **carina** (T6) innervated by the ***reccurent laryngeal nerve*** supplyed by the ***inferior thyroid artery*** drained by **jugular arch** (anterior) & **aortic arch** (left)
50
Oesophagus basic anatomy * length * course: C6, T1-4, T10 * 4 constrictions = ABCD * spinal level * innervatoin * vascular supply and drainage
* length= **25 cm** long * from **pharynx** *(C6)* to the **stomach** * Descends to **Mediastinal** lvl at (T1-4) betw/ the trachea * enters the abdomen via **abdominal hiatus** *(T10)* _4 constrictions_ 1. Aortich arch 2. Bronchus 3. Cricoid cartilage 4. Diaphragm vascular supply - _Thoracic_ **aorta**=\> _inf_ **thyroid** a=\> l**_e_**ft **gastric** a
51
etiology for both TRACHEAL and OESOPHAGEAL injury
**blunt** and **penetrating** injuries
52
blunt and penetrating injuries of the TRACHEA
Trachea * Blunt: * **hyperextensions** in _car accidents_, * _shattering_ injuries to **Cervical** & **Mediastinal** trachea * Penetrating * ​CERVICAL =\> usually involves the oesophagus too * MEDIASTINAL=\> lethal injury
53
SX in Trachea injury vs OE injury OEE in HER
Tracheal sx (HER) 1. Emphysema of the **neck** (subcutaneous air) 2. RDS 3. Hemopytsis= rx w**/ 2 drains** OE injury (OE) 1. **Odynophagia =** painful swallowing 2. Emphysema of the **mediastinum** * Emphysema of the **neck** & **mediastinum =** aerodigestive airway affected (trachea AND OE injury)
54
whic is more severe, Tracheal injury or OE injury
OE as death occurs in **12-24 hrs** without treatment
55
dg of Tracheal injury vs Dg of OE injury
Tracheal injury dg by = **Bronchoscopy** OE injury dg by = 1) Oesopho**gram** in **decubitus** position 2)Oesopha**goscopy**
56
how is TRACHEAL INJURY treated
1. Visualisation by **LMA** 2. Ventilation by **endotracheal intubation** if possible 3. Further rx depending on the state of trachea and type of injury e.g. * _Disrupted_ bronchi = **thoracotomy** * _Upper tracheal_ injury = **trache**otomy**/cricothyroid**otomy * _Severe surgery_ = CardioPulm Bypass & **debridment**
57
rx of bronchial disruption in Tracheal injury risks of the procedure
Thoracotomy is used to rx Bronchial disruption risk= iatrogenic **Pneumothorax** (air in thoracic cavity)
58
how ti intubate in case of _Penetrating_ TRACHEAL injury
intubate through the penetrating wound (connection already dont make another)
59
side effect of endotracheal intubation in Tracheal injury
Postintubation **tracheal STENOSIS** d/2 irratation and healing caused by either cuff-induced ischemic damage to the trachea, stomal injury from a tracheostomy, or a combination of the two. Patients who present with **stridor or unexplained dyspnea after a period of mechanical ventilation** should be investigated for postintubation tracheal stenosis.
60
how is Upper trachea linjury treated in TRACHEAL injury
Thoracotomy/ Cricothyroidectomy risk: infection and stenosis
61
how is _Debridement_ performed during TRACHEAL injury
* only **5cm max** can be debrided/ resected * anastomosis and dilation of the trachea post resection * mobilisation of the trachea
62
Complications of Tracheal injury
_Mediastinitis_ - if mediastinal area injured- Lethal- DEATH _Stenosis_- from primary injury or iatrogenic fom intubation/ tracheostomy _Atalectasis_- collapsed lung 2ndary to lack of tracheal airflow
63
how is OE injury treated
Surgical repair and Drainage
64
dx betw/ alkali and acid injury to OE
A L K A L I * more common * no immediate sx, deveops over 3 phases * worse * dissolves tissue by **liquefactive** necrosis * _rx_ = V I N E G A R / CITRIC _ACID_ *ACID* * *less common* * *imediate mouth burning* * ***coagulative** necrosis .* * *forms **eschar limits tissue penetration** (less severe)* * *_RX_ = Milk / antacids*
65
what is the 3 phase progression of ALKALI injurt to OE
1. _Acute necrosis_. * **day 1-4.** Coaglation of IC proteins & inflamm 2. _Ulcerisation_ & _Granulation_. * **day3-5.** slouging and granulation weakns OE 3. _Cicatrisation_. * **3weeks**

general surgery (10 decks)

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