Blunt chest trauma

Question 1

An 80 year old man was accidentally struck on the right side of his chest by his grandson with a cricket bat. He fell down on to his back and hit his head. How would you assess and investigate this patient?

Answer 1

Impression
Multi- trauma presentation, want to take primary survey approach to this patient prioritising any potential head/c-spine injuries first before assessing for thoracic and other trauma.

DDx to consider;

• Head: TBI, intracranial bleeds (subdural, extradural, ICH), facial/skull fractures
• C-spine: fracture, cord injury
• Thoracic: flail segment, pneumothorax +/- tension, haemothorax, aortic dissection, etc
• other

Goals

• assemble trauma team prior to patients arrival
• take primary survey approach to initial assessment, triage injuries according to priority and place patient in C-Spine collar if not already in one
• definitive referral +/- appropriate dispositioning (ortho, neurosurg, etc)

Question 2

Blunt trauma - Assessment

Answer 2

Assessment
- assemble team assign roles (Airway, etc)
A - patent, maintaining, tube pending GCS. Avoid NP airway incase of base of skull fracture/cribriform plate fractures.
B - RR/SP02. supplemental 02 as required. Auscultate for signs of pneumonia/haemothorax, bedside CXR, needle decompression for tensions +/- chest drain with underwater seal. eFAST scan for thoracic and abdominal free fluid/gas
C - BP/ECG/HR monitoring. IVC access and initial bloods: VBG + pre-op bloods if disposition is theatres. control any bleeding as necessary. fluids and inotropes if shocked +/- blood resuscitation if significant blood loss. stop/reverse any anticoagulation.
D - GCS, PEARL, assess for any obvious head/facial injuries, place in C-Spine collar. Neuro exam, assess for cushings response (raised ICP). Head imaging as indicated by clinical assessment and risk factors (anticoags, age, etc), utilise Canadian Head CT rule.
E - exposure, log roll for other injuries, BSL, secondary survey and clear C-Spine
FG as per normal

Question 3

Blunt trauma - History

Answer 3

History
MIST AMPLE
- A: allergies
- M: anticoags, antiplats, antiHTN
- PMHx: 
- Last meal
- E: head vs what? any blood loss?

Question 4

Blunt trauma - Examination

Answer 4

Examination

• vitals
• general appearance
• neuro: focal neurology, TBI assessment scale
• Resp: air entry, expansion, resonance/dullness to percussion, pain, flail segments
• MSK systems review for other fractues
• tertiary survey next day

Question 5

Blunt trauma - Investigations

Answer 5

Investigations
Diagnostic
- non-con CTB +/- C-spine
- CXR, eFAST
- trauma series X-Ray

• Bloods: pre-op bloods including coags

Question 6

Blunt trauma - Management

Answer 6

Management
- initial as per A to E assessment

Dispositioning

• ortho
• neurosurg
• inpatient management vs outpatient

Definitive
- rib fractures: chest physio, analgesia, incentive spirometry

Supportive

• regular monitoring, neuro obs for 4 hours
• analgesia for pain management
• patient education regarding head injury etc
• appropriate F/U