Chapter 4 - Thoracic Trauma

Question 1

What are the characteristic features of tracheobronchial tree injury?

Answer 1

Haemoptysis
Cervical subcutaneous emphysema
Tension pneumothorax
Cyanosis

Incomplete expansion following ICD placement

Question 2

What are the characteristic features of tracheobronchial tree injury?

Answer 2

Haemoptysis
Cervical subcutaneous emphysema
Tension pneumothorax
Cyanosis

Incomplete expansion and large continued airleak following ICD placement

Question 3

What is the investigation of choice to confirm a tracheobronchial tree injury?

Answer 3

Bronchoscopy

Question 4

What is the immediate treatment of a tracheobronchial tree injury?

Answer 4

Placement of one or more ICDs
Immediate surgery consult
+/- Definitive airway - VA and possible selective intubation of unaffected bronchus

Question 5

Define a tension pneumothorax

Answer 5

Develops when a one-way valve airleak develops from the lung or chest wall

Question 6

What are the signs and symptoms of a tension pneumothorax?

Answer 6

Air hunger
Tachypnoea
Respiratory distress
Tachycardia
Hypotension
Tracheal deviation away from side of injury
Unilateral absence of breathe sounds
Elevated hemithorax
Neck vein distension
Cyanosis

Question 7

What is the immediate management of an open pneumothorax?

Answer 7

Close the defect to create a flutter valve with an occlusive dressing taped on 3 sides

Question 8

Define massive haemothorax

Answer 8

Accumulation of >1.5L of blood or 1/3 of the patients blood volume within the pleural cavity or draining 200ml.hr for 2-4 hrs or BT required

Question 9

Define PEA (pulseless electrical activity)

Answer 9

Manifested by an ECG that shows a rhythm but the patient has no identifiable pulse

Question 10

Assess the circulation

Answer 10

Inspection: skin mottling, cyanosis, pallor, distended neck veins
Palpation: central pulse (quality, rate, regularity), skin to assess temperature and determine if dry or sweaty
Listen: regularity and quality of heart sounds

Question 11

List the causes of PEA

Answer 11

Cardiac tamponade
Tension pneumothorax
Severe blunt injury (blunt rupture of the atria or ventricles)
Hypovolaemia
Hydrogen ions (acidosis)
Hypo/hyperkalaemia
Hypoglycemia
Hypothermia
Toxins
Thrombosis (pulmonary or cardiac)

Question 12

What size chest tube would one use to treat a haemothorax?

Answer 12

28-32 French

Question 13

Define flail chest

Answer 13

When 2 or more adjacent ribs are fractured in 2 or more places

OR

Costochondral separation of a single rib

Question 14

Define pulmonary contusion

Answer 14

Brusie of the lung caused by thoracic trauma - blood accumulating in the lung parenchyma interferes with ventilation leading to hypoxia

Question 15

Initial signs of a flail chest

Answer 15

Abnormal cheats wall movements (may not be evident)

Crepitus on palpation from rib or cartilage fractures

Question 16

Initial treatment of flail chest and pulmonary contusion

Answer 16

Administer humidifed oxygen
Adequate ventilation - sats <90% and PaO2 <60 may require intubation within the 1st hour
Cautious fluid resuscitation

Definitive
Adequate oxygenation
Analgesia - consider IC nerve block, transcutaneous intrapleural nerve block

Question 17

Blunt cardiac injury (BCI) may result in myocardial muscle contusion, cardiac chamber rupture, coronary artery dissection and/or thrombosis and valvular disruption.

List the clinically significant sequelae

Answer 17

Hypotension
Dysrythymia
Wall motion abnormality on two-dimensional echo

Question 18

Blunt cardiac injury (BCI) may result in myocardial muscle contusion, cardiac chamber rupture, coronary artery dissection and/or thrombosis and valvular disruption.

List the clinically significant sequelae

Answer 18

Hypotension
Dysrythymia
Wall motion abnormality on two-dimensional echo

Question 19

ECG changes seen following BCI

Answer 19

Myocardial infarction
Multiple premature ventricular contractions
Bundle branch block (usually R)
Sinus tachycardia
AF
ST segment changes

Question 20

Traumatic aortic disruption

List radiographic signs of Blunt aortic injury

Answer 20

Widened mediastinum
Obliteration of aortic notch
Devation of trachea R
Depression of the L mainstem bronchus
Elevation of the R mainstem bronchus
Obliteration of the space nbetween PA and aorta
Deviation of oesophagus
Widened paratracheal stripe
Windenes paraspinal interfaces
Presence of a pleural or apical cap
L haemothorax
Fracture of 1st or 2nd rib

1-13% great vessel injury have no mediatinal or CXR abnormalities

Question 21

Most accurate diagnostic tool in suspected blunt aortic injury

Answer 21

Helical Contrast CT chest

If equivocal then - aortography