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ATLS > Chapter 4 - Thoracic Trauma > Flashcards

Chapter 4 - Thoracic Trauma Flashcards

1
Q

Injury to the upper chest can create a palpable defect in the region of the sternoclavicular joint, with posterior dislocation of the clavicular heads and upper airway obstruction. How do you reduce this injury?

A

1/ Closed reduction by extending the arm.

2/ Grasping the clavicle with a pointed instrument (e.g. a towel clamp) and manually reducing it.

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2
Q

What major thoracic injuries should be picked up on and addressed during the primary survey?

A
  1. Tension pneumothorax
  2. Open pneumothorax
  3. Flail Chest
  4. Pulmonary Contusion
  5. Massive haemothorax
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3
Q

What type of shock is a tension pneumothorax?

A

Obstructive shock

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4
Q

How does a tension penumothorax develop?

A
  1. A “one way valve” air leak occurs from the lung or through the chest wall.
  2. Air is forced into the pleural space without any means to escape.
  3. The mediastium is displaced to the opposite side, decreasing venous return and compressing the opposite lung.
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5
Q

After intubation what is one of the common reasons for loss of breath sounds in the left thorax?

A

A right mainstem intubation.

(Be aware that this can happened and don’t mistake it for a pneumothorax/haemothorax)

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6
Q

What are some causes of a tension pneumothorax?

A

1) Mechanical ventilation with positive-pressure ventilation in patients with a visceral pleural injury. (Most common)
2) Blunt/penetrating chest trauma where the lung parenchyma injury fails to seal.
3) Post subclavian/Internal jugular venous catheter insertion.
4) Traumatic defects in the chest wall.

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7
Q

What signs and symptoms are seen with a tension pneumothorax?

A
  1. Chest pain
  2. Air hunger
  3. Respiratory distress
  4. Tachycardia
  5. Hypotension
  6. Tracheal deviation away from the side of injury
  7. Unilateral absence of breath sounds over hemithorax.
  8. Elevated hemithorax w/o respiratory movement.
  9. Neck vein distension
  10. Cyanosis (late manifestation)
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8
Q

How does one manage a tension pneumothorax?

A

1/ Immediate decompression.- a large bore needle is inserted into the second intercostal space in the midclavicular line.

2/ Definition treatment - insertion of a chest tube into the fifth intercostal space (usually at the nipple level) just anterior to the mixaxillary line.

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9
Q

What size needle should you use and what percentage chance will it be effective in chest decompression?

A

A 5cm needle will reach the pleural space >50% of the time.

An 8cm needle will reach the pleural space >90% of the time.

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10
Q

In what circumstances does an open pneumothorax occur?

A

It occurs when there is a large defect in the chest wall which allows atmospheric air to rush into the pleural space, thus equalizing atmospheric and intrathoracic pressure.

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11
Q

How is an open pneumothorax managed?

A

Temporary- A sterile occlusive dressing is placed over the wound with 3 sides taped down to provide a flutter valve.

As the patient breathes in the dressing occludes the wound and thus the lung expands. On breathing out, the open end of the dressing allows air to escape.

Definitive - surgery

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12
Q

Describe how a flail chest occurs and its management.

A

1/ Trauma causing multiple rib fractures in two or more adjacent ribs in 2 or more places.

2/ Initial management -

  • Adequate ventilation
  • Administration of humidified oxygen
  • Fluid resuscitation. (But fluid resuscitation should be used carefully so as not cause overload)
  • IV morphine or intercostal blocks.

3/ Final management - surgery

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13
Q

What is the definition of a massive haemothorax?

A

A rapid accumulation of more than 1500mL of blood or 1/3 or more of the patient’s blood volume in the chest cavity .

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14
Q

What are the common causes of a massive haemothorax?

A

1/ A penetrating injury that disrupts the systemic or hilar vessels.

2/ Blunt pulmonary trauma

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15
Q

What are the signs of a massive hemothorax?

A

Shock associated with the abscence of breath sounds or dullness to percussion on one side of the chest.

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16
Q

How should a massive haemothorax be managed?

A
  1. A 36 or 40 French chest tube is inserted in the nipple line just anterior to the midaxillary line.
  2. Continue to early thoracotomy if 1,500mL of fluid is immediately evacuated.
  3. If patients continue to bleed or they require persistent transfusions, then they may also require a thoracotomy.
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17
Q

What is the most common cause of cardiac tamponade?

A

Penetrating injury.

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18
Q

How do you diagnose a cardiac tamponade?

A

Using Beck’s Triad of 1/ Venous pressure elevation 2/ Decline in arterial pressure 3/ Muffled heart tones.

ECG - PEA is suggestive.

FAST Scan

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19
Q

How accurate is a FAST scan in finding pericardial fluid? (if used by an experienced user)

A

90-95%

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20
Q

How is a cardiac tamponade managed?

A

1/ Temporarily - pericardiocentisis

2/ Surgery - Pericardiotomy via thoracotomy.

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21
Q

What are some complications of a chest tube insertion?

A
  1. Laceration or puncture of intrathoracic organs or abdominal organs.
  2. Infection
  3. Intercostal nerve damage
  4. Incorrect tube position
  5. Chest tube kinking or clogging
  6. Persistent pneumothorax - leak around the skin, leak in the underwater seal.
  7. Subcutaneous emphysema
  8. Recurrence of penumothorax upon chest drain removal.
  9. Lung fails to expand due to plugged bronchus.
  10. Anaphylactic or allergic reaction to prepartion.
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22
Q

What are some complications of pericardiocentesis?

A
  1. Aspiration of ventricular blood instead of pericardial blood.
  2. Laceration of ventricular epicardium/myocardium
  3. Laceration of coronary artery or vein.
  4. New hemopericardium secondary 2-3.
  5. Ventricular fibrillation (VF)
  6. Pneumothorax
  7. Puncture of esophagus with subsequent medistinitis.
  8. Puncture of peritoneum with peritonitis.
  9. Puncture of great vessels
23
Q

What does a “current of injury” mean?

A

In a pericardiocentesis, in the needle is advanced too far then on the ECG monitor one can see an extreme ST-T wave changes or widened & enlarged QRS complex.

If the myocardium is irritated then premature ventricular contractions can occur.

24
Q

What maneuvers can be effectively accomplished with a resuscitative thoracotomy?

A

1/ Evacuation of pericardial blood causing tamponade

2/ Direct control of exsanguinating intrathoracic hemorrhage.

3/ Cross-clamping of the descending aorta to slow blood loss below the diaphragm and increase perfusion to the brain and heart.

25
Q

Who are NOT candidates for resuscitative thoracotomy?

A

Patients who sustain blunt injuries and arrive pulseless but with PEA.

26
Q

Who are candidates for immediate resuscitative thoracotomy?

A

Patients with penetrating thoracic injuries who arrive pulseless butwith myocardial electrical activity.

27
Q

What are the 8 thoracic injuries that should be identified during the secondary survey?

A
  1. Simple pneumothorax
  2. Hemothorax
  3. Pulmonary contusion
  4. Tracheobronchial tree injury
  5. Blunt cardiac injury
  6. Traumatic aortic disruption
  7. Traumatic diaphragmatic injury
  8. Blunt esophageal rupture
28
Q

What is the most common cause of simle pneumothorax?

A

Lung laceration with air leakage from blunt trauma.

29
Q

In what situation should you not transport someone to hospital who has a simple pneumothorax?

A

You should not transport them via air ambulance due to expansion of the pneumothorax at altitude. (even in a pressurized cabin)

30
Q

How much blood is lost in a hemothorax? (not a massive hemothorax)

A

<1500mL blood.

31
Q

What is the primary cause of hemothorax?

A

Lung laceration or laceration of the intercostal vessel or internal mammary artery due to either penetrating or blunt trauma.

32
Q

When is an operative exploration required for a hemothorax?

A

Guidelines for operative exploration are:

  1. If 1500mL of blood is obtained immediately through the chest tube.
  2. If drainage of more than 200mL/hr for 2 to 4 hours occurs
  3. If blood transfusion is required.
33
Q

In what condition is pulmonary contusion most commonly seen?

A

Rib fractures.

Pulmonary contusion is the most common potentially lethal chest injury.

34
Q

If someone were to have chest trauma & subsequent pulmonary contusion, when would you think about intubating & ventilating them?

A

If they have significant hypoxia (PaO2 of <8.6kPa or SaO2 of <90% on room air.

35
Q

What is tracheobronchial tree injury?

A

Injury to the trachea or major bronchus.

Most injuries are within 1 inch of the carina.

Most patients die at the scene.

36
Q

What are the most common symptoms of tracheobronchial tree injury and how is it best diagnosed?

A
  1. Hemoptysis
  2. Subcutaneous emphysema
  3. Tension pneumothorax
  4. Incomplete expansion of the lung after placement of a chest tube.
  5. Extreme breathlessness.

It is best diagnosed with a bronchoscopy

37
Q

Blunt cardiac trauma can result in:

A
  1. Myocardial muscle contusion
  2. Cardiac chamber rupture
  3. Coronary artery dissection/thrombosis
  4. Valvular disruption
38
Q

What are some of the msot common ECG findings in blunt cardiac injury?

A
  1. Multiple premature ventricular contractions
  2. Unexplained Sinus tachycardia
  3. AF
  4. BBB (usually right)
  5. ST segment changes.
39
Q

Should we use troponins in diagnosing blunt cardiac injury?

A

Nope.

40
Q

How long should someone be monitored if they have a blunt cardiac injury?

A
  1. 24 hours - after this the risk of dysrhythmia decreases dramatically.
41
Q

When is a traumatic aortic disruption commonly seen?

A

Automobile collisions or a fall from a great height.

42
Q

In traumatic aortic disruption, when would patient’s have the highest chance of survival?

A

If there is an incomplete laceration near the ligamentum arteriosum of the aorta.

Continuity is maintained by an intact adventitial layer or contained mediastinal hematoma and prevents immediate exsanguination and death.

43
Q

Name some signs of traumatic aortic disruption that would appear on xray?

A
  1. widened mediastinum
  2. obliteration of the aortic knob
  3. Deviation of the trachea to the right
  4. Depression of the left mainstem bronchus.
  5. Elevation of the right mainstem bronchus.
  6. Deviation of the esophagus
  7. Widened paratracheal stripe
  8. Widened paraspinal interfaces
  9. Presence of a pleural or apical cap
  10. Left hemothorax
  11. Fractures of the first or second rib or scapula.
44
Q

What has been shown to be an accurate screening method for a suspected blunt aortic injury?

A

Helical CT scan. (Sensitivity and specificity of ~100%)

If the results are equivocal then do an aortography.

45
Q

What is the treatement for a traumatic aortic disruption?

A

Treatment is either through:

  1. Primary repair
  2. Resection of the torn segment and replacement with an interposition graft.
  3. Endovascular Repair (EVAR)
46
Q

Traumatic diaphragmatic injuries are most commonly seen on which side?

A

The left side because of the protective effect of the liver.

47
Q

On CXR, what finding would you see with a diaphragmatic injury?

A

An elevated right hemidiaphragm.

48
Q

What is a complication of blunt esophageal rupture?

A

Mediastinitis and an empyema.

49
Q

In what situation should a blunt esophageal rupture always be considered?

A

When a patient has a left pneumothorax, hemothorax w/o rib fractures or they received a severe blow to the lower sternum or epigastrium and is in **pain **or shock that is out of proportion to their apparent injury.

50
Q

What are the 3 significant manifestations of chest injury?

A

1/ Subcutaneous emphysema

2/ Crushing injury to the chest (Traumatic asphyxia)

3/ Rib, Sternum and Scapular Fractures

51
Q

Young people have more flexible ribs, if there are multiple rib fractures in a young person what does this imply?

A

A greater transfer of force than in an older patient.

52
Q

What do fractures of the lower ribs (10 to 12) imply?

A

Hepatosplenic injury

53
Q

The upper ribs 1 to 3 are protected by the scapula, humerus and clavicle along with other muscular attachement. If you see fracutres of these ribs what does it imply?

A

A magnitude of injury that places the head, neck, spinal cord, lungs and great vessels at risk of injury.

54
Q

What ribs sustain the majority of blunt trauma?

A

4 to 9. The middle ribs.

ATLS (7 decks)

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