Chapter 4 - Thoracic Trauma Flashcards
how can most chest injuries be treated
with airway control, decompression with a needle, finger or tube
what are the physiological complications of thoracic trauma
hypoxia, hypercarbia and acidosis
what should you do if you find a major problem during primary assessment
correct it. correct problems as you find them
if after chest tube there is still incomplete expansion of the lung or continued large air leak what is likely going on
likely to be tracheobronchial injury
we may need to place more than one chest tube
what is our initial management of an open pneumothorax
an occlusive dressing fixed down on three sides to provide a flutter valve effect, then pace a chest tube remote from the wound as soon as possible
how much blood causes massive haemothorax
> 1500ml
what three thoracic injuries that affect circulation should we assess for in the primary survey
cardiac tamponade
massive haemothorax
traumatic circulatory arrest
what arrest rhythm may be the only sign of cardiac tamponade
PEA
where do we insert chest tubes
with intercostal space, anterior to the midaxillary line
what is the classical triad of symptoms of cardiac tamponade
muffled heart sounds
hypotension
distended neck veins
what should we do when cardiac tamponade is diagnosed
emergency thoracotomy or sternotomy by experienced surgeon
what can be a temporising measure for cardiac tamponade
subxiphoid pericardiocentesis
what 8 potentially life threatening conditions should we identify during the secondary survey
simple pneumothorax haemothroax flail chest pulmonary contusion blunt cardiac injury traumatic aortic disruption blunt oesophageal rupture
what imaging should we perform as part of the secondary survey
CXR - upright if spinal column instability in not suspected
what type of shock does tension pneumothorax cause
obstructive shock
when should we correct major issues
As soon as we identify them
where does rapid deceleration cause injury
where a point of attachment meets an area of mobility
where do blast traumas cause injury
at air-fluid interfaces
how does penetrating trauma cause injury
through direct laceration, tearing or transfer of kinetic injury with cavitation
how do patients with tracheobronchial tree injury present
haemoptysis, cervical subcut empysema, tension pneumothorax or cyanosis
if we place a chest tube and there is still ongoing significant leak, what are we worried abiut?
tracheobronchial injury
what are open pneumothoraces also called
sucking chest wound
when would we suspect massive haemothroax (>1500ml blood)
when there is circulatory shock associated with reduced breath sounds or dullness to percussion
how do we initially manage massive haemothorax
simultaneous restoring blood volume and decompressing the chest cavity
where do we insert chest tube during massive haemothroax
with intercostal space, just anterior to the midaxillary line
what management option should we initiate if the chest drain returns 1500ml or more of blood
urgent thoracotomy
what is kussmauls sign and what does it suggest
it is the paradoxical increase in velour pressure during inspiration, and can be a sign of tamponade
what should we do when we have identified tamponade or pericardial fluid
emergency sternotomy or thoracotomy by qualified surgeon
how do we manage traumatic circulatory arrest
start cpr, ABC management including COETT, 100% o2, perform bilateral finger or tube thoracotomies, fluid rescusitation, 1mg adrenaline
if bilateral chest decompression does not result in ROSC in traumatic circulatory arrest, what procedure should be performed next
anterolateral or clamshell thoracotomy
what are the eight potentially life threatening injuries that should be identified in the secondary survey
simple pneumothorax haemothorax flail chest pulmonary contusion blunt cardiac injury traumatic aortic disruption traumatic diaphragmatic disruption blunt oesophageal rupture
what is flail chest
when part of the chest wall doe snot have bony continuity with the rest of the thoracic cage
what is the initial treatment of pulmonary contusion and flail chest
humidified o2
adequate ventilation
cautious fluid resuscitation
what are the signs and symptoms of traumatic aortic disruption
history of decelerating force widened mediastinum obliteration of aortic knob deviation of trachea to right depression of left mainstream bronchus left hamothorax
how can we reduce the risk of rupture of traumatic aortic disruption
B-bocker aim HR <80
BP between MAP 60-70
hypotension is a contraindication
what injuries to blunt and penetrating trauma cause to the diaphragm
blunt trauma causes radial tears that lead to herniation, penetrating trauma causes small perforations that may remain asymptomatic for years
how does blunt oesophageal tear occur
forceful expulsion of gastric contents into the oesophagus as a result of severe blow to upper abdomen. This causes linear tear allowing leakage into mediastinum
what is the clinical picture of oesophageal rupture
pain or shock out of proportion to injury. left sided pneumothorax/haemo thorax with no rib fracture.
particulate matter from chest tube
mediastinal air
how can clavicle affect airway
posterior displacement of clavicle can cause airway obstruction. reduce by extending patients shoulders or grasping clavicle with towel clamp
what else should we be concerned about in patients with 10th - 12th rib innjuries
the possibility of hepatosplenic injury
