Chest Injuries (Sources: OH's, SOPs)

Question 1

Which chest injuries cause immediate death in trauma patients?

Answer 1

Blunt rupture of the thoracic aorta, heart or major vessels

Question 2

What are the immediate life-threatening chest injuries that require immediate intervention?

Answer 2

Tension pneumothorax
Open pneumothorax
Massive haemothorax
Pericardial tamponade

Question 3

What are the immediate life-saving interventions for patients with chest trauma and what are the indications for each?

Answer 3

Intercostal drain insertion - pneumothorax, haemothorax
Urgent thoracotomy - Pericardial tamponade, diaphragmatic rupture, massive haemothorax with ongoing bleeding
Emergent thoracotomy - penetrating trauma with <10 mins down time
Intubation and ventilation - airway compromise, gross hypoventilation and/or hyperaemia
Severe head injury

Question 4

How can you identify a simple pneumothorax on a supine chest film?

Answer 4

Air collects antero-inferiorly

It’s demonstrated by a deep sulcus sign or increased radiolucency of one side of the chest compared to the other

Question 5

Describe massive haemothorax

Answer 5

Defined as > 1500mls
Causes life-threatening circulatory compromise from hypovolaemia and vena naval compression as well as hyperaemia
Requires immediate chest drain
Ongoing bleeding of >200mls/hr, or >600mls over 6 hours this is an indication for thoracotomy

Question 6

What are the causes of subcutaneous emphysema?

Answer 6

Lung puncture
Tracheobronchial fistula
Oesophageal injury
facial or pharyngeal injury
abdominal or retroperitoneal injury (air tracking upwards)

Question 7

What is the commonest cause of blunt aortic injury?

Answer 7

Severe deceleration injury causing a tear at the junction between the fixed descending aorta and the mobile aortic arch, just distal to the origin of the left subclavian artery

Question 8

How are blunt aortic injuries classified?

Answer 8

Significant injury - disruption of the intimate and full thickness of the media - high risk of rupture
Minimal injury - laceration limited to the intim and inner media - low risk of rupture

Question 9

What is the prognosis in blunt aortic injury?

Answer 9

Poor - most dying at the scene

Of those that reach hospital, at least 50% will die before repair.

Question 10

When should you suspect blunt aortic injury?

Answer 10

When mechanism is compatible with a sever decoration

• high speed MVA >50km/hr
• pedestrian vs car
• motorcycle accident
• fall from > 3 metres

Question 11

What are the CXR finding of blunt aortic injury?

Answer 11

CXR changes are caused by distortion of normal mediastinal contour by periaortic haemorrhage
Widened mediastinum (>8cm)
Obscured aortic knuckle
Opacification of the aortopulmonary window
Deviation of the trachea, left main bronchus or NG tube
Thickened paratracheal stripe

Question 12

How may blunt cardiac injury manifest?

Answer 12

Occurs due to the compression of the heart between the sternum and the spine, abrupt pressure changes within the chambers or deceleration shear injury. Can result in:
Minor ECG and cardiac enzyme abnormalities
Complex arrhythmias
Free wall rupture - usually fatal
Heart failure - may result from gross myocardial injury, spatial rupture or valvular injury
Coronary artery injury

Question 13

Describe tracheobronchial injury

Answer 13

Blunt rupture of the trachea or bronchi results from crush injury or rapid deceleration with shearing between the fixed trachea and the mobile lungs.
The proximal right main bronchus is the most common site of injury

Question 14

How do tracheobronchial injuries present?

Answer 14

Large injuries present with:
respiratory distress
subcutaneous emphysema
haemoptysis

Smaller injuries may be overlooked initially and be suspected where there is a persistent pneumothorax with a large airlock, recurrent pneumothoraces and pulmonary collapse.

Question 15

What is the normal mechanism for diaphragmatic rupture?

Answer 15

Gross abdominal compression from direct vehicular intrusion

The risk is high with lateral impact collisions but not seatbelt

Question 16

Which hemidiaphragm is more likely to rupture?

Answer 16

the left

The right is stronger and protected by the liver

Question 17

What are the symptoms of diaphragmatic rupture?

Answer 17

Non-specific

Bowel sounds may be heard on chest auscultation

Question 18

What are the clinical features of oesophageal injury?

Answer 18

Rare
Chest pain
Dysphagia
Pain on swallowing
Subcutaneous emphysema

Question 19

What are the CXR features of oesophageal injury?

Answer 19

Pneumothorax +/or hydrothorax
Mediastinal emphysema
Widened mediastinum

Question 20

Which chest injuries are markers of high-energy trauma?

Answer 20

1st and 2nd rib fractures
Scapula fracture
Sternoclavicular dislocation

Question 21

What are the causes of cardiovascular collapse on induction of anaesthesia and IPPV in chest-injured patients?

Answer 21

Excess anaesthetic agent
Hypovolaemia
Oesophageal intubation with hypoxaemia
Tension pneumothorax
Pericardial tamponade
Anaphylaxis
Systemic air embolus
Severe blunt cardiac surgery

Question 22

Describe the pathogens like to be the cause of pneumonia in patients following chest injury - early and late

Answer 22

Early onset is likely to be secondary to aspiration at the time of the injury and pathogens include Haemophilus influenza, Pneumococcus and anaerobes
Later onset nosocomial infection is more likely to be due to aerobic Gram negative bacilli and Staph aureus

Question 23

How should you assess the chest of a trauma patient?

Answer 23

Ask - does breathing feel normal?
Look - Look specifically for flail chest - anterior flail may be best seen from the foot of the bed
Chest the axilla and back in penetrating trauma and look at neck veins
Listen for cecreased AE. PTX can manifest as a wheeze
Feel - specifically for crepitus and sc emphysema

Question 24

How should you manage a pneumothorax (pre-hospital)

Answer 24

Options are:

1. Needle thoracocentesis - in peri-arrest situation prior to more formal thoracocentesis, or in resp distress in a trapped pt breathing spontaneously
2. ICD - for pneumothorax in an awake pt
3. Finger thoracostomy - For pts undergoing IPPV, actual or near traumatic cardiac arrest, shocked pts with no apparent cause

Question 25

What are the advantages and disadvantages of needle decompression of the chest?

Answer 25

Advantage: Quick
Disadvantages: Doesn’t facilitate complete lung expansion, cannula easily kinked or obstructed, easily back tracks out of the pleural cavity, many adults have soft tissue deeper than the length or a cannula, may lul you in to a false sense of security that the chest has been dealt with

Question 26

What are the advantages and disadvantages of a pre-hospital chest drain?

Answer 26

Advantage: Definitive
Disadvantages: Has the potential to re-tension - lung or clots may block the drainage holes, drain may kink within the chest, the collecting drain may kink, large airway leaks can rapidly fill the drainage bag

Question 27

What are the advantages and disadvantages of a finger thoracostomy?

Answer 27

Advantages: Can feel the lung expansion, can be re-fingered as required, avoids chest drain and associated risks of re-tensioning from blockage and kinking etc
Disadvantages: Invasive, risk of occlusion, minimal drainage of smaller haemothoraces

Question 28

How should an open chest would be managed (pre-hospital)

Answer 28

3 sided dressings have limited success
If the pt is I+V then just ensure that the wound remains open
If awake then the best solution is to place a formal chest drain away from the wound and place a dressing over the wound.

Question 29

What are the indications for emergency thoracotomy?

Answer 29

Penetrating trauma to the chest or epigastrium who have been in cardiac arrest for less than 10 minutes

Question 30

How should you open the chest in an emergency thoracotomy?

Answer 30

Concurrent intubation and IV access needs should occur
-pre chest - maxiswabs/betedine etc
-sterile gloves should be worn
-bilateral finger thoracostomies - if significant air release reassess pt
-make a broad incision following the 4th or 5th ICS bilaterally - connecting the 2 thoracostomy incisions - through skin and s/c fat
-using finger to guard the lung cut along the wound
-cut across sternum with shears or use gigli saw. Place howard kelly foceps under sterum and use to pass the saw underneath - need to ensure you don’t cause damage with the saw, attach both handles and use smooth sawing action. Take care for the blade rebound.
Extend excision to the posterior axillary line on both sides
Open the chest in a clam shell fashion - 1 person at the head end helps

Question 31

What do you do once you have opened the chest when carrying out an emergency thoracotomy?

Answer 31

Identify the heart
Using forceps lift the pericardium and make a small vertical incision using sterile scissors and extend vertically the length of the heart
Remove any clots with your hands
Inspect for wounds - finger may control bleeding or a careful mattress suture - great care should be taken not to suture any coronary arteries
If myocardial activity doesn’t spontaneously return flick the heart
If still no activity then cardiac compressions should be started
A second person can compress the aorta against the spinal column - in an attempt to reperfuse the coronary arteries
Assess whether the heart is full - IV volume as needed
If myocardial activity is sluggish then 1mg adrenaline should be given, with repeated doses as needed
If resuscitation is successful then there may be bleeding from the internal mammary arteries which should be clamped and the pt may require anaesthesia at this point.

Question 32

How should you perform internal cardiac compressions?

Answer 32

2 handed technique - compress from apex to base

Heart must be kept flat in its bed

Question 33

How should you manage VF in a patient with an thoracotomy?

Answer 33

Coarse VF - position pads as normal and close the chest
Fine VF - continue internal massage until coarse or spontaneous cardiac activity
N.B blood poos may arc