Chest Trauma Flashcards
Definition of flail chest:
2 or more contiguous ribs
#d in 2 or more places
When might flail chest be easily missed?
PPV! (Won’t get paradoxical movement.)
Analgesia options for rib fractures:
Titrated opioids
PCA
Regional:
- Serratus anterior/ Erector spinae block
- Intercostal block
- Thoracic epidural
What % of rib #s are detected on CXR?
50%
Evolution of pulmonary contusion:
May not be seen early
Can take >6 hours to be appreciated on CXR. CT will detect early.
Alveolar haemorrhage/oedema/ consolidation worsens over 72 hours, then begins to improve.
—> Deterioration can be rapid and profound
________
Always consider when resp failure in trauma, but CXR unremarkable
Management of pulmonary contusion:
Usual resp support measures
Minimise ongoing haemorrhage/oedema:
Avoid excessive fluids, colloids
Manage coagulopathy
Check for associated injuries
Pulmonary contusion on imaging:
Consolidation
- focal or diffuse
- patchy or confluent
Alveoli filled with blood/oedema
Define ‘massive haemothorax’:
>1500mls (1/3 blood volume- 70/kg adult, 80/kg infant/ 100/kg preg/neonate)
- at drain insertion
- or first 3 hours
OR
>200mls/hr for 3 hours
(3ml/kg/hr)
Is indication for thoracotomy
Types of blunt myocardial injury:
Contusion
Commotio cordis (cardiac concussion)
Traumatic AMI (coronary vessel injury)
Rupture
Valve/ chordae avulsion
Haemopericardium/ tamponade
Thrombi
Suspect in:
- Ongoing tachycardia
- Any new ECG change
Mechanism of traumatic asphyxia:
Prolonged compression to thorax
Vena cava compression
—> venous congestion to thorax and head
—> Cerebral hypoxia
See:
- Head/ neck cyanosis
- Conjunctival and retinal haemorrhage
- Petechiae
Tracheobronchial injury:
Usually:
- Close to carina (within 2cm)
- Lobar bronchi origin
Air where it shouldn’t be:
(pleura, mediastinum, soft tissues)
CLINICAL:
- Pneumothorax
–> Will present as PERSISTING AIR LEAK despite chest tube in good position
- Pneumomediastinum
–> Hamman’s Crunch
- Subcut emphysema
- Haemptysis
- Hoarse/ aphonia
DIAGNOSIS:
- CT
- Bronchoscopy definitive
MANAGEMENT:
- Fibreoptic intubation —so don’t disrupt injury further
–> May selectively intubate if distal injury
- Surgical
What is Hamman’s crunch?
Audible creps synced with HEARTBEAT, not with resps.
= pneumomediastinum
Most common site of traumatic oesophageal rupture:
Lower 1/3
Diaphragmatic rupture:
Often missed or detected late
Almost all L sided
Classic XR findings only present HALF the time:
- Elevated hemidiaphram
- Abdo contents in chest
- NGT in chest
CLINICAL:
- Hemithorax not moving
- Dull percussion
- Bowel sounds in chest
_______
Remember as DDx before inserting chest tube for ‘pneumothorax’
What chest injuries are easily missed and may be delayed diagnoses:
Diaphragmatic rupture
Tracheobronchial
Pulmonary contusion (XR)
Normal mediastinal width:
<8cm at the arch
<25% chest width (at mediastinum)
ON A PA FILM
Role of troponin in blunt cardiac injury:
Can rule out significant BCI when combined with ECG showing no new changes.
Role completely unclear beyond this!
Management of a sucking chest wound:
Open PTx.
Small wound won’t suck
Larger wounds will- path of least resistance
If sucking, and NOT blowing (or signs of tension):
- First aid: leave open
THEN
- Occlude wound (NO evidence for 3-way)
WHILE
- Chest drain
If sucking and blowing:
- Treat as any other PTx/ wound
- ie. Occlude wound, insert chest drain
GENERAL APPROACH to major chest trauma:
EXAMINE:
- Plethora, conjunct haemorrahge (traumatic asphyxia)
- Tracheal deviation
- Distended neck veins
- Subcut emphysema
- Muffled heart sounds
- Hamman’s crunch
- Paradoxical breathing (flail)
- Unequal chest movement (diaphragm rupture, tension, HTx)
- Sucking wound (open +/- tension)
- Resonant/ dull breath sounds (diaphragm rupture, PTx, haemoTx)
- Pulsus paradoxus
- Radio-radial delay
INVESTIGATE:
- Immediate CXR, erect if poss
- eFAST
- ECG (BCI)
- Gas
- Troponin
–> CT with contrast (if stable) +/- angio
Indications for EMERGENCY (not resusc) thoracotomy:
> 1500ml/>200ml/hr 3 hours ICC
Tracheobronchial injury (persisting large air leak)
Oesophageal injury
Diaphragm rupture
Tamponade (stable enough for OT)
Vascular injury
Traumatic loss of chest wall
ECG in myocardial contusion:
Sinus tachycardia
Ectopics
Non specific STE
Arrythmia
