Chest Trauma

Question 1

Why is CT becoming much more frequently used to diagnose chest trauma?

Answer 1

• Short scanning times
• Increased sensitivity and specificity compared to other modalities:- Chest radiographs for example are only able to detect the full extent of injuries in 29% of cases
• Indications for scanning is being mechanism/protocol driven. (consider what this means)
• Eliminates false positive findings. These are commonly identified on CXR as suspected great vessel injury when really they are not.

Question 2

How is minor chest trauma defined?

Answer 2

Minor – may involve cracking a rib or 2 – does not require a CXR as the demonstration of a # will not alter patient management

Question 3

How is moderate chest trauma defined?

Answer 3

Moderate – will require a CXR to demonstrate complications of rib #s. Defining the boundaries minor and moderate categories depends on clinical assessment and judgement

Question 4

How is major chest trauma defined?

Answer 4

Major – encompasses manifestly dangerous injuries in patients who may have vascular instability or respiratory complications. They may be multiply-injured or unconscious

Immediately life threatening —————–Delayed deterioration

Question 5

When are rib fractures dangerous?

Answer 5

• 1st or 2nd rib fractures require a high force, so 30% of patients die from what caused the fracture(s)
• 8th-12th rib fractures may cause damage to underlying structures - liver, spleen, kidneys

Question 6

What are the signs and symptoms of rib fracture?

Answer 6

Pain and tenderness
Chest wall instability
And as seen above subcutaneous emphysema

Question 7

What is subcutaneous emphysema?

Answer 7

Air is trapped in the layer of skin of the chest wall. Also known as surgical emphysema.

Question 8

What is flail chest?

Answer 8

Two or more adjacent ribs are broken in two or more places, producing a free floating chest wall segment.

Produces paradoxical movement, where loose part of chest wall moves inwards on inspiration and outwards on expiration (causing mediastinum to move with each breath)

Question 9

What is a simple pneumothorax?

Answer 9

Air in the pleural space with partial or complete lung ‘collapse’.

Question 10

What causes a simple pneumothorax?

Answer 10

• Chest wall penetration
• Rib fracture
• Spontaneous

Question 11

What are the signs and symptoms of a simple pneumothorax?

Answer 11

• Pain on inhalation
• Dyspnoea (difficulty breathing)
• Tachypnoea (fast breathing)

Question 12

What is an open pneumothorax?

Answer 12

• Opening in chest wall that allows air to enter pleural cavity
• Causes the lung to collapse due to increased pressure in pleural cavity
• Can be life threatening and can deteriorate rapidly

Air enters pleural cavity through hole on inhalation, so pressure increases with every inhalation until the lung can no longer inflate.

Question 13

What are the signs and symptoms of open pneumothorax?

Answer 13

• Dyspnoea
• Sudden sharp pain
• Subcutaneous emphysema
  
  • • Air collects in subcutaneous fat from pressure of air in pleural cavity
  • • Crackles
  • • Can be seen from head to groin area
• Decreased lung sounds on affected side
• Red bubbles (frothy blood) from wound on exhalation

Question 14

What is the first line treatment for open pneumothorax?

Answer 14

• ABC’s with c-spine control as indicated
• High Flow oxygen
• Listen for decreased breath sounds on affected side
  Apply occlusive dressing to wound

Question 15

What is a tension pneumothorax?

Answer 15

• One way valve forms in lung
• Air enters pleural space and gets trapped
• Pressure rises collapsing lung and pushes heart and trachea away from injured side (heart will also be compressed)
• Vena cava becomes kinked and blood cannot return to heart and cardiac output falls

Question 16

What are the signs and symptoms of tension pneumothorax?

Answer 16

• Dyspnoea
• Restlessness
• Decreased breath sounds
• Hyperresonance to percussion
• Cyanosis
• Decreasing BP
• Tracheal shift
• Jugular vein distension

Question 17

What is the initial treatment for tension pneumothorax?

Answer 17

Needle decompression:
Locate 2-3 Intercostal space midclavicular line
Cleanse area using aseptic technique
Insert catheter (14g or larger) at least 7.5cm in length over the top of the 3rd rib
Remove stylette and listen for rush of air
Place flutter valve over catheter
Reassess for improvement

Question 18

What is a haemothorax?

Answer 18

• Blood in pleural space
• Result of major chest wall trauma
• Found in 70-80% of penetrating and major blunt chest trauma

Question 19

What are the signs and symptoms of haemothorax?

Answer 19

• Rapid weak pulse,
• Cool clammy skin,
• Thirst,
• Chills,
• Hypotension,
• Collapsed neck veins,
• Decreased breath sounds,
• Dullness to percussion,
• Dyspnoea

Question 20

What is cardiac tamponade?

Answer 20

• Rapid accumulation of blood in the space between the heart and the pericardium
  
  • • Fluid can build up between layers of the pericardium as a result of infection, however cardiac tamponade refers to the effect of this accumulation on cardiac output
• Heart is compressed and blood entering heart decreases and cardiac output falls

Question 21

What is Beck’s Triad?

Answer 21

The three signs of cardiac tamponade:

• Hypotension - due to decreased stroke volume
• Increased Juggular Venous Pressure (JVP) - less blood in atrium, so blood backflows through the vena cava and juggular veins are distended
• Weak/distant heartbeat - fluid around the heart makes it difficult to hear/muffles the sounds

Question 22

What is pericardiocentesis?

Answer 22

A needle is inserted into the pericardium to aspirate (draw fluid by suction) the blood from the pericardial space/sac.

Question 23

What is aortic rupture?

Answer 23

The heart essentially hangs from the aortic arch like a pendulum, so when enough motion is applied (e.g. vehicle rapidly decelerating, fall, animal kick), the heart may rupture away from the aorta. Chances of survival are very slim. If the aorta is completely transected, then the patient will die instantly, but if there is just a small tear, they may survive.

Question 24

What is a traumatic aortic aneurysm?

Answer 24

There is shearing force on a point where the pulmonary artery joins the aorta.

The pseudoaneurysm may form when the rupture does not go through every layer of the arterial wall, blood collects between the tunica adventitia and the muscularis.