Chest trauma

Question 1

List the goals of ED resuscitative thoracotomy.

Answer 1

• Open the chest
• Identify the phrenic nerves
• Open the pericardial sac - deliver the heart
• ? stop here?!
• Repair obvious injuries? - suture, staple, foley catheter, finger
• Cross-clamp aorta?
• Hilar twist?
• Open cardiac massage?

Question 2

List the indications for ED resuscitative thoracotomy in BLUNT trauma.

Answer 2

• Signs of life on arrival
  
  • Measurable BP
  • Palpable pulse
  • Obvious cardiac rhythym - USS or electrical
  • Respiratory effort
  • Cardiac echo w/ tamponade
• <10mins of CPR

Question 3

List the indications for ED resuscitative thoracotomy in PENETRATING trauma.

Answer 3

Signs of penetrating trauma to the cardiac box PLUS

• <10mins CPR
• Signs of life

Question 4

List the CONTRAINDICATIONS for ED resuscitative thoracotomy.

Answer 4

• >10mins CPR
• Nil signs of life at scene or in ED
• System or logistical reasons -> eg nearest cardiothoracic centre a long way away.

Question 5

Give 6 indications for placement of an ICC for any PTX.

Answer 5

1. Traumatic PTX (exc’g apical, asymptomatic PTX)
2. Moderate or large PTX
3. PTX inc’g in size despite conservative mgt
4. PTX w/ HTX
5. Bilateral PTX
6. Symptomatic PTX
7. PTX and pat’t requiring I+V and/or GA
8. Aeromedical retrieval
9. Tension PTX

Question 6

List 5 indications for thoracotomy.

Answer 6

1. Initial drainage of >20ml/kg blood from ICC
2. >7ml/kg blood drainage persistently
3. Increasing HTX on CXR
4. Ongoing shock despite other haemorrhage excluded
5. Patient decomp’n after initial resus

Question 7

List ECG findings that suggest traumatic myocardial injury.

Answer 7

• Sinus tachycardia
• RBBB
• AEBs
• VEBs
• AF
• VF
• VT

NB - commonly normal ECG

Question 8

List 5 factors that are unfavourable wrt to EDT in penetrating cardiac trauma.

Answer 8

1. Gunshot wounds
2. Multiple chamber involvement
3. Injury to:
   
   1. LV
   2. Great vessels
   3. Coronary arteries
4. Multiple wounds

Question 9

List 5 factors that are favourable wrt to EDT survival in penetrating cardiac trauma.

Answer 9

1. Isolated RV involvement
2. Single wound
3. Stab wound (cf gunshot)
4. SBP >50mmHg in ED
5. Presence of cardiac tamponade

Question 10

What are the radiographic parameters for widened mediastinum?

Answer 10

• >6cm upright PA
• >8cm supine AP
• >7.5cm at aortic knob
• Mediastinal width:chest width > 0.25 at level of aortic knob

Question 11

List ten features on CXR that suggest aortic dissection.

Are these signs sensitive?

Answer 11

1. Widened mediastinum
2. Loss of aortic knob
3. Loss of AP window
4. Widened paraspinal stripe
5. Widened paratracheal stripe
6. (L) pleural effusion or HTX
7. Depression of the angle of the (L) main bronchus below 40degs
8. (L)sided deep sulcus sign
9. (R)-sided mediastinal shift
10. Pleural capping

Up to 45% of patients with dissection may have normal CXR -> all are poorly sensitive signs.

Question 12

Give a differential of widened mediastinum on CXR.

Answer 12

• Traumatic aortic dissection
• Thoracic vertebral #
• Mediastinal mass
• Great vessel abnormality
• Pneumo/haemomediastinum
• Atelectasis or lung mass abutting the mediastinum

Question 13

List the 5 most common causes of oesophageal rupture.

Answer 13

1. Iatrogenic
2. FB
3. Caustic burns
4. Blunt or penetrating trauma
5. Boerhaave’s syndrome -> emesis induced
6. Post-op anastamotic breakdown

Question 14

List 6 causes of oesophageal rupture.

Answer 14

1. Iatrogenic
2. Post-anastamotic breakdown
3. Trauma - penetrating/blunt
4. Caustic burns
5. FBs
6. Spontaneous rupture -> Boerhaave’s Syndrome

Question 15

List 8 conditions that may mimic oesophageal rupture.

Answer 15

1. PE
2. PTX
3. Spont pneumomediastinum
4. Pneumonia
5. MI
6. Aortic dissection
7. Cholecystitis
8. Pancreatitis
9. PUD