Management of blunt thoracic trauma

Question 1

High-risk mechanism of injury for blunt thoracic trauma

Answer 1

• Fall from >6m
• RTA with partial or complete ejection from the vehicle or death of a passenger in the same compartment
• Collision with pedestrian or cyclist
• Motorcycle collision >20mph

Question 2

Useful bedside imaging options for blunt thoracic trauma

Answer 2

• Portable CXR: PTX, haemothorax (>200ml), widened mediastinum
• FAST scan: PTX, haemothorax, pericardial collections

Question 3

Emergency management of a tension pneumothorax

Answer 3

• Pleural decompression with a finger thoracostomy in the safe zone
• Followed by insertion of an intercostal chest drain and connection to an underwater seal

Safe zone: anterior is the lateral border of pec major, posteriorly by the lateral border of lat dorsi, inferiorly by the 5th ICS and superiorly by the axilla

Question 4

Emergency management of a massive haemothorax

Answer 4

• Insertion of a wide bore (24Fr) intercostal drain
• If initial drainage is >1.5L or ongoing output is >200ml/hr for 2-4hr then this should prompt emergency thoracotomy

Question 5

Emergency management of flail chest

Answer 5

• Occurs when 3 or more ribs are broken in 2 or more places
• Need NIV/ HFNO/ Mechanical ventilation
• Need good analgesia to allow effective ventilation: PCA, Ketamine, Regional catheters
• Consider surgical fixation within 72 hours

Question 6

Emergency management of cardiac tamponade

Answer 6

• Beck’s triad: hypotension, muffled heart sounds and a raised JVP
• ECG- low QRS complexes electrical alternans
• Stabilise with IV fluids and blood products
• Should be transferred to operating theatre only consider needle pericardiocentesis if in extremis

Question 7

When should a resuscitative thoracotomy be considered

Answer 7

• After 10mins of CPR if no ROSC in patients with cardiac arrest secondary to thoracic traumatic injury

Question 8

Management of pulmonary contusions

Answer 8

• HFNO
• Early ambulation, chest physio, analgesia optimisation
• Avoid fluid overload

Question 9

Management of tracheobronchial injury

Answer 9

• Airway management with the ETT sitting distal to the injury if possible
• This may require ATI, asleep fibreoptic intubation or tracheostomy insertion
• VV-ECMO

Question 10

Management of bronchopleural fistula

Answer 10

• A persistent air leak due to a communication between the bronchi and pleural cavity
• Will require one lung ventilation if issues with ventilation
• Vent strategies: tidal volume 4-6ml/kg, low PEEP, permissive hypercapnia, wean to spont mode if able
• VV-ECMO

Question 11

Management of blunt cardiac injury

Answer 11

Includes: myocardial contusion, conduction abnormalities, coronary artery injury, valve injury, pericardial tears and cardiac rupture

Will require prompt surgical intervention

Question 12

Management of oesophageal injury

Answer 12

• Generally very rare will present with haematemesis, hoarse voice, haemoptysis or subcutaneous emphysema
• Should be surgically managed
• In the meantime protect the airway, NG tube only under direct endoscopic guidance, IV antibiotics and pleural drainage.

Question 13

Management of diaphragmatic injury

Answer 13

• Unusual, occurs when there is energy transfer to the abdomen rising pressure significantly and causing rupture
• Commonly occurs on the left
• Surgical repair