Thoracic Trauma Flashcards by Rebecca Stark

What can result from chest injuries?

Hypoxia, hypercarbia and acidosis

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When does a tension pneumothorax occur?

When a one way valve air leak occurs from either the lung or through the chest wall by blunt or penetrating trauma where the lung parenchymal fails to seal. It can also occur following a misplaced subclavian or internal jugular venous catheter insertion

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What happens when you get a tension pneumothorax?

Air is forced into the pleural space through the one way valve air leak, eventually completely collapsing the lung. The mediastinum is displaced onto the opposite side, decreasing venous return and compressing the opposite lung

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Why does a patient get shock when they have a tension pneumothorax?

Shock results from the marked venous return due to the decreased venous return and compression of the opposite lung. This causes a reduction in cardiac output, leading to obstructive shock

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Is a tension pneumothorax a clinical diagnosis?

Yes, confirmation via X-ray should not be waited for

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What are the signs and symptoms of a tension pneumothorax?

Chest pain
Air hunger
Respiratory distress
Tachycardia
Hypotension
Tracheal deviation
Unilateral absence of breath sounds
Elevated hemithorax without respiratory movement
Neck vein distension
Cyanosis

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How do you treat a tension pneumothorax?

Immediately with either needle decompression or a thoracostomy followed by a chest drain

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What is an open pneumothorax?

Large injuries to the chest wall that remain open/sucking chest wound

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Why does an open pneumothorax cause impaired ventilation?

Air follows the path of least resistance and if the opening to the chest wall is two thirds the diameter of the trachea or larger air will pass through the chest wall with each breath. This will the lead to hypoxia and hypercapnia due to the impaired ventilation

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What is the initial management for an open pneumothorax?

Promptly closing the wound with an occlusive dressing, taped on 3 sides to create a flutter valve as a temporary measure. On inspiration the dressing stops air from entering the chest, during expiration the dressing opens to allow air to escape

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What is the definitive management for an open pneumothorax?

Surgical management

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When does a flail chest occur?

A segment of the chest wall does not have bony continuity because of underlying rib fractures, normally when 2 or more ribs are fractures in 2 or more places, leading to paradoxical chest movement

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What is the biggest challenge in the management of flail chest?

Management of the underlying lung injury to maintain ventilation, mainly through oxygen and analgesia

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What are some examples of types of analgesia that are used for patients with flail chest?

PCA and a paravertebral block

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What is thought to cause pulmonary contusions?

Rapid acceleration or deceleration where the lung tissue collides with the chest wall, causing haematomas to form in the alveolar and lung parenchyma

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If pulmonary contusions are sever what can develop?

Acute Respiratory Distress Syndrome (ARDS)

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What is the management for pulmonary contusions?

Cautious fluid resuscitation, CPAP, invasive ventilation and in extreme circumstances referral for ECMO

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What is a haemothorax?

The accumulation of blood in the hemithorax which can significantly compromise ventilation. Massive acute accumulations of blood may present as hypotension and shock

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What is a massive haemothorax?

Accumulation of 1.5L or one third of the patients blood volume within the chest cavity, commonly caused by penetrating trauma

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How does a patient with a massive haemothorax present?

Patients suffering from severe hypovolaemia

What is the management of a massive haemothorax?

Simultaneous drainage via a chest drain and replacement with rapid infusion of blood products

What do you need to consider if a patient has an output of over 1.5L into the chest drain?

Moving to theatre for a thoracotomy

Why does a chest drain get inserted into a patient?

To allow for the drainage of air or blood from the pleural space to restore haemodynamic and respiratory stability by optimising ventilation/perfusion and minimising mediastinal shift

What kit is required for a chest drain insertion?

Gauze
Skin aseptic solution (iodine or chlorhexidine)
Selection of syringes and needles
Scalpel
Large suture
Chest drain tube (size 28-32 Fr)
Chest drain bottle with an underwater seal
1% lidocaine
Sterile drape
Instrument for blunt dissection (cured clamp)

Should you sedate someone if they are going to insert a chest drain?

Yes, with IV benzodiazepines and opiates

Why should entonox be avoided with patients with a pneumothorax?

It will expand any pneumothorax

Where is the correct position and landmarks for a chest drain?

5th inter coastal space in the mid axillar line, between the safe space: lateral edge of pectoris major and lateral edge of latissimus dorsi, base of axils and 5th intercostal space

Why is a chest drain inserted just above the upper boarder of the rib?

Each intercostal space has a nerve, artery and vein running though it and they lie just under the rib

Why is a chest drain inserted anterior to the mid-axillary line?

The long thoracic nerve runs down the lateral border of the thorax

Is cardiac tamponade caused more often by penetrating or blunt trauma?

Penetrating trauma

How does a cardiac tamponade occur?

The pericardial sac fills with blood following damage to the greater vessels, the heart or the pericardial vessels. The pericardial sac is a fibrous structure and even a small volume of blood may lead to restriction in cardiac activity and cardiac filling

Cardiac tamponade is indicated by which triad?

Becks Triad

What is Becks triad?

Low arterial pressure Distended neck veins Muffled heart sounds

What scan is appropriate to use in diagnosis of cardiac tamponade?

FAST scan

What can blunt cardiac injury result in?

Myocardial contusion Cardiac rupture Coronary artery dissection Valvular disruption

How might a patient who has had blunt cardiac injury present?

With chest discomfort

How can a true diagnosis of blunt cardiac injury be made?

By direct inspection of the injured myocardium, often at post mortem

What are the clinical symptoms of blunt cardiac injury?

Hypotension Dysrhythmias Wall motion abnormality Premature ventricular contractions Unexplained sinus tachycardia Atrial fibrillation Bundle branch block (commonly right) ST-segment changes Elevated central venous pressures

Why do patients with blunts cardiac injuries and ECG changes need to be monitored for 24 hours?

They are at high risk of dysrhythmias

When would a referral to ECMO be appropriate for a patient who has had blunt cardiac injury?

If there is haemodynamic compromise which is not responsive to traditional management

What is a common cause of death following RTCs or falls from height?

Traumatic aortic dissection

When would you have a high index of suspicion for a traumatic aortic dissection as specific signs and symptoms of an aortic dissection are usually absent?

A history of rapid deceleration forces

What could be seen on a chest X-ray if a patient has a traumatic aortic dissection?

Widened mediastinum Obliteration of the aortic knob Deviation of the trachea to the right Depression of the left mediastinum bronchus Elevation of the right mediastinum bronchus Obliteration of the space between the pulmonary artery and aorta Deviation of the oesophagus Widened paratracheal stripe Widened paraspinal interfaces Prescience of the pleural or apical cap Left haemothorax Fractures of the first or second rib

What is the gold standard of diagnosis for a traumatic aortic dissection?

CT imaging

What is the management of a traumatic aortic dissection?

Surgery or IR - either primary repair or resection of the torn segment and replacement with a graft

What are traumatic diaphragmatic ruptures commonly associated with?

Blunt trauma secondary to large tears in the diaphragm which can lead to herniating of the intraabdominal organs

How are diaphragmatic injuries detected

CT scan, often missed on xray

What is the management of diaphragmatic injuries?

Direct repair