Thoracic Trauma

Question 1

In the trauma patient what is one of the most common causes of loss of breath sounds in the left thorax?

Answer 1

Right mainstem bronchus intubation

Question 2

What cause of obstructive shock must be cautioned against in patients mechanically ventilated with PEEP and a visceral pleural injury?

Answer 2

Tension pneumothorax

Question 3

What are signs and symptoms of tension pneumothorax?

Answer 3

Chest pain, tachypnea, “air hunger”, hypotension, distendedneck veins, loss of breath sounds, tracheal deviation away from injured side, tachycardia, elevated hemithorax without respiratory movement, cyanosis

Question 4

How can tension pneumothorax and cardiac tamponade be distinguished?

Answer 4

Tension pneumothorax has absent breath sounds, tracheal deviation, and hyprerresonant percussion

Question 5

What is immediate management of a tension pneumothorax and where does placement occur?

Answer 5

Needle decompression

Mid-clavicular line and 2nd intercostal space (try to be right above a rib to avoid neurovascular bundle)

Question 6

How should an open pneumothorax (sucking chest wound) be managed?

Answer 6

Immediately secure the opening and tape it down on 3 sides

Question 7

What is treatment for flail chest?

Answer 7

Adequate oxygenation, careful fluid resuscitation, and analgesia to improve ventilation

Question 8

How can tension pneumothorax and massive hemothorax be differentiated on exam?

Answer 8

Tension ptx is hyperresonant and hemothroax is dull

Question 9

How is massive hemothorax immediately managed?

Answer 9

Control bleeding and fluid resuscitate. Place a chest tube at nipple level (4th or 5th IC space) just anterior to mid-axillary line. Next, assess patients continual blood loss and physiologic status for possible need for thoracotomy

Question 10

What is Beck’s triad? What are Kussmaul signs?

Answer 10

Elevated venous pressure (distended neck veins), reduced arterial pressure, muffled heart sounds

Kussmaul sign: rise in venous pressure with inspiration

Question 11

What may be immediate treatment of cardiac tamponade? What is the definitive management?

Answer 11

Immediately a pericardiocentesis can be diagnostic and therapeutic but all patients will require a pericardial window to assess

Question 12

Should anesthesia or PEEP be used on PTX patients?

Answer 12

No, unless they have a chest tube already in place

Question 13

What chest tube outputs should lead to consideration of operative exploration of a hemothorax?

Answer 13

> 1500 cc fluid evacuated
200 cc/hr for 2 to 4 hrs
Compromised hemodynamic status

Question 14

A trauma patient has a chest tube placed but you fail to see adequate re-expansion of the lung. What should you suspect?

Answer 14

Tracheobronchial injury

Question 15

What is the definitive tool for diagnosis of a tracheobronchial injury? What is definitive treatment?

Answer 15

Dx: Bronchoscopy
Tx: Surgery

Question 16

You see a trauma patient and notice elevated CVP with no obvious cause. You look at the 3-lead monitor and notice multiple PVCs. What diagnosis are you considering?

Answer 16

Blunt cardiac injury

Question 17

What are radiographic signs of a traumatic aortic disruption?

Answer 17

Widened mediastinum
Obliterated aortic knob
Tracheal or esophageal deviation to right
Loss of aorticopulmonary window
Elevation of right mainstem bronchus
Depression of left mainstem bronchus
Left hemothorax
Widened paratracheal stripe
Widened paraspinal interfaces
Presence of pleural or apical cap
Fractures of 1st or 2nd rib or scapula

Question 18

What is the diagnostic tool of choice for a possible blunt aortic injury? What do you use if the results are equivocal?

Answer 18

Helical CT

If equivocal: aortography

Question 19

You place chest tube in a patient and notice small particulate matter evacuated after the fluid. The patient seems to be in disproportionate pain. What is the likely dx?

Answer 19

Blunt esophageal rupture

Question 20

Why should you be concerned if a patient presents with fracture of ribs 1-3?

Answer 20

It takes a large magnitude of injury to damage those since they’re guarded by bony structures of UEs. The level of magnitude needed to cause damage may place head, C-spine, and vasculature at risk

Question 21

What is a central tenet of managing the patient with rib fractures and why?

Answer 21

Adequate analgesia to ensure good ventilation. Without analgesia they may take shallow breaths and develop atelectasis