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Ed fellowship--trauma > Thoracic trauma > Flashcards

Thoracic trauma Flashcards

1
Q

Discuss pathophysiology of oesophageal rupture

A

Perforation can occur in the upper, cervical, mid or lower oesophagus

Perforation in the upper and cervical region enter the retropharyngeal space and tissue planes extend from the base of the skull to the bifurcation of the trachea

Midoesophagus and lower enter directly into the mediastinum. As there is no serosal covering to the oesophagus the only barrier is that of the thin mediastinal parietal pleura. This is commonly overcome by copious drainage, massive inflammaotry reaction induced by chemical and bacterial mediastinitis. Once ruptured the -ve pressure of the pleura tends increase soilage

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2
Q

Discuss Boerhaaves syndrome

A

Effort rupture of the oesophagus is associated with high mortality and is universally fatal without treatment

Spontaneous rupture of the oesophagus that occurs with rapid increase in eosophageal pressure combined with -ve intrathroacic pressure - vomiting or severe strainign

Usually occurs in patient with a normal oesophagus – however those with barretts, eosinophilic oesophagitis and medication induced oesophagitis are at risk

The posterior left portion of the oesophagus is intrinsically the weakest portion and is the most common area of perforation

More than 80% occur in middle aged men who have ingested a large meal and ETOH

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3
Q

Discuss clinical features of boerhaaves syndrtome

A

Depends on rupture site

Mid or lower thoracic tends to present with severe retrosternal pain. Subcutaneous emphysema is common. May hear a systolic crunching sound on ausculation of the heart due to mediastinal air ( Hamman’s Crunch)

Clinical signs : odynophagia, dyspnea, and sepsis and have fever, tachypnea, tachycardia, cyanosis, and hypotension

Cervical rupture is rare for boerhaaves and has a more benign course. PResent with neck pain, dysphagia, dysphonia. Tenderness to palpation on the sternocleodomastoid with subcut emphyesema

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4
Q

Discuss IX of boerhavves syndrome

A

CXR may show medistinal emphesema, pleural effusion

CT cannot localise perf but shows oedema, gas in medistinum

Upper endoscopy controversial as endoscope with insullfation can worsen perforation

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5
Q

Discuss management of Boorehaves

A

Due to high mortality not only those with HD instability but any wiht signifiacnt co-morbidities should be admited to ICU for monitoring

Initial management incluedes
●Avoidance of all oral intake

●Nutritional support, typically parenteral

●Intravenous broad spectrum antibiotics

●Intravenous proton pump inhibitor

●Drainage of fluid collections/debridement of infected and necrotic tissue, if present

For well contained ruptures medical management may be sufficient

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6
Q

Discuss causes of oesophageal perforation

A

Iatrogen – most common cause

  • -Endoscopy is commenst, improved since flex scope introduced however more precedures so absolute number increased, Usually cervical rupture
  • ED intubation with nasotracheal or naso gastric intubation at the pyruiform sinus

Foriegn bodies:

  • Usually cervical – gets caught ar cricopharyngeal narrowing is the smallest region in the infants airway
  • after 4 most objects pass this region

Caustic burns

  • bimodal distribution 1-5 years old accident and usually small amount due to poor taste
  • adolesent and young adult sucide attempt
  • alkali much more likley to cause perf due to liquofactive necrosis as apposed to coagulated necrosis with acid

Penetrating and blunt trauma: Due to its position traumatic oesophageal injury is rare and is often not isolated if idt does occure

Spont rutpture

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7
Q

Discuss DDX of perf oesophagus

A 
Spont pneumomediastinum 
aortic aneurysm 
Pulmonary embolus 
Perforated peptic ulcer 
Myocardial infarction 
Pancreatitis 
esenteric thrombosis 
Cholecystitis 
Pneumonia
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8
Q

Define flail chest

A

Three or more adjacent ribs are fractured at two points allowing a free segment of chest wall to move in a paradoxical movement.

Can also occur with vertical sternal fracture + rib fractures

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9
Q

Discuss the improtance of rib fracture 1-3 and 9-12

A

1-3 are short and well protected – fractures indicate a large force and potentional for underlying vascular injury

9-12 are longer and more mobile at the anterior end. Making them more resistance to fracture – Fractures of these ribs are asscoiated with intra-abdominal injury

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10
Q

Discuss investigation of suscpected rib fracture

A

Plain CXR will only identify about 50% of single rib fractures. – its greatest value is in identifying or excluding more significant intrathoracic injury

CT chest is modality of choice if further investigation is requried. –

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11
Q

Discuss Nexus for CT chest

A

NEXUS tool for indication of CT - sensitivity of 95.4% and NPP of 93.9 – for major injury both approached 100%

Any of the following merit CT chest

  • Abnormal CXR
  • Rapid deceleration mechanisms
  • Distracting painful injury
  • chest wall tenderness
  • sternal tenderness
  • Thoracic spine tenderness
  • Scapular tenderness
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12
Q

Discuss management of rib fractures

A

ABCD - with correction of obvious underlying pathology such as haemopneumothorax prior to intuabtion \

Adequate pain relief is key for treatment of ribfractures to prevent atelectasis and infection
Continuing daily activities and deep breathing should be emphasised
- Advise patient to wait 30-45 minutes after pain relief prior to activity or incentive spirometry
Paravertebral + erecta spinae block

The greater the number of rib fractures the greater the mortality
-hospitalisation should be considered for all patient with 3 or more rib fractures

Flail segments should be treated operatively

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13
Q

Discuss complications of rib fractures

A 
Haemopneumothorax
atelectasis 
pulmonary contusion 
pneumonia 
Post traumatic neuroma 
empyema
non union 
costochondral separation
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14
Q

Describe the types of pneumothorax

A

SImple: - a pneumothorax is considered simple when there is no comminocation with the atmosphere or any shift of the mediastinum

Communicating: associated with a defect in the chest wall. Sucking chest wound is seen. – This chest wall defect leads to paradoxical collapse on insipration and slight expansion on expiration leading to a marked increase in dead space.

Tension: Progressive accumulation of air under pressure within the pleura with shift of the mediastinum to the opposite hemithorax and compression of the contralateral lung and great vessels

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15
Q

Discuss the management of simple pneumothorax

A

Small penumothoraces can be monitored – conservative management of primary spontaneous pneumothorax was noninferior to interventional management, with a lower risk of serious adverse

If indicated ICC should be inserted. Smaller french for spontaneous or isolated injury – larger if indicated for signfiicant trauma where haemothorax is likley. IF not resolving due to large air leak or haemothorax suction can be applied to 20-30 cm H20

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16
Q

Discuss indication for tube thoracostomy

A
  • Traumatic cause of pneumothorax (except for asymptomatic, apical)
  • Moderate to large pneumo
  • Respiratory symptoms regardless of size
  • Increase size of pneumothorax after intitial conservatve therapy
  • Recurrence of pneumo after removal of an initial chest tube
  • pateitn requries ventilator support
  • patient requires general anaethesia
  • asscoiated haemothorax
  • bilateral pneumothorax regardless of size
  • tension
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17
Q

Discuss complciations of tube thoracostomy

A

– Formation of haemothorax
–pulmonary oedeam
-bronchoplueral fistula
pleural leaks
-empyema
-subcut emphyesema
-infection
-intercostal artery laceration
-contralateral pneumo
-direct parenchymal injury

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18
Q

Discuss management of comminciating pneumo

A

Three way occlusive dressing out of hospital

ICC and closure of defect

19
Q

Discuss management of tension

A

If suspected place a large bore (14) catheter at least 5 cm in length through the fourth or fifth interspace laterally or the second or third itnerpace anteriorly

May be just as expeditious in the ED to insert a chest drain or to perform a finger thoracostomy

20
Q

Discsuss haemothorax

A

Accumulation of blood in the pluearl space after blunt or penetrating chest trauma that may produce hypovolameic shock

Upright CXR is the diagnostic tool of choice - BLunting of the costophrenic angle requires at least 200-300 mls of fluid.
Large haemothorax can lead to tension haemothorax

21
Q

Discuss management of haemothorax

A

Restoring circualting blood volume, controlling the airway as necessary and evacuating the accumulated blood.

Tube thoracostomy allows contsant monitoring o fhte blood loss.
Severe or persistant haemorrhage requires thoracostomy or open thoracotomy.

Autotransfusions has been used successfully in tube thoracostomy . This eliminates the risk of incompatibilyt reaction and transmission of certain disease.

Initial output of more than 1.5Litres or ongoing output of at least 200ml/hour are indications for thoractomy

22
Q

Discuss indications of thoractomy

A
  • Initial thoracostomy tube dranage is more than 20ml/kg
  • Persistent bleeding at a rate greater than 7ml/kg/hr
  • Increase haemothorax on CXR
  • Patient remains hypotensive despite adequate blood replacement - and other sites of blood loss have been excluded
  • patient decompensates after initial response to resus
23
Q

Discuss tracheobroncial injury

A

May occur with blunt and penetrating injury
Associated mortality of 10%

Clinical features

  • massive airleak through a chest tube
  • haemoptysis
  • dramatic increase in subcut emphysema
  • Hammans crunch is a crunching rasping sound that is sycnhronous with the pulse and is best heard over the precordium

Patients with tracheobronchial injury have one of two clinical pictures

1) the wound opens into the pleural space producing a large pneumothorax that is not resolved with ICC
2) there is complete transection of the tracheobronchila tree but little to no communication with pleura – the peribronchial tissue maintian the airway enought to maintain respiration – initial relativley symptom free but weeks later thye have unexplained atelectasis or pneumonia

24
Q

Discuss IX of suspected tracheobronchial injury

A

CXR
CT
flexi bronch

25
Q

Discuss management of tracheobronchila injury

A

If bronch is performed as an IX intubation can be performed over the scope
Blind intubation should not be attempted
If using video or traditional laryngoscopy the ETT should be advanced slowly for fear of creating a flas passage or converting a tear to complete

26
Q

Discuss pathophysiology of diaphragmatic rupture and herniation

A

Herniation of abdominal structures into the thoracic cavity with a potential risk of strangulation of abdominla viscera especially if small bowel is involved.

75% of cases of diaphragmatic rupture secodnary to blunt trauma occur on the left presumably due to the protection offered by the liver

CT scan folks for blunt trauma
Penetrating lesions should have thoracsopy or laparoscopy to insure that the diaphragm does not need repair

Need surgical intervention for treatment – laparoscopy and thorascopy

27
Q

Discuss myocardial concussion (commotio cordis)

A

Describes an acute form of blunt cardiac trauma that is usually produced by a sharp direct blow to the midanterior chest that stuns the myocardium and results in a brief dysrhythmia, hypotension and LOC. It is a rare event

More likley to occur if the impact occurs during early ventricular repolarization. Once this dysrhythmia occurs it can result in a non perfusing rhythm

Nil underlying structural damage

ALS algorhithm
Dispotion if ALS is successful and nil underlying structural damage is for observation

28
Q

Discuss myocardial contusion

A

Manifests clinically as a spectrum of injuries of varying severity.
Majority will have external signs of injury (contusions, abrasions, palpable crepitus, rib fractures or visible flail segment)

Most common sign of myocardial contusion is simple tachycardia

29
Q

Discuss ix of myocardial contusion

A

ECG: - Due to anterior position in the thorax and proximity to the sternum the RV is more likley to be involved. – Sublte changes missed even on right side – can show dysrhythmia or conduction disturbance or ischamia – Dysrythmias can be delayed up to 12-72 hours
ECG finding include ST or T wave changes anteriorly, heart blocks, incomplete RBBB and inferior q waves

Cardiac biomarkers
CK-unreliable
TNI- can indicate tissue involvemetn

-ve ecg and TNI has a NPV great enough to exclude myocardial contusions

30
Q

Discuss management of myocardial contusions

A

Treatment of suspected myocardial contusion is similar to that of a MI -
ABCD

Dysrythmias treated as per ACLS algorithm
Aspirin and thrombolytics are contraindicated in patient with acute trauma
MI assoicated with trauma should be ideally treated with PCI

Judicious fluid bolus (250mls) is indicated for depressed CO in cardiac contusions – if unsuccessful dobutamine is pressor of choice

Intra-aoritc balloon pumps have been shown to be affective in patient with cardiogenic shock – but need to exlude other causes of shock in trauma patient

Warrant observation if signs are present. Signifiacnt TNI or ECG warrant ECHO and cardiology input

31
Q

Discuss myocardial rupture

A

Almost universally fatal
Refers to an acute traumatic perforation of the vetnricles or atria – also incompasses rupture of the interventricular septum, interatrial septum, chordae, papillary muscles and laceration cornonary vessles.

RV most common chamber rupture
Assocaited with significant other injuries

The ability of patient to survive rupture depends on an intact pericardium – in those who do have an intact pericardium the development of haemopericardium and tamponade will develop often after only a brief period

The usual presentation of a patient with a myocardial rupture is usually that of cardiac tamponade or severe haemorrhage.

Bedside ultrasound may facilitate early diagnosis of rupture or tamponade physiology
The combination of increased JVP and shock in trauma should immediatly raise concern for tamponade or tension. If cocurrent injuries are present JVP distention may not be present

32
Q

Discuss the managementof myocardial rupture

A

ABCD
Imediate action to decompress the pericardial tamponade – needle pericardiocentesis is a diagnositc and temporising measure but will not address underlying issue
Emergent thoracotomy in the ED and pericardiotomy may be indicated – stabalisation of the rupture and transfer to theatre

33
Q

Discuss penetrating cardiac trauma

A

Mortality rate of patient who survive until hospital is 80%
RV most commonly affected due to its anterior position
coronary arteries are lacerated in 5% of cases which can lead to clinical MI

Two presentation

    • rapid exanguination if communicating with pleural
    • haemopericardium and tamponade if contained by the pericardium
34
Q

Discuss indications for ED thoractomy

A

REQUIREMENTS

  • ETT
  • shock or arrest with a suspected correctable intrathoracic lesion
  • specific diagnosis (cardiac tamponade, penetrating cardiac lesion or aortic injury)
  • evidence of ongoing thoracic haemorrhage
  • access to surgeons

Penetrating trauma

  • cardiac arrest at any point with intial signs of life in the field CPR >15min
  • systolic BP below 50mmhg after fluid resus
  • severe shock with clinical signs of cardiac tamponade

Blunt
- cardiac arrest in the ED – do not do if pulseless on arrival to the ED

35
Q

Discuss acute pericardial tamponade

A

Approximately 2% if patient with penetrating trauma to the chest and upper abdomen. Rarely seen in blunt trauma

As little as 60-100mls of fluid acutely can impair ventricular filling and reduce CO
several compenstatory mechanisms arise including increased HR and increased TPR

36
Q

Discuss clinical finding of pericardial tamponade

A

Initially can be deceptively stable if the rate of bleeding into the pericardial space is slow or if the wound allows intermittent decompression.

Physical finding known as Becks triad include, hypotension, distended JVP and muffled heart sounds

There are three distinct clinical pictures seen with pericardial tamponade

1) Haemorrhage is contact to the pericardial space – initiall normotensive with tachycardia and elevated CVP – go on to develop hypotension and tamponade
2) significant haemorrhage outside of the sac will lead to hypovolaemic shock
3) intermittent decompressing tamponade due to intermittent haemorrhage from the intrapericardial space – assocaited with better survival than 1 or 2

Pulsus paradoxus: an excessive drop in syhstolic BP during inspiratory phase may be a sign of tamponade

37
Q

Discuss IX of pericardial tamponade

A

US - enables rapid accurate and noninvasive diagnosis of pericardial tamponade. Can be performed at bedside - sensitivity and specificity of nearly 100%

Radiography is not useful as small volumes of pericardial fluid will result in tamponade physiology this will not be evident on CXR

ECG: - Electrical alternasns - due to swining heart phenomenon, low amplitude

38
Q

What is the sonograophic definition of tamponade

A

sonographic definition of tamponade is presence of pericardial fluid and diastolic collapse of the RV and systolic collapse of RA

Indirect sign is that of dilated IVC in a hypotensive patient

39
Q

Discuss management of pericardial tamponade

A

ABCD
Volume expansion with crystalloid via two or three large bore cannulae
Exclude other cause with bedside echo

Increasing controversy regarding the role of pericardiocentesis. - historically indicated for diagnositic and therapeutic value – as little as 5-10mls aspirated leads to clinical improvement – not a benign procedure and blood in the pericardial space is oftenj clotted and difficult to aspirate – complciations include pericardial tamponade, laceration of coronary artery or lung and induction of cardiac dysrhythmias.

Emergency department thoractomy: Left lateral incision is preferred beacuse it is rapidaly accomplaished and allows best exposure to the heart, aorta and hilum – if right sided issues clamshell indicated - the internal mammary arteries need to be ligated if this maneuver resotres effective perfusion - after heart exposed vertical incision in the pericardium anterior to the phrenic nerve –
There are several options to control wounds present on the heart – small wounds may be ameniable to digital pressure, large wounds can be stemmed by traction on a foleys catheter to buy time to theatre - suture of ardiac wounds over pledgets is the time honored approach but is more techniquely diffictul – stapling also option
Care to not ligate coronary arteries during repair

40
Q

Discuss blunt aortic injury

A

Usually resulting from sudden deceleration usually from automobile crashes.
Including lesions ranging from small intimal tears to frank rupture.
Most common sites of injury are the aortic isthmus and the ascending aorta just proximal to the origin of the brachiocephalic vessles.

41
Q

Discuss clinical features of blunt aortic injury

A

Despite the severe nature of the injury the clinical manifestations of an aortic rupture are often deceptively meager.
The most common symptoms is interscapular or retrosternal pain. This is often found in non traumatic dissection
Other symptoms incude dyspnea due to tracheal compression and diviation, stridor, hoarseness secodnary to recurrent laryngeal nerve compression
Dysphagia

42
Q

Discuss IX of blunt aortic injury

A

CXR– increase mediastinum is the most sensitive sign - specificty of radiographic signs is only 10% - with a multitude of other reasons for an increase in mediastinum width – up to half of patients with blunt aortic injury have a normal mediastinum

CT: gold standard almost 100% sensitivty and specificty for rapidly detecting aortic injury

43
Q

Discuss management of aortic injury

A

Repair in theatre as soon as possible due to the risk of rupture and exsanguination
Endovascular or surgical repair of the aortic rupture should be delayed in the presence of life threatening ictracranail or intra-abdominal injury
Careful regulation of BP is mandatory until definitive surgery can be perforemd
Systolic maintained between 100-120mmhg - to decreae shearing jet effect
Esmolol a short acting titratable b-blocker is ideally suited as it decreases pulse pressure and minimises sharing unlike pure venodilators – start infusion at 0.05mg/kg/min titrated up to 0.3mg/kg/min – if not adequatedly controlled add a venodilator

Endovascular repair is the definitive management of choice with success rates better and lower complications wiht the major risks of paraplegia from aortic clamping significantly reduced

44
Q

Discuss analgesic options for the management of signfiaicnt rib fractures

A

1: Ketamine infusion 2.5mic/kg/min
2: fentanyl PCA 20 mic bolus with 5 min lock out 100mic/hour limit
3) paravertebral block wiht catheter -0.25% bupivacaine, 7.5–12 ml, infusion of 0.1% bupi +2mic of fentanyl

Ed fellowship--trauma (11 decks)

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