Thoracic trauma

Question 1

Where in the tracheobronchial tree do the majority of injuries occur

Answer 1

Within 1 inch (2.5cm) of the carina

Question 2

Sx of tracheobronchial tree injury

Answer 2

Haemoptysis

Cervical s/c emphysema

Tension pneumothorax

Question 3

Tension pneumothorax physiology

Answer 3

One way valve air leak occurs from the lung and through the chest wall into pleural space with no means of escape leading to a collapse

Question 4

Most common cause of tension pneumothorax

Answer 4

Mechanical positive pressure ventilation

Question 5

Bedside imaging to diagnose tension pneumothorax

Answer 5

extended FAST scan

Question 6

Tension pneumothorax rx

Answer 6

Needle thoracotomy

If not successful, try finger thoracotomy (surgical incision, putting finger in the thoracic cavity to clear any adhesions or clots)

Question 7

Where do you perform needle thoracotomy?

Answer 7

Adults:4/5th intercostal space, anterior to mid-axillary line

Children: 2nd intercostal space, midclavicular line

Question 8

Open pneumothorax pathophysiology

Answer 8

Opening through chest wall

Every breath brings air through the hole instead of the trachea

Question 9

At what size of chest wall defect does air enter through the defect preferentially over the trachea

Answer 9

more than 2/3 of diameter trachea

Question 10

Initial management of open pneumothorax

Answer 10

close the defect with a sterile large dressing enough to overlap the edges, taped in 3 edges

Chest drain in a separate site

Question 11

Why tape the open pneumothorax dressing in three edges only

Answer 11

Dressing stops air from entering via inhalation

But allows air leaving via exhalation (if taped all 4 edges, stops air leaving leading to tension pneumothorax)

Question 12

Massive haemothorax definition

Answer 12

Collection of 1500ml in the thoracic cavity or more than 1/3rd of total blood volume

Question 13

Management of massive haemothorax

Answer 13

Restoring blood volume and decompressing the chest cavity

Followed by chest drain

Question 14

Indication for urgent thoracotomy after chest drain for massive haemothorax

Answer 14

Immediate return of 1500mls of blood

or

continuous draining of more than 200ml/hr for 2-4hrs

Question 15

Beck’s triad of cardiac tamponade

Answer 15

Muffled heart sounds

Raised JVP

Low BP

Question 16

Kussmaul’s sign

Answer 16

Normally JVP goes down on inspiration as blood is sucked out of SVC by negative intrathoracic pressure

If JVP rises with inspiration, it is a sign of constrictive pericarditis

Question 17

Management of cardiac tamponade

Answer 17

Emergency thoracotomy or sternotomy and IV fluids whilst waiting for the operation (improves pre-load)

If surgery not possible, pericardiocentesis as a temporizing maneuver

Question 18

Management of traumatic simple pneumothorax

Answer 18

Chest drain in 5th intercostal space and connect to an underwater seal apparatus

Question 19

Problems with pneumothorax and surgery

Answer 19

Ideally a pt with known pneumothorax should not undergo GA or receive positive pressure ventilation without having a chest tube

Question 20

Flail chest definition

Answer 20

2 or more adjacent ribs fractured in 2 or more places

or

Costochondral separation of a single rib from the thorax

Question 21

Pulmonary contusion definition

Answer 21

Bruise of the lung caused by thoracic trauma

Blood and other fluid accumulate in the lungs interfering with the ventilation

Question 22

Management of flail chest with or without pulmonary contusion

Answer 22

Ensure adequate oxygenation

Analgesia

Question 23

Common mechanism of injury for aortic rupture

Answer 23

deceleration injury

Question 24

Radiological signs of aortic disruption

Answer 24

of 1/2nd rib or scapula

Widened mediastinum

Obliteration of aortic knob

Deviation of trachea and oesophagus (NG) to right

Depression of left mainstem/elevation of right mainstem bronchus

Presence fo pleural/apical cap

Widened paratracheal stripe/paraspinal interfaces

Question 25

Imaging for aortic rupture

Answer 25

CXR

CT contrast

Aortogram

TOEcho

Question 26

Resus management of aortic rupture

Answer 26

Keep HR <80 and MAP 60-70 with BB or CCB

Question 27

Definitive management of aortic rupture

Answer 27

Open repair (resection and repair of the torn section)

Endovascular repair (most common)

Question 28

Why are diaphragmatic injuries more commonly diagnosed on the left side

Answer 28

Liver obscures the diaphragm on the right

Question 29

Investigations for diaphragmatic injuries

Answer 29

CXR

CXR with NG tube (if within thorax, no need for contrast)

CT

Upper GI contrast study

Question 30

Management of diaphragmatic rupture

Answer 30

Direct repair

Question 31

Management of oesophageal rupture

Answer 31

Wide drainage of pleural space and mediastinum with the direct repair of the injury