Thoracic trauma Flashcards
Where in the tracheobronchial tree do the majority of injuries occur
Within 1 inch (2.5cm) of the carina
Sx of tracheobronchial tree injury
Haemoptysis
Cervical s/c emphysema
Tension pneumothorax
Tension pneumothorax physiology
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
Most common cause of tension pneumothorax
Mechanical positive pressure ventilation
Bedside imaging to diagnose tension pneumothorax
extended FAST scan
Tension pneumothorax rx
Needle thoracotomy
If not successful, try finger thoracotomy (surgical incision, putting finger in the thoracic cavity to clear any adhesions or clots)
Where do you perform needle thoracotomy?
Adults:4/5th intercostal space, anterior to mid-axillary line
Children: 2nd intercostal space, midclavicular line
Open pneumothorax pathophysiology
Opening through chest wall
Every breath brings air through the hole instead of the trachea
At what size of chest wall defect does air enter through the defect preferentially over the trachea
more than 2/3 of diameter trachea
Initial management of open pneumothorax
close the defect with a sterile large dressing enough to overlap the edges, taped in 3 edges
Chest drain in a separate site
Why tape the open pneumothorax dressing in three edges only
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)
Massive haemothorax definition
Collection of 1500ml in the thoracic cavity or more than 1/3rd of total blood volume
Management of massive haemothorax
Restoring blood volume and decompressing the chest cavity
Followed by chest drain
Indication for urgent thoracotomy after chest drain for massive haemothorax
Immediate return of 1500mls of blood
or
continuous draining of more than 200ml/hr for 2-4hrs
Beck’s triad of cardiac tamponade
Muffled heart sounds
Raised JVP
Low BP
Kussmaul’s sign
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
Management of cardiac tamponade
Emergency thoracotomy or sternotomy and IV fluids whilst waiting for the operation (improves pre-load)
If surgery not possible, pericardiocentesis as a temporizing maneuver
Management of traumatic simple pneumothorax
Chest drain in 5th intercostal space and connect to an underwater seal apparatus
Problems with pneumothorax and surgery
Ideally a pt with known pneumothorax should not undergo GA or receive positive pressure ventilation without having a chest tube
Flail chest definition
2 or more adjacent ribs fractured in 2 or more places
or
Costochondral separation of a single rib from the thorax
Pulmonary contusion definition
Bruise of the lung caused by thoracic trauma
Blood and other fluid accumulate in the lungs interfering with the ventilation
Management of flail chest with or without pulmonary contusion
Ensure adequate oxygenation
Analgesia
Common mechanism of injury for aortic rupture
deceleration injury
Radiological signs of aortic disruption
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
Imaging for aortic rupture
CXR
CT contrast
Aortogram
TOEcho
Resus management of aortic rupture
Keep HR <80 and MAP 60-70 with BB or CCB
Definitive management of aortic rupture
Open repair (resection and repair of the torn section)
Endovascular repair (most common)
Why are diaphragmatic injuries more commonly diagnosed on the left side
Liver obscures the diaphragm on the right
Investigations for diaphragmatic injuries
CXR
CXR with NG tube (if within thorax, no need for contrast)
CT
Upper GI contrast study
Management of diaphragmatic rupture
Direct repair
Management of oesophageal rupture
Wide drainage of pleural space and mediastinum with the direct repair of the injury
