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Thorax Flashcards

1
Q

Secondary survey - Investigations & Monitoring

A
  1. Chest XR
  2. Trauma CT
  3. ABG
  4. ECG & Oximetry
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2
Q

Multiple rib fractures or fracture to 1st or 2nd ribs ?

A

Suggest significant force of impact

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3
Q

Investigative diagnosis of pneumothorax & haemothorax?

A
  1. eFAST (Extended Forcused Assessment using Sonography in Trauma)
  2. Up-right expiratory chest XR
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4
Q

The 8 leathal injuries to be identified in secondary survey?

A
  1. Simple PTX
  2. Haemothorax
  3. Flail chest
  4. Pulmonary contusion
  5. Blunt cardiac injury
  6. Traumatic aortic disruption
  7. Traumatic diaphragmatic injury
  8. Blunt oesophageal rupture
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5
Q

What is simple pneumothorax?

A

Air between the parietal and visceral pleura

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6
Q

Physiological effects of simple PTX?

A
  1. V/Q mismatch
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7
Q

Most common causes of PTX from blunt trauma?

A
  1. Lung laceration with air leak
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8
Q

Clinical signs of PTX?

A
  1. Breath sounds decreased on affected side
  2. Hyperresonant to percussion
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9
Q

What is the management of PTX?

A

Chest drain in the 5th intercostal space anterior to the midaxillary line. Connect to underwater seal +/ - Suction

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10
Q

If a patient with PTX needs ventilation?

A

A chest drain must be inserted prior

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11
Q

PTX and altitude?

A

Risk of expansion of PTX with increasing altitude even in a pressurized cabin.

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12
Q

What is haemothorax?

A
  1. Blood in pleural cavity < 1,500ml
  2. Blood > 1,500ml - Massive haemothrax
  3. > 200ml/hr for 2-4 hours - Massive HTX
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13
Q

Etiology of haemothorax from penetrating or blunt trauma?

A
  1. Lung laceration
  2. Great vessels laceration
  3. Intercostal vessels
  4. Internal mammary artery
  5. Thoracic spine fracture
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14
Q

Clinical signs of haemothorax?

A
  1. Dullness to percussion
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15
Q

Investigation of haemothorax?

A
  1. CXR in the supine position
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16
Q

Management of haemothorax?

A
  1. 28-32Fr chest drains
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17
Q

What is a flail segment?

A
  1. Trauma associated with multiple rib #s
  2. Costochondrial separation
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18
Q

What is pulmonary contusion?

A
  1. Bruising of the lungs by thoracic trauma
  2. Blood and fluid accumulation in the lungs#
  3. This can occur without rib # or flail chest
  4. Mostly young patients without ossified ribs
  5. Develops over time
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19
Q

Management of pulmonary contusion?

A
  1. Humidified oxygen
  2. Ventilation
  3. Fluid resuscitation (Low BP)
  4. Intubation if PO2 < 8.6 or sats < 90% (RA)
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20
Q

Risk factors for intubation after pulmonary contusion?

A
  1. COPD
  2. Renal impairment
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21
Q

Mechanism of blunt cardiac injury?

A
  1. Motor vehicle crash (50%)
  2. Pedestrian vs Vehicle
  3. Motorcycle
  4. Fall from height > 20ft or 6meters
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22
Q

Potential injuries from blunt cardiac trauma?

A
  1. Myocardial muscle contusion
  2. Cardic rupture
  3. Coronary artery dissection & thrombosis
  4. Valvular disruption
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23
Q

Clinical signs of Blunc Cardiac Injury?

A
  1. Hypotension
  2. Dysrrhythmias
  3. Regional wall motion abnormalities (ECHO)
  4. Raised CVP (RV dysfunction)
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24
Q

What are the common ECG changes with blunt cardiac injury?

A
  1. AF
  2. PVC
  3. Sinus tachycardia
  4. RBBB
  5. ST-segment changes
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25
Traumatic aortic disruption - Patients with best prognosis for survival?
1. Incomplete laceration close to ligamentum arteriorsum of aorta 2. Contained haematoma
26
Mechanism of traumatic aortic disruption?
1. Decelerating force
27
Radiographic signs of blunt aortic injury?
1. Wide mediastinum 2. Obliteration of aortic knob 3. Deviation of the trachea to the right 4. Depression of left main stem bronchus 5. Elevation of the right mainstem bronchus 6. Obscuration of the aortopulmonary window 7. Deviation of oesophagus to the right (NGT) 8. Wide paratracheal strip 9. Pleura or apical cap 10. Left haemothorax 11. Fracture to 1st, 2nd rib or scapula
28
Investigation modalities for blunt aortic injury?
1. About 1-13% show to XR changes 2. Helical contrast-enhanced CT (100% S & S) 3. Aortography 4. TEE (Trans-oesophageal ECHO)
29
Pharmacological Mx of blunt aortic injury?
1. Beta-blockers 2. CCBs 3. GTN or nitroprusside
30
Traumatic diaphragmatic injury is more common on what side?
The left side as the right side is protected by the liver
31
What is the effect of blunt trauma to the diaphragm?
1. Large radial teaar 2. Herniation
32
What is the effect of penetrating trauma to the diaphragm?
1. Small perforation which could be asymptomatic
33
Radiographic diagnosis of right diaphragmatic injury?
1. Raised right hemi-diaphragm
34
Radiographic diagnosis of left sided diaphragmatic injury?
1. NGT tip visualised in the chest
35
Investigations for diagnosis of diaphragmatic damage?
1. CXR 2. Upper GI contrast study 3. CT scan 4. DPL - If performed 5. Laparoscopy 6. Thoracoscopy 7. OGD
36
What is the common cause of oesophageal trauma?
1. Penetrating injury
37
Mechanism of blunt oesophageal trauma? (rare)
Forceful expulsion of gastric content in the oesophagus from severe blow to the upper abdomen. This causes a linear tear causing leakage into the mediastinum
38
Complications of oesophageal rupture?
1. Mediastinitis 2. Empyema in the pleural space
39
Clinical presentation of a patient with blunt oesophageal rupture?
1. Patient with left pneumothorax or haemothorax 2. Usually no rib fracture 3. Trauma to the lower sternum or epigastrium 4. Mediastinal air
40
Mortality risk with thoracic trauma?
This can be as high as 35% and even higher in the elderly
41
What are the most commonly injured ribs?
T4-T9
42
Implications of fracture to T10-T12?
Hepatosplenic injury
43
What are the physiological consequences of thoracic trauma?
- Hypoxia - Hypercarbia - Acidosis
44
What injury will be expected after insertion of chest drain with associated hypoxia and crepitus ?
Tracheobronchial tree injury due to large air leak. Requires second chest tube and surgical intervention
45
Requirement for operative intervention post-thoracic trauma?
- Blunt < 10% - Penetrating 15-30%
46
How do you assess life threatening chest wall trauma?
- Look - Listen - Feel
47
Common mechanisms of injury causing airway obstruction?
- Laryngeal injury - Posterior dislocation of clavicular head - Penetrating trauma to neck or chest
48
Causes of airway obstruction?
- Bleeding - Vomitus - Swelling
49
Mechanism of tracheobronchial tree injury?
- Decelerating blunt truma - Penetrating trauma - Direct laceration - Blast injury
50
Signs of tracheobronchial tree injury?
- Haemoptysis - Subcutaneous emphysema - Tension pneumothorax - Incomplete expansion of the lung - Large air leaks post chest drain
51
How is tracheobrnchial tree injury confirmed ?
Bronchoscopy
52
Signs & symptoms of tension pneumothorax?
- Tachypnoea - Air hunger - Tachycardia - Hypotension - Tracheal deviation - Unilateral absence of breath sounds - Elevated hemithorax - neck vein distention - Cyanosis - Chest pain
53
Management of tension pneumothrax?
Over the needle catheter in the 5th intercostal space slight anterior to the mid-axillary line
54
Open pneumothorax?
When the open wound in the chest wall is approximately 2/3rd or greater of the diameter of trachea, air preferentially passes through the chest wound. Atmospheric and intrathoracic pressures equilibrate
55
Treatment of open PTX?
- Occlusive dressing on three sides - Chest drain remote from the wound - Definitive surgical closure
56
What is haemothorax & treatment?
- > 1.5L of blood in one side of the chest - Chest drain and surgical intervention
57
Characteristics of haemothorax?
- Decreased breath sounds - Dull to percussion - Trachea is mid-line - Collapsed neck veins - Mobile chest wall
58
Characteristics of tension pneumothorax?
- Decreased or absent breath sounds - Hyper-resonant to percussion - Tracheal deviation - Distended neck veins - Immobile chest wall
59
Mechanism of haemothorax?
- Penetrating trauma - Systemic or hilar vessels - Blunt trauma
60
What is the indication for immediate thoracotomy?
- Immediate return of > 1.5L of blood - Continued bleeding after chest drain - Frequent transfusion - Injury medial to nipple & scapular
61
Treatment of tamponade ?
- Thoracotomy or sternotomy - Pericardiocentesis
62
Causes of traumatic circulatory arrest ?
- Severe hypoxia - Tension pneumothorax - Profound hypovolaemia - Cardiac tamponade - Cardiac herniation - Myocardial contusion
63
Treatment of traumatic circulatory arrest ?
- Bilateral thoracotomies - Pericardiocentesis - CPR
64
Mechanism of haemothorax - Penetrating or blunt trauma?
- Lung laceration - Injury intercostal vessels - internal mammary artery injury - Thoracic spine fracture
65
Treatment of haemothorax?
- 28-32 French chest tube
66
Indication for intervention in massive haemothorax?
- Return of 1.5L of blood - > 200ml/hr for 2-4 hours - Requirement of frequent blood transfusion
67
Location and characteristic of injury to the tracheobronchial tree?
- Occurs within 2.5cm of the carina - Requires a second chest drain - Requires surgical intervention
68
What are the indications for thoracotomy?
- Return of > 1.5L of blood post-chest drain - Persistent transfusion - Anterior chest would medial to nipple line - Posterior wound medial to scapula
69
What is cardiac tamponade?
- Accumulation of fluid in pericardial sac - Reduced inflow & cardiac output - Penetrating & blunt injuries
70
Signs of cardiac tamponade?
- Muffled heart sounds - Hypotension - Occasionally distended neck veins - Kussmal's signs
71
Treatment of cardiac tamponade?
- Thoracotomy - Sternotomy - Pericardiocentesis
72
Characteristics of traumatic circulatory arrest ?
- PEA - VF - Asystole cardiac
73
Causes of traumatic circulatory arrest ?
- Severe hypoxia - Tension PTX - Hypovolaemia - Tamponade - Cardiac herniation - Myocardial contusion

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