Trauma - Chest pain

Question 1

How would you manage traumatic chest pain before assessing the patient?

Answer 1

• put out 2222 call for trauma team
• move pt to resus bay

Question 2

A + B

Answer 2

A: Triple immobilize C-spine
Ensure airway patency (use of adjuncts if necessary)

Breathing:
- Administer high flow O2 (15L via non-rebreather mask)
- Gain observations: oxygen saturation, respiratory rate.
- Inspect/ palpate thorax for equal chest movements and signs of trauma e.g. broken ribs, flail segment, bruising.
- Inspect neck for tracheal deviation and dilated neck vessels and JVP
- Auscultate for any areas of reduced air entry and percuss chest for hyporesonance or hyperresonance.
- CXR
- ABG
- Manage any identified pathology

Question 3

C + D

Answer 3

Circulation and Control of haemorrhage:
- Assess haemodynamic stability with blood pressure, heart rate, peripheral circulation and an ECG
- IV access with 2 wide bore cannulae
- Send off bloods including FBC, U&E, LFT, clotting,
- Commence warmed IV fluids or O-ve blood, as indicated
- Assess for major bleeding sources – considering bleeding into thorax, abdomen, pelvis, long bones and peripherally (“blood on the floor and 4 more”). Ordering x-rays and FAST scan as required.

Disability
- Assess conscious level (GCS or AVPU)
- Assess for lateralizing sign
- Temperature
- BM/ blood glucose

Question 4

What is “blood on the floor and 4 more”?

Answer 4

life-threatening amount of blood can be lost as:
- active hemorrhage outside the body,
- in the thigh compartments of bilateral femur fractures,
- the pelvis,
- abdomen, or
- chest

Question 5

E + everything else

Answer 5

Exposure:
- Completely expose patient to assess for any missed injuries whilst avoiding hypothermia.
- Log roll if not already performed

D/w senior
Hx and secondary survey

Question 6

Diagnosis for tracheal deviation towards the right, decrease AE on L side and hyperresonance on percussion?

Answer 6

Left sided tension pneumothorax

Question 7

What type of shock does tension pneumothorax cause?

Answer 7

Obstructive shock

Question 8

What is the immediate management for tension pneumothorax?

Answer 8

1. needle decompression in the 4th or 5th intercostal space just anterior to the mid-axillary line using a wide bore cannula
2. reassess using A-E

Question 9

What is the definitive management of tension pneumothorax?

Answer 9

Left-sided chest drain

Question 10

Where would you insert a chest drain?

Answer 10

5th intercostal space just anterior to the mid axillary line

(In the safe triangle between the lateral edge of latissimus dorsi posteriorly, the lateral edge of pectoralis major anteriorly, the 5th intercostal space inferiorly OR and an imaginary line drawn horizontally from the nipple inferiorly.)

Question 11

What investigations would you order following chest drain insertion?

Answer 11

Haematological: Basic bloods (FBC, U&Es, LFT, clotting, X-match) if not already sent + repeat ABG

Radiological: CXR or CT chest

Question 12

What are indications for a chest drain?

Answer 12

• Tension pneumothorax or large symptomatic pneumothorax
• Large pleural effusion
• Pleuradesis
• Post thoracoscopy/surgery
• Empyema

Question 13

How to assess if chest drain is functioning?

Answer 13

1. patient - pain? distress?
2. bottle - fluid? content? volume? rate? bubbles? swinging?
3. tubing - fluid swinging? clamped? 3-way tap open or closed?
4. drain site - moved? leaking?
5. palpate chest - surgical emphysema?
6. auscultate chest
7. CXR
8. flush drain through 3-way tap is blocked - 20ml 0.9% saline

Question 14

If the patient becomes hypotensive and tachycardic, what does this indicate?

Answer 14

Class III haemorrhagic shock

Question 15

Define massive haemothorax. What is the management?

Answer 15

immediate drainage of >1500mls from the chest drain or more than 200mls/hr for 2 consecutive hours.

Mgx: immediate insertion of chest tube to reduce restruction on ventilation followed by surgical exploration to manage source of haemorrhage