OnlineMedEd: Surgery: Trauma - "Chest"

Question 1

Remember that rib fractures can lead to ________________.

Answer 1

penetrating chest wounds: hemothorax, pneumothorax

Question 2

How do rib fractures lead to pneumonia?

Answer 2

It hurts to expand your chest when you have a rib fracture, so people will often not breathe as deeply. As such, atelectasis and pneumonia can result.

Question 3

Rib fractures should be treated with _________________.

Answer 3

pain control (not binders!)

Question 4

Describe the presentation of pneumothorax.

Answer 4

• Penetrating chest wound (or not in the case of spontaneous)
• Dyspnea
• Decreased breath sounds
• Hyperresonance on percussion
• Decreased tactile fremitus

Question 5

What is it called when you use oxygen to treat a small spontaneous pneumothorax?

Answer 5

Nitrogen washout

Question 6

The history of a tension pneumothorax will be similar to that of which other thoracic injury?

Answer 6

Hemothorax: both present with penetrating chest trauma or rib fracture as the cause

Question 7

Describe the presentation of hemothorax.

Answer 7

• HPI: penetrating chest wound or rib fracture followed by dyspnea
• PE: decreased breath sounds, decreased tactile fremitus, dullness to percussion
• CXR: horizontal whiteout on the lower part of one lung

Question 8

How is the thoracostomy in hemothorax different from pneumothorax?

Answer 8

Pneumo is second intercostal space, hemo is lower (because blood is dependent).

Question 9

Patients with hemothorax need to go to the operating room if ______________.

Answer 9

their chest tube output is greater than 1500 mL on first draw or greater than 200 mL per hour

Question 10

What is the treatment for a tension pneumothorax (aka sucking chest wound)?

Answer 10

• Occlusive dressing: place a dressing that is sealed on three of four sides over the wound. This prevents air from moving in on inhalation, but is open to let air out if any comes out during exhalation.
• Thoracostomy

Question 11

In order to have flail chest, you need to have _______________.

Answer 11

two or more rib fractures in two or more places

Question 12

Why does the free segment move paradoxically in flail chest?

Answer 12

The free rib segments are not tethered to the chest (except by muscle). They will thus pull in with inhalation because of negative intrathoracic pressure and push out with exhalation because of positive intrathoracic pressure –exactly the opposite of what the chest wall does.

Question 13

The only rib fractures that require binders are ________________.

Answer 13

flail chest (because they need to be stabilized)

Question 14

Flail chest and ______________ often occur with damage to underlying organs (i.e., the lungs), so you need to evaluate further for these.

Answer 14

scapular fracture

Question 15

Pulmonary contusion usually presents after a _____________ and can be unilateral or bilateral.

Answer 15

massive trauma

Question 16

What is the initial presentation of pulmonary contusion?

Answer 16

Nothing –it usually presents one to two days after a trauma as a non-cardiogenic pulmonary edema

Question 17

In pulmonary contusion, you treat by ________________.

Answer 17

avoiding crystalloids; giving PEEP

Question 18

Myocardial contusions can cause ________________.

Answer 18

CHF or arrhythmia

Question 19

How do you treat myocardial contusion?

Answer 19

• Initially place on telemetry and draw troponins
• Treat CHF or arrhythmia if they arise
• Monitor for tamponade

Question 20

Aortic dissection is treated with ________________.

Answer 20

• BPs that are unequal left-to-right
• A CXR that shows widened mediastinum
• CTA (TEE or MRI are also acceptable)