Chapter 4 - Thoracic Trauma

Question 1

how can most chest injuries be treated

Answer 1

with airway control, decompression with a needle, finger or tube

Question 2

what are the physiological complications of thoracic trauma

Answer 2

hypoxia, hypercarbia and acidosis

Question 3

what should you do if you find a major problem during primary assessment

Answer 3

correct it. correct problems as you find them

Question 4

if after chest tube there is still incomplete expansion of the lung or continued large air leak what is likely going on

Answer 4

likely to be tracheobronchial injury

we may need to place more than one chest tube

Question 5

what is our initial management of an open pneumothorax

Answer 5

an occlusive dressing fixed down on three sides to provide a flutter valve effect, then pace a chest tube remote from the wound as soon as possible

Question 6

how much blood causes massive haemothorax

Answer 6

> 1500ml

Question 7

what three thoracic injuries that affect circulation should we assess for in the primary survey

Answer 7

cardiac tamponade
massive haemothorax
traumatic circulatory arrest

Question 8

what arrest rhythm may be the only sign of cardiac tamponade

Answer 8

PEA

Question 9

where do we insert chest tubes

Answer 9

with intercostal space, anterior to the midaxillary line

Question 10

what is the classical triad of symptoms of cardiac tamponade

Answer 10

muffled heart sounds
hypotension
distended neck veins

Question 11

what should we do when cardiac tamponade is diagnosed

Answer 11

emergency thoracotomy or sternotomy by experienced surgeon

Question 12

what can be a temporising measure for cardiac tamponade

Answer 12

subxiphoid pericardiocentesis

Question 13

what 8 potentially life threatening conditions should we identify during the secondary survey

Answer 13

simple pneumothorax
haemothroax
flail chest
pulmonary contusion
blunt cardiac injury
traumatic aortic disruption
blunt oesophageal rupture

Question 14

what imaging should we perform as part of the secondary survey

Answer 14

CXR - upright if spinal column instability in not suspected

Question 15

what type of shock does tension pneumothorax cause

Answer 15

obstructive shock

Question 16

when should we correct major issues

Answer 16

As soon as we identify them

Question 17

where does rapid deceleration cause injury

Answer 17

where a point of attachment meets an area of mobility

Question 18

where do blast traumas cause injury

Answer 18

at air-fluid interfaces

Question 19

how does penetrating trauma cause injury

Answer 19

through direct laceration, tearing or transfer of kinetic injury with cavitation

Question 20

how do patients with tracheobronchial tree injury present

Answer 20

haemoptysis, cervical subcut empysema, tension pneumothorax or cyanosis

Question 21

if we place a chest tube and there is still ongoing significant leak, what are we worried abiut?

Answer 21

tracheobronchial injury

Question 22

what are open pneumothoraces also called

Answer 22

sucking chest wound

Question 23

when would we suspect massive haemothroax (>1500ml blood)

Answer 23

when there is circulatory shock associated with reduced breath sounds or dullness to percussion

Question 24

how do we initially manage massive haemothorax

Answer 24

simultaneous restoring blood volume and decompressing the chest cavity

Question 25

where do we insert chest tube during massive haemothroax

Answer 25

with intercostal space, just anterior to the midaxillary line

Question 26

what management option should we initiate if the chest drain returns 1500ml or more of blood

Answer 26

urgent thoracotomy

Question 27

what is kussmauls sign and what does it suggest

Answer 27

it is the paradoxical increase in velour pressure during inspiration, and can be a sign of tamponade

Question 28

what should we do when we have identified tamponade or pericardial fluid

Answer 28

emergency sternotomy or thoracotomy by qualified surgeon

Question 29

how do we manage traumatic circulatory arrest

Answer 29

start cpr, ABC management including COETT, 100% o2, perform bilateral finger or tube thoracotomies, fluid rescusitation, 1mg adrenaline

Question 30

if bilateral chest decompression does not result in ROSC in traumatic circulatory arrest, what procedure should be performed next

Answer 30

anterolateral or clamshell thoracotomy

Question 31

what are the eight potentially life threatening injuries that should be identified in the secondary survey

Answer 31

``` simple pneumothorax haemothorax flail chest pulmonary contusion blunt cardiac injury traumatic aortic disruption traumatic diaphragmatic disruption blunt oesophageal rupture ```

Question 32

what is flail chest

Answer 32

when part of the chest wall doe snot have bony continuity with the rest of the thoracic cage

Question 33

what is the initial treatment of pulmonary contusion and flail chest

Answer 33

humidified o2 adequate ventilation cautious fluid resuscitation

Question 34

what are the signs and symptoms of traumatic aortic disruption

Answer 34

``` history of decelerating force widened mediastinum obliteration of aortic knob deviation of trachea to right depression of left mainstream bronchus left hamothorax ```

Question 35

how can we reduce the risk of rupture of traumatic aortic disruption

Answer 35

B-bocker aim HR <80 BP between MAP 60-70 hypotension is a contraindication

Question 36

what injuries to blunt and penetrating trauma cause to the diaphragm

Answer 36

blunt trauma causes radial tears that lead to herniation, penetrating trauma causes small perforations that may remain asymptomatic for years

Question 37

how does blunt oesophageal tear occur

Answer 37

forceful expulsion of gastric contents into the oesophagus as a result of severe blow to upper abdomen. This causes linear tear allowing leakage into mediastinum

Question 38

what is the clinical picture of oesophageal rupture

Answer 38

pain or shock out of proportion to injury. left sided pneumothorax/haemo thorax with no rib fracture. particulate matter from chest tube mediastinal air

Question 39

how can clavicle affect airway

Answer 39

posterior displacement of clavicle can cause airway obstruction. reduce by extending patients shoulders or grasping clavicle with towel clamp

Question 40

what else should we be concerned about in patients with 10th - 12th rib innjuries

Answer 40

the possibility of hepatosplenic injury