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MBBS Surgery > Chest Trauma > Flashcards

Chest Trauma Flashcards

1
Q

How much of blood will show on an X-ray

A

250 mls

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2
Q

Define atelectasis

A

Collapse of the alveoli

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3
Q

Signs of a massive haemothorax

A

> /= 1500 ml blood drained on Chest tube insertion
Hypovolemic shock ( decreased bp, tachycardia,peripheral vasoconstriction)
Absent breath sounds
Dull on percussion
Signs of penetrating wound
Elevated JVP with tension pneumothorax or decrease if Hypovolemia shock prevails.

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4
Q

X-ray findings on haemothorax

A

Blunting of costophrenic angles
Radio-opacity
Air fluid levels- mild (200-300ml) up to 7th rib, moderate (500-700ml ) up to 5th rib and severe( >700ml) up to 2nd rib
Very dense - no ribs seen on cxr

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5
Q

Haemothorax clinical Presentation

A

On inspection- dyspnea, respiratory distress, Hypovolemic shock (hypotension, tachycardia, diaphoresis) , pallor
On palpation- decrease in chest wall expansion, decrease in tactile fremitus
Percussion- dullness
Auscultation- decreased/ absent breath sounds

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6
Q

Haemothorax Mx

A

Ensure patent airway
Place on high flow oxygen (10-15L/min)via a re-breathable facemask
Establish IV access-2 large bore IV cannula (14-16gauge) peripherally.
IV fluid depending on haemodynamic status
Group and cross match 2 units of blood, do CBC
Catheterize on free drainage
Chest tube insertion and looking at the vol produced ( must have bloods readily available to avoid decompression)
Preload the patient with 500ml of NS as they are likely to be in Hypovolemic shock.

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7
Q

Chest tube insertion

A

Into the 5th intercostal space down the mid Axillary line to avoid long thoracic nerve ( supplies the serratus anterior - damage causes winged scapular)

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8
Q

Thoracotomy indicated if:

A

> 1500 mls immediately after chest tube placement or
A rate of 200 ml/hr for 2-4 hrs of continuous bleeding or
Penetrating trauma with pulseless extra activity
Decompensation of patient after initial stabilization
Patient is haemodynamically unstable
Multiple transfusions required

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9
Q

Why the chest does not expand after placement of a chest tube?

A 
Not sutured correctly: loose and air enters
Incorrect chest tube size
Dislodgement of tube
Clot formation
Linking of tube
Incorrect placement of tube
Leak: bronchopleura fistula
Under water steal is not done correctly
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10
Q

In a haemothorax when do you take out a chest tube?

A

Diminished drainage <50-100ml over 24hrs
Clinical examination -air entry is better than before,-chest expansion is back to normal,-percussion is resonant.
Patient is haematologically stable and improved resp rate
X-ray confirmation

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11
Q

In a pneumothorax, when do you take out a chest tube?

A

Chest wall expansion
Improvement in resp rate
Radiological evidence

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12
Q

What is a pneumothorax ?

A

Air in the pleural space

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13
Q

X-ray findings for pneumothorax

A 
Loss of lung markings
Contracted lung (collapse)
Increased luscency.
Displacement of pleural line
Air fluid level in costophrenic angle
Use interpleural distance at the level of the hilum
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14
Q

Indication for chest tube in pneumothorax

A

Asses distance from the chest wall (Europe say 2cm at hilar level, American say >3cm at apex)

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15
Q

Causes of persistent pneumothorax

A

Linking of the chest tube
Obstruction by a blood clot
Failure to secure properly to the chest wall
Tube connecting chest tube to the underwater seal not secure
Tube not fully immersed in underwater seal
Bronchopleural fistula- due to penetrating trauma
Persistent water bubbling in underwater seal

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16
Q

Investigations for pneumothorax

A

Erect chest X-ray in inspiration

CT- differentiate pneumothorax from bullous lung diseased

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17
Q

Risk factors for secondary pneumothorax

A 
Copd 
Asthma
Pulmonary fibrosis 
Cystic fibrosis
Pneumonia
Lung ca 
TB
HIV and AIDS
18
Q

Risk factor for primary spontaneous pneumothorax

A

Young age and increasing height

19
Q

Risk factor for recurrence primary spontaneous pneumothorax

A

Smoking
Tall stature
>60 yrs old

20
Q

Pneumothorax clinical presentation

A

Inspection - dyspnea, respiratory distress, use of accessory muscles
Palpation- decreased chest wall expansion
Percussion- hyper-resonant
Auscultation- decreased breath sounds, reduced air entry.

21
Q

Pneumothorax Mx

A

Resuscitations (recite)
ABGs
Simple (<2-3cm between the lung and chest wall on CXR) and asymptomatic - usually resolves spontaneously within a few days (~10days) : give supplemental oxygen via nasal cannula or mask and f/u
Simple and symptomatic or large- immediate supplemental oxygen, upright positioning

22
Q

Tension pneumothorax define

A

One way valve mechanism, air fills intrapleural space and becomes trapped

23
Q

Tension pneumothorax on X-ray

A

One side radiolucent (dark grey/black)
Tracheal deviation to contralateral side
Mediastinal shift

24
Q

Clinical presentation of tension pneumothorax

A

Inspection-Severe acute respiratory distress, cyanosis, profound hypotension, accessory muscles of respiration, distended neck veins- due to obstruction of SVC,IV. and Azygos vein, nasal flaring
Palpation- decreased chest wall expansion, tracheal deviated to the contralateral side
Percussions- hyper-resonance
Auscultation- decrease heart sounds

25
Q

Safe triangle

A

Superiorly: base of axilla
Anteriorly: lateral edge of pectoral major
Laterally: lateral edge of latissimus Dorsi
Inferiorly: line of the 5th ICS

26
Q

Needle thoracostomy

A

Insertion of large bore needle into the 2nd ICS along the midclavicular line.

27
Q

Tension pneumothorax Mx

A

Immediate needle thoracostomy followed by chest tube insertion.
Needle stays in until chest tube is inserted to avoid a repeated tension pneumothorax

28
Q

Lung contusion define

A

Blunt trauma to chest leading to loose ability to fully diffuse oxygen via alveoli.

Patient cannot oxygenated as before - hypoxia and Hypovolemia
V/Q ratio affected : Q normal; V diminished
Left shunt

29
Q

Aetiology of lung contusion

A

Flail segment or rib fractures

30
Q

Signs of pulmonary contusion

A 
Bruising of lung tissue
Usually blunt trauma
Respiratory distress
Increase airway resistance 
Decreased lung compliance Increased stunting
Atelectasis
31
Q

Flail chest define

A

2 or more rib fractures in 2 or more consecutive ribs

32
Q

X-ray findings for flail chest

A

Fluff like patchy bilateral opacifications (mottled appearance)

33
Q

Clinical presentation for flail chest

A

Inspection- patient in Immersed pain, rapid shallow respiration, paradoxical movement of the chest wall
Palpation -broken bones, feel ripple

34
Q

Lung contusion Mx

A

Monitor blood gases
Intubation and ventilation
Judicious fluid administration

35
Q

Flail chest Mx

A

Resuscitations (recite)
Conservative Mx initially
If patient worsens or fails to respond the put in chest tube
If there is further deterioration then intubation
No PPV as it will precipitate tension pneumothorax Judicious fluid Mx
Multimodal Analgesia- regional block, intercostal block, PCA pump ( no opioids! Can cause resp depression)
Serial blood gases
Continuons monitoring with pulse and ABGs

Fix fracture segment with plates

36
Q

Cardiac tamponade define

A

Collection of blood/fluids inside pericardium

25-50mls

37
Q

Clinical presentation of cardiac tamponade

A 
Becks triad 
-Distended neck veins
-Muffled heart sounds 
-Hypotension
Retrosternal pain
Tachycardia 
Abnormal resp rate
38
Q

Cardiac tamponade Mx

A

Urgent pericardiocentesis under ultrasound guidance with ECG monitoring +/- thoracotomy

39
Q

Open pneumothorax Mx

A

Aka sucking pneumothorax
Simple partially occlusive sterile dressing taped 3 out of 4 sides of the lesions
Followed by thoracostomy
Observe for any development of tension pneumothorax

40
Q

Outline the 4 classes of hemorrhagic shock

A

Class 1 : 750ml, 15% ,Bp (N), pulse (N or decreased), HR <100 , RR 14-20

Class 2: 750-1500ml, 30%, Bp (N), pulse (decreased), HR 100-120, RR 20-30

Class 3 : 1500-2000ml, 40%, Bp (decreased) , pulse (decreased), HR 120-140, RR 30-40

Class 4: >2000ml, >40%, Bp (decreased) , pulse (decreased), HR >140, RR >40

MBBS Surgery (11 decks)

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