Thoracic trauma

Question 1

Percentage of blunt trauma thoracic injuries requiring surgery

Answer 1

< 10%

Question 2

Percentage of penetrating trauma thoracic injuries requiring surgery

Answer 2

15 - 30%

Question 3

Signs of Tracheobronchial tree injury

Answer 3

Cervical subcut emphysema
Tension pneumothorax
Haemoptysis
Large air leak with dramatic bubbling after chest tube insertion

Question 4

Diagnosis of Tracheobronchial tree injury

Answer 4

Confirmed with bronchoscopy

Question 5

Management of Tracheobronchial tree injury

Answer 5

Often require placement of second chest tube

Immediate surgical consultation

Question 6

Distended neck veins are sign of what thoracic injuries

Answer 6

Pneumothorax
Tamponade

Question 7

Common mechanisms of airway obstruction

Answer 7

Laryngeal injury
Posterior dislocation of clavicular head
Penetrating trauma to neck or chest

Question 8

Mechanism of tension pneumothorax

Answer 8

One way valve
Collapsing of lung
Displaced mediastinum
Decreased venous return

Question 9

Causes of tension pneumothorax

Answer 9

Mechanical positive pressure ventilation

Complication of simple PTX

Trauma to chest wall

Question 10

Treatment of tension pneumothorax

Answer 10

Immediate decompression:
- Needle decompression
or
- Finger thoracostomy

Requires following with tube thoracostomy

Question 11

Treatment of open pneumothorax

Answer 11

Flutter valve dressing
(sterile dressing taped on three sides only)

Chest tube placement

Definitive surgical closure

Question 12

Alternative name for Open pneumothorax

Answer 12

Sucking chest wound

Question 13

How flutter valve dressing works

Answer 13

Dressing closes wound during inspiration due to negative pressure

Open during expiration with positive pressure

Question 14

Massive haemothorax definition

Answer 14

> 1500 mls blood

OR

> = one third blood volume

in one side of the chest

Question 15

Indications for urgent thoracotomy

Answer 15

Immediate return of > 1500 mls blood from chest tube

Continued significant bleeding after chest tube >200 ml for 2-4 hrs

Persistent need for blood transfusions

Penetrating anterior chest wounds medial to the nipple line

Posterior chest wounds medial to the scapula

Question 16

Most common mechanism of cardiac tamponade

Answer 16

Penetrating injuries

Question 17

How cardiac tamponade leads to reduced cardiac output

Answer 17

Decreased inflow to the heart due to compression

Question 18

Beck’s triad of cardiac tamponade

Answer 18

Muffled heart sounds
Hypotension
Distended neck veins / raised JVP

Question 19

Other signs of cardiac tamponade

(I.e not Beck’s triad)

Answer 19

Kussmaul’s sign
Pulseless Electrical Activity

Question 20

Kussmaul’s sign

Answer 20

True paradoxical rise in venous pressure during inspiration

Question 21

Diagnosis of cardiac tamponade

Answer 21

FAST scan
Echo

Question 22

Management of cardiac tamponade

Answer 22

Emergency thoracotomy / sternotomy
IV fluids

Question 23

When to perform pericardiocentesis for cardiac tamponade

Answer 23

Only as temporising manoeuvre when absolutely necessary and surgeon not available

Question 24

Causes of traumatic circulatory arrest

Answer 24

Severe hypoxia
Tension pneumothorax
Profound hypovolaemia
Tamponade
Severe myocardial contusion

Cardiac event preceding traumatic event

Question 25

Where is traumatic circulatory arrest resuscitation performed

Answer 25

Operating room with a surgeon present

Question 26

Management of traumatic circulatory arrest

Answer 26

Closed CPR Bilateral thoracostomies Continuous ECG and pulse oximetry Fluid resus Adrenaline as indicated Resuscitative thoracotomy if needed

Question 27

Life threatening injuries often identified and managed on secondary survey

Answer 27

Simple PTX Flail chest Pulmonary contusion Traumatic aortic disruption Traumatic diaphragmatic injury Blunt oesophageal rupture

Question 28

Cause of flail chest

Answer 28

Segment of chest wall does not have bony continuity with the rest of the thoracic cage Often results from >2 rib fractures in > 2 places

Question 29

Cause of pulmonary contusion

Answer 29

Fluid / blood accumulation in lung tissue inhibiting ventilation Can occur without rib fractures

Question 30

Initial treatment of flail chest / pulmonary contusion

Answer 30

Oxygenation and ventilation Fluid resus Intubation and mechanical ventilation when necessary

Question 31

Definitive treatment of flail chest / pulmonary contusion

Answer 31

Oxygenation and ventilation Fluid resus Analgesia Monitoring and re-evaluation

Question 32

Complications following blunt cardiac injury

Answer 32

Myocardial muscle contusion Cardiac chamber rupture Coronary artery dissection / thrombosis Valvular disruption

Question 33

Signs of blunt cardiac injury

Answer 33

Chest discomfort Hypotension ECG changes Elevated CVP

Question 34

Diagnosis of blunt cardiac injury

Answer 34

FAST scan Echo

Question 35

Shared feature in all survivors of traumatic aortic disruption

Answer 35

Contained haematoma

Question 36

Management of traumatic aortic disruption

Answer 36

Immediate surgical consult Heart rate and BP control Analgesia

Question 37

Most common side for traumatic diaphragmatic injury

Answer 37

Left side

Question 38

Diagnosis of traumatic diaphragmatic injury

Answer 38

XR or CT findings Displaced bowel / elevated hemidiaphragm

Question 39

Presentation of oesophageal rupture

Answer 39

Left pneumo / haemothorax without rib fracture Blow to epigastrium or lower sternum Pain / shock out of proportion for apparent injuries Pneumomediastinum

Question 40

Treatment of oesophageal rupture

Answer 40

Wide drainage of pleural space Direct repair of injury

Question 41

Other manifestations of chest injuries

Answer 41

Subcutaneous emphysema Crushing injury (traumatic asphyxia) Rib, sternum, scapula fractures

Question 42

Traumatic asphyxia cause

Answer 42

Sudden / severe compression of the chest

Question 43

Signs of traumatic asphyxia

Answer 43

Upper torso, facial and arm plethora / petechiae Massive swelling Cerebral oedema

Question 44

Cause of symptoms in traumatic asphyxia

Answer 44

Acute, temporary compression of the superior vena cava

Question 45

Treatment of traumatic asphyxia

Answer 45

Treat associated injuries

Question 46

Implication of sternal, scapula or 1st/2nd rib fractures

Answer 46

Suggests higher magnitude of injury Suspicion of associated head, neck or greater vessel injuries

Question 47

Importance of