Flashcards in Thoracic Trauma Deck (48):
What standard precautions should be used?
cap, gown, gloves, mask, shoe covers, goggles / face shield
ATLS: process of the initial assessment
Primary survey - resuscitation - reevaluation - detailed secondary survey - reevaluation - definitive care
What adjuncts are used during the primary and secondary surveys?
- Urinary and gastric catheters
- Blood gasses
- Radiology / ultrasound
What do patients with penetrating trauma require?
15-30% require surgery
What do patients with blunt trauma require?
<10% require surgery
What do the majority of thoracic trauma patients require?
Simple procedures (intern)
How are most life threatening injuries identified?
Most can be identified during the primary survey
Chest injuries that are immediately life threatening: A
1. Airway obstruction
2. Laryngotracheal injury
Chest injuries that are immediately life threatening: B
1. Open pneumothorax
2. Flail chest and pulmonary contusion
Chest injuries that are immediately life threatening: B&C
1. Tension pneumothorax
2. Massive haemothorax
Chest injuries that are immediately life threatening: C
What can life-threatening thoracic injuries lead to?
2. Hypoxia and hypoventilation = death / brain damage
3. Inadequate tissue perfusion
4. Acidosis (respiratory / metabolic)
Must be managed as soon as they are identified!
A stands for
Airway (airway injury)
How common are airway injuries?
Rare, but they are difficult to treat
How do airway injury patients usually present?
- hoarseness / change in voice (if awake and talking)
- subcutaneous emphysema
When should airway injury patients be managed?
Manage in the primary survey as soon as they are identified.
How should airway injury patients be managed?
- secure the airway
- intubate: get help if you have time
Pneumothorax: What can it result from?
- penetrating trauma
- blunt trauma
- iatrogenic: CVP, pleural tap
Pneumothorax: What can it result in?
V/Q mismatch = hypoxia
Pneumothorax: How is it diagnosed?
- hyper-resonance to percussion
- decreased breath sounds
- ultrasound / CXR
Tube thoracotomy - "chest drain"
Where is the chest drain inserted?
5th / 6th intercostal space, no lower
What is a flail chest?
2 or more fractured ribs (adjacent) in 2 or more places
What is the biggest problem with a flail chest?
How should a flail chest be managed?
- ICD if associated pneumothorax
- Intubate if needed
- Careful fluid management (avoid fluid overload)
- Most NB: analgesia!! - morphine
How is a tension pneumothorax diagnosed?
Clinical diagnosis, no time for X-ray - must act immediately!
What imaging technique may be used in the diagnosis of a tension pneumothorax?
What clinical features indicate a tension pneumothorax?
- severe respiratory distress
- distended neck veins
- unilateral decrease in breath sounds
- cyanosis (late sign)
How should a tension pneumothorax be treated?
Immediate decompression by finger thoracotomy, then ICD inserted into a second hole
How is a finger thoracotomy done?
5th intercostal space, ICD is done up to the point of the finger sweep, quick, without preparing for ICD
Not sterile, therefore second hole is made for ICD
What used to be done in the treatment of a tension pneumothorax and why is it no longer done?
Used to do decompression with a needle in the 2nd interstitial space, does not work as not enough air is released therefore the current guidelines indicate a finger thoracotomy instead.
What is a massive haemothorax defined as?
Defined as >1500mls blood loss into the chest cavity
What is the cause of a haemothorax?
Great vessel disruption: penetrating or blunt (injured main vessel)
How is a massive haemothorax diagnosed?
Ultrasound / CXR
What clinical features indicate a massive haemothorax?
- flat neck veins
- shock with no breath sounds
- percussion dullness (blood is stony dull on percussion)
How is a massive haemothorax treated?
- blood product resuscitation (NB to cross match tubes, will need blood)
- will likely require theatre
What is the difference between a haemothorax and a massive haemothorax?
The amount of blood
What is cardiac tamponade?
Blood in the pericardial sac
- prevents filling of the heart
- decreased cardiac output
What most commonly causes cardiac tamponade in our setting?
"stab heart" most common
How is the diagnosis of cardiac tamponade made?
What clinical signs are indicative or cardiac tamponade?
- pulsus paradoxus
- distended neck veins
- muffled heart sounds
- ECG: very small wave form
- pulseless electrical activity
What should be done if cardiac tamponade is suspected?
CALL THE SURGEON
Need to do thoracotomy
How successful are thoracotomies?
Only 1/100 thoracotomies actually save the patient, but its the only option - have to try.
What causes pulmonary contusion?
Usually secondary to blunt chest trauma
Clinical signs indicative of pulmonary contusion:
- dull to percussion
What may pulmonary contusion lead to?
Damage to capillaries results in blood and other fluids accumulating in the lung tissue.
- excess fluid interferes with gas exchange potentially leading to hypoxia
What does pulmonary contusion look like on X-ray?
Looks like pneumonia